普通弹簧圈联合Interlock可解脱弹簧圈栓塞体肺侧支在复杂先天性心脏病治疗中的临床应用

目的探讨COOK普通弹簧圈联合可解脱带纤维毛弹簧圈栓塞系统栓塞体肺侧支在复杂先天性心脏病(先心病)外科治疗中的应用价值及经验。方法回顾性分析2016年1月至2018年8月中国医学科学院阜外医院收治的15例复杂先心病合并体肺侧支患者的临床资料,评价COOK普通弹簧圈联合可解脱带纤维毛弹簧圈栓塞系统在体肺侧支栓塞术中的可行性、安全性和有效性。结果15例患者中共发现33支体肺侧支血管,均栓塞成功,无血管损伤、弹簧圈移位及脱落等术中并发症发生。术中共用COOK普通弹簧圈34枚,直径3~8 mm,长度3~8 cm;共用Interlock可解脱弹簧圈28枚,其中15枚为钻石型,13枚为普通2D型,弹簧圈直径为2~6 mm,长度为2.3~8.0 cm。15例患者中10例属于杂交手术,即在杂交手术室行体肺侧支栓塞术后即刻行外科手术;5例因先心病外科术后发生灌注肺或左心功能不全需持续呼吸机辅助通气,不能拔除气管插管而行心血管造影及体肺侧支栓塞术,术后均顺利拔除气管插管。结论COOK普通弹簧圈联合可解脱带纤维毛弹簧圈栓塞系统栓塞体肺侧支在复杂先心病治疗中疗效确切,可推广应用。     

发绀型先天性心脏病伴体肺动脉侧支循环的内外科联合治疗

目的 评价内、外科联合治疗对发绀型先天性心脏病伴体肺动脉侧支循环的临床效果.方法 回顾性分析27例经内、外科联合治疗的发绀型先天性心脏病伴体肺动脉侧支循环患者的临床资料,着重分析侧支血管栓堵方法 、外科手术方法 、治疗结果 及并发症.结果 24例存活,3例死亡,病死率11.1%(3/27),死因分别为心室颤动1例、低心排血量综合征1例、呼吸衰竭1例.66支侧支血管为完全阻断,11支血管为部分阻断.栓堵相关并发症:2例缺氧发作:3支侧支血管渗漏,放置弹簧圈后侧支循环均达完全阻断.结论 内、外科联合治疗伴有体肺动脉侧支循环的发绀型先天性心脏病是行之有效的方法.     

体肺侧支血管封堵治疗在肺血减少型先天性心脏病中的临床应用研究

目的:探讨肺血减少型复杂先天性心脏病体肺侧支介入封堵治疗的意义、操作技术及安全性。方法:回顾性分析58例并发体肺侧支的肺血减少型先天性心脏病的封堵介入治疗。中位年龄36个月(7~288个月),体质量6.9~64kg,平均15.96kg。本组患儿术前均经超声心动图及心脏CT检查确诊,54例术前封堵侧支血管,4例术后封堵侧支血管。结果:全组58例患者体肺侧支血管共115支,其中63支(54.7%)起源于降主动脉(胸主动脉)。对94支血管进行了封堵(82%),释放弹簧圈204枚。每位患者封堵侧支血管1~6支,放置弹簧圈1~14枚。本组10例因肺动脉未达到根治条件未手术,48例行外科根治手术,死亡3例。死亡原因:1例肝、肾衰竭,1例低心排、灌注肺,1例重症感染、多器官衰竭。结论:本组病例提示对肺血减少型复杂先心合并体肺侧支血管,先期采用经皮介入封堵侧支,再行外科治疗,安全、有效,可减少术后并发症的发生,降低手术病死率。     

