1例室间隔缺损残余漏患儿的护理

先天性心脏病室间隔缺损修补术患者,可因缺损修补不完善,修补缝线处撕破或心内感染等原因术后并发残余漏,病情险恶。我所1988年12月遇1例室间隔缺损修补术后并发残余漏患儿,经及时诊治和精心护理而获治愈,现报告如下:一、病例简介     

室间隔缺损术后残余漏的防治

目的：探讨室间隔缺损修补术后残余漏的原因，提出防治方法。方法：总结了室间隔缺损残余漏１８例，其中单室间隔缺损术后残余漏１２例，法乐氏四联症术后残余漏６例，均行二次心脏手术治疗。结果：二次心脏手术后，单纯室间隔缺损残余漏１２例，治愈１０例，死亡２例。法乐氏四联症术后残余漏６例，治愈４例，死亡２例。结论：手术技术不当、遗漏室间隔缺损是造成残余漏的主要原因。提高修补技术，术中探查室间隔缺损，掌握适当再手     

室间隔缺损修补术后残余漏的外科治疗

目的　总结室间隔缺损 (室缺 )修补术后残余漏的外科治疗经验 ,探讨残余漏的易发部位。方法　 1979年 1月至 2 0 0 3年 5月对 37例室间隔缺损术后残余漏患者行手术治疗 ,单纯室间隔缺损术后残余漏 19例、法洛四联症术后室间隔残余漏 17例、右心室双出口术后室间隔残余漏 1例 ,占同期心脏手术的 0 2 1% (37/ 180 0 0 )。其中男 2 6例、女 11例 ,年龄 3个月～ 5 3岁 ,平均 (16± 12 )岁。全组以室缺术后再度出现心脏杂音并行超声心动图检查确诊。手术用补片修补残余漏 2 6例 ,直接缝合残余漏 11例。结果　手术死亡 2例 ,病死率 5 % (2 / 37) ;手术成功 35例 ,术后随访 3个月～ 15年 ,疗效满意。结论　室间隔缺损修补术后残余漏多见于三尖瓣隔瓣根部 ,其次为第二和第一转移针处 ;室间隔缺损残余漏二次手术效果良好。     

室间隔缺损残余漏的防治

目的 探讨26（7．01％）倒室间隔缺损（VSD）修补术后残余漏的发生原因及防治方法。方法 回顾374例室间隔缺损（VSD）修补术后出现26例残余漏进行分析。结果 分析认为造成残余漏除技术原因外，还与修补的方法有关，随访21年至今，Echo示自行闭合4例，缩小6例，二次手术修补VSD 1例，无死亡。结论 提高修补技术及选择适当的修补方法，是避免残余漏的发生及防治的关键。     

室间隔缺损残余漏的防治与转归

探讨７２１例室间隔缺损修补术后２８例（３．８％）残余漏的发生原因和转归，提出正确的防治方案。分析认为造成残余漏的主要原因是手术技术问题。对残余缺损＜０．５ｃｍ无症状者，可暂不手术；＞０．５ｃｍ有症状者，应及时再手术。本组二次手术修补３例，自行闭合４例，缩小１７例，无变化１例，变大１例，死亡２例。作者提出，提高修补技术和掌握适当再手术时机是残余漏预防和治疗的关键。     

镶嵌治疗肌部多发室间隔缺损患儿的术后护理

目的介绍镶嵌治疗肌部多发室间隔缺损后护理经验,以期提高术后护理质量,减少术后并发症,提高手术成功率。方法对22例肌部多发性室间隔缺损患儿予以镶嵌和封堵治疗。结果 22例手术均成功,安返监护室,因多脏器功能衰竭死亡1例（4.5%）。21例术后随访6个月至3年,14例患儿无明显影响心功能的残余分流,7例封堵器边缘残留少量左向右分流,但全组心功能基本正常。结论保持呼吸通畅,心率、血压稳定,做好胸腔引流、心内测压管、体温的监测,加强特殊用药伊诺前列素的监护,密切监测中枢神经系统症状等是镶嵌治疗肌部多发性缺损术后护理的重点。     

