全胸腔镜下房间隔缺损封堵术186例报告

Totally Thoracoscopic Closure of Atrial Septal Defect: Report of 186 Cases

目的探讨全胸腔镜非体外循环下房间隔缺损微创封堵术治疗先天性继发孔房间隔缺损(atrial septal defect,ASD)的疗效。方法 2008年5月~2016年5月186例先天性继发孔ASD行全胸腔镜非体外循环下房间隔缺损微创封堵术。全麻,右侧第7肋间腋中线1.0 cm小孔置入胸腔镜,右侧锁骨中线微切口2.0 cm,第4肋间进胸,作为操作孔。术中经食道超声(TEE)引导下经输送器置入封堵器闭合ASD。结果 178例成功封堵,7例中转胸腔镜辅助体外循环下修补术(2例上腔型、3例下腔型、2例中央型由于房间隔缺损过大,封堵器影响二尖瓣结构),1例次日心脏彩超发现封堵器脱落立即送手术室行开胸体外循环下直视修补术。无死亡,术中出现室上性心动过速6例,Ⅲ度房室传导阻滞3例,经治疗均转为窦性心律;胸腔积液5例,经引流等治疗痊愈。术后3~7 d出院。178例随访0.5~8年,(3.2±1.9)年,彩超示封堵器无残余漏、移位,心功能Ⅰ级70例,Ⅱ级83例,Ⅲ级25例。结论全胸腔镜下房间隔缺损封堵术采用微切口入路,符合美容要求,无须体外循环,费用低,术后恢复快,临床效果确切,若封堵不成功,可同期直接改体外循环下直视修补术。

Objective To discuss the effect of off-pump thoracoscopic transcatheter closure of congenital atrial septal defect（ ASD） by micro incision. Methods A total of 186 cases of congenital atrial septal defects underwent totally thoracoscopic closure in our hospital from May 2008 to May 2016. The operation was performed under general anesthesia. We put the video into the chest on the right side of the seventh intercostal axillary midline through a 1-cm incision. And another 2-cm micro incision was made on the right midclavicular line at the fourth intercostal space for operator. The ASD was closed with special occluder device under trans-esophageal echocardiography（ TEE） guidance. Results Successful surgical occlusion was obtained in 178 cases. And there were 7 cases converted to thoracoscopic repair under extracorporeal circulation（ including 2 cases of superior vena cava type atrial septal defect,3cases of inferior vena cava type atrial septal defect,and 2 cases of central type with large defect affecting mitral valve structure） and 1case of open chest surgery due to occluder fall-off under echocardiography. There was no death. Six patients had ventricular tachycardia during the operation. Transient third degree atrioventricular block happened in 3 patients during the procedure. Pleural effusion occurred in 5 patients and was cured. The hospitalization time was 3-7 days after surgery. Follow-ups for 0. 5-8 years[（ 3. 2 ± 1. 9）years] in 178 cases showed no residual leakage or occluder shift,with heart function improved significantly（ grade Ⅰ in 70 cases,Ⅱin 83 cases,Ⅲ in 25 cases）. Conclusions Thoracoscopic transcatheter closure of atrial septal defect by micro incision needs no extracorporeal circulation and has advantages of low operating costs,rapid recovery after operation,and good clinical effects. Surgeons can directly turn to the extracorporeal circulation to repair ASD if the surgical occlusion is not successful.