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.

Minimally invasive perventricular vsd closure without cardiopulmonary bypass mid-term results from multi-centers

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.