心脏搏动下经右心室微创封堵婴幼儿肌部室间隔缺损

目的 探讨心脏搏动下经右心室微创封堵婴幼儿肌部室间隔缺损的临床效果。方法回顾性分析2010年1月至2013年1月兰州大学第一医院心血管外科39例肌部室间隔缺损患儿行心脏搏动下经右心室微创封堵肌部室间隔缺损的临床资料,其中男26例、女13例,年龄10个月至3岁,体重6～15kg。应用经胸超声心动图进行术后随访,观察封堵器的位置,有无移位、有无残余分流、塑型情况及毗邻瓣膜是否开闭等。观察各瓣膜反流情况、各瓣膜口血流及房室腔的变化,心脏功能、肺动脉高压恢复情况等。结果39例患儿中36例（92．3％）植入封堵器成功封堵,有3例患儿（7．7％）经食管彩色超声心动图（TEE）诊断不适宜行封堵治疗,其中1例由于右心室流出道有异常肌束,2例由于边缘过短不适宜行封堵手术,而改为体外循环下心内直视手术。36例患儿随访6个月以上,经胸超声心动图显示无封堵器脱落、移位,无溶血和房室传导阻滞,人工瓣膜表面光滑,无异物。心脏明显缩小,心功能正常,无神经系统并发症发生。其中3例术后存在轻微的残余分流,随访6个月均消失。结论心脏搏动下经右心室微创封堵肌部室间隔缺损是肌部室间隔缺损一种较优的治疗选择,在经食管彩色超声心动图引导下手术是镶嵌治疗成功的关键,超声科医生与外科医生的合作是手术成功的基础。     

镶嵌治疗肌部多发室间隔缺损患儿的术后护理

目的 介绍镶嵌治疗肌部多发室间隔缺损后护理经验,以期提高术后护理质量,减少术后并发症,提高手术成功率.方法 对22例肌部多发性室间隔缺损患儿予以镶嵌和封堵治疗.结果 22例手术均成功,安返监护室,因多脏器功能衰竭死亡1例(4.5%).21例术后随访6个月至3年,14例患儿无明显影响心功能的残余分流,7例封堵器边缘残留少量左向右分流,但全组心功能基本正常.结论 保持呼吸通畅,心率、血压稳定,做好胸腔引流、心内测压管、体温的监测,加强特殊用药伊诺前列素的监护,密切监测中枢神经系统症状等是镶嵌治疗肌部多发性缺损术后护理的重点.     

右心室双出口无肺动脉狭窄的外科治疗

目的回顾性总结右心室双出口(DORV)无肺动脉狭窄(PS)病人的手术治疗经验。方法1975年1月至2003年6月，38例DORV无PS病人均采用双心室修复，建立左心室至主动脉心内隧道，其中2例DORV肺动脉下室间隔缺损的婴儿行大动脉调转术。结果全组早期死亡5例(13．2％)，其中2例死于肺动脉高压危象、3例死于低心输出量综合征。33例生存者中29例(87．9％)随访1个月。23年，晚期死亡1例(2．6％)，术后95d死于室间隔残余漏所致右心衰竭。随访者心功能恢复至Ⅰ级19例，Ⅱ级9例，Ⅲ级1例。结论DORV无PS的手术治疗早、晚期效果良好。一旦诊断明确，应尽早手术治疗，以避免产生不可逆的肺血管病变，影响治疗效果。     

