介入封堵治疗室间隔缺损合并轻中度右冠状瓣脱垂的疗效观察

Clinical analysis of transcatheter closure of ventricular septal defect with mild or moderate right coronary valve prolapse

目的评价介入封堵治疗室间隔缺损(VSD)合并轻、中度右冠状瓣脱垂的有效性及安全性。方法选择2015年5月至2018年4月湖南省儿童医院收治的VSD患儿作为研究对象,术前经胸超声心动图(TTE)和(或)经食管超声心动图(TEE)诊断VSD合并轻、中度右冠状瓣脱垂,采用经导管介入封堵治疗75例(男40例,女35例)。术中通过造影及TTE检查有无残余分流、新发主动脉瓣反流或原有主动脉瓣反流加重,体表心电图评估介入封堵后是否影响传导系统。术后通过TTE和体表心电图对患儿进行随访,重点观察主动脉瓣反流程度和有无心脏传导阻滞。结果 75例患儿平均年龄(51.8±34.6)个月,平均体重(16.7±7.3)kg;嵴内型VSD 31例,膜周型VSD 44例;右冠状瓣脱垂轻度53例,中度22例。其中术前三尖瓣轻度反流3例,主动脉瓣轻度反流1例;应用对称型VSD封堵器24例,偏心型VSD封堵器30例,ADOⅡ封堵器21例。术后三尖瓣反流3例(同术前),主动脉瓣轻度反流7例(其中1例同术前),残余漏4例(术后6个月消失),室性早搏1例,三度房室传导阻滞1例(外科取伞并修补VSD后恢复窦性心律),封堵器脱落1例(紧急外科取伞并修补VSD),无左束支传导阻滞、机械性溶血发生。不同程度右冠状瓣脱垂VSD封堵术后主动脉瓣反流比较,差异有统计学意义(P=0.002);不同类型VSD封堵术后主动脉瓣反流比较,差异无统计学意义(P>0.999)。嵴内型VSD与膜周型VSD患儿手术时间[(15.00±12.66)min比(19.68±13.48)min,P=0.028]、辐射剂量[(93.97±51.45)m Gy比(123.93±58.85)m Gy,P=0.005]比较,差异均有统计学意义。术前与术后6个月左心室舒张末期内径[(31.20±3.59)mm比(27.45±2.96)mm,P=0.096]、左心室收缩末期内径[(19.60±2.22)mm比(16.71±1.87)mm,P=0.098]比较,差异均无统计学意义;而左心室射血分数[(63.85±4.77)%比(66.37±3.05)%,P=0.010]比较,差异有统计学意义。结论通过介入封堵治疗合并轻、中度右冠状瓣脱垂VSD是可行的,但仍需长期随访评价其远期疗效,及更大样本量评估术后效果。

Objective To evaluate the effectiveness and safety of transcatheter closure of ventricular septal defect(VSD)with mild or moderate right coronary valve prolapse. Methods The study population consisted of 75 children(40 boys and 35 girls)undergoing transcatheter intervention for VSD with mild or moderate right coronary prolapse in Hunan Children’s Hospital from May 2015 to April 2018. Transthoracic echocardiography(TTE)and/or transesophageal echocardiography(TEE) were performed before treatment.During the procedure,angiography and TTE were used to check whether there was residual shunt or new aortic regurgitation,and electrocardiogram was used to evaluated whether the conduction system was affected after intervention. The children were followed up by TTE and electrocardiogram. The T-test was used for comparison between groups and the Chi-square test was used for the category data. Results The average age of 75 patients was(51.8±34.6)months,the average weight was(16.7±7.3)kg. There were 31 cases of intraorbital VSD and 44 cases of perimembranous VSD. The right coronary valve prolapse was mild in 53 cases and moderate in 22 cases. There were 3 cases of mild tricuspid regurgitation and 1 case of mild aortic regurgitation before operation. A total of 24 cases were treated with symmetrical VSD occluder, 30 cases with eccentric VSD occluder and 21 cases with ADO Ⅱ occluder. Postoperative tricuspid regurgitation occurred in 3 cases(the same as before surgery),mild aortic regurgitation in 7 cases(1 case was the same as before surgery),residual shunt in 4 cases(disappeared 6 months after surgery),ventricular premature contraction in 1 case,three degree atrioventricular block in 1 case(sinus rhythm was restored after surgical occluder removal),occluder shedding in 1 case(emergency surgical occluder removal),no left bundle branch block and mechanical hemolysis was found. There was significant difference in aortic regurgitation after VSD closure with different degrees of right coronary valve prolapse(P=0.002). There was no difference in aortic regurgitation after different types of VSD closure with right coronary valve prolapse(P>0.999). There were significant difference in operation time[(15.0±12.66)min vs.(19.68±13.48)min,P=0.028]and exposure[(93.97±51.45)mG y vs.(123.93±58.85)mG y, P=0.005]between different types of VSD. There were significant differences in left ventricular end-diastolic diameter[(31.20±3.59)mm vs.(27.45±2.96)mm,P=0.096],endsystolic diameter [(19.60±2.22)mm vs.(16.71±1.87)mm,P=0.098], ejection fraction[(63.85±4.77)% vs.(66.37±3.05)%,P=0.010]before and 6 months after operation. Conclusions This study is feasible to treat VSD with mild or moderate right coronary valve prolapse by interventional closure, but long-term follow-up is still needed to evaluate its long-term efficacy,and larger sample size studies to evaluate postoperative results.