微创非体外循环房间隔缺损封堵术的临床应用

目的总结我院微创非体外循环房间隔缺损封堵术的临床应用经验。方法对10例继发孔型房间隔缺损(ASD)患者进行微创非体外循环房间隔缺损封堵术。全麻下右侧胸骨旁第4肋间4-6cm切口,食管超声(TEE)测量房间隔缺损最长径,选择适当封堵伞,TEE监测下释放封堵伞,了解有无残余分流等异常。结果10例患者手术均成功,术中未发生任何并发症,术后复查心彩超未见残余分流。2例出现术后高血压,给与降压对症治疗,1例中度肺动脉高压复查心彩超肺动脉压明显下降,术后右心大小较术前有减小。结论微创非体外循环房间隔缺损封堵术是一种微创手术治疗方法,值得推广、发展。     

经右腋下小切口外科封堵继发孔型房间隔缺损的手术体会

【摘要】目的 总结经右腋下小切口封堵治疗继发孔型房间隔缺损（ASD）的手术经验,探讨其疗效、适应证及技术要点。 方法 回顾性分析自2013年1月至2016年12月在中山大学附属江门市中心医院采用右腋下小切口行继发孔型房间隔缺损封堵的36例患者的临床资料,其中男21例、女15例,缺损大小5～36mm。所有手术均在全身麻醉、气管插管下进行。患者取左侧卧位,在腋中线与腋前线之间做直切口,长度约2～4cm,约经第4肋间进胸,切开并悬吊心包,于右心房壁缝双荷包线并切开,通过输送导管在食管超声监视下释放房间隔缺损封堵伞。结果 全组无手术死亡;术中无恶性心律失常和气栓发生,术后无脑部并发症,1例封堵伞脱落至右房,经原切口改行体外循环下手术、1例术后有2mm残余分流,术后3个月随访残余分流消失。结论 经右腋下小切口外科封堵是一种治疗继发孔型房间隔缺损的有效手术方式,具有安全可靠、简便、创伤小及术后恢复快等优点,值得临床推广。     

不同微创技术在继发孔房间隔缺损治疗中的应用

目的对比不同微创技术在继发孔房间隔缺损治疗中的应用结果,分析其优缺点,探讨最佳手术适应证。方法 2005年1月到2010年11月我院采用微创技术治疗继发孔房间隔缺损患者140例,年龄0.3～50岁,其中经皮导管封堵术60例,非体外循环下经胸封堵术30例,常温体外循环心脏不停跳腋下小切口修补术50例。观察和比较三种微创技术治疗房间隔缺损的手术成功率、切口长度、费用等。结果经皮导管封堵术、非体外循环下经胸封堵术、腋下小切口修补术的成功率分别为95、96.7及100,三组间无显著差别（P〉0.05）,无住院死亡。三组手术切口长度分别为（0.25±0.06）cm、（4.53±1.32）cm和（10.43±2.57）cm,差异有统计学意义（P〈0.01）;手术费用分别为（24146±3073）元,（24811±3255）元,（23300±4799）元,差异无统计学意义（P〉0.05）。结论三种手术方式均是继发孔型房间隔缺损安全有效和小创伤的治疗方法。     

经胸微创封堵术治疗继发孔房间隔缺损109例分析

目的 探讨经胸非体外循环房间隔缺损微创封堵术治疗房间隔缺损的疗效.方法 全组109例患者,年龄3～63岁,ASD直径6～36 mm,均在全麻下经右胸第4肋间隙小切口进胸在经食管心脏彩超引导下经输送器置入封堵器闭合ASD.结果 106例手术成功封堵,手术时间（1.5±0.3）h,术中失血量平均（41.5±10.3）ml.3例患者因术中封堵失败改为体外循环下修补.全组无死亡,术后3～9d恢复后出院.随诊3～36个月.B超示封堵伞没有残余漏,没有移位,心功能改善显著.结论 经胸微创房间隔缺损封堵手术简单、创伤小、安全性高、患者恢复快、疗效满意.     

