左胸肋间入路微创封堵手术治疗干下型室间隔缺损

Mini-invasive transthoracic closure of doubly committed subarterial ventricular septal defect through left parasternal approach

目的：总结左胸肋间入路微创封堵手术治疗干下型室间隔缺损（VSD）的初步经验。方法2014年2月至2015年9月我们对19例干下型 VSD 患儿施行外科微创封堵手术，其中男性10例，女性9例；年龄0．5～17岁，平均（3．2±4．3）岁；体重5．5～50．0 kg，平均（14．3±10．9）kg；缺损直径3.5～9．0 mm，平均（5．4±1．8）mm；合并主动脉瓣右冠瓣轻度脱垂6例，主动脉瓣局限～轻微反流3例，肺动脉瓣轻中度狭窄1例，轻度狭窄1例。均采用左胸肋间入路，在经食管超声心动图（TEE）监视下建立 VSD 输送轨道并置入封堵器，观察有无残余分流及主动脉瓣反流；于出院前、手术后定期复查经胸超声心动图和心电图。结果18例封堵手术获成功，因新发主动脉瓣中度反流及残余分流而中转开胸手术1例。术中新发主动脉瓣轻微反流2例，术前合并主动脉瓣反流患者中有2例反流加重。手术时间35～85 min，平均手术时间（55．7±15．9）min 。术中出血量3～200 mL，平均（22．7±43．3）mL。围手术期输血1例。术后住院时间3～13 d，平均（4．2±2．3）d。术后出现残余分流、上呼吸道感染、伤口感染各1例。随访6～25个月，平均（14．7±7．0）个月，随访期间1例新发主动脉瓣反流，1例术中新发主动脉瓣反流消失，2例术后仍有主动脉瓣反流患者反流无明显变化，1例残余分流愈合，无传导阻滞发生。结论左胸肋间封堵手术治疗干下型 VSD 手术安全，操作简单，创伤小，恢复快，近期效果满意，远期效果需进一步随访；对合并主动脉瓣脱垂尤其主动脉瓣反流的干下型 VSD 需慎重施行外科微创封堵手术。

Objetive To summarize the preliminary experiences of mini-invasive occlusion of doubly committed subarterial ventricular septal defect （DCSVSD）by left parasternal approach.Methods From Feb-ruary 2014 to September 2015,19 DCVSD patients underwent mini-invasive surgery.There were 10 males and 9 females with a mean age of （3.2 ±4.3）（0.5 ~17）years,a mean weight of （14.3 ±10.9）（5.5 ~50.0） kg and a mean diameter of defect （5.4 ±1.8）（3.5 ~9.0）mm.Among 6 cases of mild right coronary valve prolapse,3 of them had trivial-mild grade aortic valve regurgitation.Perventricular closure was attempted with a unique design eccentric device under the guidance of transesophageal echocardiography （TEE）.Such compli-cations as residual shunt,arrhythmia,valve regurgitation were recorded postoperatively and during follow-ups. Results Eighteen cases were successfully occluded.One case failed due to moderate regurgitation and residual shunt and converted into cardiopulmonary bypass （CPB）.During operation,2 patients developed trivial aortic valve regurgitation.Trivial-mild aortic valve regurgitation worsened in 2 patients.The operative duration was （55.7 ±15.9）min,postoperative hospitalization duration （4.2 ±2.3）days,the amount of intraoperative hemorrhage （22.7 ±43.3）ml.One patient received blood transfusion.Postoperative residual shunt,upper re-spiratory tract infection and wound infection occurred in 3 cases.During follow-ups,one patient had an onset of＆nbsp;new aortic valve regurgitation,1 patient with new onset aortic regurgitation disappeared.And one patient with residual shunt healed. Conclusions Perventricular closure of DCSVSD is safe and effective mini-invasive treatment for selected patients.Patients with aortic valve prolapse especially aortic regurgitation should be care-fully evaluated before occlusion.