室间隔缺损术后残余漏的发生原因及处理

回顾1454例室间隔缺损修补术后65例(4.5％)残余漏的发生及转归。其中单纯室间隔缺损(VSD)1152例,术后残余漏38例(3.3％);合并VSD的302例中,法乐氏四联症(TOF)201例,残余漏13例(6.5％)。本组65例残余漏患者中,二次手术修补27例(3例死亡),自行闭合9例,缩小24例,无变化5例。认为室间隔缺损＞8mm者应补片修补,残余缺损＞5mm者宜早期手术治疗,＜5mm者可随访;提高手术技术是预防残余漏发生的关键。     

介入治疗室间隔缺损修补术后残余漏的初步研究

目的:探讨室间隔缺损(VSD)外科修补术后残余漏介入治疗的方法学及临床疗效。方法:对年龄在7～58岁之间的12例VSD修补术后残余漏患者行介入治疗。封堵材料为Amplatzer非对称性室间隔缺损封堵器(AAVSDO)和对称性国产室间隔缺损封堵器(VSDO)。距手术修补时间平均为(10.2±5.5)年;9例为膜部室间隔缺损修补术后患者,3例为法乐四联征(TOF)术后患者;8例修补术后心电图示完全性右束支传导阻滞(CRBBB),1例修补术后出现Ⅲ度房室传导阻滞并安装了永久起搏器。以经食道超声(TEE)或经胸超声(TTE)以及左心室造影测量残余漏大小。9例患者各有1个残余漏口,3例患者右心室面有两个残余漏口。结果:超声及左心室造影所测残余漏直径分别为3～10 mm和4～10 mm,所选用封堵器直径为4～12 mm,封堵15分钟后造影示11例残余漏完全封堵,1例残留少量分流,术后1个月复查时残余分流消失。所有患者未出现新的心律失常及其它并发症。结论:介入治疗室间隔缺损修补术后残余漏安全有效,其远期效果需长期随访观察。     

介入封堵在治疗室间隔缺损修补术后残余漏上的疗效

目的:探讨介入封堵治疗室间隔缺损（VSD）修补术后残余漏的方法与疗效。方法: 全组18例,年龄3～46（14±11）岁。残余漏大小3～8（42±15） mm。通过建立轨道法,封堵VSD术后残余漏,封堵15 min后行左心室造影,术后1 d及3个月行超声心动图检查,观察封堵效果。结果: 全组18例VSD修补术后残余漏患者,除1例因残余漏直径过大,1例因建立轨道困难,封堵未成功外,余均治愈。结论: 介入治疗VSD修补术后残余漏疗效满意、可靠。     

经导管介入治疗室间隔缺损修补术后残余漏

随着心外科手术治疗室间隔缺损(VSD)的广泛开展,临床上经过手术治疗后仍有残余漏的病例逐渐增多,我中心于2003年4月～2005年4月应用经导管介入治疗VSD修补术后残余漏病例11例.     

经导管介入治疗室间隔缺损修补术后残余漏

经导管封堵治疗膜周部室间隔缺损(VSD)是近年先天性心脏病介入治疗的热点之一.随着VSD封堵器械的改进,其安全性不断提高,在临床上得到日益广泛的应用.VSD修补后出现残余漏是一种常见的手术并发症,过去治疗主要是二次手术再修补,近年来有作者认为经导管封堵术是治疗VSD残余漏的良好方法,但有关这方面的专门报道还很少.我们于2004年12月～2005年1对3例VSD残余漏进行了经导管封堵治疗,取得了良好的结果.报告如下.     

