不同海拔地区巨大动脉导管未闭的特点及其介入封堵治疗安全性与疗效

目的 对比探讨高海拔同平原地区巨大动脉导管未闭（patent ductus arteriosus,PDA）的特点及其介入治疗的安全性和疗效.方法 2011-04至2013-09来自海拔超过3500 m、氧气浓度小于沿海地区1/2的西藏地区巨大PDA患儿73例（高海拔组）;同期来自海拔小于2000 m,氧气浓度大于沿海地区1/2的福建等省区巨大PDA患儿28例（低海拔组）.使用国产封堵器行介入封堵手术,术后随访3个月超声心动图评价其疗效.对比观察两组间巨大PDA的特点、介入治疗效果及术后并发症.结果 高海拔组造影结果示PDA最窄处直径（17.0 ±8.3）mm,右心导管测得封堵器肺动脉收缩压（76.8±18.3）mmHg,选择蘑菇伞封堵器直径（26.0 ±9.0）mm;低海拔组造影结果示PDA最窄处直径（13.0±2.4）mm,右心导管测得封堵前肺动脉收缩压（30.87±14.68）mmHg,选择蘑菇伞封堵器直径（23±6）mm.高海拔组患儿介入手术成功率97.26％（2例未成功）,低海拔组成功率100％.术后残余分流高海拔组6例,低海拔组4例;高海拔组3例发生血小板减少症,1例外科取伞后症状好转;低海拔组2例发生血小板减少症;无死亡并发症.结论 高海拔地区巨大PDA较多、合并肺动脉高压更重,介入治疗安全、可行;巨大PDA封堵器建议按（PDA最窄处直径×1.5～ PDA最窄处直径×2）选择;介入封堵术后需警惕单纯血小板减少症,封堵后无残余分流是避免并发症、保障介入治疗成功的关键.

Comparative study of features and interventional treatment of macro-diameter patent ductus arteriosus at different altitude areas

Objective To study the safety and efficacy of interventional treatment of macro-diameter patent ductus arteriosus （PDA） at high altitude and in plain areas. Methods From April 2011 to September 2013, 73 macro-diameter PDA sufferers who came from high altitude region of Tibet （higher than3,500 metres） were as the high altitude group, and 28 patients came from low alti- tude region of Fujian （lower than 2,000 metersin） were as the low altitude group. Interventional occlusion operations werdone with the home made blockers, then were followed up by means of, ultrasonic cardiograms and electrocardiogram for 3 months to evaluate the ef- ficacy. The features, intervention treatment outcome and postoperative complications of macro-diameter PDA were observed in the both groups. Results At high altitude, macro-diameter PDA accounted for 42.20% , the mean diameter of PDA was （ 17 _＋ 8.36） mm, markedly bigger than in the low altitonde group （ P 〈 0.05 ） , and the pulmonary arterial pressure was （ 76.8 ＋- 18.32 ） mmHg, higher than that in the other group（P 〈 0.05）. At low altitude, angiography showed that there were 28 macro-diameter PDA patients, the mean diameter of PDA was （13 -＋ 2.41 ）ram, and the pulmonary arterial pressure by right heart catheterisation was （30.87 -＋ 14.68） mmHg, then the mushroom cap occluder with 23 -＋ 6 ram in diameter was chosen. The success rate of interventional operation for the high-altitude group was 97.60% （2 cases failed） , while for the low-altitude group was 100%. There were 10 cases of postoperative re- sidual shunt cases in high altitude group, 6 cases in the high-altitude group, while 4 cases in the low-altitude group. There were cases of thrombopenia of whom one improved after removing the ouluder in the high-altitude group;two cases of thrombopenia in the low-alti- tude group; and no death. Conclusion The macro-diameter patent ductus arteriosus and complicated pulmonary hypertension in the high altitude areas is more in number and heavier, and the effect of pulmonary hypertension on interventional operation security is smal- ler than in the patients from lower altitudes. The macro-diameter PDA occluder （ PDA narrowest diameter × 1.5 - PDA narrowest diameter ×2） is selected by recommendation： We should pay attention to simple thrombocytopenia, and no residual shunt after occlusion is also the key to avoid complications and ensure success for the inter- ventional treatment.