新型动脉导管未闭封堵器治疗小儿动脉导管未闭

The new amplatzer ductal occluder for transcatheter arterial duct occlusion in children

目的 总结新型动脉导管未闭封堵器（ADOⅡ）治疗动脉导管未闭（PDA）的早期临床经验。方法 选择2013年1月至2014年4月广州市妇女儿童医疗中心确诊为PDA的患儿12例，成功采用 ADOⅡ进行PDA封堵。根据经胸超声心动图、心血管造影确定动脉导管类型、导管最狭窄处直径和主动脉端大小，同时根据肺动脉压力情况选择合适的ADOⅡ。12例患儿中10例术中采用从主动脉侧建立轨道，逆向释放法，2例从肺动脉侧建立轨道，顺向释放法。释放前常规行降主动脉造影和经胸超声心动图观察封堵器位置是否合适，形态是否正常，有无残余分流及降主动脉、肺动脉血流速度；术后1 d行经胸超声心动图及心电图检查，若无异常术后第2天出院。术后1、3、6、12个月时门诊随访，行心电图及经胸超声心动图检查。结果 12例介入治疗患儿。男7例，女5例；年龄0.53～4.47（1.59±1.10）岁，体质量5.5～18.3（9.52±3.41）kg，平均肺循环血流量/体循环血流量（Qp/Qs）1.33～2.85（1.64±0.45），肺动脉收缩压23～58（32.50±10.05）mmHg（1mmHg=0.133 kPa），导管最窄直径1.6～3.8（2.40 ±0.68）mm，选择3mm×4mm封堵器7例，3mm×6mm 3例，6 mm×6mm 2例，输送长鞘为4～5F。X线曝光时间为3.2～18.2（6.39±4.16）min。10例即时心血管造影显示即时完全堵闭，2例有微量残余分流。术后经胸超声心动图确定封堵器位置、形态正常，2例有微量残余分流，主动脉血流速度及肺动脉血流速度均在正常范围。24h后经胸超声心动图检查显示12例完全堵闭，1例出现降主动脉相对狭窄，术后即刻测量升主动脉到降主动脉压差为11 mmHg，术后3个月复查经胸超声心动图提示压差为10 mmHg。6例完成术后1年随诊，3例完成了术后6个月随访。除上述1例出现降主动脉相对狭窄外，其余11例均无严重并发症。结论 ADO Ⅱ对婴幼儿中、小型、长管型或不规则型PDA 能达到完美的封堵效果，能使用4F或5F的输送鞘，可从主动脉端或肺动脉端操作释放封堵器，操作简单、方便，并发症少，封堵安全、有效。从肺动脉端释放封堵器的患儿，建议可用经胸超声心动图代替主动脉造影，可以避免穿刺主动脉，减少血管损伤。

Objective To describe early clinical experience with the new amplatzer ductal occluder II （ADO II ） for transcatheter patent ductus arteriosus （PDA） in children. Methods Twelve children were diagnosed as PDA from Jan. 2013 to Apr. 2014 in Guangzhou Children and Women＇s Hospital. All the children who were treated with the ADO H had the indication of a successful interventional therapy successfully. The size of device was chosen according to aortographic and transthoracic eehocardiography（TFE） results and pulmonary pressure. The device was delivered in a consequent or reverse way depending on the type of PDA, the minimal diameter of PDA and the size of duct ampulla. The device was delivered in a reverse way in ten patients, and two in a consequent way before detaching the device. Another aortogram was performed in order to check the position and form of the device, the velocities of blood flow in left pulmonary artery and the descending aorta though TFE and whether there was a residual shunt. All patients were examined by TrE in 24 hours after surgery and discharged without any complications 2 days later. The patients were programmed for the cardiologic consult including an TrE and electrocardiogram in 1,3,6 and 12 months after discharge. Results Twelve patients（7 male,5 female） with a median age of（1.59 ± 1.10） years（range 0.53 -4.47 years） ,a median weight of （9.52 ± 3.41 ） kg（ range 5.5 -18.3 kg） ,a median pulmonary blood flow/systemic blood flow（ Qp/ Qs） of 1.64 ± 0. 45 （ range 1.33 - 2.85 ）, a median pulmonary artery systolic pressure （ 32.50 ± 10.05 ） mmHg （ range 23 - 58 mmHg, 1 mmHg =0. 133 kPa） ,and the minimum （2.40 ± 0.68） mm （ 1.6 - 3.8 mm） ,underwent transcatheter ductal closure with the ADO 11. Device sizes used were 3 mm ±4 mm（n =7） ,3 mm x6 mm（n =3） ,6 mm ±6 mm （n = 2 ）, respectively and delivered with 4 or 5 F delivery catheters. The median fluoroscopy time was （6.39 ± 4.16 ） min（ range 3.218.2 min）. Complete ductal occlusion was achieved by the end of the procedure in 10 patients. The TIE showed good position of the occlusion and the velocities of blood flow in left pulmonary artery and the descending aorta were in a normal range. There was a trivial residual shunt after the surgery of 2 patients. No residual shunt was found after 24 hours in all 12 patients. In 1 case,the patient had a descending aortic obstruction with pressure gradient of 11 mmHg. Three months after surgery, the pressure descended to 10 mmHg by TIE. Complete ductal occlusion without aortic arch or left pulmonary artery stenosis had been identified in other 11 remaining patients on rITE follow-up of 6 months of 3 patients and 12 months of 6 patients. Conclusions The ADO II achieves excellent ductal closure rates through low profile delivery systems in small infants and children with moderate and small PDA or morphologically varied PDAs. It is simple in use with few complications. Occlusion design allows closure with ＇arterial or venous approach and delivery with 4 or 5 F delivery catheters. The children who used arterial approach, transthoracic echocardiography TIE is recommended to replace aortic angiography, so as to avoid puncturing the aorta and reduce vascular injury.