不同类型封堵器介入封堵膜部室间隔缺损致完全性房室传导阻滞比较研究

Follow-up of complete atrioventricular block after transcatheter closure of perimembranous ventricular septal defect with different occluding devices

目的通过比较应用不同类型封堵器介入封堵膜部室间隔缺损(perimembranous ventricular septaldefect,pmVSD)致完全性房室传导阻滞(complete atrioventricular block,CAVB)的发生率,探讨CAVB发生原因及处理方法。 方法收集湖南省儿童医院2013年3月至2016年12月行介入封堵治疗的pmVSD患儿临床资料(包括术前评估、术中造影、术后随访、心脏彩超和心电图检查结果等),对接受不同封堵器类型治疗后发生CAVB情况进行比较。 结果本研究共封堵pmVSD500例,发生CAVB11例,发生率2.2%;其中对称型VSD封堵器CAVB发生率为1.1%(4/359),偏心型VSD封堵器CAVB发生率为4.2%(5/93),小腰大边型VSD封堵器CAVB发生率为5.4%(2/48)。偏心型和小腰大边型VSD封堵器致CAVB发生率高于对称型VSD封堵器,差异有统计学意义(P<0.05),偏心型VSD封堵器与小腰大边型VSD封堵器致CAVB发生率无明显差别(P>0.05)。发生CAVB的11例患儿均应用糖皮质激素治疗,7例无效,3d后转外科取出封堵器,其中应用对称型封堵器的3例,偏心型封堵器的1例,小腰大边型封堵器的3例,均在1周内恢复窦性心律,均未安装临时或永久起搏器。 结论偏心型和小腰大边型VSD封堵器封堵pmVSD后CAVB发生率高于等边对称型VSD封堵器,选择偏心型和小腰大边型VSD封堵器封堵pmVSD需严格把握指征。

Objective To evaluate the incidence of complete atrioventricular block (CAVB) after transcatheter closure of perimembranous ventricular septal defect (pmVSD) with different occluding devices and explore the causes and interventions of complete atrioventricular block (CAVB). Methods From March 2013 to December 2016,500 children underwent pmVSD closure using different occluding devices.Clinical data,angiographic findings,follow-up records and ECG results were retrospectively analyzed. Results All of them were successfully managed with transcatheter closure.No statistic difference existed in age,gender,timing or occluder size.The overall incidence of CAVB was 2.2%,the incidence of CAVB with symmetric,edge type 4 and decentered occluder were 1.1%(4/359),4.2%(5/93) and 5.4%(2/48) respectively.All CAVB patients recovered after methylprednisolone dosing or occluder removing (symmetric, n =3;edge type 4, n =3;decentered, n =1).Among 11 CAVB cases on glucocorticoids,4 ineffective children were converted into surgery after 3 days.And symmetric ( n =3),decentered ( n =1) and thin-waist-big-side ( n =3) occluders were utilized.Sinus rhythm resumed within 1 week.None required implanting a temporary or permanent pacemaker. Conclusion The incidence of CAVB after implanting an edge type 4 or decentered occluder is higher than symmetric occluder during pmVSD closure.