电视胸腔镜室间隔缺损修补术67例报告

目的 :报告电视胸腔镜下室间隔缺损修补术 6 7例的结果。方法 :2 0 0 0年 6月至 2 0 0 2年 5月 ,行右侧胸壁打孔电视胸腔镜下室间隔缺损修补手术 6 7例 ,其中男性 36例 ,女性 31例 ,年龄 3～ 39岁 ,体重 13～ 6 8kg。室缺直接缝合 6 2例 ,涤纶补片修补 5例 ,同时行三尖瓣成形 5例。结果 :术中扩大切口 2例 ,室缺残余漏 1例 ,二次开胸止血 1例 ,手术时间 3 0～ 5 6h ,平均 3 1h。体外循环时间 6 2～ 15 2min ,平均 98min ;升主动脉阻闭时间 16～ 5 2min ,平均 2 8min。术后患者恢复顺利 ,治疗效果满意。结论 :电视胸腔镜下室间隔缺损修补术是可行的 ,安全的。     

Minimally invasive atrial septal defects repair.

This study reviews the current method of atrial septal defect closure at our institute with a minimally invasive approach without median sternotomy. From September 1997 to August 1998, 37 patients (13 males, 24 females) with mean age 36.5 years (range 18-67 years) underwent atrial septal defect closure by right anterior thoracotomy. Femoral vessels were cannulated through a small groin incision and extracorporeal circulation was established. Venous drainage was assisted with a centrifugal pump. Aortic crossclamping was performed through the intact chest wall using a special transthoracic clamp with sliding rod design inserted through a separate tiny 3 mm incision in the right second intercostal space in the mid clavicular line. Mean duration of cardiopulmonary bypass and aortic crossclamp time was 35 +/- 14 and 23 +/- 7 minutes respectively; mean endotracheal intubation time after surgery 6.2 +/- 3 hours; mean ICU stay 10.6 +/- 2.8 hours; mean length of thoracotomy incision 7.2 +/- 1.8 cm; and, mean hospital stay 4.2 +/- 1.8 days. There was no post-operative neurological dysfunction or femoral cannulation related complication. There was no perioperative or late mortality. No residual atrial septal defect was observed by transoesophageal echocardiography in any patient. The procedure described here provides secure closure of the atrial septal defects in minimally invasive fashion with good results.     

Conduction disorders after cardiac surgery with extracorporeal circulation

Two-hundred-fifty-eight patients who had cardiac surgery with extracorporeal circulation were studied to determine the frequency and significance of conduction disturbances. Fifty-eight (34%) developed new postoperative conduction defects. Seventeen patients developed new conduction alterations after coronary artery bypass graft. The most common disturbance was transient bifascicular block (right bundle branch block and anterior subdivision block of the left bundle branch of His) (p less than 0.01). After valvular surgery twenty-one patients developed conduction defects. Of those the most common disturbance was high degree AV block (57%). The authors found no relation between the AV block and the number of valves operated on or type of valvular surgery. After congenital heart surgery, twenty patients developed conduction defects. The most common defect was high degree AV block. The frequency of complete heart block was higher after the closure of atrial septal defects (P less than 0.01). None of the conduction defects were related to the amount of time the patient was exposed to extracorporeal circulation or to postoperative myocardial infarction. All conduction defects were transient except complete heart block in some patients with ventricular septal defect surgery. In this study there were no hemodynamic complications or mortality associated with the conduction disturbances.     

