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Analysis of Failure of Perventricular Device Closure of Ventricular Septal Defect

摘要:目的:分析微創外科室間隔缺損(ventricular septal defect,VSD)封堵失敗原因,以期提高術前超聲心動圖篩查水平。方法:回顧性分析25例微創外科VSD封堵失敗改行修補術病例,對比超聲表現及手術所見,歸納總結產生并發癥的原因。結果:殘余分流與VSD假性膜部瘤右室面具有多個出口和低估VSD大小密切相關;VSD合并主動脈瓣右冠瓣脫垂是主動脈瓣反流的主要原因;封堵器移位與低估VSD大小且使用偏心封堵器有關;原有三尖瓣反流加重和發生Ⅲ度房室傳導阻滯VSD均位于隔瓣下方;封堵失敗組較封堵成功組缺損偏大,差異具有統計學意義(Plt;0.05)。結論:超聲心動圖對VSD及其毗鄰結構的細致評估,有助于嚴格適應證,提高手術成功率。 Abstract: Objective:To analyze the failure of perventricular closure of ventricular septal defect (VSD), in order to improve the preoperative echocardiography examination. Methods: Twentyfive cases underwent surgical repair after failure of perventricular closure of VSD were included in this study. With combination of echocardiographic and surgical findings, retrospective analysis of the failure of perventricular closure of VSD were attempted to summarize the cause of complications.Results: Residual ventricular communication was due to underestimation of size of VSD and pseudomembranous aneurysm resulting in multiple outlets of VSD on the right ventricle side; preoperative prolapse of rightcoronary cusp was the main reason for mild or greater than mild aortic valve regurgitation after eccentric device closure of VSD; Underestimation of the size of VSD and using eccentric occluder device were responsible for the displacement of VSD occluder device. Postoperative aggravated tricuspid regurgitation and Ⅲ°atrialventricular block (AVB) were attributed to VSDs located under the septal leaflet of tricuspid valve. The size of VSD in group of failed perventricular device closure of VSD was larger than that in group of successful device closure of VSD,and the difference was significant(Plt;0.05). Conclusion: Echocardiography vividly reveals VSD and adjacent structures, which should be used in accessing the anomaly and defect and formulating surgical plans to reduce surgical morbidity and mortality.

經胸微創膜部室間隔缺損封堵術圍術期炎癥因子的變化

Coopdech 支氣管封堵器在搶救大咯血窒息中的應用

目的 探討Coopdech支氣管封堵器用于大咯血窒息搶救的可行性及療效。方法 在患者發生大咯血窒息時, 特別是無條件行雙腔支氣管插管或雙腔支氣管插管困難時, 在支氣管鏡引導下對2 例患者置入Coopdech 支氣管封堵器。結果 2 例大咯血患者Coopdech 支氣管封堵器置入后, 1 例保守治療成功,1 例為支氣管動脈栓塞術贏得時間。結論 Coopdech 支氣管封堵器可以有效替代雙腔支氣管導管用于搶救大咯血患者, 值得進一步臨床應用。

The Application of Transesophageal Echoeardiography for Atrial Septal Defect Blockade Operation

【摘要】 目的 評價經食管超聲心動圖(TEE) 監測房間隔缺損封堵術的臨床價值。 方法 手術前應用經胸超聲心動圖(TTE)及TEE篩選符合條件的100例單純房間隔缺損(ASD)患者行封堵術;手術中TEE監測整個封堵過程和引導封堵傘的放置;手術后評價封堵效果、殘余分流或并發癥等。 結果 100例患者均應用TTE和TEE確診,導引和監測成功閉合房間隔缺損。技術成功96例,成功率96%;4例失敗,失敗率4%。手術后復查無1例殘余分流,3例胸腔積液。經胸超聲心動圖與TEE診斷結果完全一致率40%,TEE診斷對手術前TTE診斷做出補充或修正診斷的有60例(60%)。結論 TEE對選擇適合行封堵術者、選擇封堵器大小、指導封堵器的釋放、以及療效評價均具有重要的作用。【Abstract】 Objective To evaluation the clinical role of transesophageal echocardiography (TEE) for atrial septal defect (ASD) blockade operation. Method The 100 patients with ASD were selected on transthoracic echocardiography (TTE) and TEE. During operation, TEE was applied to monitor the procedure of occlusion, to guide the occluder cites, to evaluate the effects and to make sure if there were peripheral residual shunts around the occlusion and other complications. Results All of the patients were exactly diagnosed by TTE and TEE，guiding and evaluating the successful closed ASD. The successful rate of occlusion was 96%，the failure rate was 4%. The review after surgery showed that, there were no residual review, pleural effusion in three patients. The concordance rate of TTE and TEE diagnosis result is 40%. TEE diagnosis amend the preoperative TTE diagnosis in 60 patients (60%). Conclusions TEE plays an important role in select inpatients，determining the size of the occluder，correctly before occlusion operation, guiding the placement of the occluder in operation and evaluating the effect after operation.