成年特殊房间隔缺损患者的介入封堵治疗

目的观察成年巨大继发孔型房间隔缺损患者进行介入封堵治疗的疗效和安全性。方法对43例成年继发孔型房间隔缺损患昔在经食管超声指导下进行手术,封堵前后检测肺动脉压、右室压,术前、术后72小时、术后1～3个月行心电图和超声心动图检查。结果成功封堵38例,手术后即刻成功率为88．4％。封堵前、后平均肺动脉压、平均右事压降低（P〈0．05）;术后72小时内出现封堵器脱落1例（2．6％）、术后心包积液1例（2．6％）、心律失常5例（13．2％）、急性心功能不全3例（7．9％）,术后即刻残余分流6例（15．8％）。术后l～3个月随访经胸超声心动图检查显示均完全闭合。术后1个月随访发现右室容积缩小、射血分数升高。患者随访1～3个月,均未发现有残余分流、脱落、栓塞。结论成年巨大继发孔型房问隔缺损患者行介入封堵治疗相对安伞、有效,体表超声心动图或经食管超声心动图的术中监测对提高手术成功率有指导意义。     

心脏彩超对房缺行封堵介入治疗的临床价值

目的分析心脏彩超对先天性心脏病继发孔型房间隔缺损行封堵术介入治疗的临床价值。方法随机选取我院行封堵术介入治疗的先天性心脏病继发孔型房间隔缺损患者128例,对其临床资料进行回顾性分析。结果术后对3天、1个月、3个月、6个月对患者行心脏彩超复查可知,128例先天性心脏病继发孔型房间隔缺损患者中,有125例患者手术均成功,成功率为97.7%。对其进行长达6个月的复查中均未出现脱落、残余血液分流现象。1例患者复查中出现封堵器脱落现象,2例患者因术前对其检测不当,术后出现轻度反流现象。结论心脏彩超对先天性心脏病继发孔型房间隔缺损诊断具有极其重要的决定性价值,可有效提高封堵术介入治疗的成功率,充分保证患者安全。     

房间隔缺损的微创外科治疗

目的观察微创手术治疗房间隔缺损的疗效。方法选择房间隔缺损患者21例,取胸骨右旁第4肋间做3cm切口,切开心包并悬吊,于右心房壁缝双荷包线,并切开,将输送导管(国产)插入右心房内,通过房间隔缺损口入左心房,在经左胸壁超声监视下,释放出房间隔封堵伞,用保险绳做反复牵拉试验,确认封堵伞位置合适,再做一针贯穿右房壁和伞边缘的褥式缝合固定。结果全部患者手术过程顺利,平均手术时间60min,其中平均心内操作15min。患者住院5～7d,术后2～6个月复查,心脏彩超检查封堵伞无移位,无残余分流。结论在经胸壁超声监视下房间隔缺损封堵术是一种微创、安全、简便的治疗方法。     

微创非体外循环房间隔缺损封堵术的临床应用

目的小结微创非体外循环下房间隔缺损(ASD)封堵术的临床应用经验. 方法对12例继发孔型ASD患儿,年龄2～16岁,平均(5.9±3.8)岁,进行微创非体外循环房间隔缺损封堵术.全麻下经右胸第4肋间胸骨旁2～3 cm小切口入胸,根据超声心动图选择合适的封堵器类型,超声引导下释放封堵器关闭ASD,实时监测封堵器的位置、有无残余分流以及是否累及房室瓣及冠状静脉窦. 结果12例患儿均1次封堵成功,超声引导下释放封堵器的时间为3～14 min,平均(6.5±3.1)min,无封堵器脱落,无残余分流.术后3～5天出院.结论经右胸小切口置入房间隔缺损封堵器是一种安全、有效的治疗方法,值得推广使用.     

