经右侧腋下途径微创封堵膜周部室间隔缺损的临床经验和近期随访结果

Clinical Experience and Short-term Outcome for Minimally Invasive Occlusion in Patients With Peri-membranous Ventricular Septal Defect via Right Subaxillary Route

目的：总结应用食管超声引导经右侧腋下途径微创封堵治疗膜周部室间隔缺损的临床经验和近期随访结果。方法：2014-01至2015-07采用右侧腋下途径微创封堵术的膜周部室间隔缺损患者共122例,男54例,女68例,年龄0.5~9.7（2.7±2.2）岁,体重6.1~38.0（13.9±6.0）kg,缺损大小2.5~7.0（3.8±0.8）mm,患者取左侧卧位,沿右腋中线在第3至第4肋骨之间做约2~3 cm的切口,经第4肋间进胸,于右心房表面缝荷包,穿刺,在食管超声引导下,插入中空探条,经三尖瓣入右心室,再将探条对准或穿过室间隔缺损入左心室,沿探条送入导丝,再送入输送鞘管建立输送轨道,常规释放封堵器。术后定期随访,复查经胸超声心动图、心电图和X线胸片。结果：122例患者中119例封堵成功（97.5%）;封堵失败的3例（2.4%）术中直接经原切口中转为体外循环手术。封堵器大小为4~10（4.9±1.1）mm,均为对称伞。围手术期间：12例（10.1%）发生新的微量至轻度三尖瓣反流,16例（13.4%）术后发生不完全性右束支传导阻滞,4例（3.4%）术后发生残余漏,其中2例分别于术后随访1个月和3个月时自行闭合。定期随访1.0~19.8（8.3±5.0）个月中无完全性房室传导阻滞、新发主动脉瓣反流及封堵器脱落。结论：食管超声引导下经右侧腋下途径微创封堵膜周部室间隔缺损,是一种安全、有效、可行和更美观的治疗方法,但长期结果需要进一步观察。

Objective： To summarize the clinical experience and short-term outcome of minimally invasive occlusion in patients with peri-membranous ventricular septal defect（PmV SD） via right subaxillary route under trans-esophageal echocardiography（TEE） guidance.Methods： A total of 122 PmV SD patients treated in our hospital from 2014-01 to 2015-07 were summarized. There were 54 male and 68 female with the mean age of（2.7±2.2, 0.5-9.7） years, mean body weight of（13.9±6.0, 6.1-38.0） kg and mean PmV SD diameter of（3.8±0.8, 2.5-7.0） mm. The patients were taken left lateral position, a（2-3） cm incision was performed along right mid-axillary line between the 3rd rib and 4th rib, the thoracic entrance was at 4th inter-costal space. A purse-string suture was conducted on right atrial surface, a special hollow probe was inserted into right atrium and crossed tricuspid into right ventricle under TEE guidance; the probe was adjusted to the point or crossed VSD into left ventricle followed by guide wire insertion to establish a deliver pathway, and finally, occlusion device was regularly deployed to close the defect. Postoperative ECG, TEE and chest X-ray were conducted for followed-up study.Results： There were 119/122（98.4%） patients occluded successfully and 3 failed patients were converted to cardiopulmonary bypass surgery at the original incision. The average size of occluder was（4.9±1.1, 4-10） mm and all devices were concentric. The patients were followed up at the mean of（8.3±5.0, 1.0-19.8） months, during that period, 12/119（10.1%）had new mild tricuspid regurgitation, 16（13.4%） suffered from incomplete right bundle branch block, 4（3.4%） had small residual shunt and 2 of them were self-closed at 1 and 3 months after operation respectively. There were no complete atrioventricular block, no new aortic valve regurgitation and no device dislocation.Conclusion： Minimally invasive occlusion of Pm VSD via right subaxillary route under TEE guidance was a safe, effective, feasible and better cosmetic method for treating relevant patients; while its long-term outcome should be further observed.