悦灵胶预防室间隔缺损术后残余漏效果观察

60例室间隔缺损（VSD）修补术患者,随机分为A、B组,各30例。A组使用使用常规的VSD修补方法。B组在A组基础上使用国产纤维蛋白胶（悦灵胶）。结果A组术后发生残余漏7例,残余漏直径（0.99±1.70）mm;B组分别为1例、（0.05±0.30）mm。两组残余漏发生率和残余漏直径相比,P均〈0.05。认为悦灵胶的应用能显著降低VSD术后残余漏发生率,缩小残余漏直径。     

经导管封堵室间隔缺损修补术后残余分流并发机械性溶血一例

患者,女性,32岁.因"发现心脏杂音32年,胸闷气喘心悸1月余"入院.患者出生时即诊断为室间隔缺损(ventricular septal defect,VSD),24年前(1988年)首次行VSD修补术,术后复查超声心动图(echocardiography,UCG)发现残余分流.2000年行VSD残余分流修补术,术后复查UCG仍有残余分流.复查心电图(electrocardiogram,ECG):交界性逸搏心律、频发室早二联律.2012年1月初患者出现活动后胸闷气喘心悸,遂入我院治疗.入院查体:血压130/72mmHg,嘴唇无紫绀.     

介入法治疗室间隔缺损修补术后残余漏

目的评价室间隔缺损（VSD）修补术后经导管封堵治疗的临床效果。方法9（男4,女5）例患者,年龄5～40岁。其中膜部VSD术后7例,法洛四联症（TOF）术后2例。经胸超声心动图测量VSD术后残余漏直径为3～12mm。有7例为1个残余漏口,2例有2个残余漏口。结果左心室造影5例膜部瘤的左室面直径14～28mm,漏口均在膜部瘤的出口。其中3例残余漏有1个孔,其大小分别为4、6和7mm,用6、9和10mmVSD封堵器。2例有2个孔,其大小分别为3、6mm和9、7mm,两孔之间距离分别为8和10mm,均放置两个封堵器,1例为5和9mmVSD封堵器,1例为14mmVSD封堵器和12/14mm动脉导管未闭封堵器。2例膜部VSD,其漏口直径分别为3和10mm,用5和14mm封堵器。2例TOF术后并发VSD残余漏,其漏口直径分别为9和14mm,用12和18mm封堵器。术后即刻左心室造影8例无残余分流,1例两个封堵器的患者有少量残余分流。升主动脉造影全部患者无主动脉瓣返流。随访1～6月复查超声心动图,有残余分流的1例在3月消失,全部患者封堵器无移位,无主动脉瓣返流。结论经导管封堵治疗室间隔缺损修补术后残余漏是一项操作安全、疗效可靠的治疗方法。     

室缺修补术后并发残余漏的原因及预防(附7例报告)

残余漏是先天性心脏病室间隔缺损修补术后常见并发症之一。它不仅影响手术效果 ,也影响患者预后。因此 ,探讨其发生原因和采取相应的预防措施 ,对提高手术成功率和治愈率至关重要。1　临床资料我院施行各类型室缺修补术 1 6 5例 ,发生术后残余漏 7例 ,发生率为 4.2 %。其中 6例位于膜部 ,1例位于肌部。7例术后心前区仍可触及震颤 ;胸骨左缘第三、四肋间可闻及 /6级或以上较粗糙收缩期杂音 ;UCG检查仍有左向右分流束。本组随访 5例 ,2例失访。其中 1例 5岁男性患儿系巨大膜部室缺补片修补术后残余缺损 1 .0 cm,术后心衰 ,家长拒绝再次手术…     

室间隔缺损术后残余漏

室间隔缺损 (VSD)是常见的先天性心脏病 ,可单独发生 ,也可以是法洛四联症 (TOF)、大动脉转位等复杂畸形的一部分。随着体外循环技术及手术技巧的提高 ,VSD修补术的死亡率目前已很低 ,但仍存在不少并发症 ,其中残余漏是主要并发症之一。严重残余漏可造成血液破坏、心功能衰竭、心内感染等 ,甚至危及生命。因此 ,临床上对 VSD术后残余漏应积极采取措施进行预防及治疗。本文将国内外近年来对残余漏病因、预防、诊治等方面的研究综述如下。1　残余漏的好发部位残余漏多发于三尖瓣前、隔瓣基底周围 ,这可能与该区域邻近主动脉瓣和传导束等…     