重症法洛四联症的镶嵌手术治疗

目的 总结重症法洛四联症(TOF)镶嵌手术的临床经验,探讨其方法、效果和意义.方法 筛选病例:重症发绀型法洛四联症17例,通过超声心动图和螺旋CT检查确诊.术前介入治疗:重症TOF在根治术前予以侧支血管堵塞术,其中2例采用AGA Plug血管塞堵闭体肺侧支血管,1例采用国产先健动脉导管未闭(PDA)Amplatzer封堵器,其余均采用COOK非可控弹簧圈栓塞体肺侧支血管.侧支血管堵塞术后立即行一期外科根治手术.结果 全组手术皆获得满意效果.随访2.0～2.5年,无严重并发症,患儿发育正常.结论 镶嵌手术治疗重症TOF安全、有效、可行,比单一外科手术效果好.     

复杂紫绀型先天性心脏病并发体肺侧支的内外科镶嵌治疗

目的:总结并发体肺侧支的复杂紫绀型先天性心脏病内外科镶嵌治疗的临床经验,探讨其治疗意义、操作技术及安全性。方法: 回顾性分析41例并发体肺侧支的复杂紫绀型先心病患者,年龄1～28（15±10）岁,体质量（18±8）kg。均行螺旋CT检查确诊,38例术前封堵侧支血管,3例术前漏诊术后封堵侧支血管。全组均行外科一期矫治手术。结果: 全组治愈37例。死亡4例:1例死于肺部感染,3例死于顽固性心力衰竭。侧支血管直径2.5～9.4（5.3±2.1） mm。每位患者放置弹簧圈3～21（10±6）枚。3例术后因侧支血管再通而二次封堵。术后4例并发肺部感染,3例肺水肿,2例灌注肺。结论: 并发体肺侧支的复杂紫绀型先心病,在围手术期应当内外科联合处理侧支血管的问题。可采用经皮介入封堵法,有效、简单、安全,可行多支、多次封堵,有效减少并发症的发生,降低手术死亡率。     

介入栓塞联合外科矫治治疗体肺侧支丰富的法洛氏四联症临床价值

目的分析评价在法洛氏四联症矫治术前应用介入栓塞联合外科根治治疗体肺动脉侧支血管丰富的法洛氏四联症患者的临床价值。方法 2005年12月～2010年6月,对16例体肺动脉侧支血管丰富的法洛氏四联症患者的体肺动脉侧支血管先进行有选择的介入栓塞,而后行法洛氏四联症矫治术。结果心血管造影明确诊断体肺动脉侧支血管56支,行介入封堵45支（80.35%）,外科手术结扎6支（10.71%）,其余侧支血管未予栓塞或结扎。总栓塞结扎率91.07%,共用弹簧栓子91枚。外科矫治术中回心血量不多,术野暴露良好,体外循环灌注压平稳。术后16例均痊愈出院。结论对伴有丰富体肺动脉侧支循环的法洛氏四联症患者,在矫治术前行体肺动脉侧支血管栓塞合并结扎术,可有效减少手术创伤,保持术野清晰,减少术后并发症的发生,有益于提高手术成功率和治愈率。     

第Ⅱ代动脉导管未闭封堵器栓塞幼儿体肺侧支的临床应用

目的探讨Amplatzer第Ⅱ代动脉导管未闭封堵器(amplatzer duct occluderⅡ,ADOⅡ)栓塞幼儿体肺侧支的可行性及效果。方法入选2014年3月3日至2015年4月1日7例患儿(其中男6例,女1例)选用ADOⅡ栓塞体肺侧支,栓塞后行选择性体肺侧支造影,观察封堵器的位置、形态及封堵效果。结果 7例介入栓塞患儿,年龄5~71个月,体质量4.2~22.0 kg。有6例患儿栓塞成功,1例栓塞后出现严重低氧血症放弃介入治疗,择期行外科体肺侧支结扎术。介入栓塞15支体肺侧支,共用ADOⅡ7枚、COOK公司不可控弹簧圈22枚和波科公司可控微弹簧圈2枚。即刻造影示无残余分流2例,少量残余分流4例,少-中量残余分流1例。6例介入成功患儿立即行外科术,其中5例行肺动脉闭锁根治术,1例行体肺分流术。外科术中回血不多、未见死亡,随访未见溶血及外周血管损伤等并发症发生。结论 ADOⅡ可控性高、输送鞘小、对血管损伤小,应用于幼儿合并较粗大、迂曲体肺侧支的介入治疗是安全可行的。     

