低龄低体重患儿经胸小切口封堵膜周部室间隔缺损的策略及早期疗效

Strategy and Short-term Outcomes of Transthoraic Occlusion via a Small Incision in Low Birth-weight Infants with Ventricular Septal Defect

目的探讨经胸小切口封堵治疗低龄低体重先天性心脏病膜周部室间隔缺损(ventricular septal defect,VSD)患儿的手术方式及疗效。方法 2010年10月～2011年11月,对51例经胸心脏超声选择的分流口直径4～8 mm、距主动脉瓣距离>1 mm的膜周部VSD患儿,经胸小切口封堵治疗。年龄4～12个月,(8.6±2.1)月,体重6～11 kg,(7.4±2.1)kg。胸骨下端4～5 cm切口,在食道超声(TEE)引导下经右心室前壁,置入导引钢丝,导入输送鞘管和装置鞘管,将封堵器安放在VSD部位。并对手术方式及疗效进行回顾性分析。结果无手术死亡。封堵成功46例(90%),5例封堵失败,改体外循环(cardiopulmonary bypass,CPB)下心内直视修补。封堵成功患儿无残余漏、脱伞、心律失常,心彩超下无主动脉瓣反流,新增加三尖瓣轻度反流5例(13%)。3例(5.8%)输血50 ml。术后住院3～7 d,(3.9±0.7)d。46例全部随访,随访时间1～12个月,(3.6±1.4)月。无死亡,均行心电图、胸片及心脏彩超检查,无心律失常、残余漏、脱伞、血栓、出血事件,无新发瓣膜反流,心功能Ⅰ级。结论对于低龄低体重、分流口直径4～8 mm、距主动脉瓣距离>1 mm的先天性心脏病膜周VSD,实施经胸小切口封堵治疗,手术方式可行,效果良好。

Objective To study the surgical techniques and efficacy of transthoracic occlusion through a small chest incision for low birth-weight infants with ventricular septal defect （VSD）. Methods Totally 51 low birth-weight infants with VSD, who received transthoracic occlusion in our hospital during October 2010 to November 2011, were enrolled into this study. The shunt diameter was 4 -8 mm, as shown by echocardiography, and was over 1 mm away from the aortic valve. The patients aged from 4 to 12 months with a mean of （8.6 ± 2.1 ） months ; the mean body weight was （7.4 ± 2.1 ） kg （ ranged from 6 to 11 kg）. Via a 4- to 5-mm incision below the sternum, under the guidance by TEE, we introduced a guide wire through the right ventficular anterior wall, and then placed occlusion device at the VSD site. The surgical procedure and efficacy was analyzed retrospectively afterwards. Results No mortality occurred during peri-operative period. The success rate of transthoracic occlusion was 90% （46/51）. The five patients, who failed in the procedure, were transferred to cardiopulmonary bypass （CPB） for a VSD repair in a direct surgical field. In the 46 successful cases, no residual leakage, dislocation of occlusion device, or arrhythmia occurred; echocardiography showed no aortic regurgitation, however, 5 （13%） patients developed mild tricuspid valve regurgitation. Three patients （5. 8% ） received blood transfusion of 50 ml. The patients were discharged from hospital in a mean of （3.9 ± 0. 7） days （ranged from 3 to 7 days）. Afterwards, all the 46 successful cases were followed up for （3.6 ± 1.4 ） months （ranged from 1 to 12 months） , during which no patient died,and ECG, echocardiography, and chest X-ray found nothing abnormal, the cardiac faction was in grade I in all the cases. Conclusions For low birth-weight infants with VSD with a shunt diameter of 4 - 8 mm, and 〉 1 mm away from the aortic valve, transthoracic occlusion through a small chest incision is feasible and effective.