中华胸心血管外科杂志
中華胸心血管外科雜誌
중화흉심혈관외과잡지
Chinese Journal of Thoracic and Cardiovascular Surgery
2015年
9期
527-532
,共6页
室间隔缺损%封堵%封堵器%心脏外科手术%婴幼儿%心肺转流术
室間隔缺損%封堵%封堵器%心髒外科手術%嬰幼兒%心肺轉流術
실간격결손%봉도%봉도기%심장외과수술%영유인%심폐전류술
Ventrical septal defect%Closure%Occlusion device%Cardiac Surgical operation%Infant%Cardiopulmonary bypass
目的 前瞻性随机对照研究经胸微创封堵与右腋下小切口直视修补治疗婴幼儿膜周部室间隔缺损(PmVSD)的疗效和随访结果.方法 2010年1月至2013年1月,530例限制性PmVSD患儿纳入研究,年龄＜3岁,体质量＜15 kg.应用随机数字表法随机分为两组:微创封堵组265例,采用胸骨下端小切口非体外循环经食管超声(TEE)引导,穿刺右心室游离壁,应用改良封堵器直接闭合VSD;右腋下小切口直视修补组265例,在常规体外循环(CPB)下采用右腋下小切口直视修补VSD.对比两组患儿手术成功率、手术时间、用血量、失血量、呼吸机辅助时间、ICU滞留时间、住院时间以及并发症发生率和医疗费用等指标.结果 两组患儿全部得到有效治疗,均无死亡和危及生命的严重并发症.微创封堵组中10例(3.77％)封堵失败,适当延长原切口后中转常规直视手术成功修补;255例(96.23％)一次性封堵成功者中术后发生心律失常30例(11.76％),包括不完全左支传导阻滞(ILBB)3例(1.18％)、完全右束支传导阻滞(CRBB)3例(1.18％)、不完全右束支传到阻滞(IRBB) 16例(6.27％)、Ⅰ度房室传导阻滞(AVB)8例(3.14％),微到少量残余分流(RS) 18例(7.06％),新增三尖瓣少量反流(TR) 29例(11.37％).右腋下小切口直视修补组患儿全部成功(100％),术后心律失常116例(43.77％),包括CRBB 61例(23.02％)、IRBB 52例(19.62％)、临时性完全性房室传导阻滞(CAVB)和ILBB各2例(0.75％)、交界性异位心动过速(JET)1例(0.38％);微到少量RS 16例(6.04％),新增少量TR11例(4.15％),心功能不全17例(6.42％).所有患儿随访12个月以上,无新增或加重的瓣膜反流,无迟发的CAVB以及其他并发症.两组比较,最终疗效相仿.微创封堵组住院天数、手术时间、用血量、失血量、呼吸机辅助时间、ICU滞留时间、住院时间及费用等结果明显低于右腋下小切口直视修补组(P＜0.05),TR病例多于右腋下小切口直视修补组(P＜0.05);右腋下小切口直视修补组右束支传导阻滞发生率高于微创封堵组(P＜0.05),切口长度大于微创封堵组,但是其隐蔽性更好;微创封堵组无需体外循环,但术后需服用抗凝药物3～6个月.结论 经胸微创封堵和右腋下小切口直视修补术都是膜周部室间隔缺损有效治疗方式.微创封堵虽然有一定的局限性,但其操作简单、创伤小、恢复快、并能节约大量医疗资源,对于有治疗适应证的患儿可作为治疗首选.
