室间隔缺损介入治疗后并发三尖瓣返流原因的探讨

Discussion of tricuspid insufficiency after transcatheter closure of perimembranous ventricular septal defects

目的探讨经导管介入治疗室间隔缺损(VSD)发生三尖瓣返流的原因和预防措施。方法VSD封堵术后发生三尖瓣返流13(男7,女6)例,年龄3～12(平均5.0±2.7)岁。膜周部VSD伴膜部瘤患者11例,单纯膜周部VSD2例。其中囊袋型缺损10例,漏斗型缺损3例,VSD左室面直径为4～14(7.3±2.3)mm。结果13例患者,左心室造影测量VSD直径为4～15(7.5±2.4)mm,VSD距三尖瓣距离2.0～3.4(2.6±0.5)mm。囊袋型缺损右室面均有多个出口,其最大出口直径2～6mm。术后即刻9例有三尖瓣少量返流,1例三尖瓣少～中量返流。1例三尖瓣少量返流伴有海鸥鸣,术后24h海鸥鸣消失,3d三尖瓣已无返流。1例5岁患儿,其三尖瓣前腱索附着异常(在缺损口附近),术后24h无三尖瓣返流,5d超声心动图发现三尖瓣前瓣腱索断裂伴中～大量返流。1例VSD直径15mm、右室面多孔、最大孔直径6mm的患者,放置了16mm封堵器,术后即刻、7d、1月无三尖瓣返流,3月新出现三尖瓣少～中量返流。结论VSD封堵治疗后发生的三尖瓣返流可能与导管损伤隔瓣腱索、输送钢丝损伤腱索、封堵器磨损腱索及封堵器本身的设计缺陷有关。

AIM:To invesgate the reason and prevention measures of tricuspid insufficiency after transcatheter closure of perimembranous ventricular septal defects (VSDs) . METHODS:13 patients (male 7,female 6) suffered with tricuspid insufficiency attempted transcatheter closure of a VSDs at a median age of 5±2.7 years (range 3 to 12) . Among them 11 cases was perimembranous VSDs associated with an aneurysmal septum,2 cases was simple perimembranous VSDs. 10 cases was cystoma-type defects and 3 cases was infundibular-type defects. The mean VSD diameter at its left ventricular side by the left ventricular graphies(LVG) was 4~14(7.3±2.3) mm . RESULTS: The mean VSD diameter at its left ventricular side was 4~15(7.5±2.4) mm,the distance of VSDs to tricuspid valve was 2~3.4(2.6±0.5)mm . the right side of cystoma-type defects had several outlets with largest outlet diameter of 2~6 mm . 9 cases suffered with tricuspid small insufficiency and one immediately after the procedures, one cases with small to moderate tricuspid insufficiency.one cases suffered with tricuspid insufficiency with sea-gull-moo, sea-gull-moo was disappeared 24 hours after procedure and tricuspid insufficiency was disappeared 3 d after procedure.a five-year-old child with anomally attachment of tricuspid chordae tendineae (near to defects) ,no tricuspie insufficiency was found 24 hours after the procedure,however,moderate to large tricuspie insufficiency was found due to tear of anterior valve chordae tendineae detected by thransthoracic echocardiography.one case with diameter of 15mm associated with right side multiple outlets with largest outlet 6mm, 16 mm occluder was implanted,echocardiographt revealed that there was no triscupid insufficiency immediately 7 d. 1 m after the procedure,however, a small to moderate tricuspid insufficiency was detected by echocardiography at 3 month follow up. CONCLUSION: tricuspid insufficiency after transcatheter closure of perimembranous ventricular septal defects (VSDs) may be related to injury of tricuspid chordae tendineae by catheter or wire.abration of chordae tendineae and device desigh.These problems should be alert to physicians.