特殊室间隔缺损的外科经胸封堵治疗

Transthoracic Occlusion of Ventricular Septal Defect for Special Patients

目的探讨特殊室间隔缺损（ventricular septal defect,VSD）经胸封堵治疗的安全性和手术效果。方法 2010年2~11月,应用外科经胸封堵治疗6例特殊VSD,包括2例不接受锯胸骨和X线辐射的先天性VSD（A组）,3例内科介入封堵失败的先天性VSD（B组）,1例急性心肌梗死室间隔穿孔形成的后天性VSD（C组）。经胸骨下段小切口不锯胸骨（A组）或锯部分胸骨（B组）或正中大切口（C组）行外科经胸封堵术。于右心室表面选择适当的穿刺点,在食道超声实时引导下,用输送鞘将封堵伞送入封堵VSD。术后密切随访病情变化,定期复查超声心动图、心电图和胸部X线片。结果 6例全部封堵成功,无死亡。5例采用对称封堵伞,1例因VSD上缘距主动脉瓣较近采用非对称的偏心封堵伞。4例术后即刻和3个月及9个月复查超声心动图均无分流和其他异常;1例术后即刻复查有3 mm分流,1例术后即刻复查有5 mm分流、3个月复查仍有3 mm分流,仍在随访中。无新发的主动脉瓣和三尖瓣反流、完全性房室传导阻滞、左或右室流出道狭窄,无溶血或血栓形成,无封堵伞移位。结论外科经胸封堵VSD是一种简单有效而又安全的治疗方法,尤其对于一些特殊的VSD病例不失为一种良好的选择。

Objective To evaluate the efficacy and safety of transthoracic occlusion of ventricular septal defect（VSD） for special patients. Methods From February to November 2010,we performed transthoracic occlusion of VSD on six patients,including two congenital cases who denied sternotomy and X-ray radiation（group A）,three congenital patients who failed in catheter intervention（group B）,and 1 patient who suffered from perforation of the ventricular septum caused by acute myocardial infarction（group C）.Transthoracic occlusion was performed via small incision at the lower sternum（group A）,partial sternotomy（group B）,or middle incision（group C）.Under the guidance of transesophageal ultrasonography,the best location for right ventricular puncture was selected and a channel was established by TEE guidance.Proper devices were delivered and then deployed to occlude the defect.Patients were followed up closely with a standard protocol,arranged for echocardiography,electrocardiogram and chest X-ray.Results In all the cases,VSD were successfully occluded without patients died.Symmetrical devices were implanted into 5 of the 6 patients and the other patient whose VSD closed the aortic valve were occluded with an asymmetrical occluder.Follow-up was done to all the patients for a period ranged from 3 to 9 months postoperatively.One patient had 3-mm residual shunt immediately after the operation.Another one patient had 5-mm residual shunt immediately after operation and 3-mm residual shunt in 3 months.These 2 patients were still in follow-up.No residual shunt,aortic and tricuspid incompetence,atrioventricular block,stenosis of the left or right ventricular outflow tract,hemolysis and thrombus were detected in the other 4 patients.Conclusion Transthoracic occlusion of VSD is a simple,effective and safe intervention for special VSD patients.