左胸微创切口在儿童干下型室间隔缺损直视修补术中的应用

目的总结左胸微创切口在儿童干下型室间隔缺损(ventricular septal defect,VSD)直视修补术中的应用方法,并评价临床效果。方法回顾性分析2015年10月至2019年4月上海交通大学医学院附属新华医院心胸外科21例干下型VSD儿童的临床资料,其中男13例、女8例,年龄5~13(9.1±2.2)岁,体重22~55(35.6±9.5)kg。VSD最大直径4~15(9.1±3.3)mm,术前合并主动脉瓣右冠瓣轻度脱垂8例,主动脉瓣轻到轻中度关闭不全4例。取左侧第2或第3肋间胸骨旁横切口进胸,股动、静脉插管建立体外循环,阻断升主动脉后,在肺动脉瓣上横行切开肺动脉,根据VSD大小、形态直接缝合或补片修补干下型VSD。出院前及随访常规复查经胸超声心动图评价VSD修补效果及主动脉瓣开闭情况。结果全组患儿均顺利经左胸微创切口完成VSD直视修补术,无转为正中开胸手术者。VSD修补方法:补片修补(n=15),直接缝合(n=6)。体外循环时间45~68(57.1±6.3)min,主动脉阻断时间23~40(32.6±4.7)min,术后呼吸机辅助时间5~9(6.3±1.3)h,术后24 h胸腔引流量33~105(57.5±17.7)mL,术后住院时间5~8(5.7±1.0)d。出院前及随访复查经胸超声心动图提示VSD闭合良好,无VSD残余漏;主动脉瓣轻度关闭不全1例。围术期及随访无死亡病例,无房室传导阻滞、切口愈合不良、胸廓畸形等并发症发生。结论左胸微创切口可安全、有效地应用于儿童干下型VSD直视修补术中,早、中期治疗效果满意。

The application of left anterior minimally invasive thoracotomy to surgical repair of subarterial ventricular septal defect in children

Objective To summarize the application and clinical effect of left anterior minimally invasive thoracotomy to surgical repair of subarterial ventricular septal defect(VSD)in children.Methods From October 2015 to April 2019,21 children with subarterial VSD underwent surgical repair via left anterior minimally invasive thoracotomy.There were 13 males and 8 females,aged 5-13(9.1±2.2)years,and weighing 22-55(35.6±9.5)kg.The diameter of subarterial VSD was 4-15(9.1±3.3)mm.Eight patients had right coronary valve prolapse,and 4 aortic valve regurgitation(3 mild and 1 mild-to-moderate).The minimally invasive surgery was performed via left parasternal thoracotomy through the second or third intercostal space.The peripheral perfusion was performed with femoral arterial and venous cannulation.After aortic cross-clamp(ACC),subarterial VSD was performed with direct suture of patch closure through an incision on the root of pulmonary artery.Results All patients successfully underwent surgical repair(patch closure,n=15;direct suture,n=6)of subarterial VSD through left anterior minimally invasive thoracotomy.The cardiopulmonary bypass time was 45-68(57.1±6.3)min.The ACC time was 23-40(32.6±4.7)min.The postoperative ventilation time was 5-9(6.3±1.3)h,postoperative in-hospital time was 5-8(5.7±1.0)d and drainage volume was 33-105(57.5±17.7)mL in postoperative 24 h.No death,residual VSD shunt,atrioventricular block,wound infection or thoracic deformity occurred during the perioperation or follow-up.Only one patient still had trivial aortic valve regurgitation.Conclusion Left anterior minimally invasive thoracotomy could be safely and effectively applied to surgical repair of subarterial VSD in children,with satisfactory early-and mid-term outcomes.