Evaluation of ventricular septal defect repair using intraoperative transesophageal echocardiography: frequency and significance of residual defects in infants and children

Intraoperative transesophageal echocardiography (IOTEE) is commonly used to assess for residual defect and the need to return to bypass after repair of ventricular septal defect (VSD). The frequency and significance of residual septal defects as noted on IOTEE has not been well defined. We evaluated the frequency of residual VSD via IOTEE and the relationship between size of a residual VSD and rate of reoperation. In addition, we looked at the relationship between the presence of a residual VSD via IOTEE and the presence of residual VSD at follow-up transthoracic echocardiography (TTE). Residual VSD was measured via the largest width of the Doppler color jet diameter originating at the left ventricular septal surface. Of the 294 patients evaluated with IOTEE after VSD repair, one-third had a residual defect by IOTEE Doppler color flow mapping. Two-thirds of these defects closed spontaneously on TTE by the time of hospital discharge. There was no difference in frequency of residual VSD between simple (VSD closure alone, n = 90) and complex (VSD with associated lesions, n = 204) repair. Return to bypass with immediate reoperation was undertaken in nine patients, all of whom had significant shunt via oximetry (Qp/Qs > 1.5:1.0). All had residual VSD color jet diameters > 3 mm. Seven patients had residual color jet equal to 3 mm; however, hemodynamic studies did not reveal a significant shunt and none of these had reoperation. Seven patients with no VSD or < 3 mm residual VSD via had late reoperation to close residual VSD at 4 days to 5 months after initial operation. These were due to patch dehiscence or development of an "intramural" VSD in patients with conotruncal anomaly. A residual defect on IOTEE color Doppler measuring > or = 4 mm predicts the need for immediate reoperation, while a 3 mm defect may be significant and requires additional intraoperative hemodynamic evaluation. The majority of small defects noted on IOTEE are not present at discharge TTE. Patients with conotruncal defect repair should be followed closely for development of late significant "intramural" defects.     

残余室间隔缺损的外科治疗

本文报道因术后残余室间隔缺损而再次手术治疗２６例（２７次），其中单纯室间隔缺损１９例（２０次），法乐氏四联症６例，主动脉窦瘤合并室间隔缺损１例。手术死亡７例。本文对残余室间隔缺损的原因、手术时机的选择以及其预防措施进行了讨论。     

Late results of valve xenograft conduits between the right ventricle and the pulmonary arteries in patients with pulmonary atresia and extreme tetralogy of Fallot

Between 1975 and 1982, valve xenograft conduits were used to establish continuity between the right ventricle and the pulmonary arteries in 28 patients between the ages of 3 to 39 years (mean 14.7 years) with 4 hospital deaths (14%). The indications for operation were pulmonary atresia types I and II in 7, extreme tetralogy of Fallot with hypoplastic pulmonary artery and valvular ring in 10, secondary obliteration of the infundibulum following Waterston shunt in 4, pulmonary valve insufficiency after transannular right ventricular outflow tract patch in 5 and tetralogy of Fallot with anomalous coronary artery in 2. Twenty-one patients (87%) between 9 and 41 years of age (mean 17.4 years) were available for follow-up 1/2 to 8 years after operation. The late death incidence during the follow-up period was 8% (2/24). Postoperative cardiac catheterization, which included right and left ventriculogram and measurements of gradients, was performed in 14 patients 4 months to 6 years after operation. Four patients were in New York Heart Association (NYHA) class 1, 6 in class II and 4 in class III. The other 7 non-catheterized patients were in class II. There were resting peak systolic gradients of 15 to 35 mmHg in 4, 36 to 55 mmHg and more than 55 mmHg across the xenograft valve and the proximal anastomosis in 4 other patients. The right and left ventricular end-diastolic pressures (RVEDP, LVEDP) averaged 18 and 17.5 mmHg, respectively, in 3 patients. The mean ratio of PRV/PLV quotient in NYHA class I group was 0.3, in class II 0.45 to 0.7 and in class III greater than 0.7 (including 2 with residual VSD and pulmonary hypertension). Late densitometric studies for assessing pulmonary valve competence revealed regurgitant fraction of up to 40% of the total stroke volume in the absence of a residual shunt 2 to 4 years after conduit implantation. Three children underwent uneventful surgical replacement of calcified xenograft conduit 1 1/2 to 4 1/2 years after surgery with antibiotic-sterilized valve allograft. Four other patients have residual ventricular septal defects (VSD), 2 of them underwent surgical reclosure while the other 2 patients with pulmonary hypertension still have their residual VSD open.(ABSTRACT TRUNCATED AT 400 WORDS)     