右胸微创切口心脏不停跳房间隔缺损修补手术学习曲线

目的 总结右胸微创切口心脏不停跳房间隔缺损修补手术学习曲线.方法 回顾性分析2011年6月至2013年4月间由同一术者连续完成的60例右胸微创切口心脏不停跳房间隔缺损修补手术病例资料,按手术先后顺序分为A、B、C、D 4组,每组15例.从各组手术时间、体外循环转机时间、中转开胸率、术后24 h引流量、ICU停留时间及手术并发症等指标比较手术效果,同时使用对数曲线拟合学习曲线,得出学习曲线相关模型.结果 各组病例年龄、性别差异无统计学意义（P＆gt;0.05）.全部患者均成功完成手术,手术时间、转机时间、中转开胸率、术后24 h引流量、ICU停留时间、术后并发症发生率等指标随手术例数增加呈下降趋势,且各组间差异有统计学意义（P〈0.05）.此外,学习曲线相关模型为：手术时间（min）=143.5-16.7×ln（手术例数）,转机时间（min）=77.5-13.0×ln（手术例数）.结论 右胸微创切口心脏不停跳房间隔缺损修补术是安全可行的,手术学习曲线约为30例左右.     

右腋下小切口心脏不停跳修补房间隔缺损的临床经验

目的 总结经右腋下直切口行体外循环直视、心脏不停跳下房间隔缺损修补手术的临床经验,探讨其适应证及技术要点。 方法 2011年1月至2016年12月我们共完成92例经右腋下直切口的体外循环心脏直视手术,其中男52例、女40例,患者年龄12个月至28岁,平均(5.2±3.3)岁,体重8.5～52.0(17.9±8.6)kg。其中2例合并部分型肺静脉异位引流,6例存在中度以上肺高压,同期行三尖瓣成形39例。所有手术均在全身麻醉、体外循环心脏不停跳下进行。患者取左侧卧位,切口位于腋中线与腋前线之间,皮肤切口长度约5～8cm,约经第3或第4肋间进胸,切开并悬吊心包,行升主动脉及上、下腔静脉插管建立体外循环,经右心房切口修补房间隔缺损及三尖瓣成形。结果 全组手术均顺利完成,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,2例术后出现少量气胸、皮下气肿,1例出现肺不张,1例随访有1～2mm残余分流。结论 右腋下小切口心脏不停跳下心内修补房间隔缺损手术具有安全、可靠,美容效果好、创伤轻、手术时间短以及术后恢复快等优点,患者及家属满意率高,值得临床推广。     

New surgical approach to device closure of multiple apical ventricular septal defects

We present an alternative technique for closing multiple ventricular septal defects difficult to access during surgery. A guidewire is advanced through the right ventricular free wall and through the main apical defect to the left ventricle, and this approach is used to place an Amplatzer device to occlude the ventricular septal defects. The procedure is performed in the beating heart, under intraoperative transesophageal echocardiographic guidance, and without extracorporeal circulation. It appears to be a simple and reproducible procedure with excellent short-term results.     

Treatment of atrial septal defects in symptomatic children aged less than 2 years of age using the Amplatzer septal occluder

AIMS: To assess results of closure of atrial septal defects within the oval fossa by devices delivered by catheterisation in symptomatic infants and children under 2 years of age. METHODS AND RESULTS: The Amplatzer septal occluder was used. Results, and complications of transcatheter device treatment in patients aged below 2 years were compared to previous results from our institution. PATIENTS: We attempted closure in 12 consecutive patients below the age of 2 years who presented with an atrial septal defect between May 1997 and 1999. Symptoms were failure to thrive in 6, frequent chest infections in 5, and the need for treatment of heart failure in the other. All were thought to have a defect suitable for interventional closure. The atrial defects were seen in isolation in 10 children, but 2 had associated pulmonary stenosis which had been treated by balloon dilation prior to placement of the Amplatzer occluder. RESULTS: The Amplatzer septal occluder was implanted at a mean age of 1.4 +/- 0.4, with a range from 0.8 to 1.8 years. Ratios of pulmonary-to-systemic flow had been 2.1 +/- 0.5, with a range from 1.6 and 3.2, and the defect was measured at 12 +/- 4 mms. Fluoroscopy time was 12.8 +/- 10.2 minutes, with a range from 5 to 43 minutes, and the time of the overall procedure was 162 +/- 70 minutes, with a range from 85 to 360 minutes. It proved necessary to remove the device in 2 patients (16%) because of a residual shunt and movement after release. One of these developed transient neurological complications. Both subsequently underwent surgical treatment. CONCLUSION: Symptomatic patients less than 2 years of age can undergo successful closure of an atrial septal defect using the Amplatzer device, but the rates of success are less, and procedure time longer, than in older children or adults.     

