剑突上正中及胸骨左缘小切口入路在婴幼儿经胸室间隔缺损封堵应用中的比较研究

Comparison of two approaches for transthoracic device closure of ventricular septal defect in infants

目的:探讨在经食管超声心动图(transesophageal echocardiography,TEE)引导下,剑突上正中小切口及胸骨左缘第3或第4肋间小切口入路行经胸室间隔缺损(ventricular septal defect,VSD)封堵术的疗效、安全性及优缺点。方法:回顾性分析2014年1月至2018年12月在福建省立医院采用不同微创入路行TEE引导下经胸VSD封堵术的179例2岁以内(3~21个月)VSD患儿的临床资料。其中,采用剑突上正中小切口(切口大小为1.0~1.5 cm,A组)87例,采用胸骨左缘第3或第4肋间小切口(切口大小为1.0~1.5 cm,B组)92例,两组均经右心室面无血管区穿刺完成封堵。采用t检验和χ2检验分析比较两组封堵成功率、手术操作时间、术后胸液引流量、并发症发生率等。结果:A组及B组的封堵成功率分别为97.7%(85/87)和96.7%(89/92),组间比较,差异无统计学意义(P>0.05)。A组和B组的手术操作时间分别为(52.7±15.4)min和(39.3±12.3)min,术后胸液引流量分别为(49.2±11.8)ml和(31.7±6.9)ml,组间比较,差异均有统计学意义(P均<0.05)。A组术后近中期发生胸廓畸形4例,B组无胸廓畸形发生。随访12~72个月,两组均无封堵伞脱落、残余分流、房室传导阻滞、瓣膜反流等并发症发生。结论:采用剑突上正中小切口及胸骨左缘第3或第4肋间小切口入路行TEE引导下经胸VSD封堵安全、可行,且后者与前者相比操作更简便、用时更短、胸液引流量更少,创伤更小、更美观,同时避免了胸廓畸形的发生。对于术中TEE评估封堵概率低的患儿,为避免多处皮肤切口,采用剑突上小切口更合适。

Objective To explore the safety and efficacy of ransthoracic device closure of ventricular septal defect(VSD)guided by transesophageal echocardiography(TEE)and compare the advantages and disadvantages of two approaches in infants.Methods From January 2014 to September 2018,retrospective review was performed for clinical data of 179 infants aged 3-21 months undergoing transthoracic device closure of VSD through right ventricular route guided by TEE.The approaches were median sternotomy(group A,n=87)and left parasternal approach(group B,n=92).The incision size ranged from 1.0-1.5 cm.The relevant intrao/postoperative data were collected and two groups were compared with regards to operative duration,drainage volume and complications.Results No significant differences existed in gender,age,weight,lesion size or device.The rate of successful device closure in group A was similar to group B(97.7%,85/87 vs.96.7%,89/92).There was no significant difference(P>0.05).As compared with group A,operative duration was shorter(52.7±15.4 vs.39.3±12.3 min)and there was less drainage volume(49.2±11.8 vs.31.7±6.9 ml)in group B(P<0.05).Four cases of thoracic deformity at incision site in group A,yet none in group B during mid-term follow-ups.During a follow-up period of 12-72 months,there was no occurrence of residual leakage,arrythimia,valve damage,device dislocation or dropout.Conclusions Median sternal or left parasternal approach is safe,efficacious and mini-invasive for device closure of VSD.With a shorter operative duration and a less drainage volume,left parasternal approach is easier to handle with minimal trauma.However,median sternal approach is superior since it avoids multiple incisions.