第二代动脉导管未闭封堵器封堵 特殊类型室间隔缺损2例报告

目的　总结分析应用第二代动脉导管未闭封堵器（ADO-Ⅱ）对特殊类型室间隔缺损（VSD）封堵的技巧。方法　研究对象为2011年8月至9月在上海交通大学医学院附属上海儿童医学中心行介入治疗的患儿2例,因应用常规VSD封堵器封堵困难,遂选取ADO-Ⅱ进行治疗。常规建立动静脉轨迹后,采用主动脉内释放,然后行左室、升主动脉造影和心脏超声检查,如封堵器位置好,无残余分流、瓣膜反流则释放。结果　例1左室造影显示为膜周VSD,左室面7.6 mm,较大假性室隔瘤形成,右室分流口弥散,最大约2.3 mm,缺损上缘距主动脉为6.1 mm。导丝建轨后,7 F长鞘无法通过分流口,最后选用5F长鞘,“6 mm×4 mm”的ADO-Ⅱ封堵成功,术后心脏超声三尖瓣轻微分流。例2心室造影为肌部VSD,左室面6.3 mm,右室分流口为2 mm,上缘距主动脉16 mm。因VSD走行异常且分流口小,最终选冠脉导丝建轨成功,应用4 F长鞘,“4 mm×4 mm”ADO-Ⅱ封堵成功。2例患儿术后1d复查心脏超声和心电图,无异常,观察5 d后出院随访,并口服阿司匹林［3～5 mg/（kg·d）］。结论　对于一些形态较特殊的VSD,常规VSD封堵器无法成功封堵时,可选择ADO-Ⅱ进行封堵,手术操作简单、安全、可靠而并发症少。     

小儿膜周部室间隔缺损介入治疗并发心律失常22例分析

目的探讨经导管介入治疗小儿膜周部室间隔缺损(VSD)发生心律失常的特点及其处理。 方法南京医科大学附属南京市儿童医院心血管科2002 09—2006 03经导管介入治疗VSD 108例，其中发生心律失常的患儿共计22例,动态观察22例患儿封堵术前心电图(ECG)以及封堵后发生心律失常ECG的变化及其处理。 结果22例中2例在术中反复出现Ⅲ度房室传导阻滞(AVB)，被迫中断；8例患儿术后3d内出现加速性交界性或室性自主心律伴干扰性房室分离，经治疗后均转为窦性心律，其中2例患儿1个月后才恢复窦性心律；6例患儿术后3d内出现束支传导阻滞，经治疗后3例恢复正常，3例仍存在不同程度的束支传导阻滞；5例患儿术后3d内发生高度AVB，其中3例经使用激素、维生素C、果糖及静滴异丙肾上腺素和临时起搏器治疗后，均在1周内恢复窦性心律，另2例患儿经治疗后，1例于10d后转为窦性心律，1例于术后2年时仍有完全性右束支阻滞+左前分支阻滞；1例患儿术后1个月随访发现完全性右束支阻滞。 结论术后早期出现的心律失常多能恢复，而后期出现的传导阻滞多为器质性损伤。对已经出现传导阻滞的患儿关键是早期治疗，适当延长术后观察时间。     

经导管室间隔缺损封堵术后传导阻滞的处理及随访

目的随访经导管室间隔缺损(VSD)封堵术后并发的传导阻滞，探讨其发生机制及预后。 方法2002 06—2005 07山东省立医院小儿心脏科经导管介入治疗89例VSD患儿，对临床资料、心电图、心脏超声、心血管造影资料及随访结果进行分析。 结果89例患儿应用Amplatzer膜部VSD封堵器67例，国产对称型VSD封堵器20例，Amplatzer导管封堵器1例，pfm弹簧圈1例。术后出现间歇性完全性房室传导阻滞2例次，其中1例应用临时起搏器治疗，分别于术后第10天、第20天恢复窦性心律；完全性左束支阻滞3例次，完全性右束支阻滞3例次，左前半分支阻滞2例次，不完全性右束支阻滞5例次，加速性交界性心律合并完全性左束支阻滞1例次。 结论传导阻滞是VSD介入治疗术后的常见并发症，经治疗预后良好，及时发现、及时处理是诊疗的关键，对心内传导系统远期的影响仍需进一步评价。     