Peratrial closure of atrial septal defects without cardiopulmonary bypass

The objective of this study was to introduce a new technique for occlusion of an atrial septal defect without cardiopulmonary bypass, using a modified Amplatzer device. Between October 2004 and November 2005, 96 secundum atrial septal defects in 83 patients were occluded by this method. A 3-cm incision in the right 4(th) intercostal space and a minithoracotomy were performed. Via this incision, the right atrium was exposed and the septal closure device was deployed under transesophageal echocardiographic guidance. The sizes of the defects ranged from 10 to 39 mm. The mean device size was 34.1 +/- 9 mm (12-46 mm). There was no operative mortality and no major morbidity on follow-up of 3-15 months. This new minimally invasive method of secundum atrial septal defect closure is safe and cosmetically superior to conventional surgery. Avoidance of cardiopulmonary bypass can reduce recovery time and complications. The indications are more extensive than percutaneous transcatheter closure, and the results are encouraging.     

Functional closure of atrial septal defects

Three patients with left to right shunts at the atrial level and clinical findings of atrial septal defect were studied at 8 months to 2 years of age. The subsequent clinical course of these children indicated that the atrial defect had closed. The second heart sound became normal although systolic ejection murmurs remained. Hemodynamic studies confirmed the functional closure of the atrial septal defect although probe patency of the foramen ovale was still present in 2 patients. Although functional closure of atrial septal defects may not be a common occurrence, the possibility should be kept in mind and elective surgery should not be undertaken during the first few years of life.     

新型封堵器经胸封堵房间隔缺损386例(英文)

目的:探讨新型封堵器经胸关闭房间隔缺损的有效性和安全性。方法:设计一种新型的封堵器和传送系统:封堵器由外鞘管、内鞘管、传送杆经第4肋间和右侧房壁送出,封堵房缺。通过这种经胸方式共治疗患者386例,年龄1～79(平均11.8)岁,分析临床资料。结果:房缺平均直径为20.4(4～38)mm,成功植入封堵器382例,因房间隔多发缺损植入2个封堵器22例。整个手术时间为35～62(平均44±7.4)min;术后24h经胸B超证实手术成功率为98.9%;植入术中封堵器脱落1例,因此取出封堵器改用手术方法封闭房缺;另1例患者房缺成功封闭,术后当晚发生颅内出血,经神经外科治疗成功康复。结论:对于大多数房缺患者,经胸封闭房缺是有效且安全的,其操作也较为简便。     

Sinus arrhythmia in children with atrial septal defect: an analysis of heart rate variability before and after surgical repair.

The expression of sinus arrhythmia depends on separation of the systemic and pulmonary venous return to the heart as well as on normal autonomic control mechanisms. Patients with atrial septal defect provide a naturally occurring experiment of communication between the two venous systems. In adults with atrial septal defect sinus arrhythmia is minimal or absent. But children with atrial septal defect retain appreciable sinus arrhythmia, although this is not recognised in published reports. To understand why this is so, continuous electrocardiograms were recorded before and after operation in 10 children (aged 4-16 years, mean 6.3) with atrial septal defects and in 10 normal children (aged 5-7 years, mean 6.1). Mean RR intervals were calculated for periods of one minute, and the standard deviation was used as an index of heart rate variability (that is sinus arrhythmia). Frequency analysis (spectral analysis) was also performed on a continuous beat to beat record of heart rate to describe the frequency components that may reflect autonomic activity. The results confirmed the presence of considerable sinus arrhythmia in children with unoperated atrial septal defect. None the less, the standard deviation of RR intervals in the children with unoperated atrial septal defect was significantly less than that for the normal children, and variation increased after closure of the defect. Power spectral analysis of instantaneous heart rate indicated that the high frequency (0.15-0.45 Hz) vagally mediated component of variability was lower for patients than for controls which may indicate abnormalities of autonomic control of heart rate in these children. The comparative retention of sinus arrhythmia in children with atrial septal defect may relate to the small size of the right atrium or differences in myocardial compliance compared with adults.     