Percutaneous closure of postoperative ventricular septal defects with the Amplatzer device.

The objective of this study was to look at the procedure, the results, and the follow-up of patients who underwent percutaneous closure of a residual ventricular septal defect (VSD) following a surgical closure using the Amplatzer VSD device. Four patients had an original diagnosis of tetralogy of Fallot, two patients had a patch leak following a surgical repair of a VSD, and three patients had a VSD not repaired at the time of surgery. All patients fulfilled the currently accepted surgical criterion for reoperation (Qp/Qs>1.5). The mean Qp/Qs was 1.8+/-0.3 (1.5-2.3). Four patients underwent VSD closure using an Amplatzer perimembranous VSD device and in five patients an Amplatzer muscular VSD device was implanted. We performed percutaneous closure in nine patients. The size of the residual shunt ranged from 6 to 14 mm and the size of device used ranged from 8 to 16 mm. The arteriovenous loop needed to be recreated in two patients because of failure to advance the delivery sheath. There was complete closure of the defect in six cases, and a small residual shunt remained in three cases. Percutaneous closure of postoperative VSDs appears to be an effective way to resolve a hemodynamically significant residual shunt. There were no difficulties encountered with implantation of the devices. These promising short-term results need reinforcement with additional long-term data.     

Transcatheter closure of congenital muscular ventricular septal defect

The success with occlusion devices for the closure of atrial septal defects and patent ductus arteriosus prompted the transcatheter closure of single and multiple muscular ventricular septal defects (VSD). The procedure for VSD was first attempted by Lock et al. in 1988 and devices originally designed for the closure of other intracardiac defects (Rashkind umbrella device, Lock clamshell, Cardioseal, coils, Sideris buttoned device etc.) were used with a variable success rate and a residual shunt. Recently, specially designed Amplatzer muscular VSD occluder and Sideris device are in use. The Amplatzer muscular VSD occluder has been undergoing clinical trial since 1998 after the animal experiments had shown 100% occlusion and complete endothelization at 3 months. The procedure was first attempted in August 1995 using the Rashkind umbrella device and since April 1998 only the Amplatzer muscular VSD occluder has been used. Of the149 patients who underwent transcatheter closure of VSD, 50 had muscular trabecular defects in various locations: mid-muscular, anterior, posterior, or apical. All cases were selected by detailed transthoracic and/or transesophageal echocardiography (TTE) and aneurysm of the muscular septum was observed in three of them. The age range was 3-28 years and the diameter of VSD was 4-11 mm. In all but one patient, the device was deployed from the venous side. Simultaneous TTE was done for proper positioning of the device and continuous electrocardiographic monitoring was also done for any arrhythmia/conduction defects. All patients were followed up every 3 months and received 3-5 mg/kg aspirin for 6 months. The procedure was successful in all patients. The Rashkind umbrella device (17 mm) was used in two and Amplatzer muscular VSD occluder (6-14 mm) in 48 patients. Forty-four devices were delivered by antegrade transvenous approach and six by the transjugular route. None had residual shunt, new aortic regurgitation, or tricuspid regurgitation. Transient complete heart block after 24 hours was noticed in one patient. On a follow-up of 2-90 months, the device was in position in all patients. There was no embolization of the device, and no late-conduction defects, infective endocarditis, or hemolysis. Transcatheter closure of muscular VSD is safe and efficacious, and should be considered as a procedure of choice as an alternative to surgery that avoids cardiopulmonary bypass.     

Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: Results of a U.S. Registry.

The objective of this study was to assess the immediate and mid-term results of transcatheter closure of postinfarct muscular ventricular septal defects (VSDs) using the new Amplatzer postinfarct muscular VSD device (PIMVSD). Ventricular septal rupture occurs in 0.2% of myocardial infarcts and remains associated with very high morbidity and mortality. Data were prospectively collected for 18 patients who underwent attempted device closure of postinfarction VSDs between 2000 and 2003. Five patients underwent the closure in the acute phase (within 6 days from the infarct); the remaining patients underwent closure on day 14-95 after the diagnosis of the infarct. Outcome parameters included procedural success, evidence of residual shunts on echocardiography, and occurrence of procedure-related complications. The procedure was successful in deploying a device across the VSD in 16 of 18 patients. The 30-day mortality was 28%. Eleven patients are still alive and have been followed up for a median of 332 days. Two patients required a second procedure to close a residual VSD. At the most recent outpatient follow-up, the VSD was completely closed in two patients, six patients had a trivial or small residual shunt, and two patients had a moderate residual shunt. We conclude that percutaneous device closure of postinfarction VSDs using the Amplatzer PIMVSD occluder appears to be safe and effective. Further trials are required to assess long-term efficacy and compare the results with those of surgical closure.     

The results of transcatheter closure of VSD using amplatzer® device and nit occlud® Lê coil

Objective: We retrospectively reviewed the result of patients who underwent transcatheter closure of ventricular septal defect (VSD) using Amplatzer® Perimembranous or Amplatzer® muscular VSD device (the Amplatzer® group) and Nit Occlud® Lê VSD Coil (the Pfm group). Background: Perimembranous type (PmVSD) and doubly committed subarterial (DCSA) VSD were the major isolated congenital heart defects in Thai children. Transcatheter device closure technique for both types of VSD has emerged as an alternative treatment to surgery. Methods: Retrospectively, data was reviewed between 2003 and 2009. Results: 116 patients were enrolled. Device or coil was successfully implanted in 94%. Complete closure at 24 hr is slightly higher in the Amplatzer® group. The average size of VSD in the Amplatzer® group was larger than the Pfm group (P = 0.001). The Pfm coil was primarily deployed in DCSA VSD when compared with the Amplatzer® group (P < 0.01). At 6 months follow‐up the residual shunt was comparable (P = 0.054). There was only one transient AV block (AVB) in the Pfm group and 5 AVB in the Amplatzer® group. Four pacemakers were placed in the Amplatzer® group. Conclusions: Transcatheter closure of VSD in both Pm VSD and DCSA can be achieved by using either of the device. The Amplatzer® VSD device had the advantage of closure of larger defects with immediate less residual shunt but appeared to have a significant number of 3° AVB, which required pacemaker implantation. The Nit Occlud® Lê VSD Coil had the advantage of closure of both types of defects, in particular DCSA VSD with only small residual shunt. © 2011 Wiley Periodicals, Inc.     

