微创非体外循环下经胸小切口继发孔房间隔缺损封堵术失败后转外科修补手术的临床分析

Surgical closure of atrial septal defect after the failure of occlusion therapy via non-cardiopulmonary bypass minimally invasive intercostal incision

目的 探讨微创非体外循环下经胸小切口继发孔房间隔缺损（ASD）封堵术失败后转外科修补手术的治疗方法及临床疗效.方法 2008年1月至2008年12月,我院行微创非体外循环下经胸小切口继发孔ASD封堵术268例,其中封堵术失败后需再行外科修补手术者12例,包括术中封堵器脱落6例,术中封堵失败3例,术后封堵器脱落1例,Ⅲ度房室传导阻滞1例,残余漏1例.外科修补手术于体外循环下进行,取出封堵器,修复缺损.结果 外科修补手术探查继发孔ASD直径平均为（28.6±6.2）mm,大于术前经食管超声心动图测量的值[（24.3±4.1）mm,P＜0.01].术中探查证实,6例术中封堵器脱落患者缺损为下腔型4例、中央型2例 术后1例封堵器脱落患者缺损为中央型 术中3例封堵失败患者中筛孔状缺损1例,下腔型2例 Ⅲ度房室传导阻滞1例为中央型 1例残余漏患者缺损为中央型,但边缘菲薄.外科修补术后所有患者均恢复窦性心律,无手术死亡,无残余分流.结论 微创非体外循环下经胸小切口继发孔ASD封堵术失败后应及时采取外科修复手术治疗,这样可有效治疗封堵术失败后的并发症.而这种急诊手术并没有增加患者的病死率和严重并发症的发生率,所以可以对患者先尝试封堵,不成功再行外科修补手术.

Objective To assess the therapeutic methods and results of surgical closure of atrial septal defect （ASD） after the failure of occlusion therapy via non-cardiopulmonary bypass （CPB）-minimally invasive intercostal incision （MⅢ）. Methods From January 2008 to December 2008, twelve patients from 268 patients underwent occlusion therapy via non-CPB- MⅢ, were performed surgical closure of ASD after the failure of occusion. The causes accounting for the transition consist of introoperative or postoperative dislodgment of occusion device in 6 cases and 1 case respectively, infeasibility in 3 cases, Ⅲ °atrio-ventricular block （AVB） in 1 case and residual shunt in 1 case. All patients underwent the removal of occlusion device and surgical closure of ASD. Results The mean stretched diameter of the ASD （28.6 ± 6.2 mm） was significantly larger （ P 〈 0.01 ） than that measured by transesophageal echocardiography （TEE） （24.3 ±4.1 mm）. The pathological type of ASD was confirmed with the inferior vena cava type in 4 cases of introoperative dislodgment of occusion device, the central tyepe in 2 cases and 1 case of introoperative or postoperative dislodgment repectively, the sieve pore type in 1 cases infeasible to occlusion, and with thin marginal tissue in 1 case with residual shunt. Sinus rhythm was postoperatively observed in all patients. No perioperative mortality and postoperative residual shunt was found. Conclusion Surgical treatment should be performed in time after the failure of occlusion to achieve a good outcome.