目的 前瞻性隨機對照研究經胸微創封堵與右腋下小切口直視脩補治療嬰幼兒膜週部室間隔缺損(PmVSD)的療效和隨訪結果.方法 2010年1月至2013年1月,530例限製性PmVSD患兒納入研究,年齡＜3歲,體質量＜15 kg.應用隨機數字錶法隨機分為兩組:微創封堵組265例,採用胸骨下耑小切口非體外循環經食管超聲(TEE)引導,穿刺右心室遊離壁,應用改良封堵器直接閉閤VSD;右腋下小切口直視脩補組265例,在常規體外循環(CPB)下採用右腋下小切口直視脩補VSD.對比兩組患兒手術成功率、手術時間、用血量、失血量、呼吸機輔助時間、ICU滯留時間、住院時間以及併髮癥髮生率和醫療費用等指標.結果 兩組患兒全部得到有效治療,均無死亡和危及生命的嚴重併髮癥.微創封堵組中10例(3.77％)封堵失敗,適噹延長原切口後中轉常規直視手術成功脩補;255例(96.23％)一次性封堵成功者中術後髮生心律失常30例(11.76％),包括不完全左支傳導阻滯(ILBB)3例(1.18％)、完全右束支傳導阻滯(CRBB)3例(1.18％)、不完全右束支傳到阻滯(IRBB) 16例(6.27％)、Ⅰ度房室傳導阻滯(AVB)8例(3.14％),微到少量殘餘分流(RS) 18例(7.06％),新增三尖瓣少量反流(TR) 29例(11.37％).右腋下小切口直視脩補組患兒全部成功(100％),術後心律失常116例(43.77％),包括CRBB 61例(23.02％)、IRBB 52例(19.62％)、臨時性完全性房室傳導阻滯(CAVB)和ILBB各2例(0.75％)、交界性異位心動過速(JET)1例(0.38％);微到少量RS 16例(6.04％),新增少量TR11例(4.15％),心功能不全17例(6.42％).所有患兒隨訪12箇月以上,無新增或加重的瓣膜反流,無遲髮的CAVB以及其他併髮癥.兩組比較,最終療效相倣.微創封堵組住院天數、手術時間、用血量、失血量、呼吸機輔助時間、ICU滯留時間、住院時間及費用等結果明顯低于右腋下小切口直視脩補組(P＜0.05),TR病例多于右腋下小切口直視脩補組(P＜0.05);右腋下小切口直視脩補組右束支傳導阻滯髮生率高于微創封堵組(P＜0.05),切口長度大于微創封堵組,但是其隱蔽性更好;微創封堵組無需體外循環,但術後需服用抗凝藥物3～6箇月.結論 經胸微創封堵和右腋下小切口直視脩補術都是膜週部室間隔缺損有效治療方式.微創封堵雖然有一定的跼限性,但其操作簡單、創傷小、恢複快、併能節約大量醫療資源,對于有治療適應證的患兒可作為治療首選.
목적 전첨성수궤대조연구경흉미창봉도여우액하소절구직시수보치료영유인막주부실간격결손(PmVSD)적료효화수방결과.방법 2010년1월지2013년1월,530례한제성PmVSD환인납입연구,년령＜3세,체질량＜15 kg.응용수궤수자표법수궤분위량조:미창봉도조265례,채용흉골하단소절구비체외순배경식관초성(TEE)인도,천자우심실유리벽,응용개량봉도기직접폐합VSD;우액하소절구직시수보조265례,재상규체외순배(CPB)하채용우액하소절구직시수보VSD.대비량조환인수술성공솔、수술시간、용혈량、실혈량、호흡궤보조시간、ICU체류시간、주원시간이급병발증발생솔화의료비용등지표.결과 량조환인전부득도유효치료,균무사망화위급생명적엄중병발증.미창봉도조중10례(3.77％)봉도실패,괄당연장원절구후중전상규직시수술성공수보;255례(96.23％)일차성봉도성공자중술후발생심률실상30례(11.76％),포괄불완전좌지전도조체(ILBB)3례(1.18％)、완전우속지전도조체(CRBB)3례(1.18％)、불완전우속지전도조체(IRBB) 16례(6.27％)、Ⅰ도방실전도조체(AVB)8례(3.14％),미도소량잔여분류(RS) 18례(7.06％),신증삼첨판소량반류(TR) 29례(11.37％).우액하소절구직시수보조환인전부성공(100％),술후심률실상116례(43.77％),포괄CRBB 61례(23.02％)、IRBB 52례(19.62％)、림시성완전성방실전도조체(CAVB)화ILBB각2례(0.75％)、교계성이위심동과속(JET)1례(0.38％);미도소량RS 16례(6.04％),신증소량TR11례(4.15％),심공능불전17례(6.42％).소유환인수방12개월이상,무신증혹가중적판막반류,무지발적CAVB이급기타병발증.량조비교,최종료효상방.미창봉도조주원천수、수술시간、용혈량、실혈량、호흡궤보조시간、ICU체류시간、주원시간급비용등결과명현저우우액하소절구직시수보조(P＜0.05),TR병례다우우액하소절구직시수보조(P＜0.05);우액하소절구직시수보조우속지전도조체발생솔고우미창봉도조(P＜0.05),절구장도대우미창봉도조,단시기은폐성경호;미창봉도조무수체외순배,단술후수복용항응약물3～6개월.결론 경흉미창봉도화우액하소절구직시수보술도시막주부실간격결손유효치료방식.미창봉도수연유일정적국한성,단기조작간단、창상소、회복쾌、병능절약대량의료자원,대우유치료괄응증적환인가작위치료수선.
