Siyanotik Konjenital Kalp Hastalarında Sistemik-Pulmoner Şant Teknikleri: 24 Yıllık Klinik Deneyimin Analizi

Öz

Amaç: Aortopulmoner şant operasyonları, kompleks siyanotik kalp hastalıklarında pulmoner kan akımının arttırılması ve pulmoner arterlerin gelişmesi, dolayısı ile sistemik oksijen saturasyonunun iyileştirilmesini amaçlayan palyatif prosedürlerdir. Çalışmadaki amaç, palyatif aortopulmoner şant operasyonu uygulanan hastalarda preoperatif durum, operatif teknik ve yaklaşımlar ile postoperatif seyir arasındaki ilişkileri tespit etmek, mortalite ve morbiditeye etki eden risk faktörlerini araştırmak ve değerlendirmektir. Gereç ve yöntemler: Çalışmaya Kasım 1985-Ağustos 2009 tarihleri arasında İstanbul Üniversitesi Kardiyoloji Enstitüsü Kalp Damar Cerrahisi Anabilim Dalı’nda Modifiye Blalock-Taussig şant (MBTS) operasyonu uygulanan 587 olgu dahil edildi. Retrospektif olarak preoperatif ve operatif veriler kaydedilerek, hastalar patofizyolojinin tek ya da çift ventrikül tamirine uygunluğu temel alınarak (univentrikül/biventrikül) iki grupta sınıflandırıldı. Birincil sonuç olarak hastane ölümü veya iyi hal ile taburcu olma kabul edildi. Yaş grupları (neonatal, 1 ay-1 yaş ve 1 yaş üzeri) ve cerrahi yaklaşım (torakotomi, sternotomi) temel alınarak, yaklaşımlar arasındaki farkların birincil sonuç üzerine etkisi değerlendirildi. Mortalite ve morbidite üzerine etki eden risk faktörleri istatistiksel olarak araştırıldı. Bulgular: Çalışmaya katılan 364’ü erkek (%62), 223’ü kız (%38), ortalama yaşı 21,6±31,2 ay (0-240) ve ortalama kilosu 10.7±7.2 kg (2.7-54) olan 587 hastanın, 66'sı1 aylık (%11.2), 236'sı 1 ay-1 yaş (%40.2) ve 285'i 1 yaş üzeri (%48.6) grupta değerlendirilmiştir. Yüzdoksanbir hastada univentriküler (%32.5) ve 396 hastada biventriküler (%67.5) tamir planlanmış, 141 hastada median sternotomi (%24), 446 hastada torakotomi (%76) uygulanmıştır. Erken dönem mortalite oranı %11.6’dır. Şant yetmezliği açısından; yaş, tanı, ekstrakorporeal dolaşım (ECC) kullanım ihtiyacı, cerrahi yaklaşım, şant çapı anlamlı bulunmuş ve çoklu değişken lojistik regresyon analizi sonucunda cerrahi yaklaşım bağımsız risk faktörü olarak saptanmıştır (p=0.002). Mortalite açısından anlamlı bulunan yaş, şant çapı ve cerrahi yaklaşım arasında lojistik regresyon analizi ile sternotomi (p=0.0001) ve 1 ay-1 yas arası grup (p=0,008) bağımsız risk faktörü olarak izlenmiştir. Sonuç: Halen özellikle kompleks konjenital kalp hastalıklarında palyatif cerrahinin altenatif yaklaşımlarının azlığı sebebi ile kalp cerrahisindeki yerini koruyacağı görülmektedir. Günümüzde MBTS prosedürü için cerrahi yaklaşımlar ve yoğun bakım takip protokollerinde geniş bir bilgi birikimi ve deneyim edinilmiş olsa bile, bu hasta grubunda mortalite ve morbiditeye etkili risk faktörlerini uzun dönem sonuçları ile araştıran prospektif çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• Konjenital kalp hastalığı
• Siyanotik
• Palyatif işlem
• Şant

Systemic to Pulmonary Shunt Techniques in Cyanotic Congenital Heart Disease Patients: An Analysis of 24 Years of Clinical Experience

Öz

Purpose: Aortopulmonary shunt operations are palliative interventions that are used in complex cyanotic cardiac conditions to improve systemic oxygen saturation and maturating pulmonary arteries by increasing pulmonary blood flow. In this study, we aimed to investigate and evaluate the association between preoperative conditions, operative techniques, and postoperative outcomes; as well as to determine the risk factors that are related to morbidity, and mortality in patients receiving palliative aortopulmonary shunt procedures. Material and methods: Five hundred eighty-seven patients who underwent MBTS operation in Istanbul University, Institute of Cardiology, Department of Cardiovascular Surgery between November 1985 – August 2009 were included in the study. Preoperative and postoperative data were examined, and patients were retrospectively grouped into two, regarding their pathology for either univentricular, or biventricular repair. Primary outcome was investigated as means of in-hospital death, or being discharged in good health. Three age groups (neonatal, 1 month-1 year, older than 1 year), and two surgical technique groups (thoracotomy, sternotomy) were established to determine their effects on primary outcomes. Risk factors for mortality and morbidity were statistically analyzed. Results: Among the 587 patients enrolled, 364 were male (%62), and 223 were female (%38). Average age and body weights were 21,6±31,2 months (0-240 months), and 10,7±7,2 kg (2,7–54 kg), respectively. Age groups were as follows: 66 were under 1 month (%11,2), 236 were between 1 month and 1 year (%40,2), 285 were over 1 year (%48,6). One hundred ninety-one cases (%32,5) underwent univentricular repair, and biventricular repair procedure was planned for the remaining 396 patients (%67,5). Median sternotomy was the approach preferred for 141 patients (%24) and thoracotomy for the other 446 (%76). Early mortality rates were calculated as %11,6. Age, diagnosis, use of ECC, surgical approach and shunt diameter were found to be important risk factors for shunt failure. Among those, only surgical approach was found to be an independent risk factor according to multi-variate logistic regression analysis (p=0,002). Among mortality factors found to be statistically significant such as age, shunt diameter, and surgical technique, only sternotomy (p=0,0001) and being between 1month – 1 year of age (p=0,008) were considered to be independent risk factors. Conclusion: In complex congenital heart defects, palliative surgical treatment seems to be the primary approach due to lack of alternatives. Today, there is an extensive experience on MBTS procedure and on its intensive care follow up protocools but there is still a need for long term prospective trials to establish the risk factors affecting mortality, and morbidity.

Anahtar Kelimeler

• Congenital heart disease
• Cyanotic
• Palliative procedure
• Shunt

Kaynakça

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