经导管双封堵器封堵治疗伴膜部瘤形成的室间隔缺损

Transcatheter clousure for ventricular septal defect with aneurysm using double occluders

目的评价经导管双封堵器封堵治疗伴膜部瘤形成的室间隔缺损(ventricular septal defect,VSD)的可行性、有效性及安全性。方法回顾性分析2005年至2013年在复旦大学附属中山医院心内科住院的16例VSD患者,包括14例膜周部VSD,1例法洛氏四联症(tetralogy of Fallot,TOF)纠治术后室间隔残余分流和1例VSD修补术后室间隔残余分流,均伴有室间隔膜部瘤,在常规左心室造影并建立右侧股动脉-左心室-VSD-右心室-右侧股静脉导丝轨道后,使用第1枚封堵器封堵VSD后,复查左心室造影提示有大量残余分流,重复上述方法使用第2枚封堵器封堵残余分流,左心室造影、升主动脉造影、经胸超声心动图(transthoracic echocardiography,TTE)以及心电图(electrocardiogram,ECG)未提示有严重并发症则释放封堵器。术后1周内监测ECG、TTE、血常规、尿常规及肾功能。术后1、3、6、12个月随访ECG和TTE。结果所有患者均使用双封堵器封堵成功,封堵后即刻行左室造影见封堵器位置良好,轻微残余分流6例,未见三尖瓣或动脉瓣。反流加重术后1周内随访ECG见2例有一过性传导阻滞,包括1例完全性右束支传导阻滞和1例一度房室传导阻滞;随访血常规有1例血小板较术前下降幅度>50%,但无明显溶血和出血,术后无对比剂肾病发生;左心房内径、左室舒张末内径及肺动脉收缩压在术后1周内明显改善(P=0.001,0.008及0.001)。术后1年内随访,患者心脏杂音消失,TTE提示封堵器位置良好,TTE测及残余分流者逐步减少至2例,无心脏瓣膜受累,ECG提示未见新发心脏传导阻滞。结论对于特定的VSD患者使用双封堵器经导管封堵治疗是可行的,术后近、中期疗效满意,安全性高。

Objective To explore the feasibilty,effectiveness and safety of transcatheter closure for ventricular septal defect（VSD） with aneurysm using double occluders. Methods We retrosepectively analyzed 16 VSD patients with aneurysm including 14 cases of perimembranous VSD,1 case of residual shunt after repair of tetralogy of Fallot（TOF）and 1 case of residual shunt after operation of VSD,who underwent transcatheter closure from2005 to 2013 in Zhongshan Hospital,Fudan University.After left ventriculography and establishment of guidewire track from the right femoral artery to the right femoral vein through the left ventricle,VSD and right ventricle,the first occluder was implanted through the guidewire.Then the left ventriculography was performed again and unacceptable severe residual shunt was confirmed.A second occluder was implanted using the same way to close the residual shunt.Two occluders were released if no severe complications were detected by ventriculography,angiography,transthoracic echocardiography（TTE）and electrocardiogram（ECG）.All patients were followed up by routine blood count,routine urine test,kidney function,TTE and ECG within 1 week and by TTE,ECG1,3,6,12 months after the procedure,respectively. Results All patients were successfully implanted with two occluders.Six cases of mild residual shunt were found by left ventriculography immediately after the procedure without aggravating tricuspid or aortic valve regurgitation.Transient post-operative conductive disturbance occurred in 2 patients within 1 week including 1 case of complete right bundle branch block and 1 case of degree Ⅰatrioventricular block.Significant decreased platelet count was observed in 1 patient over 50% compared with pre-operative and no contrast-induced nephropathy was witnessed.The left atrium diameter,left ventricular enddiastolic diameter and pulmonary artery systolic pressure decreased significantly within1 week after the precedure（P=0.001,0.008,0.001）.Heart murmur disappeared in all patients,and no aortic or tricuspid valve regurgitation and conduction disorder were found during the follow-up of 1 year after the procedure,but still 2 patinets had mild residual shunt detected by TTE. Conclusions Transcatheter closure of VSD with double occluders was feasible for particular paients,with satisfactory effectiveness and safety in short-and mid-term.