室间隔缺损介入封堵术后并发溶血的探讨

The Discussion of the Hemolysis after Transcatheter Closure of Ventricular Septal Defect

目的探讨室间隔缺损介入封堵术后溶血并发症的预防及处理策略.方法 2012年1月至2014年1月昆明医科大学第一附属医院心内科行室间隔缺损(VAD)介入封堵157例,其中3例(男2例,女1例)发生术后机械性溶血,其缺损口大小分别为11、15、18 mm,其中病例1为急性心肌梗死所致的后间隔基底部室间隔穿孔,余均为先心病膜部VSD.所选用的封堵器依次为16 mm的国产对称性VSD封堵器、18 mm的国产PDA封堵器、24 mm国产对称性VSD封堵器.结果 3例患者分别于术后10、7、4 h发生溶血.病例1术后无残余分流、病例2少量残余分流,病例3约3 mm的残余分流,病例1、病例2经保守治疗6 d、3 d后溶血停止;病例3术后间断溶血,保守治疗28 d再次出现较大量溶血,后经心脏外科开胸取出封堵器并行VSD修补术后好转.结论VSD介入封堵术后并发溶血可能与封堵器大小、残余分流有关;溶血并非只出现在有残余分流的患者,但尽可能的完全封堵缺损口,无残余分流是预防术后溶血的根本措施;溶血发生后需积极补液、碱化尿液、利尿,严防急性肾功能衰竭发生,停用阿司匹林、肝素、稳定细胞膜等减轻溶血.严重时需立即行外科手术取出封堵器并行VSD修补术.

Objective To discuss the prevention and treatment strategies of hemolysis after transcatheter closure of ventricular septal defect.Methods There were 157 cases of transcatheter closure of ventricular septal defect at the Department of Cardiology of the First Affiliated Hospital of Kunming Medical University from January 2012 to January 2014,and three of them （2 males and 1 female） were complicated with intervascular hemolysis after transcatheter closure.The defect sizes of the three patients were 11,15,and 18 mm,respectively.Case 1 was due to acute myocardial infarction,the other two were CHD membranous VSD.We chose 16mm domestic symmetry VSD occluder,18mm domestic PDA occluder,and 24mm domestic symmetry VSD occluder for the three patients.Results Hemolysis occurred in 3 patients 10,7 and 4 hours after transcatheter closure of ventricular septal defect.After transcatheter closure,case 1 had no residual shunt,case 2 had little residual shunt and and case 3 had approximately 3mm residual shunt.After conservative treatment for 6 days and 3 days,hemolysis was blocked in Case 1 and Case 2.Interval hemolysis occurred in Case 3,and after conservative treatment for 28 days,hemolysis became more serious,at last the patient underwent surgery to remove the VSD occluder and repair VSD in cardiac surgery.Conclusion Hemolysis after VSD transcatheter closure may be related with occluder size and residual shunt.Hemolysis not only occurs in patients with residual shunt,but also in patients without residual shunt.No residual shunt is the most important measure to prevent postoperative hemolysis.After hemolysis,it is necessary to actively give rehydration,urine alkalization,and diuresis to prevent acute renal failure,and to stop aspirin,heparin and sometimes prescripe glucocorticoids to relieve hemolysis.When hemolysis became serious,we must perform surgery to remove the VSD occluder and repair VSD in cardiac surgery immediately.