经导管室间隔缺损封堵术与外科手术治疗膜周部室间隔缺损的对比研究

目的　分析比较经导管室间隔缺损封堵术 (TCVSD)与外科修补术治疗膜周部室间隔缺损的疗效及优缺点 ,为临床提供优选依据。方法　外科组包括接受外科手术治疗的 4 5例膜周部室间隔缺损 (VSD)患者 ,采用直接缝合或补片修补VSD ;TCVSD组包括同期接受TCVSD术的 4 5例膜周部VSD患者 ,采用新型偏心状Amplatzer膜周部室间隔缺损封堵器封堵VSD。比较两组的疗效、并发症和费用等情况。结果　TCVSD组 4 4例封堵成功 (技术成功率 98% ) ,术后出现少量残余分流3例 (均小于 2mm) ,出现完全性左束支传导阻滞 1例 ,无其他严重并发症发生 ;外科手术组全部手术成功 ,无死亡 ,术后出现残余分流 1例 (3～ 4mm) ,心包积液 1例 (后行切开引流术 ) ,切口内出血 1例(后行二次缝合术 ) ,左前分支阻滞 2例。两组间治疗前后左室舒张末径 (LVEDD)的减小程度无明显差异 (P >0 0 5 ) ,总住院天数及特护天数TCVSD组要明显少于外科组 ,治疗总费用及器材费TCVSD组要明显高于外科组。结论　TCVSD术疗效与外科手术相当 ,具有并发症较少 ,术后恢复快 ,不留疤痕等优点 ,但治疗费用较高 ;对于部分选择性病例 ,TCVSD术可以逐步替代外科手术成为治疗膜周部VSD的首选方法。     

Impact of intraoperative echocardiography on surgical management of congenital heart disease

Intraoperative echocardiography was performed by epicardial, 2-dimensional, low- and high-pulsed repetition frequency, continuous-wave Doppler and color flow mapping in 50 patients. Forty studies were performed before and 44 studies after cardiopulmonary bypass. Studies before cardiopulmonary bypass agreed with preoperative evaluation. After cardiopulmonary bypass, studies revealed that 11 of 25 patients who underwent repair of ventricular septal defects had residual ventricular septal defects, and 1 of 25 patients who underwent atrial septal repair had 1 residual atrial communication. One patient with a "Swiss cheese" ventricular septum underwent repeat cardiopulmonary bypass to close residual ventricular septal defects. The patient with a residual atrial communication required immediate reoperation because of a right to left shunt after a modified Fontan procedure. Eight of 10 remaining residual ventricular septal defects spontaneously closed 1 to 41 days after operation. Assessment of postcardiopulmonary bypass and postoperative valvular regurgitation in 21 valves revealed good correlation (p less than 0.01). However, 1 patient required reoperation for mitral valve replacement on the sixth postoperative day. The correlation was fair between postcardiopulmonary bypass and postoperative residual stenotic pressure gradients in 12 surgically repaired stenotic lesions. This study shows that little additional information is added to a comprehensive preoperative evaluation by precardiopulmonary bypass intraoperative echocardiography. Postcardiopulmonary bypass intraoperative echocardiography is useful in identifying residual shunts. Assessment of stenotic gradients and valvular regurgitation must be interpreted in light of a changing hemodynamic state.     

室间隔缺损介入治疗后并发封堵器移位的原因分析

目的探讨经导管介入治疗室间隔缺损（VSD）发生封堵器移位的原因和预防措施。方法介入治疗后封堵器移位患者4（男3,女1）例,3例为膜周部VSD伴膜部瘤,1例为嵴内型VSD,缺损直径分别为13、12、12和10mm,所选用的封堵器分别为16、12mm国产对称型膜部VSD封堵器,14mmAmplatzer膜部VSD封堵器和14mm国产偏心型膜部VSD封堵器。结果4例均一次性封堵成功。术后即刻均无残余分流。2例在术后4和12h分别发生溶血,超声心动图检查封堵器位置无明显变化,但均有明显残余分流。经药物治疗后,溶血恢复正常,残余分流消失。1例术后第4天,心电图检查为Ⅲ度房室传导阻滞,超声心动图发现封堵器明显向囊袋出口移位。转心脏外科手术取出封堵器并修补缺损,术后患者Ⅲ度AVB恢复。1例嵴内型VSD术后2周,超声心动图发现封堵器向右心室移位,有明显残余分流。随访4个月残余分流减少。结论VSD封堵治疗后,封堵器移位与缺损的病理解剖特性有关。多发生在伴有膜部瘤的膜部VSD和嵴内型VSD。