经食管超声在微创外科房间隔缺损封堵术中的应用

目的 评价经食管超声(MTEE)在微创外科房间隔缺损封堵术中的应用价值.方法 经胸多普勒超声心动图(TTE)选择先天性心脏病继发孔房间隔缺损(房缺)适合于微创外科封堵术治疗的患者50例.34例患者房缺为34～40 mm,16例患者为房间隔膨出瘤合并多孔房缺.患者均在术中经MTEE再次明确诊断,并在监测引导下,选择房缺合适封堵器的型号,置入Amplatzer封堵器闭合缺损,术后3～5 d超声随访.结果 依据术中MTEE测值,48例适合做微创外科封堵,封堵成功42例,型号不适的6例.术中即刻经MTEE测量右心室舒张末期容积(78±23)ml、右心室每搏输出量(41 ±13)ml分别较封堵前明显减小[(94±32)ml,(52 ± 20)ml,均P＜0.05];左心室舒张末期容积(73±19)ml、左心室每搏输出量(50±11)ml分别较封堵前增加.[(56±14)ml,(34±12)ml;均P＜0.05].术中发现5例患者封堵器边缘存在少量残余分流,术后TTE发现2例有少量分流,但心腔径线明显恢复.结论 经MTEE在微创外科房缺封堵术中的价值:①对房间隔缺损进一步明确诊断;②对选择Amplatzer封堵器型号提供依据;③对释放封堵器提供正确引导;④判定术后疗效;⑤监测术中并发症.

Application of transesophageal echocardiography in intraoperative device closure of secundum atrial septal defects

OBJECTIVE: To evaluate the clinical value of transesophageal echocardiography (TEE) in guiding intraoperative device closure of secundum atrial septal defect (ASD). METHODS: Fifty ASD patients, aged 40 +/- 18 (15-72), 34 with an ASD ranging from 30 to 40 mm and 16 with atrial septal aneurysm accompanied by double or more ASDs, underwent intraoperative device closure through a right minithoracotomy without cardiopulmonary bypass and fluoroscopy. Under general anesthesia, a probe was inserted into the esophagus, and TEE was conducted at different planes to observe the characteristics of the ASD. The size of implanted device was determined by TEE. Small parasternal incision was made in the right third or fourth intercostal space. A specially designed plastic sheath loaded with Amplatzer occlusion device was inserted through the purse-string sutures placed on the right atrium. Guided by transesophageal echocardiography, the Amplatzer occlusion device was advanced through the ASD into the left atrium and was deployed in place. The right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), right ventricular stroke volume (RVSV), right ventricular ejection fraction (RVSV), left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), left ventricular stroke volume (LVSV), and left ventricular ejection fraction (LVEF) before and after the operation were calculated. RESULTS: The procedure was successful conducted in 48 patients. And the other two patients failing to receive this procedure, one having a large ASD that could not be occluded and the other with ASD accompanied by partial anomalous pulmonary venous connection, were shifted to operation with cardiopulmonary bypass. After the operation, the RVEDV was (94 +/- 32) ml, and the RVSV was (52 +/- 20) ml respectively, both significantly lower than those before the operation [(78 +/- 23) ml and (41 +/- 13) ml respectively, both P < 0.05]. The LVEDV and LVSV after operation were (73 +/- 19) ml and (50 +/- 11) ml respectively, both significantly higher than those before operation [(56 +/- 14) ml and (34 +/- 12) ml respectively, both P < 0.05]. CONCLUSION: TEE provides valuable information in further confirmation of diagnosis of ASD, selection of appropriate size of Amplatzer occluder, guidance of the deployment of occluder, observation of the effects of operation, and prompt detection of complication.