经胸微创非体外循环下封堵膜部室间隔缺损

Minimally Invasive Transthoracic Closure of Perimembranous Ventricular Septal Defect without Cardiopulmonary Bypass

目的探讨一种新的经胸微创非体外循环下封堵膜部室间隔缺损（VSD）的手术方法,总结临床应用经验,观察中期随访结果。方法自2007年3月至2009年6月,采用改良新型输送系统封堵技术连续对136例膜部VSD患者施行修补,年龄3个月-15岁,平均年龄1.8岁;体重4.0-26.0 kg,平均体重12.7 kg;VSD直径3-12mm,平均5.1 mm。患者经胸部微创小切口（胸骨下端3-4 cm纵行小切口或胸骨左缘第3肋间2-3 cm横切口）在非体外循环下手术,于右心室表面选择适当的穿刺点,在食管超声心动图（TEE）实时引导下,建立VSD输送轨道,将封堵器安放在VSD部位,封堵VSD。术后密切随访病情变化,按期复查经胸心脏超声心动图、心电图和胸部X线片检查。结果 136例患者中131例（96.3%）封堵成功,手术时间少于90 min,安置封堵器时间5-42 min（16.3±5.7 min）。89例（67.9%）采用对称封堵器,42例（32.1%）采用偏心封堵器。术后即刻用TEE监测,3例存在轻微残余分流,4例发生新的微量至轻度三尖瓣反流,但所有术前有三尖瓣反流患者未见反流加重,主动脉瓣未受影响,无左、右心室流出道梗阻和完全性房室传导阻滞发生。1例患者术后第4 d发生一过性完全性房室传导阻滞,但经内科处理3 d内恢复正常心律。5例（3.7%）术中改为常规体外循环手术。介入封堵成功的131例患者均获得随访,随访时间6-30个月（18.3±6.6个月）。随访期间3例原有轻微VSD残余分流者分流全部消失;所有患者未出现新的三尖瓣和主动脉瓣反流,无血栓和溶血,无封堵器位置移动现象,未发现左、右心室流出道狭窄。手术切口隐蔽,基本不影响美观。结论在TEE引导下经胸微创封堵VSD技术不需要体外循环辅助,适用于大多数膜部限制性VSD患者,是一种简单、安全、有效的治疗方法。远期结果尚需要随访观察。

Objective To introduce a new technique： transthoracic closure of perimembranous ventricular septal defect（VSD） without cardiopulmonary bypass（CPB） under transesophageal echocardiography（TEE）guidance,and summarize the clinical experiences and mid-term follow-up results.Methods A total of 136 patients with perimembranous VSD,3 months to 15 years averaging 1.8 years,underwent transthoracic device closure.The weight of these patients ranged from 4.0 to 26.0 kg with an average weight of 12.7 kg.The diameter of their VSD ranged from 3 to 12 mm averaging 5.1 mm.A small transthoracic incision（3-4 cm incision by inferior sternotomy or 2-3 cm transverse incision in the third intercostal space） was made and the best location for right ventricular puncture was chosen and the delivery pathway was established under TEE guidance.Proper devices were delivered and then deployed to close the defect.Patients were followed up closely with a standard protocol,arranged for echocardiography,electrocardiogram and chest X-ray film.Results In all the cases,131 cases of VSD（96.3%） were successfully closed.The procedure time was less than 90 minutes and the implanting time was 5-42 minutes（16.3±5.7 min）.Symmetrical devices were implanted into 89（67.9%） of the 131 patients and the other 42 patients（32.1%） were closed with asymmetrical ones.The result of TEE soon after operation showed that 3 patients had tiny residual shunt,4 had new trivial and mild tricuspid regurgitation（TR）.However,no TR worsening,aortic regurgitation（AR）,complete atrioventricular heart block,or left or right outflow tract obstruction was detected in all patients.One patient with transient atrioventricular block restored to sinus rhythm after 3 days of medical treatment.Five cases（3.7%） were converted to conventional open heart repair during the operation.Follow-up was done to all the patients for a period ranged from 6 months to 30 months（18.3±6.6 months）.Tiny residual shunt in the 3 cases mentioned above vanished during the follow-up period.No new TR,AR,hemolysis,thrombosis,dislocation of the devices,or outflow stenosis was detected postoperatively.The tiny incision caused less psychologic depression.Conclusion Minimally invasive transthoracic device closure of VSD without CPB is a simple,effective and safe intervention under guidance of TEE for most of perimembranous VSD patients.The short and mid-term clinical outcomes are promising.Long-term follow-up is indispensable.