Effectiveness and safety of perventricular device closure in congenital perimembranous ventricular septal defects: A systematic review and meta-analysis

Objective To investigate the safety and effectiveness of perventricular device closure (PDC) for congenital ventricular septal defects (VSD) by a meta-analysis.Methods PubMed, The Cochrane Library, EMbase and China Biology Medicine (CBM) databases were searched for studies on PDC of VSD up to October 2018 by computer. We included studies only with more than 80% patients diagnosed with perimembranous VSD. A meta-analysis was performed to obtain pooled estimates of success rate and incidences of complications with 95% confidence interval (CI). Subgroup analysis stratified by percentage of perimembranous VSD was performed. Risk difference (RD) was used in the comparison of perioperative data with follow-up data. Results Fifteen studies (2 randomized controlled trials, 3 retrospective cohorts, and other 10 retrospective single-arm studies) involving 4 164 patients (3 848 patients with perimembranous VSD) were included in this meta-analysis. The pooled success rate was 95.4%. Incidences of residual shunt, aortic insufficiency, tricuspid insufficiency, and third-degree atrioventricular block were 5%, 0.1%, 3%, and less than 0.001% respectively. Improvements of residual shunt and aortic insufficiency were confirmed in follow-up patients. Conclusion PDC of congenital perimembranous VSDs is safe and yields good results. Because some limitations can not be overcomed, multicenter randomized controlled trials are needed to confirm our results.

動脈導管未閉合并重度肺動脈高壓患者的介入與外科治療

目的 探討動脈導管未閉(PDA)合并重度肺動脈高壓(PH)患者外科手術治療與介入封堵治療的適應證和治療效果。 方法 回顧分析1998年5月至2008年5月我科收治的30例PDA患者的臨床資料，其中男14例，女16例；年齡14～41歲，平均年齡25.8歲。18例行外科手術治療，12例行介入封堵治療。 結果 經外科手術和介入封堵治療患者術后即刻的肺動脈收縮壓(608±120 mm Hg vs. 100.2±14.2 mm Hg; 60.3±11.6 mm Hg vs. 108.4±17.6 mm Hg)和平均肺動脈壓(401±98 mm Hg vs. 76.1±11.3 mm Hg; 40.2±10.5 mm Hg vs. 79.5±13.6 mm Hg)均較術前明顯降低（Plt;0.05）。術后4例手術患者中有2例出現聲音嘶啞，2例殘余分流；介入封堵治療患者術后未出現明顯并發癥。隨訪29例，隨訪時間3個月~2年；1例失訪。隨訪期間患者無明顯胸悶、氣促等，超聲心動圖檢查大動脈水平未探及殘余分流，1例術前伴有心房顫動的患者在封堵術后2個月時猝死，死亡原因不明。28例患者術后90 d復查超聲心動圖提示：肺動脈收縮壓均較術前明顯降低（Plt;0.05），兩種治療方法的療效差異無統計學意義（Pgt;0.05）。 結論 介入封堵治療PDA合并重度PH的患者與外科手術治療相比較具有創傷小、風險小、并發癥少和恢復快等優點，尤其是介入封堵治療可行試驗性封堵，對鑒別動力性和阻力性PH具有不可替代的優越性。但一些特殊類型的PDA患者仍需外科手術治療。

經胸“打孔”食管超聲引導下封堵主動脈竇瘤破裂一例

Minimally Invasive Transthoracic Closure of Ventricular Septal Defect through Left Parasternal Approach: A Report of 15 Cases