体-肺侧支栓塞术在紫绀型先天性心脏病杂交治疗中临床价值

目的评价体-肺侧支栓塞术在侧支血管形成的紫绀型先天性心脏病患者杂交治疗中的临床价值。方法2008年6月—2009年4月共8例患者(男6例,女2例),年龄6～25岁,均行螺旋CT检查存在侧支血管,在我院行体-肺侧支介入栓塞术+外科根治术。根据其治疗情况,分为补救组(外科矫治术后出现灌注肺不能脱机,再行介入封堵侧支)和主动组(明确侧支后,先行介入封堵,再送外科手术矫治)。对两组患者的体外循环时间、呼吸机辅助时间、ICU监护时间、术后住院时间等指标进行对比研究。结果补救组3例治愈,1例死亡。主动组全部治愈,较补救组在体外循环时间、呼吸机辅助时间、术后ICU监护时间、术后住院时间方面均要明显缩短。结论外科术前体-肺侧支栓塞术具有较高的临床应用价值。     

法洛四联症合并体肺侧支血管一站式镶嵌治疗的临床效果

目的：总结法洛四联症（TOF）合并体肺侧支血管的患者采取一站式内外科镶嵌治疗（Hybrid）的临床效果。方法入选2008年1月至2013年6月于武汉亚洲心脏病医院就诊的79例TOF合并体肺侧支患者,平均年龄（5.4±3.9）岁,平均体重（18.2±5.7）kg,术前均经心脏彩超检查明确诊断,全组患者在术前行64排心脏增强CT检查,肺血管无不良发育,McGoon指数为1.7±0.6, Nakata指数为176.7±7.3。76例初步筛查有体肺侧支血管,术前均行心血管造影检查。3例术前漏诊,术后行心血管造影确诊。结果本研究患者中死亡4例,死亡率5.1%。1例死于肺部感染,3例死于顽固性心力衰竭。所有患者侧支血管直径最小2.5 mm,最粗9.4 mm,平均（5.3±2.1）mm。每例患者最少放置弹簧圈2枚,最多21枚,平均10.2枚;其中一支血管最多置入弹簧圈9枚。封堵血管最少1支,最多11支,平均3.7支。1例患者术后出现侧支血管再通（或出现新的侧支血管）,再入导管室行侧支封堵术。术后14例患者并发肺部感染,3例出现肺水肿。75例患者随访12～75个月,均存活。4例TOF行心内修复术后NYHA心功能分级Ⅲ～Ⅳ级,其余患者心功能分级好于Ⅱ级。结论合并有体肺侧支的TOF患者在围术期采取内外科镶嵌治疗技术处理体肺侧支,可提高手术成功率,改善预后,减少术后并发症。     

法洛四联症体肺侧支循环闭合时机二例报告

法洛四联症（TOF）是常见的发绀型先天性心脏病,发病率约占所有先心病的10％,占发绀型先心病的50％左右[1].外科手术是唯一的根治治疗方式,杂交技术在重症TOF矫治中的应用越来越广泛.2013年1～12月期间我院有2例法洛四联症合并体肺侧支循环（MAPCAs）的患者.2例患者MAPCAs闭合的时间不同,给患者造成的住院时间、治疗费用等不同.这里简单探讨治疗MAPCAs血管栓塞的时机.现报道如下.     

Embolisation procedures in congenital heart disease.