国产封堵器介入治疗房间隔缺损的临床分析

目的总结应用国产封堵器介入治疗房间隔缺损（ASD）的临床疗效。方法本组22例ASD患者均为继发孔型，男性5例，女性17例，年龄3～67岁，体重11～65kg，缺损直径8～32mm，合并动脉导管未闭1例，多孔ASD2例，轻度肺动脉压升高6例，均经股静脉途径应用国产封堵器行封堵术，术后超声心动图随访。结果22例患者均成功封堵。术后即刻完全封堵19例，3例有少量残余分流，随访分流消失，无严重并发症。结论国产封堵器介入治疗房间隔缺损是一种安全、有效的方法。     

儿童经胸小切口房间隔缺损封堵术的临床体会

目的 探讨经胸小切口房间隔缺损封堵术治疗房间隔缺损（ASD）的疗效.方法 胸骨右旁第4肋间切口长2cm,切开心包并悬吊,于右心房壁缝双荷包线,并切开,将输送导管（国产）插入右心房内,通过房间隔缺损口入左心房,在经食管超声监视下,释放出房间隔封堵伞,调整左右侧伞盘夹紧封堵ASD,用保险绳做反复牵拉试验,确认封堵伞位置合适.结果 8例均成功封堵,手术时间25～35 min,平均30 min;术后住院3～6d.术后2～10个月复查,心脏彩超检查封堵伞无移位,无残余分流.结论 在经胸壁超声监视下房间隔缺损封堵术是一种微创、安全、简便,值得推广的方法.     

经胸超声心动图在继发孔房间隔缺损封堵术围手术期中的应用价值

目的评价经胸超声心动图（VrE）在继发孔房间隔缺损（ASD）围手术期中的应用价值。方法术前筛选86例有外科手术适应证的继发孔ASD患者,TTE测量各切面ASD大小及残边情况,指导选择封堵器（ASO）型号,术中监测ASO置放及释放过程,术后随访观察。结果86例患者术前TTE测得ASD最大直径5～34（24．4±5．63）mm,所用ASO直径为8—40（27．5±7．12）mm。TTE成功引导81例ASO置人,总成功率为94．2％,其中双孔ASD2例,均置入单个ASO成功。5例术后即刻有微量或少量残余分流,术后3个月复查TTE分流完全消失。结论经导管ASD封堵术是安全可行的方法,T珏对ASD封堵术前病例选择、残边评估、ASO型号选择、术中监测ASO的置放全过程和术后疗效评价有重要临床价值。     

Detection of atrial septal defect by right sternal border echocardiography

The atrial septum can be visualized by right sternal border 2-dimensional echocardiography (2-D echo). To evaluate the usefulness of this approach in the evaluation of atrial septal defect (ASD), 50 patients who underwent cardiac catheterization were studied by 2-D echo. Twenty-one patients (Group A) had ASD (3 ostium primum, 18 ostium secundum) and 29 (Group B) had mitral valve disease and an intact atrial septum. Subcostal and right sternal border approaches were used to visualize the atrial septum. Both approaches identified the 3 cases of ostium primum ASD; secundum ASD was identified using the subcostal approach in 11 patients and using the right sternal border approach in 13. In 15 patients the ASD was imaged at least by 1 of the 2 approaches. Two-dimensional contrast echocardiography showed a positive or negative contrast effect in 13 of 18 cases (12 with standard approaches, 11 with right sternal border approach). In all patients in Group B, the right sternal border approach showed an intact atrial septum. Thus, the right sternal border approach is a useful approach that increases the sensitivity of 2-D echo in the diagnosis of ASD.     

Pulmonary arterial thrombosis in secundum atrial septal defect

Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.     

经胸超声心动图监测下用Amplatzer封堵器治疗房间隔缺损

目的：评价在经胸超声心动图(TTE)监测下用Amplatzer封堵器介入治疗房间隔缺损(ASD)的可行性及实用价值。方法：全组共18例继发孔型ASD患者，均在常规C型臂X线机透视和TTE指导下经导管置入Amplatzer封堵器。结果：18例患者中有2例未放置成功而改为开胸手术；16例均成功置入Amplatzer封堵器，即刻完全堵闭，术后随访3个月至2年，TTE示ASD仍被完全封闭，未见残余分流。随访期间无任何并发症。结论：在TTE和X线透视指导下用Amplatzer封堵器治疗继发孔型ASD安全可行，具有一定实用价值。     

