左腋下途径外科微创封堵干下型室间隔缺损的随访结果

The follow-up outcome for minimally surgical device closure of doubly committed sub-arterial ventricular septal defect via left sub-axillary route

目的探讨经左腋下干下型室间隔缺损（VSD）外科封堵的有效性和安全性。方法选取2014年6月至2016年8月在河南省人民医院儿童心脏中心经胸和经食管超声心动图筛选后适合封堵的干下型VSD患儿45例，男39例，女6例；年龄（2.2±2.1）岁（0.5～8.0岁）；体质量（13.8±7.1） kg（7.0～34.1 kg）；缺损大小（4.5±1.0） mm（3.0～8.0 mm）。全身麻醉成功后，取平卧位，经食管超声评估适合封堵，变换体位为右侧卧位，沿腋中线在第3肋间与第5肋间之间行2～3 cm垂直小切口，经第4肋间入胸，经右心室流出道穿刺建立输送轨道在食管超声引导下释放封堵器闭合VSD。结果41例（91.1%）患儿封堵成功，封堵器大小（6.0±1.5） mm（4～10 mm），均为非对称伞。2例（4.4%）因术中封堵器释放后明显残余分流转为体外循环直视手术，1例（2.2%）因封堵器释放后主动脉瓣明显反流转为体外循环下直视手术，1例（2.2%）术后封堵器脱落至肺动脉，后体外循环下直视封堵器取出并直视修补。4例封堵失败，其中2例（4.4%）发生轻微残余漏，分别于1个月和3个月随访时自行闭合。封堵成功患儿均于术后5～8 d出院。随访（10.4±5.0）个月（3～24个月），效果良好，无心包积液、封堵器脱落、房室传导阻滞、新增瓣膜功能异常等严重并发症。结论经左腋下食管超声引导对干下型VSD进行外科微创封堵是一种安全、有效的治疗方法。该术式创伤更小，术后渗出少，瘢痕小，切口更隐蔽、美观，但仍需长期随访结果。

Objective To investigate the feasibility and safety of surgical device closure of doubly committed sub-arterial ventricular septal defect via left sub-axillary.Methods A total of 45 patients diagnosed as doubly committed sub-arterial ventricular septal defect （dcVSD） with transthoracic echocardiography （TTE） and transesopha-geal echocardiography（TEE） were enrolled from June 2014 to August 2016 in Henan Children Heart Center, Henan Provincial People′s Hospital.There were 39 males and 6 females, with the mean age of （2.2±2.1） years old（0.5-8.0 years）, the body weight （13.8±7.1） kg（7.0-34.1 kg）, the defect size （4.5±1.0） mm（3.0-8.0 mm）. After general anesthesia, the patients were in supine and evaluated by TEE which indicated whether they were fit to closure.Then, they were turned to the right lateral position while this technique was determined.A vertical incision of 2-3 cm was made between the third and the fifth intercostal space and invasion in thoracic space via fourth intercostal space.Puncture was done at the anterior surface of right ventricular outlet tract to build a delivery tract.The occluder was released and the VSD was occluded under transesophageal echocardiography guidance.Results Forty-one patients had a successful surgical dcVSD closure with asymmetric occluders sized （6.0±1.5） mm（4-10 mm）. Among 4 failure cases, 2 cases（4.4%） were switched to open-heart surgical repair, 1 case（2.2%） due to device related aortic regurgitation, the rest 1 case（2.2%） experienced a dislocation of occluder into pulmonary artery and was converted to surgical repair after retrieve of occluder.Trivial residual shunt was detected in 2 cases （4.4%） postoperatively, a spontaneous closure was observed by 1 month follow-up and 3 months follow-ups, respectively.All the patients were discharged 5 to 8 days after the operation.With a follow-up of （10.4±5.0） months [3-24 months], there were no complications such as pericardial effusion, displacement of device, atrioventricular block or new valvular dysfunction. Conclusions Minimally invasive device closure of doubly committed sub-arterial ventricular septal defect via left sub-axillary is a feasible and safe treatment for closure of dcVSD.This technique has advantages of minor wound, less exudation, covert incision, however, long term follow-up is necessary.