Eight therapeutic embolisation procedures were performed by the transcutaneous catheter technique in seven patients with congenital heart disease. After surgical correction of tetralogy of Fallot (four patients), catheter embolisation was used to occlude two large aortopulmonary collaterals (one patient), three small aortopulmonary collaterals (one patient), and two Blalock-Taussig shunts (two patients). In two patients congenital coronary anomalies were occluded--a coronary arteriovenous malformation and a coronary artery/bronchial artery anastomosis. In one patient a pulmonary arteriovenous malformation was embolised. Detachable balloons were used to occlude six large arteries, the three small arteries were occluded with small gelfoam fragments, and the pulmonary arteriovenous malformation was occluded with multiple steel coils and large gelfoam pieces. Successful occlusion was achieved in all cases. No complications were encountered and the procedure was well tolerated even in the two patients receiving postoperative intensive care. Therapeutic embolisation in suitable cases is a safe and effective alternative to surgery and the detachable balloon technique is effective in occluding high flow vessels.     

Embolisation procedures in congenital heart disease

Eight therapeutic embolisation procedures were performed by the transcutaneous catheter technique in seven patients with congenital heart disease. After surgical correction of tetralogy of Fallot (four patients), catheter embolisation was used to occlude two large aortopulmonary collaterals (one patient), three small aortopulmonary collaterals (one patient), and two Blalock-Taussig shunts (two patients). In two patients congenital coronary anomalies were occluded--a coronary arteriovenous malformation and a coronary artery/bronchial artery anastomosis. In one patient a pulmonary arteriovenous malformation was embolised. Detachable balloons were used to occlude six large arteries, the three small arteries were occluded with small gelfoam fragments, and the pulmonary arteriovenous malformation was occluded with multiple steel coils and large gelfoam pieces. Successful occlusion was achieved in all cases. No complications were encountered and the procedure was well tolerated even in the two patients receiving postoperative intensive care. Therapeutic embolisation in suitable cases is a safe and effective alternative to surgery and the detachable balloon technique is effective in occluding high flow vessels.     

Evaluation of pulmonary arterial morphology in cyanotic congenital heart disease by magnetic resonance imaging

Before and after surgical therapy, the anatomy of the pulmonary arteries in cyanotic congenital heart disease is often distorted. Pulmonary arterial anatomy was evaluated by magnetic resonance imaging (MRI) and angiography in 20 patients, ages 3 months to 20 years, with cyanotic heart disease associated with decreased pulmonary blood flow. Excellent correlation between MRI and angiographic estimates of pulmonary artery diameter was obtained (main pulmonary artery, r = 0.96; right pulmonary artery, r = 0.93; left pulmonary artery, r = 0.96). A similar excellent correlation (kappa = 0.83) was found in the assessment of the presence and severity of proximal pulmonary arterial stenoses. However, stenoses in the peripheral pulmonary arteries visualized with angiography were missed with MRI. MRI and angiography showed complete agreement in determining the patency of 11 surgical shunts. MRI did not demonstrate all of the systemic collateral vessels present with angiography, and the distal connections of collaterals were not detected with MRI. MRI is comparable to angiography in the evaluation of central pulmonary arterial anatomy over a wide range of ages. These findings suggest an important role for noninvasive MRI in the serial evaluation of pulmonary artery morphology in patients with cyanotic congenital heart disease before and after surgical repair.     