Three different types of atrial septal defects in the same family]

Most of the time atrial septal defects (ASD) are sporadic. Familial forms are characterised by the same type of the ASD, and are frequently associated by other cardiac, osteoarticular (Holt-Oram syndrome) or atrioventricular conductions abnormalities (ostium secundum ASD with prolonged PR, sinus venosus ASD with sinusal bradyarrhythmia). This report describes a family in which the father and his two children present an ASD, each one of a different type (ostium primum ASD, ostium secundum ASD, sinus venosus ASD), without any other associated malformations. To the best of our knowledge, this is the first report of a family in which three different ASD types are present.     

Percutaneous closure of ostium secundum atrial septal defects using the Amplatz device. Preliminary study on 29 patients]

The aim of the study was to assess the results of percutaneous closure of ostium secundum atrial septal defects (ASD) by the Amplatz device and to compare them with those obtained by other methods. Over a one year period, closure of ASD was performed in 28 patients aged 7 to 66 years (mean of 32 years) with exclusive left-to-right shunts. The selection of patients was made by transthoracic echocardiography. Cardiac catheterisation was performed to measure the stretched diameter of the defect. After patient or parental consent, the procedure was performed under general anaesthesia. The implantation was performed under transoesophageal echocardiographic control. The diameter of the Amplatz device corresponded to the stretched diameter of the ASD. The patients were discharged from hospital 48 hours later under platelet anti-aggregant therapy for 6 months. Clinical, electrocardiographic, radiological and echocardiographic examinations were performed at 1 month, 3 months and 1 year after implantation. The stretched diameter was 12-27 mm (mean 22 mm). The device was withdrawn in one case because of a double ASD and, in another patient, failure was due to embolisation of the obturator to the pulmonary artery before its implantation. The closure was complete in 21 of the 26 cases immediately after the procedure; at one month, two residual shunts were observed but they had disappeared at 3 months and at 1 year. Out of 46 ASD closed by the Sidéris button prosthesis, occlusion was total in 29 cases and partial in 17 cases. The authors conclude that the Amplatz device is an effective prosthesis for closure of ostium secundum ASD. With strict selection procedures, the results are excellent.     

Role of intracardiac echocardiographic guidance in transcatheter closure of atrial septal defects and patent foramen ovale using the Amplatzer device

Transesophageal echocardiography (TEE) has been successfully used for guiding transcatheter device closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO). However, the use of TEE for device closure requires general anesthesia. Experience with intracardiac echocardiographic (ICE) guidance to close ASD and PFO is limited. One hundred eleven patients (76 female/35 male) with secundum ASD (82 patients) and PFO (29 patients) associated with a stroke underwent an attempt of transcatheter closure of their defects under ICE guidance using the new AcuNav catheter. The median age of patients was 40 years (range 2.5-80.7) and the median weight was 66 kg (range 12.7-128 kg). The median two-dimensional size of secundum defects as measured by ICE was 17 mm (range 3-32 mm). The median balloon stretched diameter of the ASDs was 22 mm (range 4-36 mm). Five patients had more than one defect that required placement of two devices to close the defects. The median Qp/QS ratio for patients with secundum ASD was 2.1 (range 1-18). ICE provided adequate views of the defects and surrounding structures and the various stages of device deployment. All patients had successful device placement, including the patients who received simultaneous two devices with immediate complete closure of the defects in 100 patients, whereas four and seven patients had trivial and small residual shunt, respectively. The median fluoroscopy time was 10.2 minutes (range 3.7-38.4 minutes) and the median total procedure time was 60 minutes (range 28-180 minutes). There were no complications related to the use of the AcuNav catheter. We conclude that ICE provided unique images of the atrial communications and facilitated device closure of secundum ASD and PFO in children and adults. We believe ICE should replace TEE as a guiding imaging tool for ASD and PFO device closure, thus eliminating the need for general anesthesia.