Objective To compare the treatment outcomes between minimally invasive perventricular device occlusion (MIPDO) and right subaxillary incision surgical repair(RSISR) on perimembranous ventricular septal defect(PmVSD) in children less than 15 kilograms.Methods From January,2010 to January,2013,a total of 530 infants(age ＜ 3 years,weigh ＜ 15 kg) with PmVSD enrolled and they were divided into two groups according to different treatment methods at random.Group 1 (265 cases) was arranged perventricular device closure with modified occluders through a lower partial median sternotomy under transesophageal echocardiography (TEE) guidance;group 2 (265 cases) was arranged surgical repair on cardiopulmonary bypass(CPB) through a right subaxillary small incision.A prospective randomized controlled study was performed between two groups on success rate,operation time,volume of blood loss and transfusion,length of intubation and ICU stay,complications,expenses and follow-up results etc.Results All patients in two groups obtained effective treatment with no death or serious life-threatening complications.Group 1:255 cases (96.23％) underwent successfully MIPDO.The remainder 10 cases (3.77％) who failed in attempt were successfully converted to conventional open heart operation by extending the original incision.Different arrhythmias arose in 30 cases(11.76％),including incomplete left bundle branch block(ILBB) in 3 cases(1.18％),complete right bundle branch block(CRBB) in 3 cases(1.18％),incomplete right bundle branch block(IRBB) in 16 cases(6.27％),Ⅰ° atrioventricular block(Ⅰ°AVB) in 8 cases(3.14％);trivial residual shunt(RS) in 18 cases(7.06％);newly arose trivial tricuspid regurgitation(TR) in 29 cases(11.37％).Group 2:All the patients(100％) underwent successful surgical repair through right subaxillary incision.Different arrhythmias occurred in 116 cases (43.77％),including transient complete atrioventricular block(CAVB) and ILBB in 2 cases respective(0.75％),junctional ectopic tachycardia(JET) in 1 cases(0.38％),CRBB in 61 cases(23.02％),IRBB in 52 cases(19.62％);trivial RS in 16 cases (6.04％);newly arose trivial TR in 11 cases(4.15％);heart dysfunction in 17 patients(6.42％).All patients were followed up for more than 12 months,and there were no newly happened or aggravated valve regurgitation or late onset CAVB in two groups.The final treatment effects are similar in both groups.But group 1 was significantly superior to group 2 in the aspects of operation time,volume of blood loss and consumption,length of intubation and ICU stay,hospitalizations and costs(all P ＜ 0.05).The incidence of TR is higher in group 1 (P ＜ 0.05),and that of right bundle branch block was higher in group 2 (P ＜ 0.05).The incision is longer in group 2,but in a less exposed location.CPB is not needed in group 1,but anticoagulant drug is required for 3-6 months.Conclusion Both RSISR and MIPDO are effective treatment methods of PmVSD.Though having some limitations,MIPDO which characterized by simple procedure,minimal invasion,quick recovery,saving of medical resources could not only minimize the surgical trauma to patients,but also ensure the safety of operation to the maximum extent.However,the patient selection is vital.For selected patients,especially those of moderate PmVSDs with obvious clinical symptoms but no cardiac valve regurgitation,it is an ideal approach.