Sinus arrhythmia in children with atrial septal defect: an analysis of heart rate variability before and after surgical repair

The expression of sinus arrhythmia depends on separation of the systemic and pulmonary venous return to the heart as well as on normal autonomic control mechanisms. Patients with atrial septal defect provide a naturally occurring experiment of communication between the two venous systems. In adults with atrial septal defect sinus arrhythmia is minimal or absent. But children with atrial septal defect retain appreciable sinus arrhythmia, although this is not recognised in published reports. To understand why this is so, continuous electrocardiograms were recorded before and after operation in 10 children (aged 4-16 years, mean 6.3) with atrial septal defects and in 10 normal children (aged 5-7 years, mean 6.1). Mean RR intervals were calculated for periods of one minute, and the standard deviation was used as an index of heart rate variability (that is sinus arrhythmia). Frequency analysis (spectral analysis) was also performed on a continuous beat to beat record of heart rate to describe the frequency components that may reflect autonomic activity. The results confirmed the presence of considerable sinus arrhythmia in children with unoperated atrial septal defect. None the less, the standard deviation of RR intervals in the children with unoperated atrial septal defect was significantly less than that for the normal children, and variation increased after closure of the defect. Power spectral analysis of instantaneous heart rate indicated that the high frequency (0.15-0.45 Hz) vagally mediated component of variability was lower for patients than for controls which may indicate abnormalities of autonomic control of heart rate in these children. The comparative retention of sinus arrhythmia in children with atrial septal defect may relate to the small size of the right atrium or differences in myocardial compliance compared with adults.     

Minimal incision cardiac surgery for atrial septal defects

Minimal incision cardiac surgery for atrial septal defects was performed in 4 consecutive patients. No special devices or new techniques were used to perform this operation. Clamping of the aorta and snaring of the inferior vena cava could be simply omitted from this procedure. A limited(6 to 7 cm) median skin incision was made, followed by a mini-sternotomy from the second intercostal space to right side of the xiphoid process. Through this limited approach, atrial septal defect closure was performed conventionally with a patch under hypothermic circulatory arrest(less than 10 min). The scar was short(5.5 to 7.3 cm) and cosmetically acceptable in all patients. This mini-incisional procedure is a useful option for atrial septal defect closure that can be completed without sophisticated instruments.     

The correction of congenital heart defects with less invasive approaches

BACKGROUND: The minimally and less invasive approaches for the surgical treatment of different heart diseases are rapidly increasing because of their cosmetic and recovery-related advantages. Presented here are the results of less invasive surgery in 51 patients with congenital heart defects. METHODS: From June 1996 to January 1999, we used less invasive techniques for the correction of congenital heart defects in 51 patients. In 32 patients, we performed right anterolateral thoracotomy (6-13 cm), and on the other 19 patients, we used the partial inferior sternotomy (4-7 cm). The ascending aorta and the caval veins were cannulated in all patients. RESULTS: The following congenital heart defects were corrected: ostium secundum atrial septal defect (n = 35), sinus venosus atrial septal defect with partial anomalous pulmonary venous connection (n = 7), ventricular septal defect (n = 7), tetralogy of Fallot (n = 1), and cor triatriatum sinistrum (n = 1). The average age of the patients was 15 years old ranging from 2 months to 48 years and the average weight 39.6 kg (range 3.8-86 kg). The patients were removed from artificial respiratory support on average 8 hours (range 1-48 hours) after surgery and left the hospital after 7 days (range 2-10 days). In 16 patients, blood transfusions were required, an average 5.7 ml/kg BW (range 1.45-19.75 ml/kg BW). The postoperative course was uneventful in all patients. Follow-up (range 3-33 months, mean 17.5 months) was complete with no late deaths or residual defects. CONCLUSION: The right anterolateral thoracotomy and the partial inferior sternotomy provide a safe approach for the correction of certain congenital heart defects. These techniques enable operative correction without any additional risks being incurred and can be performed with standard instruments and cannulation. Additional approaches for extracorporeal circulation are unnecessary.     