Esophageal varices in association with unilateral pulmonary vein atresia

A 27-yr-old woman with recurrent episodes of hemoptysis (and hematemesis due to esophageal varices) was found to have unilateral pulmonary vein atresia. Reversed flow In the left pulmonary artery, a finding highly suggestive of this rare congenital anomaly, was demonstrated during cardiac catheterization. The definitive diagnosis was afforded by pulmonary wedge angiography, which not only demonstrated the atretic leftsided pulmonary veins, but also revealed a serpiginous system of systemic collateral veins to be the cause of her esophageal varices. Pneumonectomy of the nonfunctioning hypoplastic lung, the most successful approach to this disorder, may be complicated by severe bleeding of the numerous systemic arterial collateral vessels transacted during surgical mobilization of the affected lung. Percutaneously delivered vascular occlusion coils were used in this case to occlude the large systemic to pulmonary artery collateral arteries immediately prior to pneumonectomy. Intra- and perioperative bleeding was minimal, and the patient has done well without further episodes of hemoptysis or hematemesis. Percutaneous occlusion of systemic to pulmonary collaterals may prove useful as a preoperative step for other congenital heart disease patients requiring lung or heart/lung transplantation. © 1996 Wiley-Liss, Inc.     

Hybrid approach to surgical correction of tetralogy of Fallot in all patients with functioning Blalock Taussig shunts.

BACKGROUND: In total surgical correction of tetralogy of Fallot (TOF) with functioning Blalock Taussig shunts (BTS), shunt take down increased surgical time, bleeding, and might injure phrenic and recurrent laryngeal nerve and thoracic duct. OBJECTIVES: A routine hybrid approach using transcatheter BTS closure immediately before total surgical correction of TOF in all patients might reduce these problems. We analyze the safety and feasibility of this approach. METHODS: Transcatheter BTS closure was achieved using single or multiple stainless steel embolization coils, Amplatzer vascular plugs, or duct occluders. When coils were released without control by bioptome forceps, coil migration in larger shunts was prevented by proximal or distal balloon occlusion. RESULTS: This routine hybrid strategy was followed in 22 consecutive patients aged 1-13 years over 4-year-period and 21 procedures were successful. Among the 16 patients attempted with coils, 13 had successful closure, 2 needed Amplatzer duct occluder devices, and 1 sent for surgical shunt takedown due to acute angulation of the shunt. New Amplatzer vascular plugs were used in six patients. Bioptome was used in six patients and proximal or distal balloon occlusion of flow was used in three patients. Four patients had closure of associated aortopulmonary or chest wall collaterals. CONCLUSION: Hybrid approach using routine transcatheter closure of all BTS immediately before surgical correction of TOF shunts with coils/plugs/devices is safe, feasible, and reproducible.     

Adult cyanotic congenital heart disease: surgical experience.

Cyanotic congenital heart diseases constitute about 10 percent of total congenital heart disease cases in adults in the developing world. Prolonged cyanosis and old age adversely affect the outcome of surgery, thus posing a challenge to the cardiac surgeons. This study was conducted to assess the feasibility, safety and outcome of surgery in this group of patients. From January 1991 to December 1997, a total of 303 patients, aged 14 to 54 years (mean 19.8 +/- 1.5 years) with diagnosis of various cyanotic congenital heart diseases were operated at our institute. There were 210 males (69.3%). Two hundred and forty-seven patients (81.5%) had tetralogy of Fallot's physiology, 51 patients (16.8%) had single ventricle physiology and five (1.6%) had other lesions. Sixty-six patients (21.7%) had pre-operative complications such as haemoptysis, epistaxis, cerebrovascular accidents, brain abscess and infective endocarditis. Sixty patients (19.8%) had previous palliative shunts and 26 patients (8.5%) had coil embolisation of major aortopulmonary collaterals prior to surgery; 229 patients (75.5%) underwent biventricular repair, 52 (17.1%) had univentricular repair, 22 (7.7%) had palliative shunts and one patient had open ligation of a major aortopulmonary collateral in addition. In-hospital mortality was 3.3 percent. Follow-up period ranged from five months to seven years (mean 4.2 +/- 1.8 years). There were two late deaths. Of the 291 survivors, 11 were lost to follow-up. Two hundred and fifty-eight patients (92.1%) are in New York Heart Association class I. Significant residual defects warranting reoperation were present in four patients (1.3%). It is concluded that congenital heart surgery in older cyanotic patients can be performed safely with satisfactory results.