心尖部室间隔缺损修补临床分析

Analysis of the Surgical Treatment for Apical Muscular Ventricular Septal Defects

目的探讨心尖部室间隔缺损(VSD)外科治疗方法的选择,以提高治疗水平. 方法回顾性分析1999年1月～2004年7月间29例存在心尖部VSD行室间隔修补术患者的临床资料,其手术切口入路共有4种:右心房切口、右室心尖部切口、左室心尖部切口和右心室流出道联合左室心尖部切口;并分析比较不同入路的手术效果.结果本组患者手术死亡2例(6.9%),1例为左室心尖部切口术后发生低心排血量死亡,1例术中不能停机,行心肌活检示心内膜弹力纤维增生症死亡;发生残余漏4例(13.8%),直径3～5mm,均为右心房切口,不需再次手术治疗;其余患者均治愈出院.术后11例患者随访2～34个月,超声心动图显示均未见室壁瘤形成. 结论心尖部VSD患者手术结果良好,但残余漏的发生率仍较高,术终应常规行食管超声心动图检查.手术切口选择应根据术中VSD的实际位置,尽可能采用右心房切口,必要时可经右室心尖部切口,避免左心室切口.

Objective To discuss the methods and results of the surgical treatment of apical muscular ventricular septal defects （VSD） , in order to improve the surgical outcome of this disease. Methods The clinical data of 29 patients with apical muscular VSD of Fuwai hospital through Jan. 1999 to July 2004 were analyzed retrospectively. The apical VSDwere repaired via 4 different approaches： right atrium, apical right ventriculotomy, apical left ventriculotomy and the incision of the outflow tract of right ventricle combined with apical left ventriculotomy. The operative outcomes between different approaches were analyzed and compared. Results There were 2 perioperative deaths （6. 9%）. One patient repaired via apical left ventriculotomy died of low cardiac output syndrome, the other died intraoperatively from endocardial fibroelastosis, which was confirmed by myocardial biopsy. There were residual VSD in 4 （13. 8%） patients, who were repaired via the right atrium, which did not necessitate reoperation. Other patients were discharged uneventfully. Follow up was completed {n 11 patients and extended 2 to 34 months, none of the 6 survivors had apical ventricular aneurysms. Conclusions The operative outcome of patients with apical VSD is satisfactory although the incidence of residual VSD is higher. The intraoperative transesophageal echocardiography （TEE） should be performed routinely. Surgical approach should be chosen on the actual site of the VSD at operation. Try to repair the VSD via the right atrium as possible, via the apical right ventrieulotomy if needed and try to avoid left ventriculotomy.