小儿房间隔缺损40例临床分析

目的:对小儿房间隔缺损进行临床分析。方法:回顾2008年3月-2010年8月来我院治疗小儿房间隔缺损的患儿40例,其中,男患儿14例,女患儿26例。年龄在2～14岁,平均年龄10.5岁。体重9～42kg,平均体重32.5kg。经心电图、X线片、超声心动图确诊为房间隔缺损,采用介入治疗对小儿房间隔缺损进行临床分析。结果:40患儿介入封堵术全部成功,手术时间20～50min,平均40min,术后3～7d出院,出院前对患儿进行进行心脏超声、心电图检查以及X线片检查,患儿有明显改善。封堵器位置准确安全,无并发症以及残余分流发生。结论:对小儿房间隔缺损及时确诊和治疗,防止并发症发生。     

彩色多普勒超声心动图在房间隔缺损和室间隔缺损介入治疗中的应用

目的探讨经胸超声心动图(TTE)及实时三维超声心动图在房间隔缺损(ASD)、室间隔缺损(VSD)封堵术中的临床应用价值。 方法应用二维及三维超声心动图对2004 10—2005 10在天津市儿童医院就诊的24例继发孔ASD，10例VSD进行术前检查筛选，术中超声引导及术后随访检查。 结果24例ASD患儿术前经TTE检测ASD直径(15.6±7.9)mm(5~26mm)，所选Mmplatzer封堵器直径为(19.1±5.1)mm(5~32mm)，23例封堵成功。室间隔膜部缺损直径：左室面缺损为5~9mm，右室侧口的直径为2.4~6.0mm，术中选择Amplatzer封堵器型号为4~6mm，10例VSD无残余分流。 结论二维及三维TTE联合应用于ASD、VSD介入治疗具有很好的应用价值。     

先天性心脏病介入治疗与传统外科手术治疗的临床比较

目的对房间隔缺损(ASD)、室间隔缺损(VSD)、动脉导管未闭(PDA)的介入治疗(Amplatzer封堵器)和外科手术治疗的临床疗效进行比较。 方法研究对象为2004 05—2005 05在北京安贞医院小儿心脏科住院患儿80例，符合单一左向右分流畸形ASD、VSD、PDA,根据治疗方法不同分为介入组(40例)和手术组(40例)；比较2组在疗效、费用、并发症、输血量及住院时间等方面的异同；通过放免法测定2组ASD及VSD治疗前后的心钠素(ANP)水平。 结果2组手术成功率均为100%；介入组均未输血,手术组均输血治疗；术后住院时间介入组少于手术组(P<0.01)；治疗费用介入组高于手术组(P<0.01)；ANP水平，外科手术及介入治疗后均较治疗前降低。 结论单一ASD、VSD、PDA的介入治疗与手术治疗临床效果相同；介入组不需输血,术后住院时间短,但治疗费用较昂贵。     

封堵器介入治疗儿童继发孔房间隔缺损术后房室传导阻滞分析

探讨应用Amplatzer封堵器 （ASO）介入治疗儿童继发孔房间隔缺损（ASD）术后房室传导阻滞（AVB）的发生率、危险因素及防治措施。方法　1998年3月至2005年12月在广东心血管病研究所心儿科450例继发孔ASD患儿接受ASO封堵术。对术前及术后随访的心电图资料进行回顾性分析,统计AVB的发生率及类型,并分析与AVB发生有关的危险因素及防治措施。结果　共有14例发生各种类型的AVB,发生率为3.1%,分别为Ⅰ度AVB 6例,Ⅱ度AVB 4例,Ⅲ度AVB 4例。所有AVB均发生于术后1～2 d内。14例中12例为术后新出现的AVB,2例术前为Ⅰ度AVB术后发展为Ⅱ度和Ⅲ度AVB（各1例）。统计学分析显示,使用过大ASO及小年龄与术后AVB的发生密切相关。AVB发生后常规应用激素等治疗,4例Ⅲ度AVB实施外科手术取出ASO。AVB绝大多数于短期随访内恢复或好转,未见复发。结论　AVB是应用ASO介入治疗儿童继发孔ASD术后的严重并发症。对年龄较小患儿避免置入过大ASO是降低术后AVB的关键。AVB发生后及早给予内科或外科干预,多可于短期内恢复,术后长期随访十分重要。     