Intraoperative Device Closure of Atrial Septal Defects with Minimal Transthoracic Invasion: A Single-Center Experience

Atrial septal defect is one of the most common congenital heart defects. Open-heart repair via midline sternotomy or right thoracotomy and cardiopulmonary bypass has been considered the standard treatment for the closure of atrial septal defects, but transcatheter closure with the Amplatzer septal occluder has recently become a viable option. We have adopted a 3rd alternative: intraoperative device closure with minimal transthoracic invasion.From May 2007 through June 2011, 250 patients with secundum atrial septal defect underwent cardiac surgery at our institution. Open-heart repair with cardiopulmonary bypass was performed in 72 patients, and intraoperative device closure was performed in 178 patients. This minimally invasive approach, which required a full evaluation of the atrial septal defect by transthoracic echocardiography, was performed by deploying the device through the delivery sheath to occlude the atrial septal defect. The approach was successful in 175 of the 178 patients. The size of the implanted occluder ranged from 12 to 46 mm in diameter. Minor complications included transient arrhythmias (n=7) and pleural effusion (n=25). After complete release, the intraoperative occluder device dislodged in the right atrium in 3 patients, who then underwent immediate surgical repair with cardiopulmonary bypass. All discharged patients were monitored for 2.3 years to 5 years.As monotherapy, intraoperative device closure of atrial septal defect with minimal transthoracic invasion is a safe and feasible technique. It is particularly beneficial for elderly patients or patients with pulmonary hypertension and is associated with better cosmetic results and less trauma than is surgical closure.Key words: Heart defects, congenital; heart septal defects, atrial/therapy; prosthesis implantation; retrospective studies; septal occluder device; surgery, minimally invasive; treatment outcome; ultrasonography, interventionalAtrial septal defect (ASD), one of the most common congenital cardiac defects, accounts for approximately 6% to 10% of all congenital heart disease.¹ Most pediatric patients with ASD are asymptomatic and could await elective surgical or catheter-based closure until reaching school age. Open-heart repair via a midline sternotomy or right thoracotomy and with the aid of cardiopulmonary bypass (CPB) has been considered the standard treatment for closure of ASDs. In recent years, transcatheter closure with the AMPLATZER septal occluder (St. Jude Medical, Inc.; St. Paul, Minn) has become another standard treatment for most ostium secundum ASDs.² Although the safety and feasibility of both methods have been demonstrated, the use of CPB is still necessary in association with surgical secundum ASD closure, and the midline incisions cause physical and psychological trauma. Catheter-based closure requires “selective and suitable” patients, and the exposure to radiation is contraindicated for small children.^3–5 Our approach is to use an intraoperative device and minimally invasive surgery for ASD closure, which improves the cosmetic results compared with open-heart surgery. The aim of the present retrospective study was to evaluate the safety and feasibility of intraoperative device closure of secundum ASDs via minimal transthoracic invasion.     

Primary surgical repair of ventricular septal defect

Between January 1983 and December 2000, 78 patients underwent primary repair of a ventricular septal defect. There were 42 males (54%) and 36 females (46%) of whom 13 (17%) were under 1 year old, 50 (64%) were aged 1-10 years, 11 (14%) were aged 10-20 years, and 4 (5%) were over 20 years old. The ventricular septal defect was a perimembranous type in 60 patients (77%), subarterial (outlet) type in 10 (13%), and atrioventricular canal (inlet) type in 4 (5%). Operative repair was performed with a patch in all except 2 patients. Early postoperative complications included insignificant aortic regurgitation in 4 patients, persistent complete heart block in 1, and residual shunt in 4. There were 5 early deaths (6.4%) and 1 late death (1.8%) in 56 patients followed up. Early primary closure of ventricular septal defects, usually via a right atriotomy, can be performed with acceptable mortality and morbidity rates.     

