室间隔缺损介入封堵入路术式研究

Successful Experience of Transcatheter Closure by Left Route Method in Patients with Ventricular Septal Defects

目的分析室间隔缺损（VSD）经导管介入封堵术传统术式失败的原因，总结左侧入路的临床经验。方法根据超声心动图选择符合介入治疗条件的VSD25例行传统术式封堵，VSD直径为2-12（7±6）mm。传统术式建立动静脉轨道，输送系统从右室侧进入左心室。左侧入路术式封堵者无需建立动静脉轨道，仅将导丝经缺损送达右心室、肺动脉．沿导丝将输送鞘管送至右心室，将封堵器送至缺损部位进行封堵。结果其中传统术式成功20例，失败5例，均因为输送鞘不能通过缺损，改行左侧入路后4倒成功，1例失败。VSD传统术式封堵成功率为80％（20／25），总体封堵成功率为96％（24／25），介入封堵后即刻存在少量残余分流3例（12．5％），21倒（87．5％）无分流，1例（4％）三尖瓣少量返流，1例（4％）术中出现一过性房室传导阻滞。结论针对部分VSD患者，传统术式失败时，可尝试进行经左室入路介入封堵VSD，初步表明经左室入路介入封堵VSD安全有效．对部分合适的患者，如直接选用经左室入路，有可能缩短手术时间和X线暴露时间。

Objective To analyze the causes of failure of transcatheter closure of ventricular septal defects （VSD） with VSD occluder by traditional operational method （right route method） and share some experience of left route methods. Methods We selected 25 cases of patients with VSD by echocardiograpy, the VSD diameter was 2 -12（7±6）mm. All the patients met such features： the margin of defect to the aortic valve was more than 2mm, and the diameter of defect was less than 12mm. Results All the patients were treated by routine right method, among them, 20 cases were successfully occluded, the failured 5 cases were treated by left route method and 4 of them were successful. In the left route procedure,a wire was advanced to right ventricle through aorta , left ventricle and VSD. Then the deliver sheath was advanced to right ventricle along the wire. Finally the VSD occluder was advanced to right ventricle and positions it to the VSD site guided by fluorescence. The successful rate of VSD traditional ocluder is 80% （20/25）. The totally successful closure rate was 96% （24/25）, there was no residual shunt in 21 of 24 patients （87.5%） immediately after the procedure, 3 patients （12.5%） had a mild residul shunt that disappeared at the three months follow up, one case （4%） suffered with mild tricuspid regurgitation, another one （4%） had a transient complete atrioventricular block. Conclusion Transcatheter closure of VSD from left ventricle route is an effective and safe technique. The combination of two method can improve the successful rate of transcatheter closure of ventricular septal defects.