高度の肺血圧症を伴う心室中隔欠損症の手術適応及び手術至適年令について
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概要
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From April, 1970 to December, 1978, there were 112 cases with ventricular septal defect and severe pulmonary hypertension (VSD+PH, Pp/Ps over 0.75), ranging in age from 3 months to 34 years. Intracardiac repair using cardiopulmonary bypass was performed in 106 cases except for 6 cases with Eisenmengerization, and fifteen of the operated cases died. The indication and the optimal age for operation of VSD+PH were considered by the investigation of pre- and postoperative cardiac catheterization, lung scintiscanning, lung pathology and clinical course of these cases. The 112 cases ware divided into 3 groups according to age (group 1; 25 cases, 1-11 months, group 2; 43 cases, 1-2.11 years, group 3; 44 cases, over 3 years). Cardiac catheterization was performed in all 112 cases and postoperatively in 97 cases, the ratio of pulmonary to systemic arterial systolic pressures (Pp/Ps), pulmonary to systemic vascular resistance (Rp/Rs) and pulmonary to systemic blood flow (Qp/Qs) were calculated and used to evaluate hemodynamics. Lung scintiscanning was performed in 84 cases, the derangement of distribution pattern, the ratio of pulmonary blood flow distribution in upper and lower lung field (U/L ratio) and the right to left shunt ratio (R to L shunt ratio) were used as the parameters. Lung specimens were obtained from 66 cases before the cardiopulmonary bypass and light and electron microscopically studied. Pulmonary vascular obstructive change was graded by Heath-Edwards' criteria and the pathological change of alveolar septum (septitis) was also graded and investigated. The results and conclusions are as follows; 1) The U/L ratio of the group 1 was 0.50-1.00 (mean 0.72), that of the group 2 was 0.45-1.27 (mean 0.86) and that of the group 3 was 0.69-1.52 (mean 1.02). The U/L ratio of all the 6 cases with Eisenmengerization ranged in high level from 1.18 to 1.52(mean 1.33). 2) In 12 cases with deranged distribution in both lungs, mean Pp/Ps was 0.94, mean Rp/Rs was 0.72 and U/L ratio was 1.12. Four of these were Eisenmengerization and 4 of the 8 operated cases died. 3) R to L shunt was observed in 25 cases and the ratio ranged from 3.5 to 33.0% (mean 13.8%). In the 6 cases with Eisenmengerization, it ranged between 5.5 and 33.0% (mean 24.9%). 4) In the groups 1 and 2, Rp/Rs decreased to below 0.4 postoperatively in all cases except 1, but in the group 3, it remained above 0.4 in 5 cases where pulmonary vascular obstructive change exceeded grade 3. One of these died 5 years after the operation. 5) The operative results were affected by severe septitis in patients under 6 months of age, and by high pulmonary vascular resistance in those over 3 years. 6) To decide the limitation o£ indication for the intracardiac repair, Rp/Rs was not always reliable, particularly in younger age group. In addition to the Rp/Rs above 0.75, the U/L ratio ahove 1.2, the R to L shunt ratio above 0.2 and the deranged distribution on both lungs should be taken as the criteria of limitation together with clinical findings such as cyanosis and clubhing finger. 7) The optimal age for intracardiac repair is from 1 to 3 years by this study. However, in the cases which accompany medically uncontrollable cardiac and respiratory failure in early infancy, surgical intervention is inevitahle.
- 神戸大学の論文