早期新生儿先天性心脏病的筛查和随访

目的降低先天性心脏病（简称先心病）的发病及减少病死率,探索在基层医院的管理模式.方法2002至2005年对北京市郊区两所妇幼保健院（大兴、门头沟）出生的足月活产儿5640例,在生后7 d内查体筛查先心病,可疑者用彩色多普勒超声心动图进行诊断,出院后定期随访.结果足月活产儿中共检出先心病65例,检出率11.52‰.65例先心病中非青紫型占76.9%,以室间隔缺损（简称室缺）为主（60.1%）,青紫型23.1%,以肺动脉狭窄（9.1%）及法洛四联症（6.2%）为主.随访12例重症先心病,10例家长放弃治疗（其中6例已死亡）,仅2例手术治愈.先心病占同期婴儿死因的首位35.3%（6/17）.室缺37例随访中缺损自行闭合（自闭）、扩大及无明显变化者约各占1/3.缺损直径＜5 mm者23例,12例（52%）自闭,缺损≥5 mm者14例中,自闭1例（7%）,8例（57%）缺损继续扩大（x^2=9.4,P＜0.01）,其中2例死亡,3例已手术矫治.结论防治先心病应自宫内筛查作起,对重症难治的先心病建议及早终止妊娠,经定期随访不能自闭的病例,选择最佳时期手术矫治,降低病死率.     

经导管膜周部室间隔缺损封堵术并发三尖瓣损伤8例临床分析

摘要：目的　分析经导管膜周部室间隔缺损（PMVSDs）封堵术并发三尖瓣损伤原因，探讨其预防及处理措施。 方法　2002年10月至2009年12月广东省心血管病研究所825例PMVSDs患儿，均进行了经导管介入封堵，其中8例出现三尖瓣损伤。8例患儿中男4例，女4例；年龄3.5～8.0岁。8例三尖瓣损伤患儿中4例出现三尖瓣狭窄，其中2例严重狭窄者行外科手术治疗，术中见封堵器右室盘与三尖瓣腱索缠绕，予松开缠绕、取出封堵器并修补室间隔缺损；2例轻度狭窄者予随诊观察。8例中其余4例出现三尖瓣关闭不全，其中3例反流严重予外科手术治疗，术中见三尖瓣腱索断裂1例，腱索断裂并瓣膜撕裂1例，三尖瓣隔瓣腱索被封堵器牵拉1例。术中将断裂的腱索缝合，取出封堵器并修补室缺，合并三尖瓣撕裂者行三尖瓣整形。余1例三尖瓣隔瓣脱垂并轻至中度反流的病例予随诊。结果　5例外科手术治疗者中，4例三尖瓣功能恢复良好，1例三尖瓣血流速度稍增快。三尖瓣损伤不重未行外科处理的3例病例随诊1月至2年，三尖瓣病变无加重，患儿无明显临床症状。结论　经导管PMVSDS封堵术并发三尖瓣损伤有多方面原因。操作中应避免轨道钢丝穿过三尖瓣腱索，出现腱索与封堵器或输送钢缆缠绕时切勿使用暴力牵拉。三尖瓣损伤严重时应外科手术治疗。     

单心动周期实时三维超声心动图在胎儿房室间隔缺损诊断中的应用

目的:探讨单心动周期实时三维超声心动图(s RT-3DE)在胎儿房间隔缺损(ASD)及室间隔缺损(VSD)诊断中的临床应用价值。方法:将满足纳入条件的320例孕妇,分别进行胎儿心脏二维超声心动图(2DE)及s RT-3DE检查,对两种检查方法的胎儿图像进行采集、结果记录以及数据进行分析比较,并对产前诊断为ASD及VSD的41例孕妇产后进行追踪随访,对婴幼儿行2DE检查。结果:320例孕妇中,对单纯性ASD或有ASD的胎儿,s RT-3DE产前诊断16例(5.00%),高于2DE产前提示诊断6例(1.88%),差异有统计学意义(P0.05);对单纯性VSD或有VSD的胎儿,s RT-3DE产前诊断25例(7.81%),高于2DE产前诊断12例(3.75%),差异有统计学意义(P0.05)。随访到28例患儿,1例为假阳性,生后检查未见室间隔连续性中断。结论:s RT-3DE可较直观显示胎儿室间隔、房间隔及卵圆窝的成像,在产前诊断胎儿房室间隔缺损中具有一定优势。     

Spontaneous closure of ventricular septal defects in the first year of life.

