室间隔缺损介入治疗术后Ⅲ度房室传导阻滞的特点及防治

Characteristics and prevention of degree Ⅲ atrioventricular block induced by interventional therapy for ventricular septal defect

目的探讨经导管介入治疗先天性心脏病室间隔缺损（ventricular septal defect，VSD）发生Ⅲ度房室传导阻滞的特点及防治。方法观察本院先天性心脏病诊疗中心VSD患者763例，男352例，女411例，年龄1．6～18岁，平均（8．2±6．0）岁。分析所有患者封堵术前后心电图的变化、经胸心脏彩色超声多普勒的VSD病变特点及植入的封堵器的情况。结果术后3～5天发生Ⅲ度房室传导阻滞5例，其中1例术中出现Ⅲ度房室传导阻滞，药物治疗后恢复窦性心律；3侧术前心电图即存在右束支传导阻滞；1例封堵器型号偏大。4例经激素治疗、营养心肌治疗在发生Ⅲ度房室传导阻滞7～10天内心电图恢复正常；1例经临时心脏起搏7天后心电图恢复正常，该患者在术后3个月再次间断出现Ⅲ度房室传导阻滞，内科治疗无效，于15个月后安装永久起搏器。结论术前有柬支传导阻滞、术中出现一过性柬支传导阻滞或房室传导阻滞的膜周部VSD是术后发生Ⅲ度房室传导阻滞的高危因素。对于这类患者，在介入操作中要动作轻柔，切忌粗暴牵拉，谨慎选择封堵器，术后强化激素治疗。

Objective To discuss the characteristics and prevention of degree Ⅲ atrioventricular block （Ⅲ- AVB） after interventional treatment of congenital heart disease of ventricular septal defect（VSD）. Methods From the diagnosis and treatment center of congenital heart disease of the hospital,total 763 VSD patients,male patients 352 and female 411 ,age 1.6--18 years old,average （8.2±6.0） years old, were observed. The electrocardiogram change was analyzed,pathological characteristics of VSD were checked by heart color Doppler ultrasound and the type of the replaced Amplazer in all the patients pre- and post- interventional therapy was discussed. Results Five cases had I]I- AVB post-interventional therapy three to five days, one of them occurred during interventional therapy, after pharmacological treatment recovered to sinus rhythm. Three cases had right bundle branch block pointing out by ECG pre-interventional therapy. The pathological characteristics were perimembranous VSD; one case, the Amplazer was bigger;four cases after hormone treatment and nutrition cardiac muscle treatment in occurrence of Ⅲ-AVB 7 10 days, ECG restored normally;one case had temporary cardiac pacing seven days later,ECG restored normally,but after three months,this patient experienced interrupted Ⅲ-AVB, the internal medicine treatment was invalid, so was treated by permanent cardiac pacing after 15 months. Conclusion Perimembranous VSD has the bundle branch block preoperation,temporary bundle branch block or atrioventricular block occurs during the operation, which is a high-risk factor of Ⅲ-AVB. This kind of patient must be operated gently, the doctor should also not pull crudely, choose cautiously, strengthen post-operation hormone treatment.