经皮胸前穿刺封堵室间隔缺损的近期效果CSCD

目的 观察经皮胸前穿刺技术对室间隔缺损（VSD）封堵的近期效果,进一步探讨该技术的可行性.方法 自2015年3月,22例患儿接受经皮胸前穿刺VSD及VSD残余漏封堵术.男15例,女7例;年龄2岁6个月~11岁7个月,体质量13.5~44.0 kg.6例为术后残余漏,残余漏大小4.8~7.0 mm,分别位于膜部、嵴内或双干下;余16例为单纯VSD,缺损大小3.5~5.1 mm.患儿均于胸骨左侧第3或4肋间穿刺进入右心室,21例导丝顺利通过VSD入左心室,在导引钢丝引导下,经输送鞘管分别置入5~10 mm VSD封堵伞各1枚;1例穿刺点选择不当,术中改经胸小切口封堵.结果 21例患儿置入21枚封堵器,等边伞18枚,偏心伞3枚,大小5~10 mm.患儿术中、术后超声心动图均显示残余分流消失,各瓣膜均未出现新的反流,无手术死亡及意外并发症.术后4例超声心动图见心包腔内心底部5~7 mm积液,观察后无加重,未予以处理.所有患儿术后随访1年余,心功能良好.结论 经皮胸前穿刺行VSD或VSD残余漏封堵可行最适用于需再次手术患者及单纯VSD患者,近期效果良好.     

Surgical management of muscular trabecular ventricular septal defects

Despite recent advances in diagnosis, surgical techniques, and postoperative care of children with congenital cardiac defects, muscular trabecular ventricular septal defects (VSDs) are still a therapeutic challenge. Among these defects, it is more difficult to achieve secure and complete closure of low trabecular or apical VSDs because of the presence of numerous muscular trabeculations overlying the defect. When they are associated with “Swiss cheese”-type of VSDs, it is almost impossible to visualize the true edges of the defect through the transatrial approach. Consequently, there remains an unacceptable incidence of mortality and morbidity when compared to those that occur with closure of the usual perimembranous VSD. Although various techniques for closure of these difficult trabecular VSDs have been attempted, there is still a significant incidence of complications in the surgical management of trabecular VSDs, mostly significant residual shunts, a need for multiple reoperations, and severe left ventricular dysfunction. This article describes the anatomical details and classification of muscular trabecular VSDs. It also reviews several techniques currently utilized and their outcomes.     

Left ventriculotomy for closure of muscular ventricular septal defects. Treatment of choice.

Closure of muscular ventricular septal defects (VSDs) through the right atriotomy or right ventriculotomy may be difficult. These VSDs are often located behind the hypertrophied trabeculae carnae or papillary muscle. Residual or recurrent VSD may result from the difficult approach. Between March 1971 and December 1975, we have used the left ventriculotomy near the apex for closure of muscular VSDs in ten children. The patients' ages ranged from five months to eight years and three months. The diagnosis was established by cardiac catheterisation and left ventricular angiocardiogram in all patients. Six patients had multiple VSDs; in four patients VSD in the muscular septum was present (three apical, one midseptal). Operations were performed on cardiopulmonary bypass with moderate hypothermia and intermittent anoxic arrest. VSDs in the membranous septum were closed through the right atrium. Muscular VSDs were approached through a small vertical incision in the left ventricle near the apex. The postoperative course was uneventful in eight patients. Two patients, aged 16 months and eight years, died; histology showed grade IV pulmonary vascular disease in both. All survivors are well four months to five years after the operation, without clinical evidence of residual or recurrent VSD.     

Repair of multiple muscular ventricular septal defects: septal obliteration technique

BACKGROUND: The management of the apical multiple muscular ventricular septal defects (VSDs) remains still controversial. There are various surgical techniques and approaches for closure of "Swiss-cheese" VSDs. In this study, we report the outcome of multiple muscular VSDs repair, using the septal obliteration technique. METHODS: We used the septal obliteration technique in five "Swiss-cheese" ventricular septal defects cases through right atriotomy. Four of the cases had isolated multiple VSDs. One case also had an aortic arch interruption type A, which was repaired prior to cardiopulmonary bypass. Their ages varied between 43 days and 6 years. RESULTS: We did not experience any mortality or serious morbidity. Tracheostomy was required in one patient. There was no important residual shunt in postoperative period, except a minimal shunt in one case. CONCLUSION: The closure technique of "Swiss-cheese" trabecular multiple VSDs using a large single patch was not troubling. Transatrial approach prevented postoperative problems of ventricular incision. Using a large needle with a large pledgett is the key, which provides deep tissue penetration to avoid residual shunt.     

