嵴内型室间隔缺损介入治疗中远期随访及评价

Mid-to-long term follow-up and evaluation of transcatheter interventional treatment for intracristal ventricular septal defect(IVSD)

目的探讨经导管介入治疗嵴内型室间隔缺损(IVSD)的疗效及并发症的中远期随访评价。方法回顾性分析西安交通大学第一附属医院结构性心脏病中心2012年1月至2020年12月诊断为嵴内型室间隔缺损(IVSD)并行经导管介入治疗的患者共39例,经胸超声心动图检查IVSD缺损(4.9±1.6)mm(2~8 mm),36例(92.3%)患者经导管介入治疗成功,封堵器型号为(10.3±2.3)mm(5~14 mm)。封堵器选用对称型VSD封堵器(20/36,55.6%)或零边偏心型VSD封堵器(16/36,44.4%)(上海)。其他3例(7.7%)中2例行外科手术干预,1例左向右分流细小终止手术。术后1、3、6、12个月以及之后每一年,至少达5年为观察终点,通过心电图(ECG)和(或)24h动态心电图(Holter)、经胸超声心动图(TTE)、胸部X线片等对其介入封堵效果、并发症进行中远期随访评价。结果围手术期及随访期间所有患者均无死亡、需要置入永久性起搏器、主动脉瓣重度返流外科手术、心包填塞等主要并发症,无主动脉瓣及肺动脉瓣返流中至大量增加,均无感染性心内膜炎及封堵器相关血栓等次要并发症发生。36例手术成功(成功率92.3%)。封堵器移位1例(2.6%),残余分流1例(2.6%),急性溶血1例(2.6%)。围手术期并发轻度主动脉瓣返流患者10例(25.6%),2例(5.1%)术中置入封堵器后即出现主动脉瓣返流量由轻度增加至中度以上,终止介入后行外科修补手术。心律失常发生8例(20.5%)。随访期并发轻度主动脉瓣返流患者7例(17.9%),其中2例(5.1%)为新发轻度主动脉瓣返流。心律失常2例(5.1%)为不完全性右束支传导阻滞及房性早搏。介入封堵手术以后中远期随访发现主动脉瓣返流无明显增加,心律失常发生明显减少,与围手术期有差别(P<0.05)。结论经导管介入治疗缺损8 mm以下IVSD具有创伤小、成功率高、术后及中远期并发症少,尤其是主动脉瓣返流增加及严重心律失常发生率低,中远期疗效随访观察结果良好。

Objective Assessment of the efficacy of transcatheter interventional treatment for intracristal ventricular septal defect(IVSD) and mid-to-long term follow-up evaluation of complications. Methods Retrospective analysis of 39 patients of intracristal ventricular septal defect(IVSD) diagnosed between January 2012 and December 2020 at the Structural Heart Disease Center, First Affiliated Hospital of Xi’an Jiaotong University, with mean IVSD defect of 4.9 ± 1.6 mm(2~8 mm) measured by transthoracic echography(TTE). Among all patients, 36 patients(92.3%) were successfully occluded, with Symmetrical VSD occlude(20/36, 55.6%) or zero side eccentric type VSD occluder(16/36, 44.4%)(Shanghai). Among the other 3 patients(7.7%), 2 patients received surgical intervention, 1 patient had small left to right shunt to terminate the operation. After the procedure, to assess mid-to-long term the efficacy of interventional occlusion and common post-procedure complications, patients were followed up with Electrocardiogram(ECG) and/or 24-hr Holter, Transthoracic echocardiography(TTE), Chest radiograph, etc., at 1, 3, 6, 12 months and annually thereafter for a total minimum 5 years of observation period. Results During perioperative and follow-up period, there was no cases of death or requirement of permanent pacemaker or severe valve regurgitation surgery or other severe complications. There was no mild increase of aortic valve and pulmonary valve regurgitation, infective endocarditis, pericardial tamponade or other secondary complications. 36 patients were successfully occluded(success rate 92.3%). There were 1 case of occlude displacement(2.6%), 1 case of residual shunt(2.6%), and 1 case of acute hemolysis(2.6%). There were 10 cases of perioperative mild aortic regurgitation(25.6%), In 2 cases(5.1%), the aortic regurgitation flow increased from mild to moderate after the occluder was placed during the operation, and surgical repair was performed after the intervention was terminated. There were 8 cases of Arrhythmia(20.5%). 2 cases of severe aortic valve prolapse with large defects requiring surgical intervention were found during intraoperative left ventricular angiography(5.1%). 7 cases(17.9%) of combined mild aortic regurgitation were found during follow-up, among which there were 2 cases(5.1%) were new-onset mild aortic regurgitation, and 2 cases(5.1%) of arrhythmia with incomplete right bundle branch block and premature atrial contractions. Post interventional occlusion treatment, the mid-to-long term follow-up showed no significant increase in aortic regurgitation, and the occurrence of arrhythmia was significantly reduced compared to the perioperative period(P<0.05). Conclusion Transcatheter interventional treatment of IVSD<8 mm features small incision, high success rate, low complication rate post treatment and during mid-to-long term follow-up, especially the incidence of increased aortic regurgitation and severe arrhythmia are low, mid-to-long term follow-up observation showed good patient outcome.