经右胸-右心房途径微创室间隔缺损封堵术

New minimally invasive technique of peratrial device closure of ventricular septal defect through a right parasternalapproach

目的探讨经右胸-右心房途径微创封堵室间隔缺损（VSD）的可行性、安全性和优势。方法2011年5月至2012年7月，采用经右胸-右心房途径微创封堵VSD47例（经右心房组），分年龄段随机选取同期经胸骨正中-右心室途径行微创封堵术的膜周部VSD47例作为对照（经右心室组）。经右心房组手术于胸骨右缘第4或第3肋间、长1．5-2．0cm的切口进胸，于右心房表面缝荷包，穿刺，插入特殊构型的中空探条，经三尖瓣人右心室。在食管超声引导下将探条对准VSD，沿探条孔送入导丝，再送入输送管和封堵器完成封堵。结果两组均封堵成功。经右心房组VSD出口直径2．0-7．0mm，置入封堵器型号4-12mm。心内操作时间[经右心房组（15±13）min，经右心室组（8±5）min]和手术时间[经右心房组（56±24）min，经右心室（72±16）min]组间差异均有统计学意义，P〈0．01。随访1-12个月，两组均无封堵器脱落等并发症。结论经右胸-右心房途径微创封堵VSD安全、可行，创伤更小，手术时间更短。

Objective The aim of this study was to evaluate the feasibility, safety and efficacy of peratrial device closure of ventricular septal defect （VSD） through a fight parasternal approach. Methods Between May 2011 and July 2012,47 pa- tients （peratrial group）, aged 7 months to 37 years, underwent peratrial device closure of VSD through a right parasternal ap- proach. According to the same inclusion criteria, 47 patients who underwent perventricular device closure of VSD were random- ly chosen as the control group （ perventricular group）. In the peratrial group, a 1.5 to 2.0 cm parasternal incision was made in the fight fourth or third intercostal space. The pericardium was incised and cradled. Two parallel pursestring sutures were placed at the right atrium near the atfioventrieular groove. After puncture, a specially designed hollow probe was inserted into the fight atrium. The probe was passed through the tricuspid valve into the fight ventricle. Under transesophageal echocardio- graphic guidance, the tip of the probe was adjusted to point to or cross the defect. A flexible guidewire was rapidly inserted into the left ventricle through the channel of the probe to establish a delivery pathway, and the delivery sheath was introduced through the defect over the wire. Then the device was deployed to close the defect. Results Successful implantation of the de- vice was achieved in both groups of patients （ 100% ）. In the peratfial group, the entrance and the exit diameter of the VSD were （7.4 ± 4.1 ） mm （ range, 2.0 to 20.0 ram） and （3.4 ±1.2 ）mm （ range, 2.0 to 7.0 ram） , respectively. The mean de- vice size was （6.3 ± 1.5 ）mm （range, 4.0 to 12.0 ram）. The mean intracardiae manipulation time is longer in the peratrial group [ （15 ± 13） min l than in the perventricular group[ （8 ± 5 ）rain ], P 〈 0, 01. But the procedure time is shorter in the peratrial group[ （56 ±24） mini than in the pervcntrieular group[ （72 ± 16） mini, P 〈0.01. During the follow-up period of 1 to 12 months, no device-related complications were found. Conclusion The peratrial device closure of VSD is feasible, safe, and efficacious. It has the advantages of less invasiveness, better cosmetic results, and a shorter procedure time.