经胸微创非体外循环下封堵室间隔缺损:多中心经验和近中期随访结果

目的 总结多中心应用食管超声引导、经胸微创小切口、非体外循环(CPB)下封堵室间隔缺损(VSD)的临床经验和近、中期随访结果.方法 432例病儿,男235例,女197例;年龄3个月～15岁,平均(3.2±1.9)岁;体重4.0～26.0 kg,平均(13.3±5.6)kg.膜周部VSD 351例,嵴上或嵴内型VSD 57例,肌部VSD 24例(17例多发VSD).VSD直径3～12 mm,平均(5.3±1.6)mm.膜周部VSD,经剑突下或胸骨下端3～4 cm小切口进胸;嵴内或嵴上VSD,经胸骨左缘第3肋间2～3 cm小横切口进胸.暴露右心室表面,在食管超声引导和实时监测下,穿刺右心室游离壁,导引钢丝经右心室腔穿过VSD到达左心室腔,沿导引钢丝导入输送鞘管建立轨道.通过输送鞘管直接将封堵器安放在VSD部位.经食管超声多切面反复评估封堵器的位置和与周边组织的关系,若无异常情况即可释放封堵器.结果 432例中417例封堵成功(96.5%),15例(3.5%)术中改为常规CPB手术.封堵成功者中,选用对称伞238例(57.1%),偏心伞179例(42.9%).13例(3.1%)发生新的微量至轻度三尖瓣反流,11例(2.6%)术后发生不完全右束支传导阻滞,3例(0.7%)术后发生一过性完全性房室传导阻滞.术后383例(91.8%)病儿在2 h内拔除气管插管,3～5天出院.术后416例(96.2%,416/432例)随访12～38个月,平均(19.3±11.6)个月,无近、中期死亡.1例术后6个月发生完全性房室传导阻滞.其余无明显异常.结论 应用食管超声引导、经胸微创非CPB下封堵VSD技术,是一种相对简单有效的治疗方法,近、中期临床结果满意,但远期结果需要进一步观察.

Abstract：

Objective Transesophageal echocardiography (TEE) guided, minimally invasive perventricular device occlusion of ventricular septal defects ( VSDs) without cardiopulmonary bypass ( CPB) has been applied in multiple centers. We reported experiences and the mid-term results. Methods Four hundred and thirty-two cases from 4 cardiac centers were involved in the study. There were 235 males and 197 females, aged from 3 months to 15 years, with a body weight varying from 4.0 to 26.0 kg. Three hundred and fifty-one patients had perimembranous VSDs, 57 had intracristal or supracristal VSDs and 24 had muscular VSDs (17 had multiple muscular VSDs). The diameter of the VSD ranged from 3 to 12 (5.3 ±1.6 ) mm.For those with perimembranous or muscular VSDs, a 3 to 5 cm inferior sternotomy was made, but for those with intracristal or supracristal VSDs, a 2 to 3 cm incision was made parastemally through the left third intercostal space. Being monitored and guided with TEE, the device was deployed to occlude the VSD through the puncture at the free wall of the right ventricle. TEE was used for assessing the residual shunting, the left and right ventricular outlet tracts, valvular function and for detecting any arrhythmia, The devices would be released if the heart rhythm was normal, as well as the residual shunting and valvular regurgilalion were not detected. Results The procedure was completed successfully in 417 cases(96.5% ) and converted to traditional surgical closure with CPB in the other 15 cases(3.5% ). Concentric devices were used in 238 cases(57.1% )and eccentric devices were used in 179 patients(42.9% ). Successful procedures finished in less than 90 minutes, and the deployment and evaluation of the devices were completed in 5 to 60 (18. 2 ± 8.6) minutes. No residual shunt and detectable aortic or tricuspid insufficiency and arrhythmia was observed. Patients were extubated within 2 hours and discharged 3 to 5 days after the operation. During fellow-up period from 3 months to 2 years, no clinically significant complications occurred. Conclusion The minimally invasive device closure of VSD under TEE guidance without CPB is proved to be a simple, safe and effective treatment for a considerable number of children with VSD. Its use in the clinical practice should be encouraged.     

