肌部室间隔缺损封堵剖析

目的:探讨肌部室间隔缺损封堵的超声心动图筛选适应证及价值。方法:应用HPsonos1500和5500彩色超声诊断仪检查12例拟行封堵术的患者,观测左右室侧缺损口大小、缺损残端距主动脉瓣和三尖瓣的距离。结果:9例封堵成功,左右室侧缺损口大小差异显著,分别为8.5±2.6（6.0～14.0）mm及6.1±1.2（4.0～7.0）mm,残端距主动脉右瓣距离6.0～13.0mm,距三尖瓣7.0～15.0mm,室缺多位于室间隔中部或调节束上方。3例封堵不成功,2例室缺口较大且左右室面大小相同,位于右室流入道部,放置封堵器时因出现Ⅲ度房室传导阻滞而放弃。另1例右室侧缺损口过小,造成穿隔失败。结论:用超声心动图筛选适应证对肌部室间隔缺损封堵成功与否有重要的作用。     

导管介入或镶嵌治疗心尖部肌部室间隔缺损

目的探讨经导管介入或镶嵌治疗心尖部肌部室间隔缺损的治疗方法、疗效及随诊情况。方法选择2006年1月至2011年12月在广东省人民医院术前诊断为心尖部肌部室间隔缺损的患儿27例为研究对象,其中男18例,女9例,年龄1个月～13岁,中位年龄4.5岁。患儿分别经导管介入及镶嵌治疗,其中镶嵌治疗3例,经导管介入治疗24例。结果介入封堵组除1例因缺损小,未行治疗外,其他23例均介入治疗成功。室间隔缺损直径为(4.94±1.08)mm,选择6～10 mm肌部缺损封堵器,输送长鞘为6～9 F。镶嵌治疗组3例均成功治疗。随诊时间平均25个月。介入封堵组术后随诊有5例少量残余分流,2例中度三尖瓣反流。结论经导管介入治疗心尖部肌部室间隔缺损的疗效确切,应尽量减少三尖瓣的并发症。年龄小于1岁及体质量小于5 kg的婴儿,可考虑采用镶嵌治疗方法。     

室间隔缺损介入封堵术后传导阻滞14例分析

2005年3月～2005年12月,我院共行室间隔缺损（VSD）介入封堵术157例,术后发生传导阻滞14例。现分析如下。     

外伤性肌部室间隔缺损封堵术一例

患男．32岁，因“被人尖刀刺伤左前胸群后6天”由外院转入我院。患6天前在执行公务时被尖刀刺伤左前胸部而昏剧，30分钟内被同事送往当地医院抢救，诊断为“左侧开放性血气胸、肺脏破裂、右心室前壁破裂、失血性休克”．立即进行右心室前壁、肺脏修补术和血气胸引流术及纠正休克治疗，经3小时积极抢救后患神志清醒，术后出现发热、胸闷、气促．当地医院治疗无好转．6天后转入我院。     

经导管介入封堵治疗室间隔缺损126例

目的 经导管介入封堵治疗室间隔缺损(VSD),并对近期疗效和并发症进行观察.方法 126例经临床和经胸超声心动图确诊为室间隔缺损,采用经导管介入封堵术治疗,术后即刻采用造影或术后72 h行经胸心脏超声检查观察疗效.结果 VSD介入封堵成功率为98.3%,不成功原因为缺损直径过大以及缺损位置特殊,术中未发生任何严重并发症.结论 经导管介入封堵治疗VSD是一种创伤小、成功率高、并发症少的一种可靠治疗手段.     

超声心动图引导经皮室间隔缺损封堵治疗术

目的探讨超声心动图引导经皮室间隔缺损(VSD)封堵术的可行性。方法于2014-2至2014-10在我院检查并治疗的单纯VSD患者28例,平均年龄(9.5±3.1)岁,VSD大小(4.6+0.9)mm,单纯采用超声心动图引导经皮室间隔缺损封堵术。超声实时监测封堵全过程,评估封堵效果。术后1个月、3个月、半年及一年超声随访,观察患者封堵效果。结果 21例患者在经胸超声心动图引导下成功完成经皮VSD封堵术,5例经食管超声引导下成功完成经皮VSD封堵术,1例患者因导管未能沿导丝通过VSD,改经食管超声心动图引导下经胸小切口封堵成功,1例患者因封堵后残余分流大于2衄,改常规外科手术治疗成功。患者的平均手术时间为(63.3±11.7)min;术后1个月及3个月随访,未发现瓣膜损伤、心包积液、封堵器脱落、残余分流、主动脉瓣反流及外周血管损伤等介入并发症。结论超声心动图可以独立安全引导经皮室间隔缺损介入封堵术,无需使用大型造影设备,减少了病人及医护人员射线损伤及手术成本。     