BACKGROUND AND PURPOSE: The recent increase in the prevalence of ventricular septal defect (VSD) has been ascribed to the improved detection of small defects with echocardiography and the wider use of screening. The aim of this study was to determine the prevalence and timing of spontaneous closure of specific types of VSD in neonates using echocardiographic screening and follow-up. METHODS: Two-dimensional color Doppler echocardiography was performed in 3,472 clinically normal full-term neonates born at Cathay General Hospital to detect isolated VSD. The relative prevalence of muscular versus perimembranous defects and their outcome in the first year of life were evaluated. RESULTS: VSD was found in 74 neonates (34 male, 40 female), resulting in a prevalence of 21.3/1,000 live births. There were 48 muscular, 25 perimembranous, and one subpulmonic defects. Of the 74 patients, 11 were lost to follow-up. Within the observation period of 12 months, spontaneous closure occurred in 40 patients in the muscular group and in six patients in the perimembranous group. The overall rate of spontaneous closure was 73% by the end of the first year. Only five patients with perimembranous defects received digoxin therapy. CONCLUSIONS: The prevalence of VSD in this series of neonates was 21.3/1,000 live births. The most common location of VSD in the neonatal period was in the region of the muscular septum. Muscular defects were more likely to close spontaneously than perimembranous defects. Most muscular defects underwent spontaneous closure during the 12-month follow-up period.     

Results of Senning operation for transposition of great arteries.

We report our results with 10 infants and children who underwent atrial repair using the Senning operation between 1985 and 1990. All cases had abdominal situs solitus, levocardia and atrio-ventricular concordance (D-bulboventricular loop). Nine patients had simple D-transposition of the great arteries without ventricular septal defects (VSD) or left ventricular outflow tract obstruction. The other patient had a double outlet right ventricle with subpulmonic VSD and pulmonary hypertension (PHT) and underwent a palliative Senning procedure. All patients had a balloon atrial septostomy (BAS) before surgery, except for one with Taussig-Bing syndrome. One patient had a Blalock-Hanlon operation after BAS. The age at the time of surgery ranged from two months to four years seven months (mean: 22 months) and weight ranged from 4.3-12 kg. There were two hospital mortalities including the patient with VSD and PHT. All of the patients had echocardiographic examinations and six of the eight survivors received cardiac recatheterization four to 19 months (mean: 7.4 months) postoperatively. No baffle leaks were noted in the survivors. Two patients had both mild tricuspid regurgitation and slightly decreased right ventricular contractility, and one patient had a pressure gradient of 6 mmHg between the superior vena cava and neo-right atrium. The clinical follow-up interval was eight to 64 months (mean: 31.4 months). All survivors showed a sinus rhythm on their latest electrocardiogram and were participating in normal daily activities without medication.     

The genetic and clinical outcome of isolated fetal muscular ventricular septal defect (VSD)

Introduction: Our objective was to evaluate the incidence of chromosomal aberration (both microscopic and submicroscopic) and the clinical outcome of fetuses with isolated muscular ventricular septal defect (VSD).

Material and methods: The study included 40 pregnant women whose fetuses were diagnosed with isolated muscular ventricular septal defect (mVSD). Of these, 30 patients underwent amniocentesis and 10 declined. All samples were tested by chromosomal microarray analysis (CMA). Of the 40 women in the study, 32 gave birth and the clinical outcome of the children was retrieved from the patients’ medical records.

Results: Of the 30 patients who underwent amniocentesis, one was detected with mosaic Klinefelter syndrome and one was detected with a pathogenic copy number variant unrelated to the VSD. Clinical follow-up was performed on 26 children after birth. The first postnatal echocardiography did not detect a VSD in 13 (50%) of the followed-up children. Spontaneous closure occurred in another eight (30.8%) children during the postnatal follow-up period. In only five children (19.2%) VSD was still detected by echocardiography after the first year of life.

Discussion: Isolated muscular VSD diagnosed prenatally does not appear to be a significant risk factor for chromosomal abnormalities and has a favorable clinical outcome.     