Experience with autologous pericardial patch closure of ventricular septal defect

Background Conventionally, Ventricular Septal Defects (VSDs) are repaired with synthetic patch—Dacron (polyethylene terephthalate) or Goretex (expanded polytetrafluoroethylene). Recently, we began using glutaraldehyde—treated autologous pericardial patch to repair VSDs. We review our experience. Material and Method Between July to November 2005, 60 children had their VSDs repaired with glutaraldehyde—treated autologous pericardium. There were 40 males and 20 females, aged between 5 months and 12 years with a median age of 1 year. The diagnosis was isolated VSD in 37 patients, multiple VSD in 3; Tetralogy of Fallot (TOF) in 15 and Double Outlet Right Ventricle (DORV) in 5 patients. The chest was opened by a median sternotomy incision. After establishing cardiopulmonary bypass, a strip of pericardium was harvested from the patient and fixed in 0.6% glutaraldehyde (Polyscientific, Bayshore, NY) for about 20 minutes. It was then washed out with 0.9% saline solution. The defect was repaired with 4/0 or 5/0 prolene suture using a continuous suture technique. Results There was no hospital mortality. Postoperative echocardiogram revealed trivial shunts in 10 patients. Follow up was for 3 to 6 months (mean 2 months). No patient required reoperation for residual VSD. Conclusion Glutaraldehyde—treated autologous pericardium is an excellent material for surgical patch clousre of VSD. It is easily available and does not require sterilization. Further follow-up is required to assess its long term efficacy.     

Surgical management of transposition of great arteries associated with multiple ventricular septal defects.

OBJECTIVE: The presence of associated multiple ventricular septal defects (VSDs) increases the risk of the anatomic repair for transposition of the great arteries (TGA). The aim of this study was to define the optimal management of this complex anomaly. METHODS: Between January 1988 and December 1998, 45 patients underwent anatomic repair of TGA associated with multiple VSDs. The median age was 50 days and the median weight 4 kg. Eighteen (40%) had undergone previous palliation including 17 pulmonary artery banding procedure (PAB), seven associated with coarctation repair and one isolated coarctation repair. The perimembraneous septum was involved in 24 patients, the trabecular in 43, the inlet in seven and the infundibular in two. Closure of the VSDs included Dacron or pericardial patchs and matress sutures. The initial approach was through right atriotomy which was sufficient in 15 patients. VSDs were closed through right ventriculotomy in 13 patients, through pulmonary artery in six, through the aorta in one and in the remaining (n = 10) combined approaches were used. Only one patient required left apical ventriculotomy. RESULTS: There were five hospital deaths (11%; 70% CL: 6-18%) including the one early reoperation for residual VSD closure. Five patients had successful early reoperation for secondary PAB for residual VSD. Three late deaths occurred (7%; 70% CL: 3-13%). At the last visit, 95% of survivors were asymptomatic and without any cardiac medication. CONCLUSION: Mid-term survival with good quality of life can be achieved following either one or two-stage repair of this complex anomaly. In the presence of VSD closure failure a secondary PAB may be the procedure of choice.     

未闭合膜部室间隔缺损的外科处理

为了探明位于三尖瓣边缘上的小室间隔缺损（ＶＳＤ）术后易发生心内残余分流的原因，１９９１年１月至１９９２年６月，我们于术中观察了３０例这一类型的ＶＳＤ。发现有以下特点：（１）三尖瓣隔瓣及其腱索与室间隔粘连；（２）隔瓣下隐蔽着一个较大的膜部室间隔缺损（ＭＶＳＤ）；（３）隔瓣边缘上的１个或多个缺损间及与隔瓣下的ＭＶＳＤ相互交通。我们认为，隔瓣边缘上的小“ＶＳＤ”可能是ＭＶＳＤ未完全闭合的一种形式。采用切开隔瓣，修补ＭＶＳＤ，再缝合隔瓣切口的手术方法，成功地避免了术后心内残余分流。     

Repair of isolated multiple muscular ventricular septal defects: the septal obliteration technique