膜部瘤型室间隔缺损介入封堵分析

目的结合膜部瘤型室间隔缺损(PPVS)的经胸超声心动图(TTE)图形与左室造影,指导封堵器的选择。方法 2010年7月—2011年5月,43例PPVS患者行介入封堵,分别用TTE及左室造影,对两种方法进行比较,并对封堵后效果进行评估。结果超声图形与左室造影相关性良好,所有患者均成功封堵。结论 PPVS封堵较复杂,对拟行介入封堵的PPVS患者的TTE前期进行分析,可以帮助预计介入封堵方案。介入封堵疗效可靠、安全。     

创伤性室间隔缺损介入治疗1例

创伤性室间隔缺损临床上较为少见，治疗方法多为外科手术缝合，国内外也有部分术者采用介入封堵的方法成功治疗创伤性室间隔缺损。本文报道了1例采用肌部室间隔缺损封堵器成功治疗心尖部创伤性室间隔缺损的病例，术后患者活动耐量好转，临床效果满意。     

室间隔缺损介入封堵术后发生传导阻滞临床分析

目的探讨室间隔缺损（VSD）介入封堵术（TCO）后发生传导阻滞的特点及转归。方法选择在我院施行VSD者TCO患者45例，术中2例、术后11例出现传导阻滞，动态观察患者术前心电图及术后出现传导阻滞的时间、类型及转归，用统计学软件进行分析比较。结果传导阻滞手术前后发生率有显著性差异（P〈0．01），术后6个月的发生率与术前无差异（P〉0．05）。其中2例术中反复出现完全性房室传导阻滞（CAVB），被迫中止手术；术后11例发生传导阻滞，其中一度房室传导阻滞1例、二度房室传导阻滞2例、三度房室传导阻滞1例、完全性右束支传导阻滞（CRBBB）3例、CRBBB并左前分支阻滞（CLAFB）2例、不完全性RBBB及LAFB各1例。除1例二度房室传导阻滞及1例CRBBB未恢复外，其余均在14d内恢复，结论传导阻滞是VSD者TCO常见并发症，多数可恢复正常。故VSD者TCO是一种安全有效的治疗方法，近期疗效肯定，中远期疗效尚需进一步观察。     

室间隔缺损介入封堵术后迟发性感染性心内膜炎一例

目前介入封堵治疗室间隔缺损安全有效，术后感染性心内膜炎（infective endocarditis，1E）罕见，现报道介入治疗术后迟发性IE一例。     

Perventricular Device Closure of Residual Muscular Ventricular Septal Defects after Repair of Complex Congenital Heart Defects in Pediatric Patients