目的總結左胸骨旁小切口微創封堵分流方向偏向流出道的室間隔缺損（VSD）的初步經驗。 方法2014年2～8月廣州醫科大學附屬第一醫院對15例分流方向偏向流出道的VSD患者施行左胸骨旁小切口微創封堵手術，其中男7例，女8例；年齡10個月～19歲（4.5±4.6）歲；體重5.5～54.0（14.6±14.1）kg；其中干下型6例，嵴內型6例，膜周部型3例；缺損直徑2.5～6.5（4.0±1.2）mm，距主動脈瓣環距離≤1 mm 9例，≤2 mm4例，>2 mm 2例；合并主動脈瓣右冠瓣輕度脫垂5例；采用左胸骨旁第2或第3肋間1.5～2.5 cm切口，在經食管超聲心動圖（TEE）監視下在右心室流出道表面選擇適當的穿刺點，建立VSD輸送軌道并置入封堵器，觀察有無殘余分流、主動脈瓣反流；術后3個月復查經胸超聲心動圖。 結果15例均成功封堵，無中轉開胸，無殘余分流和心律失常，新發主動脈瓣輕微反流2例，圍手術期輸血1例；手術時間30～120（58±28）min，術中出血量5～200（26±50）ml；術后住院時間3～13（4.3±2.6）d，無二次開胸止血、Ⅲ°房室傳導阻滯、主動脈瓣反流加重、溶血、切口感染等并發癥；術后3個月返院復查經胸超聲心動圖13例，無新發主動脈瓣反流和封堵器脫落；2例術中新發主動脈瓣反流加重，其中1例出現殘余分流。 結論左胸骨旁小切口封堵分流方向偏向流出道VSD 手術安全、切口小、操作簡單，近期效果尚滿意；對合并主動脈瓣輕度脫垂VSD 需慎重施行外科微創封堵手術。

先天性心臟病介入治療48例

目的 總結對先天性心臟病患者行介入治療的臨床經驗，以提高介入治療的成功率。 方法 48例先天性心臟病患者采用Cardiacure-TM封堵器行介入治療，其中房間隔缺損（ASD）21例，動脈導管未閉（PDA）12例，室間隔缺損（VSD）12例，ASD合并PDA 1例，VSD合并PDA 2例。 結果 全組患者無死亡，一次性封堵成功44例，介入封堵治療成功率為91.7％（44/48）;15例次 PDA患者介入封堵治療成功率為100％（15/15）; 22例次ASD患者成功率為90.9%（20/22）, 14例次VSD患者成功率為85.7％（12/14）。 封堵傘于術中脫落3例，其中ASD傘脫落2例，VSD傘脫落1例；介入治療未成功1例。4例封堵未成功的患者中3例擇期行體外循環修補手術治愈，1例行急診體外循環修補手術治愈。隨訪40例，隨訪時間1~19個月，復查心臟雜音消失，心臟彩色超聲心動圖提示無殘余分流。 結論 介入治療是治療先天性心臟病的有效方法，心胸外科醫師掌握該項技術有其較多的優勢。

Efficacy of minimally invasive transthoracic closure of atrial and ventricular septal defects

Objective To evaluate the efficacy and safety of transthoracic minimally invasive occlusion operation for the treatment of congenital atrial and ventricular septal defects. Methods The clinical data of 88 patients who underwent surgical occlusion operation from December 2015 to February 2017 were summarized. There were 52 males and 36 females, aged 6.8±7.5 years ranging from 1.6 to 24.0 years. All the patients were followed up by ultrasound and electrocardiogram at postoperative 3, 6 and 12 months. The efficacy of minimally invasive thoracotomy was analyzed by statistical methods. Results The patients were followed up for 3-15 (6.8±2.3) months, and the follow-up rate was 92.0%. Ultrasound showed occluder fixed well and no residual shunt, valve regurgitation, thrombosis or other complications occurred. The heart was reduced, the ejection fraction was greater than 55%, and heart function rating for all patients was grade Ⅰ. Conclusion Transthoracic mini-invasive surgical occlusion of atrial and ventricular septal defects is safe and effective. The short and middle-term effect is satisfying. It can be widely used in clinical, but multi-center and long-term follow-up and assessment still need to be carried out.