Amplatzer封堵器治疗动脉导管未闭临床评价

目的采用Amplatzer堵闭器(ADO)治疗动脉导管未闭(PDA),评价其疗效及并发症。方法31例患儿,男12例,女19例,年龄1~19岁,平均7.5岁,体质量4.6~50.0 kg,平均20.5 kg。超声心动图(UCG)测PDA直径2.0~10.6 mm,平均5.8 mm。采用直径4~12 mm、平均7.6 mm,较PDA直径大0.8~5.5 mm、平均2.9 mm的ADO进行封堵。术后48 h1、、3、6个月、1年行UCG复查。结果1例PDA造影直径0.67 mm,因无合适ADO而放弃。失败2例,成功植入ADO 28例(93.3%)。术后造影即刻完全封堵22例(78.6%),4例(14.3%)有微量分流,2例(7.1%)有少量分流。48 h UCG复查均无残余分流。随访1年全组未出现心脏感染、溶血、封堵器脱落,ADO突入降主动脉(DAO)引起DAO轻度狭窄3例,ADO突入左肺动脉(LPA)引起LPA轻度狭窄1例。结论应用ADO治疗PDA安全可靠,但要注意封堵器对DAO和LPA的影响,以避免造成大血管狭窄。     

Transcatheter Closure of a Large Patent Ductus Arteriosus in a Young Child Using the Amplatzer Duct Occluder

The Amplatzer duct occluder (ADO) provides a safe and effective therapy for patients with moderate- to large-sized patent ductus arteriosus (PDA), but there have been few reports of transcatheter closure of very large PDAs in young children and infants. We report a successful transcatheter closure of a very large PDA, 10.5 mm in diameter at the narrowest point, with a 14/12-mm ADO. To our knowledge, this is the largest PDA ever closed by an interventional method in such a young child.     

经导管Amplatzer封堵器和外科手术治疗动脉导管未闭对照试验的Meta分析

目的评估经导管Amplatzer封堵器治疗动脉导管未闭(PDA)的疗效,为临床应用提供指导。方法采用Meta分析方法,对国内外有关经导管Amplatzer封堵器和外科手术治疗PDA的对比临床研究进行综合定量分析,采用RevMan4.2.2软件进行数据处理,计算各组技术失败率、并发症及严重并发症发生率、残余分流率等的相对危险度(RR)及其95%可信区间(CI)。结果符合纳入标准共5篇文献,总样本量349例。经导管Amplatzer封堵器组技术失败率高于外科手术组[5组对照试验(CT),349例,3.0%vs0,RR=4.29,95%CI(0.77,23.95)],但无显著性差异(P=0.10);并发症发生率低于外科手术[5组CT,343例,3.1%vs38.0%,RR=0.11,95%CI(0.05,0.23)](P<0.00001);严重并发症发生率显著低于手术组[5组CT,343例,0.5%vs6.0%,RR=0.23,95%CI(0.06,0.90)](P=0.03);Amplatzer封堵器组治疗后即时残余分流率高于手术组[4组CT,304例,16.3%vs0,RR=16.06,95%CI(3.0,86.12)](P=0.001);出院时残余分流率虽高于手术组,但无显著性差异(2.5%vs0,P=0.33)。结论经导管Amplatzer封堵器治疗PDA尽管成功率低于外科手术,但其创伤小、并发症发生率低、疗效与手术相仿,随着封堵器及其输送系统的不断改进和完善,在适应证范围内经导管Amplatzer封堵器治疗可作为PDA外科手术治疗的替代方法。     

Transcatheter Closure of Patent Ductus Arteriosus and Interruption of Inferior Vena Cava with Azygous Continuation Using an Amplatzer Duct Occluder

Two cases with interrupted inferior vena cava and azygous continuation requiring patent ductus arteriosus (PDA) occlusion per cardiac catheterization are presented. A technique is described enabelmy occlusion of PDA using an Amplatzer ductal occluder despite interruption of inferior vena cava and azygous continuation.     

Right-Sided Pulmonary Venous Obstruction Between a Right Aortic Arch and an Amplatzer Septal Occlusion Device Following Closure of a Secundum Atrial Septal Defect

Right-sided pulmonary venous obstruction between a right aortic arch and an Amplatzer Septal Occluder device developed following closure of a large secundum atrial septal defect. The obstruction was not apparent on postprocedure transesophageal echocardiogram but developed over time. The patient recovered completely following surgical removal of the device.     

Amplatzer Angled Duct Occluder for Closure of Patent Ductus Arteriosus Larger than the Aorta in an Infant

Transcatheter closure of patent ductus arteriosus (PDA) by Amplatzer duct occluder is the treatment of choice. However, closure of very large ducts in infants with low weight is a challenge for the interventionalist because a large device may obstruct the aorta or left pulmonary artery. Difficulty is also encountered in advancing the device around the curve of the right ventricular outflow tract toward the pulmonary artery; this curve is tight, more or less at a right angle in infants, leading to kinking of the sheath, which increases fluoroscopic time. This is the first reported case of a very large PDA (8.7 mm), larger than the aorta (8.2 mm), successfully closed by an Amplatzer angled duct occluder in an infant weighing 5 kg.     

