선천성 심장 기형의 우심실-폐동맥 인조혈관 연결 수술후 중장기 성적

Abstract

[한글]

선천성 심장 질환 교정 수술에서 우심실과 폐동맥을 도관(conduit)으로 연결해주는 Rastelli 술식은 술후 임상증상을 현저히 호전시킬 수 있지만, 환아의 성장이나 도관의 협착

으로 재수술이 불가피하다는 약점을 안고 있다.

저자 등은 1978년 부터 1993년 10월까지 연세대학교 의과대학 세브란스 병원 흉부외과에 입원한 선천성 심장질환자 중 우심실과 폐동맥 사이에 도관을 연결해 주는 Rastelli 술식을 이용하여 교정수술한 총 47례에 대해 평균 76.1 ± 51.3 개월간 추적 관찰하여 Rastelli 수술후 장기적인 성적에 미치는 인자를 알아보고자 본 연구를 하여 다음과 같은 결과를 얻었다.

1) 수술시 사용한 도관은 판막이 있는 도관을 사용한 경우가 30례(63.8%), 판막이 없는 도관을 사용한 경우가 17례(36.2%)였다. 수술후 47례중 8례가 수술사망(17%) 하였는데 수술사망을 도관 종류별로 보면 판막이 있는 도관을 사용한 경우가 5례(16.7%), 판막이

없는 도관을 사용한 경우가 3례(17.6%)로 양군간에 통계학적으로 유의한 차이는 없었다.

수술시 사용한 판막의 크기는 체표 면적과 통계적으로 유의한 상관 관계가 있었다. (Y=3.86X + 14.6, R=0.55, p<0.01)

2) 추적기간 동안 10례(30.3%)에서 도관 재치환 수술을 받았다. 도관 재치환술을 시행한 경우를 도관 종류별로 보면 lonescu-Shiley 판막도관이 3례중 1례(33%), Carpentier-Edwards 판막도관이 13례중 4례(30.8%), Hancock 판막도관이 5례중 4례(80%), 판막없는 도관을 사용한 환자 11례중 1례(9.1%)가 재수술하였다. Kaplan-Meier의 누적한계 생존 분석에 의한 수술후 median 재수술 회피 기간은 판막 있는 도관이 110개월, 판막없는 도관이 79개월 이었으나 통계적으로 유의한 차이는 없었다. 판막도관의 종류별 median 재수술 회피 기간은 lonescu-Shiley 판막도관이 110개월, Csrpentier-Edwards 판막도관이 112개월, Hancock 판막도관이 102개월로 이들간에도 통계적으로 유의한 차이가 없었다.

3) 재수술을 하지 않은 23례 모든 환자들은 현지 운동능력 제한 없이 건강하게 지내고 있으며 (New York Heart Association functional classification: class I), 이들 환자 23례중 10명에 대해 심장 Doppler 초음파 검사 결과 우심실과 폐동맥간의 압력차는 20 ±

11 mmHg(0mmHg - 40 mmHg) 였으나, 재수술한 환자의 재수술전 우심실과 폐동맥간의 압력차는 92 ± 9 mmHg(80mmHg - 110mmHg)로 매우 높았다.

4) 인조혈관 및 판막 협착으로 인해 재수술한 10례중 Gore-tex 18mm 인조 혈관으로 재치환술을 시행한 경우가 3례, Vascutec 20mm 가 3례, 기존의 인조판막 혈관에 판막을 제거하고 첨포확장을 해 준 경우가 2례, 첨포 확장시 monocusp 판막으로 폐동맥 판막을 만들어준 경우가 1례, 자신의 폐동맥이 발달하여 자신의 폐동맥에 첨포 확장술을 시행한 경우가 1례였다. 이중 재수술전 심내막염이 있었던 2례가 패혈증으로 사망하였다. 그외 8례에서는 재수술 후 2개월에서 89개월(평균 32.7 ± 33.9)이 지난 현재 운동 능력 제한없이 건강하게 지내고 있다.

5) 전체 퇴원 환자의 5년(n=23), 7년(n=19), 10년(n=4) 재수술 회피율은 각각 96%, 91%, 29%였으며 5년(n=23), 7년(n=20), 10턴(n=5) 생존율은 각각 82%, 82%, 71%였다.

이상의 결과로, 선천성 심기형 환자에서 Rastelli 수술을 이용하여 교정한 결과 비교적 좋은 성적을 보여 주고 있으며, 향후 판막 도관 및 도관의 선택에 대한 장기적인 추적 관찰을 하는것이 필요할 것으로 생각된다.

Intermediate and long term results for extracardiac conduit repair between right

ventricle and pulmonary artery in congenital cardiac defects

Hoon Kim

Department of Medical Science The Graduate School, Yonsei University

(Directed by Professor Bum Koo Cho)

Rastelli operation which connects right ventricle to pulmonary artery with

artificial graft in correction of congenital heart disease, can improve clinical

manifestations, but it needs inevitable reoperation due to stenosis of artificial

graft with the develoment of patients.