BACKGROUND: Isolated multiple ventricular septal defects (mVSDs) remain a surgical challenge. The dilemma of whether to perform a complete repair ultimately rests with the surgeon, who must decide if all significant septal defects can be located. Avoidance of a pulmonary arterial band (as part of a two-stage repair) will negate the need for future pulmonary arterial reconstruction and will reduce the incidence of late right ventricular diastolic dysfunction. METHODS: We performed a retrospective analysis of hospital and echocardiographic data of eight children who underwent a septal obliteration technique (SOT) as part of their correction of mVSDs (with and without coarctation of the aorta). RESULTS: Eight children with a mean age of 10.5 months (range 1.5 to 36 months), and weight of 6.2 kg (range 2.1 to 13.5 kg), respectively, underwent correction of mVSDs. All had a single, large, perimembranous defect, additional VSDs within the muscular trabecular septum (juxtaposed to the moderator band), and apical mVSDs. All VSDs were repaired via the right atrium, with avoidance of either a right or left ventriculotomy. The posterior and apical defects were excluded from the right ventricular cavity with a pericardial patch (SOT). The follow-up period remains limited to a mean of 20.9 months (8 to 39 months). Two children repaired with SOT had previous pulmonary artery bands (neonatal coarctation repair). All children were successfully discharged home with a mean postoperative Qp:Qs of 1.09:1. One pacemaker was required, but this child has since reverted back to normal sinus rythm. CONCLUSIONS: Our initial experience using the SOT in the treatment of apical VSDs as a component of isolated mVSDs has been rewarding. All children are currently alive, in normal sinus rhythm, and have no residual significant left-to-right shunts.     

Long-term results of primary closure for ventricular septal defects in the first year of life

The long-term results of primary closure for large ventricular septal defects (VSDs) in infants under 1 year of age with severe symptoms were studied over a period of more than 10 years. Between January, 1971 and March, 1982, 49 infants underwent primary closure of a VSD through a right ventriculotomy using complete cardiopulmonary bypass with mild hypothermia. There were four hospital deaths but no late deaths. Two of four infants with residual shunts had a left ventricular-right atrial shunt which necessitated reoperation. Surgical heart. block occurred in two infants who recovered sinus rhythm in the late period. The cardiothoracic ratio decreased from 60.5% preoperatively to 50.6% in the late postoperative period. Examination by cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio (Pp/Ps) of 23 patients with a Pp/Ps of over 0.75 fell from 0.89 ± 0.09 preoperatively to 0.42 ± 0.12 by 1 month postoperatively, then to 0.27 ± 0.05 in the late postoperative period. The latest values for the cardiac index and left ventricular ejection fraction were 3.41 /min per m² and 64.4%, respectively. More than 10 years after their operation, all the survivors were growing normally and maintaining a good quality of life, which supports our recommendation that primary repair should be performed in the first year of life for infants with large VSDs.     

New approach to multiple ventricular septal defect closure with intraoperative echocardiography and double patches sandwiching the septum

OBJECTIVE: This was an evaluation of a new approach to the management of multiple muscular ventricular septal defects. The defects were located with epicardial echocardiography, then transfixed with a guide wire inserted directly through the right ventricular free wall. They were closed with a custom-made multilayered double-patch device under cardioplegic arrest through a standard right atriotomy. METHODS: This was a retrospective study of 14 consecutive patients. RESULTS: The median age and body weight at repair were 40 days (range 1 week-8 years, 3 months) and 4.1 kg (2.8-24 kg), respectively. Five patients (36%) had undergone at least one previous sternotomy; 11 patients (78%) had associated cardiac lesions. Closure of the multiple septal defects was successful in 12 patients (85%). Failure to localize all defects led to pulmonary artery banding in 2 patients. One patient had the residual septal defect closed with a percutaneous device 6 months later, and in the second patient the residual defect was closed with a conventional approach 11 months afterward. Two patients had permanent pacemaker insertion. In 279 patient-months of follow-up, there was 1 cardiac arrest on day 1 and no early or late deaths; all children but one are free of cardiac medications, and no significant residual left-to-right shunts were demonstrated in any patient. CONCLUSION: The reported management of multiple ventricular septal defects has been successful in this series, even in neonates and infants with complex associated cardiac lesions. It appears safe, simple, and effective.