经导管Amplatzer堵塞器治疗动脉导管未闭的评价

为研究评价新的自膨性Ａｍｐｌａｔｚｅｒ堵塞器关闭动脉导管未闭（ＰＤＡ）的疗效,于１９９８年８月至１９９９年２月应用Ａｍｐｌａｔｚｅｒ堵塞器关闭突兀 ,年龄０．８～１１岁（平均３．９岁）,体重７～３９ｋｇ（平均１５．８ｋｇ）,ＰＤＡ最狭处直径２．３～６．４３ｍｍ（平均３．５ｍｍ）。应用６Ｆ长鞘经股静脉插至降主动脉递送堵塞器,术后１０～１５分钟作主动脉造影评价即职效。关闭术后２４小时、１月、３月、６月     

Catheter Closure of Perimembranous/Membranous Ventricular Septal Defects Using the Amplatzer Occluder Device

Perimembranous ventricular septal effects (PMVSDs) are the most common congenital cardiac defects of clinical importance. During the last decade, transcatheter closure of PMVSDs has been attempted using various occluders with variable success. This article reviews the existing literature and our experience with transcatheter closure of PMVSDs with the new Amplatzer occluder device.     

A Novel Use of Amplatzer Duct Occluder

This report describes the use of the Amplatzer patent ductus arteriosus occluder to close a left ventricle to descending aorta conduit. The patient was a 10-year-old male who was born with critical aortic stenosis and left ventricular outflow tract obstruction. After initial valvotomy, he underwent left ventricular to descending aorta conduit placement. At the age of 10, he had a Konno procedure to enlarge the left ventricular outflow tract and 21-mm St. Jude aortic valve placement. Closure of the conduit was not addressed because it was inaccessable from median sternotomy. Postoperatively, echocardiogram revealed significant flow through the conduit with a wide pulse pressure. Cardiac catheterization was performed with the premise to close the conduit with an Amplatzer patent ductus arteriosus occluder device.     

Long-Term Results of Transcatheter Closure of Patent Ductus Arteriosus in Infants Using Amplatzer Duct Occluder

Objective

Patent ductus arteriosus (PDA) is one of the most frequently seen congenital heart diseases. Its closure is recommended because of the risk of infective endocardis, as well as morbidity and mortality in the long. The aim of this study was to assess the long term results of the transcatheter closure of PDA in infants using amplatzer duct occlude (ADO).

Methods

From May 2004 to September 2011, forty eight infants underwent transcatheter closure of PDA. A lateral or right anterior oblique view aortogram was done to locate PDA and to measure its size. Before discharge, repeat aortogram was performed to evaluate eventual residual shunt and to confirm the appropriate deployment of the ADO. Follow up evaluations were done with transthoracic echocardiography at discharge, 1 month, 6 months, 12 months and yearly thereafter.

Findings

The mean age of patients at procedure was 9.18±2.32 (range 3 to 12) months, mean weight 6.73±1.16 (range 4.5 to 10.1) kg. The PDA occluded completely in 20 out of the 48 patients. Twenty four patients had trivial or mild shunt and two patients had moderate residual shunt which disappeared in one patient within 24 hours and other patient with moderate shunt in 1 month. One patient (age 8 months) had mild LPA stenosis. The device emobolization occurred in two patients, immediately after the procedure in one and during night in the other patient

Conclusion

The long term results suggested that transcatheter closure of PDA using Amplatzer duct occluder is a safe and effective treatment in infants less than 1 year of age with minimal complications.     

Aortic Stenosis and Patent Ductus Arteriosus: Pressure Gradients Pre- and Posttranscatheter Ductal Occlusion

Three patients with patent ductus arteriosus and moderate aortic stenosis had a marked reduction in aortic valve gradient following transcatheter ductal occlusion. The hemodynamic effects of an aortopulmonary shunt on the severity of left ventricular outflow obstruction and the implications on intervention are discussed.     

介入治疗对动脉导管未闭患儿心肌的影响

目的研究PDA介入治疗是否会导致心肌损伤和炎性反应,分析介入治疗致心肌损伤的影响因素。方法选取2008年10月-2010年8月在本院住院的37例PDA患儿。于术前,术后即刻,术后4 h、2 d、3 d、7 d,采集静脉血,应用ELISA法检测其血清心肌肌钙蛋白I(cTnI)和CRP水平,并记录年龄、缺损大小、曝光时间和造影剂量等相关危险因素。应用SPSS 13.0软件进行统计学处理。结果 PDA介入治疗术后即刻、4 h、2 d和3 d cTnI水平分别为0.08(0.00～1.37)μg.L-1、0.09(0.00～0.68)μg.L-1、0.06(0.00～0.96)μg.L-1及0.04(0.00～0.96)μg.L-1,较术前[0.05(0.00～0.58)μg.L-1]升高;术后7 d[0.04(0.00～0.44)μg.L-1]已低于术前水平,高峰出现在术后4 h,与术前cTnI水平比较差异有统计学意义(P<0.05);术后各时段cTnI均低于正常水平。于术后4 h CRP[0.36(0.00～28.00)mg.L-1]开始升高,至术后3 d达峰值[7.79(0.20～52.40)mg.L-1],继之下降;与术前[0.30(0.00～17.06)]相比,术后3 d及7 d CRP水平[4.10(0.20～34.57)mg.L-1]均显著升高(Pa<0.05);术后各时段CRP均低于正常水平。年龄、曝光时间、缺损大小和造影剂量等与cTnI变化无明显相关性。结论 PDA介入治疗未引起明显心肌损伤及炎性反应,是一种安全的治疗手段。     

Use of an Amplatzer Duct Occluder for Closing an Aortico-Left Ventricular Tunnel in a Case of Noncompaction of the Left Ventricle

Aortico-left ventricular tunnel (ALVT) is a very rare congenital anomaly. Noncompaction of the left ventricle or spongy myocardium is another rare congenital cardiomyopathy. We report probably the first case in which these two rare anomalies causing pump failure coexisted in a 4-year-old male and the tunnel was successfully treated nonsurgically. Transcatheter closure of ALVT with the Amplatzer duct occluder is feasible and safe in a case of noncompaction of the LV with reduced LV function.