CAJ | 학술논문

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.
목적 총결다중심응용식관초성인도、경흉미창소절구、비체외순배(CPB)하봉도실간격결손(VSD)적림상경험화근、중기수방결과.방법 432례병인,남235례,녀197례;년령3개월～15세,평균(3.2±1.9)세;체중4.0～26.0 kg,평균(13.3±5.6)kg.막주부VSD 351례,척상혹척내형VSD 57례,기부VSD 24례(17례다발VSD).VSD직경3～12 mm,평균(5.3±1.6)mm.막주부VSD,경검돌하혹흉골하단3～4 cm소절구진흉;척내혹척상VSD,경흉골좌연제3륵간2～3 cm소횡절구진흉.폭로우심실표면,재식관초성인도화실시감측하,천자우심실유리벽,도인강사경우심실강천과VSD도체좌심실강,연도인강사도입수송초관건립궤도.통과수송초관직접장봉도기안방재VSD부위.경식관초성다절면반복평고봉도기적위치화여주변조직적관계,약무이상정황즉가석방봉도기.결과 432례중417례봉도성공(96.5%),15례(3.5%)술중개위상규CPB수술.봉도성공자중,선용대칭산238례(57.1%),편심산179례(42.9%).13례(3.1%)발생신적미량지경도삼첨판반류,11례(2.6%)술후발생불완전우속지전도조체,3례(0.7%)술후발생일과성완전성방실전도조체.술후383례(91.8%)병인재2 h내발제기관삽관,3～5천출원.술후416례(96.2%,416/432례)수방12～38개월,평균(19.3±11.6)개월,무근、중기사망.1례술후6개월발생완전성방실전도조체.기여무명현이상.결론 응용식관초성인도、경흉미창비CPB하봉도VSD기술,시일충상대간단유효적치료방법,근、중기림상결과만의,단원기결과수요진일보관찰.
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.