室间隔缺损(VSD)介入治疗中封堵器的个体化应用

 目的  研究室间隔缺损(ventricular septal defect,VSD)介入治疗中封堵器个体化选择对疗效和并发症的影响。方法  选择符合介入治疗标准的137例VSD患者为研究对象,男性71例,女性66例,年龄3~76 (31.52±16.13)岁。其中膜周部98例,单纯肌部10例,嵴内型12例,外科修补术后残余分流VSD11例,心肌梗死后室间隔穿孔VSD 5例,外伤引起的室间隔肌部穿孔VSD 1例。根据左心室造影VSD的形态、大小、与主动脉瓣及三尖瓣的关系进行个体化选择封堵器介入治疗,术后即刻、24 h、1个月、3个月、6个月和12个月观察随访其疗效、并发症、心腔大小和肺动脉压力的变化。结果  124例患者成功封堵(90.51%),共使用了126个封堵器(2例患者分别使用了2个封堵器)：对称型封堵器26个(20.6%),边3型18个(14.3%),边4型44个(34.9%),边5 型13个(10.3%),偏心型14个(11.1%),肌部11个(8.7%)。29例(23.4%)术后出现心律失常,分别是Ⅰ度房室传导阻滞、左前分支传导阻滞、完全性左束支传导阻滞、不完全性右束支传导阻滞、完全性右束支传导阻滞、室上性早搏和加速性交界性心动过速,总恢复率为96.6%,无Ⅲ度AVB。左心房前后径和左心室舒张末内径在术后24 h明显缩小(P=0.001及0.002);左心室收缩末内经在术后24 h及术后1个月均缩小(P=0.007);左心室射血分数在术前术后、24 h、术后随访中变化无明显统计学意义。肺动脉收缩压术后24 h较术前有明显下降(P=0.001),术后1、3、6、12个月均未见进一步下降(P=0.820)。结论  经导管介入治疗VSD，封堵器应个体化选择,选择合适的封堵器既能有效封堵VSD,又可减少发生或避免医源性并发症。

Individualized selection of occluder in interventional treatment of ventricular septal defect (VSD)

Objective  To study the application of individualized selection of ventricular septal defect (VSD) occluder in interventional treatment and its efficacy and complications.Methods  One hundred and thirty seven VSD patients,male 71 cases,female 66 cases,aged 3 to 76 (mean 31.52±16.13) years were enrolled,including perimembraneous VSD (98 cases),muscular VSD (10 cases),intracristal VSD (12 cases),residual shunt after surgical repair of VSD (11 patients),ventricular septal perforation after myocardial infarction (5 cases), and ventricular septal muscular rupture caused by trauma (1 case).Different occluders were selected according to the shape,the size of VSD and the relationship with the aortic and tricuspid valves.The efficacy,complications,size of chambers of heart
 and pulmonary artery pressure were assessed at 24 hours,1 month,3 months and 6 months respectively after procedures.Results  Among 137 cases,124 were successfully proceed(90.51%) and 126 occluders were used during the procedures with two occluders placed in 2 patients respectively.The occluders were symmetric (26,20.6%),edge 3 type (18,14.3%), edge type 4 (44,34.9%),edge type 5 (13,10.3%),decentered (14,11.1%) and muscular (11,8.7%).Arrhythmia occurred after operation in 29 cases included degree 1 atrioventricular block(AVB),left anterior hemiblock(LAH),complete left bundle branch block (CLBBB),and incomplete right bundle branch block(IRBBB),complete right bundle branch block (CRBBB),supraventricular tarrhythmias.The recovery rate was 96.6%.There was no Ⅲ AVB happened.The anteroposterior diameter of the left atrium (LADap) and left ventricular end diastolic diameter (LVDd) decreased significantly (P=0.001 and 0.002) 24 hours after the procedures.The left ventricular end systolic diameter (LVDs) decreased but change was not statistically significant (P=0.097) 24 hours after the procedures.The LVDs continued to decrease significantly 1 month after procedures (P=0.007).The left ventricular ejection fraction(LVEF) showed no significant difference in pre process,post process and follow up after procedures.The pulmonary artery systolic pressure (PASP) 24 hours after procedures decreased significantly (P=0.001) compared with that before,but there was no further decline 1 month after the procedures (P=0.820).Conclusions  The occluder of the treatment of transcatheter closure of VSD should be chosen individually according to different types of VSD.Thus,we can not only close VSD effectively,but also reduce or avoid the occurrence of iatrogenic complications.