Analysis of atrial and ventricular performance by tissue Doppler imaging in patients with atrial septal defects before and after surgical and catheter closure

OBJECTIVE: To compare the effects of surgical and device closure of atrial septal defects on atrial and ventricular performance assessed by the novel tissue Doppler derived strain rate. BACKGROUND: Despite the increasing number of transcatheter closures, there is no information comparing the effect of the transcatheter closure technique on atrial performance with that of conventional surgery. Tissue Doppler derived strain rate can effectively quantify local myocardial function independent of the overall heart motion. DESIGN AND PATIENTS: Twenty-four patients [aged 21.5 (6-70) years] with isolated atrial septal defect of the secondum type before and 1 week after surgical (n = 12) or Amplatzer Septal Occluder closure (n = 12) and 30 healthy controls [aged 26.0 (2-58) years] were studied. Atrial and ventricular strain rate curves were assessed in the middle of their corresponding lateral walls in an apical four-chamber view. The systolic, early diastolic, and late diastolic strain rates peaks were measured. RESULTS: Compared to preclosure condition, the right atrial late diastolic (P < 0.01), right ventricular systolic (P < 0.01), right ventricular early diastolic (P < 0.01), and left atrial late diastolic peak (P < 0.01) strain rates were reduced after surgery but not after Amplatzer Septal Occluder closure. The LV parameters did not significantly differ before and after atrial septal defect closure by either technique. CONCLUSIONS: In contrast to surgery, transcatheter closure of atrial septal defect preserves atrial and right ventricular function. Tissue Doppler derived strain rate can be applied to provide quantitative analysis of regional atrial and ventricular performance.     

Heart rate behavior in children with atrial septal defect

The aim of this study was to assess heart rate variability, a noninvasive parameter for studying the neurohumoral control of heart rate, in children with atrial septal defect. We examined five time-domain and three frequency-domain indices of heart rate variability determined from 24-hour Holter recordings in 20 children, aged 3-14 years, with secundum atrial septal defect who were about to undergo operation. The measures were compared to normal ranges and to the hemodynamic data of the preoperative cardiac catheterization. Most indices of heart rate variability were moderately depressed in children with atrial septal defect. Our data revealed negative correlations between indices and the mean right atrial pressure and the enddiastolic right ventricular pressure, respectively. The study demonstrates the importance of the right ventricular filling pressures for the autonomic control of the heart in children with atrial septal defect.     

Transcatheter closure with use of the SHSMA occluder in 180 patients with congenital heart defects: preliminary results

Transcatheter closure of congenital heart defects with the use of septal occluders has been widely accepted as a preferred treatment; however, the high cost of these devices limits their clinical application in some countries. Few clinical data are available regarding lower-cost products. Accordingly, we evaluated the efficacy and safety of the Chinese-made Shanghai Shape Memory Alloy (SHSMA) occluder in patients with congenital heart defects. From December 2001 through December 2008, a total of 180 patients with congenital heart defects (ages, 3-68 yr; mean age, 17.35 ± 13.22 yr) underwent transcatheter closure with use of the SHSMA occluder: 73 had atrial septal defects; 64, ventricular septal defects; 40, patent ductus arteriosus; and 3, complex congenital defects. The mean diameters of the defects were 20 ± 7.6 mm (atrial septal), 4.9 ± 2.1 mm (ventricular septal), and 5.6 ± 2.2 mm (patent ductus arteriosus). The procedural success rates were 98.6% for atrial defects, 98.4% for ventricular defects, and 100% for patent ductus arteriosus and for complex defects. The overall incidences of sequelae were 5.5%, 9.4%, 2.5%, and 0, respectively. Six months postprocedurally, complete occlusion was associated with a significant decrease in the right ventricular Tei index in atrial septal defect patients (P < 0.05) and with improvement of body mass index in 11 children. These results suggest that the SHSMA occluder is a safe, effective device for the transcatheter closure of congenital heart defects. For confirmation, a randomized controlled trial with more patients and a longer follow-up period is warranted.