巨大动脉导管未闭的介入治疗策略

Interventional strategy of transcatheter closure for huge patent ductus arteriosus

目的探讨巨大动脉导管未闭(PDA)的介入治疗策略与经验。方法选取2001年5月至2015年12月沈阳军区总医院经超声心动图诊断为巨大PDA的患者166例,通过术前心血管造影检查进一步明确诊断,后行经皮PDA封堵介入治疗,10 min后行主动脉弓降部造影,术后24 h、1个月、3个月、6个月行X线胸片、心电图及超声心动图检查,观察治疗效果。结果 166例患者中男43例(25.9%),年龄6个月～63.0岁(18.8±16.3)岁。心血管造影检查排除合并畸形血管患者2例,PDA试封堵术排除不适合行介入封堵治疗患者3例。最终161例患者行介入封堵治疗,1例发生封堵器脱落,其余160例患者均成功封堵。封堵术后10 min肺动脉平均压均较术前有不同程度下降,但仍有7例患者虽然肺动脉压力较封堵前下降,但仍显著高于正常值,术后给予口服靶向降肺动脉压药物治疗,术后中远期超声心动图评估肺动脉压明显下降。封堵术后5例(3.1%,5/160)患者出现血小板减少,给予激素、止血药物等相关处理,其中4例患者于出院前血小板恢复正常,1例患者出院前血小板虽未恢复至正常,但无下降趋势,于术后半年恢复正常;1例(0.6%,1/160)患者出现血红蛋白尿,给予激素、止血药物、降压药物等相关处理,尿色逐渐变浅,于术后第4天恢复正常。术前伴不同程度的主动脉瓣狭窄和二、三尖瓣关闭不全患者,随访复查时均较术前有不同程度减轻,且无明确血流动力学意义。结论巨大PDA行介入封堵治疗有其特殊性,也存在一定风险,但介入治疗策略正确,仍为一种安全有效的方法。

Objective To explore the interventional strategy and experience of transcatheter closure with huge patent ductus arteriosus（ PDA）. Methods From May 2001 to December 2015,166 patients were diagnosed with huge PDA（ diameter of PDA≥6 mm in patients wit body mass 8 kg or PDA ≥10 mm in adults） by echocardiography. All patients received interventional examination before closure and angiography of the aorta descendens 10 minutes after the closure. X-ray,ECG and echocardiography were performed at 24 hours,1 month,3 month,6 month and 1year after operation. Results Among the 166 patients（ 43 males and 123 females）,age from 6 months to 63 years（ 18. 8 ± 16. 3） years,2 patients were found to have complex deformity under angiography and 3 patients were identified as unsuitable for further interventional therapy after empirical experimental closure. 161 patients received interventional closure of high PDA. Fall off of occluder was identified in 1 patient. 5 patients had thrombocytopenia and 1 patient had hemoglobinuria after operation, who were cured with medicine. The mean pulmonary pressure,aortic stenosis,mitral valve insufficiency and tricuspid incompetence were all decreased with different extent after occlusion. Conclusions Transcatheter closure for huge PDA is a special procedure with relatively high risk. It is still a safe and effective method to treat PDA with correct approach and strategy.