Residual muscular ventricular septal defects are surgical challenges, especially after the repair of complex congenital heart defects. We investigated perventricular device closure as a salvage technique in pediatric patients who had postoperative residual muscular ventricular septal defects.From February 2009 through June 2011, 14 pediatric patients at our hospital had residual muscular ventricular septal defects after undergoing surgical repair of complex congenital heart defects. Ten patients met our criteria for perventricular device closure of the residual defects: significant left-to-right shunting (Qp/Qs >1.5) or substantial hemodynamic instability (a defect ≥2 mm in size). The patients'' mean age was 20.4 ± 13.5 months, and their mean body weight was 10 ± 3.1 kg. The median diameter of the residual defects was 4.2 mm (range, 2.5–5.1 mm).We deployed a total of 11 SQFDQ-II Muscular VSD Occluders (Shanghai Shape Memory Alloy Co., Ltd.; Shanghai, China) in the 10 patients, in accord with conventional techniques of perventricular device closure. The mean procedural duration was 31.1 ±9.1 min. We recorded the closure and complication rates perioperatively and during a 12-month follow-up period. Complete closure was achieved in 8 patients; 2 patients had persistent trivial residual shunts. No deaths, conduction block, device embolism, or other complications occurred throughout the study period.We conclude that perventricular device closure is a safe, effective salvage treatment for postoperative residual muscular ventricular septal defects in pediatric patients. Long-term studies with larger cohorts might further confirm this method''s feasibility.Key words: Cardiac surgical procedures/instrumentation/methods, equipment design, heart defects, congenital/adverse effects, heart septal defects, ventricular/complications/pathology/therapy, hemodynamics, postoperative complications, prostheses and implants, surgical procedures, minimally invasive/methods, treatment outcomeMuscular ventricular septal defects (VSDs) constitute approximately 20% of all VSDs¹ and are possibly associated with other complex congenital heart conditions, such as tetralogy of Fallot and double-outlet right ventricle.² Surgical closure is the mainstay treatment for most VSDs; however, muscular VSDs cannot be approached adequately without a ventricular incision, especially when associated with a large left-to-right shunt, pulmonary hypertension, or interventricular septal hypertrophy.^3–5 After complex congenital heart defects with severe left-to-right shunting are repaired, residual muscular VSDs can significantly increase the patient''s risk of death.^4,5 Particularly in pediatric patients, postoperative residual muscular VSD poses a surgical challenge. Open surgical repair is associated with repeat cardiopulmonary bypass (CPB), the risk of ventriculotomy because of an inadequate operative field of vision, and postoperative ventricular dysfunction.^5,6 Fluoroscopically guided transcatheter device closure is another treatment option; however, restricted vascular access and the technical difficulty of this procedure are well documented in pediatric patients. Radiation exposure and hemodynamic instability during device positioning can also compromise the prognosis.^2,7 Perventricular device closure of VSDs with transesophageal echocardiographic (TEE) guidance was first reported by Amin and colleagues.⁸ This method enables direct access, which is especially suitable in closing apical muscular VSDs.⁹ We investigated the feasibility of perventricular device closure as a salvage procedure in pediatric patients who had residual muscular VSDs after having undergone repair of complex congenital heart defects.     

Device Closure of Congenital Ventricular Septal Defects

Ventricular septal defect is the most common congenital heart malformation. Surgical closure, when indicated, has been practiced for over 50 years with good results; however, surgical closure is still associated with significant morbidity and mortality. Over the past decade, several occluding devices have been developed that made catheter device closure an attractive alternative to surgery with widely satisfactory results. In this article, a comprehensive review of percutaneous and perventricular (hybrid) device closure of each type of ventricular septal defect is presented.     

Percutaneous Closure of Postmyocardial Infarction Ventricular Septal Defect

Postinfarction ventricular septal defect remains an important complication for myocardial infarction. It is associated with high mortality and morbidity. Despite early surgical closure attempts, mortality remains about 19–49%. Percutaneous approach, especially in high surgical risk patients is a promising alternative to traditional surgical closure, thus avoiding the deleterious effects of cardiopulmonary bypass and the ventriculotomy. The Amplatzer P.I. Ventricular Septal Defect Occluder is a device specifically designed to percutaneously close these defects in adult patients. The results reported using this device are comparable (if not better) to those for surgical closure. Here, we review the experience using this device and depict in detail the technical aspects of the procedure.     

Percutaneous Closure of Atrial Septal Defects Under Transthoracic Echocardiography Guidance Without Fluoroscopy or Intubation in Children

Objective

Demonstrate the benefits of percutaneous atrial septal defect (ASD) closure under guidance of transthoracic echocardiography (TTE) without fluoroscopy.

Methods

From February 2013 to April 2014, 127 consecutive patients with an isolated type II ASD were recruited to undergo percutaneous closure under either TTE (n = 60, TTE group) or TEE (n = 67, TEE group) guidance. The TTE group received local anesthesia or sedation with propofol, and the TEE group received general anesthesia with endotracheal intubation. Follow‐up examinations were performed for both groups at 1 month, 3 months, 6 months, and 1 year after discharge and annually thereafter.

Results

The TTE group had a significantly shorter procedure time and respirator ventilation duration than the TEE group. The dose of propofol required, the cost, and the pharyngeal complication rate were significantly lower in the TTE group than in the TEE group. The median follow‐up of 11.6 months was uneventful in all patients.

Conclusions

Percutaneous ASD closure with TTE guidance as the only imaging tool avoids fluoroscopy, endotracheal intubation, and probe insertion and is associated with a satisfactory procedural success rate and lower costs. This procedure is a safe and reliable treatment for ASD.