经胸骨旁途径嵴内型嵴上型室间隔缺损微创封堵术

New minimally invasive technique of perventricular device closure of supracristal or intracristal ventricular septal de- fects through a parasternal approach

目的探讨经胸骨旁途径微创封堵嵴内型和嵴上型事间隔缺损（VSD）的町行性、安全性和效果。方法全组49例，于胸骨左缘第2或第3肋间作长1．5～3．0cm的切口，不进入胸膜腔，剪开心包。于朽心室流出道前壁缝荷包，穿刺，插入携带相应封堵器的特制输送管，在经食管超声引导下，经VSD进入左心室，依次推出封堵器左、右伞，卡闭VSD。结果本组成功封堵47例（96％），其中嵴内型26例，嵴上型21例。VSD平均直径嵴内型（4．4±1．7）mm，嵴上型（2．7±0．9）mm。置入封堵器型号：嵴内犁（7．0±2．3）mm，嵴卜型（4．8±1．1）mm.心内操作平均（17±16）min。随访3～24个月，无封堵器脱落、主动脉瓣受累等并发症。结论经胸骨旁途径微创封堵直径8mm以下的嵴内型和5mm以下的嵴上型VSD是简单、安全、可行的。

Objective To evaluate the feasibility, safety and efficacy of pe^ventricular device closure of supracristal or intracristal ventricular septal defects （VSD） using a minimally invasive technique through a parasternal approach. Methods 49 patients, aged 4 months to 53 years [ median 4.8 years], were era＇oiled in this study. A I. 5 to 3 cm parasternal incision was made in the left second or third intercostal space. The pericardium was incised and cradled without entering the pleura] space. Two parallel pursestring sutures wm~ placed at the right ventricular outflow tract. After puncture, the specially designed delivery sheath loaded with the device was inserted into the right ventricle. Under transesophageal echocardiographic guidance, the sheath was advanced through the defect into the left ventricle. Then the device was deployed to close the defect. Results Successful implantation of the device was achieved in 47 patients （96%）, including 26 in intracristal group and 21 in supracri- sta] group. The concentric, eccentric, and muscular occluders were used in 17, 28 and 2 patients, respectively. The mean di- ameter of VSD was （4.4 ± 1.7） mm in the intracristal group and （2.7 ± 0.9） mm in the supracristal group. The mean device size was （7.0 ± 2.3 ）mm and （4.8 ± 1.1 ）mm in the intraleristal and supracristal group, respectively. The mean intracardiac manipulation time was （17 ± 16） rain. During the follow-up period of 3 to 24 months, no device-related complications were found. Conclusion The perventricular device closure of small-sized supracristal or under medium-sized intracfistal VSD is feasible, sge, and efficacious through a left parasternal approach.