小儿经胸微创室间隔缺损封堵术的临床经验

Minimally invasive experiences on perventricular device closure of ventricular septal defects in children

目的总结2个儿童心脏中心食道超声经胸微创室间隔缺损（ventricular septal defect，VSD）封堵术的临床经验。方法回顾性分析2008年7月至2011年7月浙江大学医学院附属儿童医院及宁波市妇女儿童医院2个儿童心脏中心行食道超声经胸微创VSD封堵术142例的临床资料。其中，膜周部VSD95例，嵴内型VSD37例，肌部VSD10例。VSD直径：经胸超声下3．0-8．5mm，平均（4．7±0．8）mm；食道超声下2．5-8．0min，平均（4．3±i．O）mm。结果142例中140例当时封堵成功（97．2％），其中1例（0．70,4）术后第5天出现Ⅲ。房室传导阻滞、阿斯综合征，术中转体外循环（CPB）下封堵器取出＋VSD修补，术后逐渐恢复窦性心律；1例（0．7％）嵴内型肺动脉瓣下VSD当时封堵成功，术后5h出现封堵器脱落嵌于左肺动脉，急诊CPB下主肺动脉切开封堵器取出＋VSD修补。选用膜周部对称伞85例，偏心伞47例，肌部伞8例。3例（2．1％）新出现微量三尖瓣反流。9例（6．4％）术后出现不完全性右束支传导阻滞，1例（0．7％）术后出现Ⅱ。I型房室传导阻滞伴心室内差异传导，经过甲基强的松龙静滴后转为窦性心动过速，偶发房早。术后在监护室当天拔气管插管，第2天转回普通病房。平均（7．1±2．2）d出院。术后133例（95．oH）随访至今，分别在术后1个月、3个月及每年复查心电图、胸片及心脏超声，最长已36个月。无死亡，未见伞片移位、未见残余分流及瓣膜反流加重，无严重心律失常等并发症。结论经胸微创室间隔缺损封堵术是一种微创手术治疗方法，操作简单，安全性高，具有推广应用价值。

Objective To introduce the minimally invasive experiences on perventricular device closure of ventricular septal defects （VSDs） under transesophageal echocardiography （TEE） guidance in two children hospital heart centers. Methods 142 cases of VSDs undertook perventricular device closure under TEE guidance in two centers between July 2007 and July 2011, in which perimembra- nous VSDs was found in 95 cases, intracristal VSDs in 37 cases and muscular VSDs in 10 cases. Their clinical data was retrospectively analyzed. The diameter of the VSD ranged from 3. 0 to 8. 5 mm （mean 4. 7 mm） by TTE, and ranged from 2. 5 to 8. 0 mm （mean 4. 3 mm） by TEE. Results The procedures was completed successfully in 140 cases （97. 2%）. 1 patient （0. 7%） was complicated with III atrial- ventricular conduction block in post-operation 5th day. VSD was closed with CPB in the secondary op- eration, the patient gradually reached to sinus rhythm in post-operation. The device in 1 patient （0. 7%） fell off and located in the left pulmonary artery after the operation. The device was taken out and followed by VSD closure with CPB in the secondary operation. Concentric devices were used in 93 cases and eccentric devices were used in 47 cases. During fellow-up, no clinically significant complica- tions were found. Conclusions The minimally invasive penventricular device closuer of VSD without CPB is a safe and effective therapy in children. It should be encouraged in clinical practice.