膜周部室间隔缺损经导管封堵术后早期心律失常危险因素的探讨

Risk factors for arrhythmia early after transcatheter closure of perimembranous ventricular septal defects

目的心律失常是经导管封堵膜周部室间隔缺损术后的常见并发症,不仅影响术后心功能的恢复,而且直接关系到预后。分析18岁以内患者膜周部室间隔缺损经导管封堵术后早期心律失常及其危险因素,以期降低术后心律失常的发生率。方法2002年6月—2004年6月,89例膜周部室间隔缺损患者根据家长意愿接受了经导管应用Amplatzer装置及国产封堵器进行堵塞。80例应用AGA公司制造的Amlatzer膜周部室间隔缺损封堵器,9例应用国产封堵装置,术后定期行心脏超声及心电图检查。结果89例膜周部室间隔缺损封堵术均获成功。11例术后5d内发生了不同类型的传导阻滞,发生率为12%,分别为Ⅰ°房室传导阻滞1例,Ⅲ°房室传导阻滞1例,左前分支阻滞5例,不完全(部分)性右束支传导阻滞4例,完全性右束支传导阻滞3例,其中3例并发两种传导阻滞。分析本组心律失常的影响因素,发现:(1)室间隔缺损上缘距主动脉右冠瓣距离<3mm;(2)室间隔缺损直径≥8mm,封堵器直径≥10mm;(3)穿刺成功后动脉静脉(A-V)轨道建立时间≥60min及术中pH值<7·35与心律失常密切相关。结论心律失常是膜周部室间隔缺损封堵术后早期严重的并发症;严格选择手术适应证、缩短手术操作时间、防止酸中毒是降低膜周部室间隔缺损介入封堵术后心律失常发生率的有效措施。

Objective Perimembranous ventricular septal defects （PMVSDs） is the most common type of congenital ventricular septal defects （VSD）, which accounts for 70% -80% of VSD. The structure of PMVSDs is very complex, it is close to tricuspid valve, mitral valve and aortic valve. The atrioventricular （AV） node is located in the posterior upper membranous ventricular septum and branches into left and right bundle in the posterior lower margin . This increases the risk of transcatheter closure of PMVSDs. Arrhythmias is the common complication after transcatheter closure of PMVSDs. The present study aimed to identify the risk factors resulting in arrhythmias after transcatheter closure of PMVSDs in patients under 18 years of age to decrease the incidence of arrhythmias after the interventional catheterization. Methods A retrospective analysis was performed on the patients treated with trancatheter intervention from June 2002 to June 2004. Transcather closure of PMVSDs with Amplatzer membranous septal occluder and a domestic product was performed in 89 cases after obtaining consent themselves and/or their guardian or parents, 47 cases were males and 42 females. The age of the cases ranged from 3 to 18 years （mean 8.2 years） and the body weight ranged from 13 to 55 kg （ mean 26. 7 kg）. They were all diagnosed as having PMVSDs with trans-tboracic echocardiography （TIE） before the interventional catheterization, the electrocardiographic （ECG） and chest X-ray （CXR） findings were recorded. A simultaneous care ECG and TIE were performed during operation in order to identify the effect of the transcatheter closure, the heart structure and functional changes and whether or not arrhythmias occured, respectivdy. In 80 cases AGA Amplatzer membranous septal occluder was used and in 9 cases a domestic product was used. Follow-up was performed based on the echocardiography and ECG. Results The devices were successfully implanted in 89 cases; 11 cases （12%） developed various block of heart conduction within 5 days, which included frist degree AV block in 1 patient, third degree AV block in 1, left anterior bundle branch block in 5, partial right bundle branch block in 4, complete right bundle branch block in 3, and 3 patients had two kinds of heart block. Eight patients were treated with corticosteroids, 6 of them recovered within 14 days, 1 patient within 1 month and in 1 case the problem shifted from first degree block and left anterior bundle branch block to left anterior bundle branch block 5 days later and that persisted for 6 months. It was found that the distance from upper margin of defects to the aortic valve 〈3 mm, the diameter of ventricular septal defect ≥8 mm, the diameter of device 10 mm, blood pH 〈 7.35 and arteriovenous track building time afrer the success of the Seldinger technique ≥ 60 min were independent predictors of post-closure arrhythmias. Contlusion Arrhythmias remain the severe early complications after interventional catheterization for PMVSDs in patients under 18 years of age. Shortening of operation time, prevention of acidosis and strict selection of indications may be the most effective measures to prevent arryhthmias after transcatheter closure of PMVSDs in patients under 18 years of age.