Andersons pediatric cardiology 778
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (83.43 KB, 3 trang )
excellentsuccessformanyyears,andtheoperativemortalityisnowexpectedto
beessentiallyzeroincentersexperiencedinthesurgicalcorrectionofcongenital
cardiacmalformations.Thesurgicalapproachtodefectswithintheovalfossa
consistsofeitherdirectsutureorpatchclosure,dependingonthesizeofthe
opening(Video29.9).Whenasinusvenosusdefectispresent,apatchisalways
necessary.Itcanusuallybeplacedsoastoclosetheinteratrialcommunication
andatthesametimeredirectanomalouslydrainingpulmonaryveinsintotheleft
atrium(Video29.10).Perioperativecomplicationsarerare.Theyincludethe
postpericardiotomysyndromeandtransientarrhythmias.Airembolizationisan
uncommonbuttragiccomplication.Itismorelikelywhenarightlateral
thoracotomyisused,sincethisapproachmakestheevacuationofairmore
difficult.Obstructionatthesuperiorcavalveinmayrarelyoccurfollowingrepair
ofasuperiorsinusvenosusdefect,whereasamisplacedpatchduringtherepair
ofaninferiordefectmayresultincyanosisduetoshuntingfromtheinferior
cavalveintotheleftatrium.
Whenthisprocedureisperformedinapatient'schildhood,thelong-term
resultsofsurgeryareexcellentandresidualshuntsareveryrare.Resolutionof
cardiomegalyasseenonthechestradiographandofrightventricular
hypertrophyseenontheelectrocardiogramisexpected.Radiographicevidence
ofcardiacenlargementcanpersistinsomepatients,50ascanrightventricular
enlargementasrevealedbyechocardiography.93Actuarialsurvivalcalculated
over27yearsforpatientsundergoingsurgeryatlessthan24yearsofagewas
identicaltocontrols.37Incontrast,areviewofmorethan100patientswho
underwentsurgeryatlessthan14yearsofageandwerefollowedforanaverage
of14.5yearsrevealedrightventriculardilationin25%.94Numerousstudies
havealsoshownsurgicalinterventioninadults,eventhoseabove60yearsof
age,tobesafeandeffective.37,88,95–97Arrhythmias―includingsinusnodal
dysfunction,supraventriculartachycardia,andatrioventriculardisturbancesof
conduction―dooccasionallyoccuraftertherepairofatrialseptaldefects.39,50,98
Implantationofapacemakermayberequiredinasmallnumberofpatients.94,98
Theincidenceoftachyarrhythmias,particularlyatrialflutterorfibrillation,
increaseswithageatoperation.82,99Patientswithsinusvenosusdefectsappear
tobemoreatriskforbradyarrhythmiasthanthosewithdefectswithintheoval
fossa.13
TranscatheterClosure
Manypatientswithovalfossadefectswillnowavoidsurgery(Video29.11).
Manydevicesarenowavailablefortranscatheterclosureinthecardiac
catheterizationlaboratory.Theassessmentofdefectsforsuitabilityhasbecome
partoftheechocardiographicassessment.Necessarily,thefollow-upisshortfor
somedevices,buttheriskofseriousharmduringimplantationislow,andthe
lateriskprofileseemssimilartothatofsurgery,albeitwithsomespecific
concerns(e.g.,erosionofthedeviceintoadjacentstructures)forsomedevices.
AnnotatedReferences
CampbellM.Naturalhistoryofatrialseptaldefect.
BrHeartJ.1970;32:820–826.
Thisimportantstudypermittedcalculationsoflife
expectanciesforpatientswithunoperated
defects.Fromadifferentera,whenassociated
abnormalitiessuchasrheumaticheartdisease
weremoreprevalent,thisstudyhighlightedthat
interatrialcommunicationsarenotbenign
defects..
FreedMD,NadasAS,NorwoodWI,Castaneda
AR.Isroutinepreoperativecardiac
catheterizationnecessarybeforerepairof
secundumandsinusvenosusatrialseptal
defects?JAmCollCardiol.1984;4:333–336.
Thisstudywasoneofthefirsttohighlightthe
importanceofaccuratepreoperativeassessment
usingnoninvasivetechniquesinchildren
undergoingrepairofatrialseptaldefects,
negatingtheneedforcardiaccatheterization..
MurphyJG,GershBJ,McGoonMD,etal.Longtermoutcomeaftersurgicalrepairofisolated
atrialseptaldefect:followupat27to32years.
NEnglJMed.1990;323:1645–1650.
Animportantlong-termfollow-upstudyof123