The purpose of this study was to evaluate factors which could influence the long

term results after Rastelli operation. We have the fellowing results from 47

patients with Rastelli operation who had been performed for Rastelli operation

between 1978 are october. 1993. The patients had been followed up for 76.1 ± 51.3

months.

1) The number of artificial grafts with valve used in operation are 30 cases

(63.8%), and those without valve are 17 cases(36.2%). There were 8 surgical deaths.

Among them, valved conduit was used in 5 patients and nonvalved conduit was used in

3 patients. However there is no statiscally significant difference. There were

good linear correlations between the body surface area(X) and the size of used

conduit(Y)(Y3=86X + 14.6, R=0.55, P<0.01).

2) Ten patients underwent re-replacement of artificial graft: lonescu-Shiley

valved conduit: one case(33%), Carpentier-Edward valved conduit: 4 cases. Haycock

valved conduit: 4 cases(80%). and artificial graft without valve: one case(9.1%).

Median duration of reoperation-free interval is 110 months in the patients with

valved conduit and is 79 months in patients with non-valved conduit. However, there

is no statistically significant difference between the two groups. Median duration

of the reoperation since primary operation is 110 months for Ionescu-Shiley, 112

months for Carpentier-Edward, 102 months for Hancock valved oconduit. There were no

statistically difference between them.

3) Patients who did not have reoperation are well without difficulty of physical

activity. (New York Heart Association functional classification. class Ⅰ). Ten

randomly selected patients underwent a doppler echocardiography and the pressure

gradient between the right ventricle and pulmonary artery is 20 ± 11 mmHg, and 92

± 9 mmHg respectively for the patlents who had have operation.

4) Among 10 cases which had operations due to stenosis of artificial vessel and

valve. 3 cases had replacement operation with patch enlargement fo previous valved

conduit after removal of the valved one case with monocusp valve with the patch

enlargement, and 1 case with patch enlargement.

Eight cases are doing well without physical problems during 2 months to 89

months(mean 32.7 ± 33.9 mouth) after reoperation and the remaining 2 cases died of

sepsis by endocarditis which occurred before the reoperation.

5) The percentage of reoperation-free among the patients at 5 years, 7 years. ard

10 years is 96%, 91%, 29% respectively, and the survival rata shows 82%, 82% 71%

respectively.

In conclusion. the above findings show good results for congenital heart dlsease

patients who had been corrected with Rastelli operation. However, it is suggested

that long term follow up for selection of conduit is necessary.

[영문]

Rastelli operation which connects right ventricle to pulmonary artery with artificial graft in correction of congenital heart disease, can improve clinical manifestations, but it needs inevitable reoperation due to stenosis of artificial graft with the develoment of patients.

The purpose of this study was to evaluate factors which could influence the long term results after Rastelli operation. We have the fellowing results from 47 patients with Rastelli operation who had been performed for Rastelli operation between 1978 are october. 1993. The patients had been followed up for 76.1 ± 51.3

months.

1) The number of artificial grafts with valve used in operation are 30 cases (63.8%), and those without valve are 17 cases(36.2%). There were 8 surgical deaths. Among them, valved conduit was used in 5 patients and nonvalved conduit was used in

3 patients. However there is no statiscally significant difference. There were good linear correlations between the body surface area(X) and the size of used conduit(Y)(Y3=86X + 14.6, R=0.55, P<0.01).

2) Ten patients underwent re-replacement of artificial graft: lonescu-Shiley valved conduit: one case(33%), Carpentier-Edward valved conduit: 4 cases. Haycock valved conduit: 4 cases(80%). and artificial graft without valve: one case(9.1%).

Median duration of reoperation-free interval is 110 months in the patients with valved conduit and is 79 months in patients with non-valved conduit. However, there is no statistically significant difference between the two groups. Median duration

of the reoperation since primary operation is 110 months for Ionescu-Shiley, 112 months for Carpentier-Edward, 102 months for Hancock valved oconduit. There were no statistically difference between them.

3) Patients who did not have reoperation are well without difficulty of physical activity. (New York Heart Association functional classification. class Ⅰ). Ten randomly selected patients underwent a doppler echocardiography and the pressure

gradient between the right ventricle and pulmonary artery is 20 ± 11 mmHg, and 92 ± 9 mmHg respectively for the patlents who had have operation.

4) Among 10 cases which had operations due to stenosis of artificial vessel and valve. 3 cases had replacement operation with patch enlargement fo previous valved conduit after removal of the valved one case with monocusp valve with the patch enlargement, and 1 case with patch enlargement.

Eight cases are doing well without physical problems during 2 months to 89 months(mean 32.7 ± 33.9 mouth) after reoperation and the remaining 2 cases died of sepsis by endocarditis which occurred before the reoperation.

5) The percentage of reoperation-free among the patients at 5 years, 7 years. ard 10 years is 96%, 91%, 29% respectively, and the survival rata shows 82%, 82% 71% respectively.

In conclusion. the above findings show good results for congenital heart dlsease patients who had been corrected with Rastelli operation. However, it is suggested that long term follow up for selection of conduit is necessary.