经右侧腋下途径微创封堵膜周部室间隔缺损的临床经验和近期随访结果

宋书波，范太兵，李斌，梁维杰，董好举，吴开元，韩宇



经右侧腋下途径微创封堵膜周部室间隔缺损的临床经验和近期随访结果

宋书波，范太兵，李斌，梁维杰，董好举，吴开元，韩宇

摘要

关键词外科手术，微创性 ；室间隔缺损；超声心动描记术

作者单位：450003 郑州市，河南省人民医院 心血管外科 河南省儿童心脏中心

Clinical Experience and Short-term Outcome for Minimally Invasive Occlusion in Patients With Peri-membranous Ventricular Septal Defect via Right Subaxillary Route

SONG Shu-bo,FAN Tai-bing,LI Bin,LIANG Wei-jie,DONG Hao-ju,WU Kai-yuan,HAN-Yu.
Department of Cardiac Surgery,Henan Provincial People’s Hospital,Zhengzhou(450003),Henan,China
Corresponding Author:FAN Tai-bing,Email:Fantb@zzu.edu.cn

Abstract

Objective:To summarize the clinical experience and short-term outcome of minimally invasive occlusion in patients with peri-membranous ventricular septal defect(PmVSD)via right subaxillary route under trans-esophageal echocardiography(TEE)guidance.

Methods:A total of 122 PmVSD patients treated in our hospital from 2014-01 to 2015-07 were summarized.There were 54 male and 68 female with the mean age of(2.7±2.2,0.5-9.7)years,mean body weight of(13.9±6.0,6.1-38.0)kg and mean PmVSD diameter of(3.8±0.8,2.5-7.0)mm.The patients were taken left lateral position,a(2-3)cm incision was performed along right mid-axillary line between the 3rdrib and 4thrib,the thoracic entrance was at 4thinter-costal space.A purse-string suture was conducted on right atrial surface,a special hollow probe was inserted into right atrium and crossed tricuspid into right ventricle under TEE guidance;the probe was adjusted to the point or crossed VSD into left ventricle followed by guide wire insertion to establish a deliver pathway,and finally,occlusion device was regularly deployed to close the defect.Postoperative ECG,TEE and chest X-ray were conducted for followed-up study.

Results:There were 119/122(98.4%)patients occluded successfully and 3 failed patients were converted to cardiopulmonary bypass surgery at the original incision.The average size of occluder was(4.9±1.1,4-10)mm and all devices were concentric.The patients were followed up at the mean of(8.3±5.0,1.0-19.8)months,during that period,12/119(10.1%)had new mild tricuspid regurgitation,16(13.4%)suffered from incomplete right bundle branch block,4(3.4%)had small residual shunt and 2 of them were self-closed at 1 and 3 months after operation respectively.There were no complete atrioventricular block,no new aortic valve regurgitation and no device dislocation.

Conclusion:Minimally invasive occlusion of PmVSD via right subaxillary route under TEE guidance was a safe,effective,feasible and better cosmetic method for treating relevant patients;while its long-term outcome should be further observed.

Key words Surgical procedure,minimally invasive;Heart septal defects,ventricular;Echocardiography

(Chinese Circulation Journal,2016,31:272.)

室间隔缺损（VSD）是最常见的先天性心脏病之一，其中大约70%为膜周部VSD[1]，传统治疗方法主要是体外循环下直视手术和内科经皮介入封堵术，两种手术方式各有优缺点[2-5]。经胸微创封堵术是近十年来发展起来的一种集内、外科治疗方法优点于一体的新技术[6-8]，该技术可以达到安全、有效、美观的手术效果。而常规经胸微创封堵膜周部VSD的切口为胸骨下段或胸骨右缘，手术切口不够隐蔽，且有胸骨畸形等风险，为此我们儿童心脏中心自2013-06始通过研制中空导引探条，在国内及早开展非体外循环下经腋下途径微创封堵治疗常见先天性心脏病的研究[9-11]，并取得了良好的效果，现将这项技术的临床应用经验和近期随访结果报道如下。

1　资料与方法

1.1一般资料

选取2014-01至2015-07在我们儿童心脏中心由经胸超声心电图（TTE）诊断为膜周部VSD的患者，参考先天性心脏病经导管介入治疗指南[12]和经胸微创VSD封堵术中国专家共识[13]，确立入选标准：（1）膜周部VSD；（2） 年龄≥6个月；（3）左向右分流，无主动脉瓣脱垂或中度以上关闭不全；（4）2.5 mm≤VSD右心室侧出口直径≤7 mm；（5）VSD上缘距主动脉瓣≥2 mm；（6）膜部瘤有多个出口者，出口间距小，比较集中。……