婴幼儿继发孔型房间隔缺损介入治疗的可行性及长期疗效

Transcatheter closure of secundum atrial septal defect in infants:the feasibility and long-term effects

目的总结经导管介入治疗婴幼儿先天性继发孔型房间隔缺损的可行性及长期疗效。方法研究海南省人民医院心内科2000年5月至2013年12月间经导管介入治疗的159例婴幼儿继发孔型房间隔缺损的临床资料。所有患儿术前均经临床体检、X线胸片、心电图、经胸超声心动图确诊为继发孔型房间隔缺损。经胸超声心动图测量房间隔缺损最大径、右心室舒张末期内径（RVDD）、右心房横径（RALD）及估测肺动脉收缩压,根据经胸超声心动图观察和测量房间隔缺损最大径结果选择适当的封堵器。结果入选159例患儿,其中中央型房间隔缺损143例,近上腔型房间隔缺损5例,近下腔型房间隔缺损11例。入选患儿中房间隔缺损合并其他畸形17例,房间隔缺损合并肺动脉高压15例。159例患儿中156例成功封堵（成功率98.1%）,未成功的3例均为缺损下腔静脉缘残端不足（小于5 mm）。患儿房间隔缺损最大径（10.2±2.5）mm,封堵器直径（11.7±3.6）mm,输送鞘8.5（7～10）F。导管操作时间（15.6±2.2）min。随访时间为（7.4±2.1）年,时间范围为1个月～13年,随访期间患者无封堵器脱落或移位,也无栓塞及心内膜炎等并发症的发生。随访过程中,4例患儿术后即刻出现一过性窦性心动过缓,1例患儿在术后第2天出现二度1型房室传导阻滞,予地塞米松治疗7 d后恢复窦性心律;2例患儿分别在术后的第1年和第5年发现一度房室传导阻滞,在分别随访2年和4年中未发现进行性加重。术后第1天复查超声心动图发现3例新发的三尖瓣轻度反流和7例少量残余分流（宽约1～2 mm）,发现三尖瓣轻度反流患儿在分别随访的1年,3.5年及10年中未发现反流加重及右心扩大,发现残余分流患儿有2例在1个月后恢复,4例在3个月后恢复,1例在1.5年后恢复。15例合并肺动脉高压患儿术后1个月肺动脉收缩压下降[（53±11.2）mm Hg vs.（32±4.8）mm Hg,P〈0.01;1 mm Hg=0.133 k Pa],右心负荷降低（右心室舒张末期内径：（13.7±4.3）mm vs.（11.5±3.2）mm,P〈0.01;右心房横径：（31.5±5.3）mm vs.（28.6±5.6）mm,P〈0.01）。结论经导管介入治疗婴幼儿继发孔型房间隔缺损是一项安全、可行的技术,长期疗效良好。

Objectives To study the feasibility and long-term effects of transcatheter therapy in 159 infants with congenital secundum atrial septal defect（ASD）. Methods Transcatheter closure using double-disk septal occluder was performed in 159 infants with secundum ASD from May 2000 to December 2013 in Hainan General Hospital. All the patients underwent clinical examination,x-ray,electrocardiography and transthoracic echocardiography for diagnosis of secundum ASD. Stretched diameter of the defect,end-diastolic diameter of right ventricle（RVDD）,lateral diameter of right atrial（RALD） and pulmonary arterial pressure were detected and measured by transthoracic echocardiography. Proper occluder was selected according to the defect diameter measure by transthoracic echocardiography. Results The procedure was performed in 159 infants,of which,there were 143 cases with ostium secundum defects,5 cases with defects adjacent to the superior vena cava and 11 cases with defects adjacent to the inferior vena cava. There were 17 cases with ASD complicated with other abnormalities and 15 cases with ASD complicated with pulmonary hypertension. The device was successfully placed in 156 out of 159 infants [98.1% closure rate,the 3 failed cases were with insufficient inferior vena cava stump（〈5 mm） ]. Stretched diameter of the defects was（10.2±2.5） mm. Size of the occluder device implanted was（11.7 ±3.6） mm. Size of the delivery sheath was 8.5（7-10） F. Duration of the operation was（15.6 ±2.2） min. The period of follow-up was（7.4 ±2.1） years,ranging from 1 month to 13 years. No displacement or detachment of the occluder,embolization,thrombus formation or endocarditis was observed in the follow-up period. During the follow-up,transient sinus bradycardia occurred in 4 cases immediately after procedure. Mobitz type I second-degree atrioventricular block occurred in 1 case on the second day after procedure,which was reversed by dexamethasone after 7 days. Sustained first-degree atrioventricular block occurred in 2 cases on the first and fifth year after procedure,but no progress was observed during 2 and 4 years ＇ follow-up after that. In 24 hours after procedure,7 patients with trivial residual shun（ranged 1-2 mm） and 3 patients with trivial tricuspid regurgitation were found by echocardiology. The regurgitation did not become severe during the longest follow-up of 10 years. Two infants with trivial tricuspid reguritation recovered in 1month,4 in 3 months and 1 in 1.5 year. In 1 month＇s follow-up,clinical development was observed in 15 infants complicated with pulmonary hypertension ： pulmonary hypertension ： [（53.0 ±11.2） mm Hg vs.（32.0 ±4.8） mm Hg,P〈0.01; 1 mm Hg =0.133 k Pa ]; RVDD： [（13.7 ±4.3） mm vs.（11.5 ±3.2） mm,P〈0.01; RALD： [（31.5 ±5.3） mm vs.（28.6±5.6） mm,P〈0.01 ]. Conclusions Transcatheter closure of secundum ASD is an efficient method that can be safely used in infants with significant long-term effects.