宫腹腔镜术后联合GnRH—a治疗轻中度内异症性不孕的疗效分析

目的：探讨宫腹腔镜术后联合不同药物对轻、中度子宫内膜异位症（EMs）性不孕患者妊娠率的影响。方法：回顾分析2008年9月至2011年12月在我院就诊的82例Ⅱ～Ⅲ期EMs性不孕患者的临床资料，患者均行宫腹腔镜联合保留生育功能的手术。按照严格的纳入和剔除标准，筛选出有自然受孕能力的患者，术后按个人意愿用药。按患者术后用药情况分为对照组（18例）、促性腺激素释放激素激动剂组（GnRH．a，博恩诺康）（31例）和口服避孕药组（去氧孕烯炔雌醇片，妈富隆）（33例），比较3组患者在术后不同时期的妊娠率及异位妊娠的发生率。结果：博恩诺康组、妈富隆组和对照组患者术后1年内的妊娠率分别为77．42％（24／31）、51．52％（17／33）和33．33％（6／18），博恩诺康组显著高于对照组及妈富隆组（P〈0．05），而后两组则无显著差异（P〉0．05）。3组患者的异位妊娠率分别为3．23％（1／31）、6．06％（2／33）和5．56％（1／18），均无显著差异（P均〉0．05）。术后1年内，Ⅱ期EMs患者中，3组妊娠率差异显著（P=0．020）；Ⅲ期EMs患者中，3组妊娠率无显著差异（P=0．297）。II、HI期患者中，3组的异位妊娠率均无显著差异（P〉0．05）。结论：宫腹腔镜术后联合博恩诺康有利于改善轻、中度EMs性不孕患者的生育能力。     

Transcatheter control of intractible gastrointestinal bleeding.

A series of 23 patients with intractible gastrointestinal (GI) bleeding were managed by the transcatheter method. The series included 5 with hemobilia, 8 with upper GI (UGI) bleeding, 5 with lower GI (LGI) bleeding and 5 with variceal bleeding. The etiology of the hemobilia was surgery, or percutaneous transhepatic cholangiography and drainage (PTCD) complicated by various degrees of biliary tract infection. The causes of UGI bleeding included erosive gastritis, gastric and duodenal ulcers, and traumatic duodenal laceration. All 5 LGI bleedings were due to ischemic colitis and all 5 variceal bleedings were due to hyperdynamic portal hypertension from arterio-portal (A-P) shunting for hepatocellular carcinomas (HCC). Intra-arterial vasopressin infusion was performed on 17 (4, hemobilia; 8, UGI; and 5 LGI bleeding) of these 23 cases as initial management. The success rate for vasopressin in hemobilia, UGI and LGI bleeding was 75% (3/4), 38% (3/8), and 60% (3/5), respectively. The overall initial success rate of vasopressin was 52% (9/17). The relatively poor success rate of vasopressin infusion for UGI bleeding was due to ulcers and laceration. The incidence of rebleeding for vasopressin infusion was 22% (2/9) including one case each of UGI and LGI bleeding. Three patients (1 hemobilia and 2 UGI bleeding) among these 17 cases underwent transarterial embolization (TAE) after failure of intra-arterial vasopressin infusion. One of these 23 cases with hemobilia underwent TAE for initial transcatheter control of the GI bleeding. Five cases of active esophageal variceal bleeding, caused by A-P shunting in HCC, were all successfully controlled by TAE.(ABSTRACT TRUNCATED AT 250 WORDS)     

白血病骨髓抑制期患者采用护理干预对肛周感染发热的影响解析

目的：分析探讨护理干预对白血病骨髓抑制期患者肛周感染发热的影响。方法：选取40例白血病骨髓抑制期患者作为研究对象,按照数字抽签法将其随机分为研究组与对照组,每组20例,研究组患者行系统的护理干预,对照组患者仅行常规护理,比较两组患者肛周感染发热的发生率。结果：研究组肛周感染发热并发症的发生率为5.0%,对照组发生率为30.0%,研究组患者肛周感染发热并发症发生率明显低于对照组（P〈0.05）,组间比较差异有统计学意义。结论：对白血病骨髓抑制期患者行系统的护理干预可以提高患者的机体免疫力,降低肛周感染发热并发症的发生率,提升患者生活质量。