经导管膜周部室间隔缺损封堵术并发三尖瓣损伤8例临床分析

摘要：目的　分析经导管膜周部室间隔缺损（PMVSDs）封堵术并发三尖瓣损伤原因，探讨其预防及处理措施。 方法　2002年10月至2009年12月广东省心血管病研究所825例PMVSDs患儿，均进行了经导管介入封堵，其中8例出现三尖瓣损伤。8例患儿中男4例，女4例；年龄3.5～8.0岁。8例三尖瓣损伤患儿中4例出现三尖瓣狭窄，其中2例严重狭窄者行外科手术治疗，术中见封堵器右室盘与三尖瓣腱索缠绕，予松开缠绕、取出封堵器并修补室间隔缺损；2例轻度狭窄者予随诊观察。8例中其余4例出现三尖瓣关闭不全，其中3例反流严重予外科手术治疗，术中见三尖瓣腱索断裂1例，腱索断裂并瓣膜撕裂1例，三尖瓣隔瓣腱索被封堵器牵拉1例。术中将断裂的腱索缝合，取出封堵器并修补室缺，合并三尖瓣撕裂者行三尖瓣整形。余1例三尖瓣隔瓣脱垂并轻至中度反流的病例予随诊。结果　5例外科手术治疗者中，4例三尖瓣功能恢复良好，1例三尖瓣血流速度稍增快。三尖瓣损伤不重未行外科处理的3例病例随诊1月至2年，三尖瓣病变无加重，患儿无明显临床症状。结论　经导管PMVSDS封堵术并发三尖瓣损伤有多方面原因。操作中应避免轨道钢丝穿过三尖瓣腱索，出现腱索与封堵器或输送钢缆缠绕时切勿使用暴力牵拉。三尖瓣损伤严重时应外科手术治疗。

Tricuspid injury in transcatheter closure procedure of perimembranous ventricular septal defects：a clinical analysis of 8 cases.

Abstract：Objective　To study prevention and treatment methods for tricuspid injury in transcatheter closure procedure of perimembranous ventricular septal defects（PMVSDs）. Methods　Eight cases with tricuspid injury in transcatheter closure procedure of PMVSDs were enrolled from Oct. 2002 to Dec. 2009. Tricuspid stenosis presented in 4 cases，of whom 2 needed surgery. The right disc and screw of PMVSDs occluder got entangled into the chordae of anterior tricuspid leaflet in both operative cases. Tricuspid regurgitation occurred in 4 cases. Three cases received surgery repair and device removal. The operation finding was anterior papillary muscle rupture in 1， anterior papillary muscle rupture combined with anterior tricuspid leaflet tear in 1 and chordae tendineae of septal leaflet stretched by device screw in 1 case. Another patient with mild to moderate tricuspid regurgitation and septal leaflet prolapse also received follow-up study. Results　Among the 5 patients with surgery， tricuspid valve got to normal in 4 cases and valve flow velocity slightly accelerated in 1 case. In the follow-up study， there were no clinical symptoms in the cases with mild or mild to moderate tricuspid injury with no repair. Conclusion　In procedure of transcatheter closure of PMVSDs， passing the arteriovenous circuit wire through tricuspid chordae can lead to tricuspid injury. Sever tricuspid injury should be repaired by surgery.