膜周部室间隔缺损经导管介入封堵后早期并发症危险因素的分析

目的：探讨膜周部室间隔缺损（VSD）经介入治疗后早期并发症的危险因素。方法：回顾性纳入2015年10月1日至2017年10月1日在重庆医科大学附属儿童医院行膜周部VSD介入封堵术的患儿，从医院电子病历系统中截取临床资料，分析术后总并发症、新发心律失常、残余分流、新发中度及以上反流的危险因素。结果：①186例患儿进入本文分析，男97例，年龄18~148（45.4±25.4）个月，体重8.5~48（15.7±6.1) kg；超声缺损（5.6±1.9）mm，压差（68.6±13.7）mmHg，距主动脉瓣距离＜3 mm 8例（4.3%），术前有心律失常18例（9.7%），合并膜部瘤70例（37.6%）；封堵器大小（6.3±1.2）mm，封堵器形状对称178例（95.7%）、偏心8例；麻醉方式为全麻147例（79%）、局麻39例，手术时间（38.8±15.0）min。②术后住院期间共发生并发症60例（32.3%），新发心律失常30例（16.1%）；残余分流30例（16.1%），其中1例为大量分流；新发中度及以上瓣膜反流9例（4.8%），均为三尖瓣反流。③多因素Logistic回归分析显示，总并发症：超声下大缺损（OR=1.264，95％CI: 1.040～1.536，P=0.019）和偏心型封堵器（OR=6.732，95％CI: 1.018～44.509，P=0.048）为危险因素；残余分流：超声下大缺损（OR=1.577，95％CI: 1.154～2.155，P=0.004）和右心室收缩压升高（OR=1.080，95％CI: 1.001～1.165，P=0.047）为危险因素，左心室平均压升高为保护因素（OR=0.913，95％CI: 0.864～0.966，P=0.001）；新发中度及以上瓣膜反流：右心室收缩压升高（OR=1.068，95％CI: 1.006～1.133，P=0.030）和更大的封堵器（OR=1.585，95％CI: 1.003～2.506，P=0.048）为危险因素。结论：超声下VSD大小、封堵器的大小与形状、右心室收缩压、左心室平均压与膜周部VSD介入治疗术后早期并发症发生有关，同时提示血流动力学稳定性、右心功能在术后并发症发生中的重要作用。

Risk factors for complications at the early stage after transcatheter closure of peri-membranous ventricular septal defect

Objective:To investigate the risk factors for complications at the early stage after transcatheter closure of peri-membranous ventricular septal defect (pm VSD).Methods:This retrospective study included children treated with transcatheter closure of pm VSD in Children's Hospital of Chongqing Medical University from 1st October, 2015 to 1st October, 2017. The clinical data were extracted from the electronic medical record system, to explore the risk factors for total complications, new arrhythmia, residual shunt and new medium or more serious valve regurgitation at the early stage after transcatheter closure.Results:① A total of 186 cases were enrolled, of whom 97 patients were male. The age ranged from 18 to 148 months with the average age of 45.4±25.4 months. The weight ranged from 8.5 to 48 kg with the average weight of 15.7±6.1 kg. The average size of pm VSD detected by transthoracic echocardiography was 5.6±1.9 mm. The average pressure differential between both sides of the defect was 68.6±13.7 mmHg. The distance between the defect and the tricuspid rim was less than 3 mm in 4.3%(8/186) of the patients. Preexisting arrhythmia was found in 9.7%(18/186) of the patients, and aneurysm was found in 70(37.6%) cases. The average size of the occluders was 6.3±1.2 mm, and asymmetric occluders were used in 8(4.3%) cases. 79%（147/186）underwent transcatheter closure of pm VSD under general anesthesia. The average operation time was 38.8±15.0 min. ②The incidence rate of total complications was 32.3%(60/186), including new arrhythmias 16.1%(30/186), residual shunt 16.1%(30/186), new medium or more serious valve regurgitation 4.8%(9/186). All of valve regurgitation was found in tricuspid valve. A 20-month-old girl developed serious residual shunt. She was suffered from serious residual shunt, valve regurgitation and mechanical hemolysis, and discharged from hospital after surgical procedure. ③Based on analysis by multivariate logistic regression. Larger size of pm VSD detected by transthoracic echocardiography （OR=1.264，95％CI: 1.040-1.536，P=0.019） and asymmetric occluders（OR=6.732，95％CI: 1.018-44.509，P=0.048） were independent risk factors for total complications. Large size of pm VSD detected by transthoracic echocardiography (OR=1.577，95％CI: 1.154-2.155，P=0.004) and increased right ventricular systolic pressure (OR=1.080，95％CI: 1.001-1.165，P=0.047) were independent risk factors for residual shunt. Increased left ventricular mean pressure (OR=1.068，95％CI: 1.006-1.133，P=0.030) was a protective factor for residual shunt. Increased right ventricular systolic pressure (OR=1.068，95％CI: 1.006-1.133，P=0.030) and larger size of occluders（OR=1.585，95％CI: 1.003-2.506，P=0.048） were independent risk factors for new medium or more serious valve regurgitation.Conclusion:The current study provides evidence of correlative factors for total complications, residual shunt and new medium or more serious valve regurgitation at the early stage after transcatheter closure of pm VSD. Further research is needed to assess the association between complications and hemodynamic changes, function of left heart.