应用Amplatzer封堵器治疗室间隔缺损及对心脏传导系统的影响

Transcatheter closure of perimembranous and muscular ventricular septal defects using the new Amplatzer VSD occluder and the effect of cardiac conductive system

目的 探讨新型Amplatzer室间隔缺损封堵器治疗膜周部及肌部室间隔缺损 (VSD)的疗效和对心脏传导系统的影响。方法 2 0 0 3- 0 7～ 2 0 0 4 - 0 4采用新型Amplatzer膜部及肌部VSD封堵器对 12例膜周部VSD和 2例肌部VSD患者进行封堵治疗。对心脏多普勒超声检查符合导管封堵条件病人术前常规进行心导管检查 ,测定血流动力学各项参数。在X线透视、食管或经胸超声的监测下建立股动静脉轨道 ,经右心系统释放封堵器。对 12例膜周部VSD病人在手术前、后进行心内电生理检查 ,测定房室传导时间 (AV间期 )和房室结不应期 ,观察封堵手术对心脏传导系统的影响。病人分别于术后 2周、1个月、3个月、6个月进行随访。结果 14例患者 (男 8例 ,女 6例 )封堵器置入全部成功。术后即刻超声及造影均示完全封堵 12例 ,微量残余分流 2例 ,均在 1d内消失 ,总完全封堵率为 10 0 %。 12例膜周部VSD病人封堵后即刻AV间期有不同程度的延长 ,其中 3例术后AV间期 >2 0 0ms,1周后心电图检查 2例PR间期恢复正常。封堵前后房室结不应期无明显变化。未出现Ⅱ度以上房室传导阻滞和束支传导阻滞 ,无心肌受损表现 ,无其它严重并发症发生。结论 应用新型Amplatzer膜部和肌部VSD封堵器治疗膜周部和肌部VSD是安全有效的 ,近期效果良好 。

Objective To evaluate the feasibi1ity and efficacy of transcatheter closure of perimembranous and muscular ventricular septal defects (VSD) using the new Amplatzer membranous and muscular VSD occluder and observe the effect of membranous VSD occluding procedure on atrioventricular(AV) conductive system.Methods Twelve patients (7 males,5 females) with perimembranous VSD and two patients (1 male,1 female) with muscular VSD underwent an catheter closure using the new Amplatzer membranous and muscular VSD occluder.All patients who were eligible for device closure by means of cardiac Doppler echocardiography were routinely measured the parameters of blood dynamics before catheter closure. Artery-venous track was set up under the X-ray fluoroscopy,transesophageal (TEE) or transthoracic echocardiography (TTE) guidance. Devices were released in the right ventricular side.Twelve patients with perimembranous VSD underwent the cardiac electrophysiologic examination,including atrioventricular conductive time (AV interval) and atrioventricular nodal refractory time,before and after catheter closure.A11 patients were followed up at 2 weeks,1 month,3 months and 6 months after the procedures.Results The devices were deployed successfully in 14 patients.There was complete closure in 12 patients immediately,and tiny (<2mm) residual shunt in 2 patients.The residual shunt all disappeared within 1 day.A-V interval was more prolonged after catheter closure than before in 12 patients with perimembranous VSD (P<0.01),of which 3 cases had the AV interval more than 200ms;the AV interval in 2 cases had recovered normal within one week follow-up period.There were no obvious changes of atrioventricular nodal refractory time before and after catheter closure.There were no other severe complications.Conclusion Transcatheter closure of membranous and muscular VSD using the new Amplatzer membranous and muscular VSD occluder were safe and effective.The AV conductive system may be affected in the occlude of membranous and VSD.It is necessary to monitor and prevent the AV and bundle branch block.