经皮与经胸介入封堵治疗婴儿大型动脉导管未闭

Clinical efficacy of percutaneous and transthoracic interventional occlusion in the treatment of large patent ductus arteriosus in infants

目的 鉴于婴儿大型动脉导管未闭(patent ductus arteriosus, PDA)的介入治疗充满挑战性,主要原因是婴儿外周血管细,组织稚嫩,而所需封堵器大、输送鞘粗,造成经皮封堵的难度和风险增大。本文旨在探讨经胸与经皮介入封堵婴儿大型PDA的临床疗效。方法 回顾性分析145例婴儿期大型PDA患者(PDA直径≥4 mm)临床资料,收集患者的PDA直径、左室舒张末期内径、手术相关数据等指标,根据介入途径的不同,将患儿分为DSA引导下经皮组(95例)和食管超声引导下经胸组(50例)。观察两组患儿的手术疗效。结果 两组患儿均取得良好的手术成功率,7~12月龄的两组患儿中,经胸组肺动脉侧缺损平均直径(5.80±1.29)mm(范围4.00~10.00 mm);主动脉侧缺损平均直径(8.14±2.16)mm(范围5.20~15.00 mm),封堵器大小为(8.12±1.65)mm(范围6.00~12.00 mm);经皮组肺动脉侧缺损平均直径(5.14±0.94)mm(范围4.00~9.50 mm);主动脉侧缺损平均直径(6.66±1.25)mm(范围4.00~12.70 mm),封堵器大小为(7.83±1.93)mm(范围6.00~10.00 mm)。以上数据以及两组患者的术后的肺动脉收缩压(pulmonary artery systolic pressure, PASP)均较术前有不同程度的下降(P<0.05)。0~6月龄的两组患儿中,经胸组肺动脉侧缺损平均直径(5.14±1.51)mm(范围4.00~10.00 mm)、主动脉侧缺损平均直径(6.68±1.80)mm(范围4.00~10.00 mm);经皮组肺动脉侧缺损平均直径(5.11±1.24)mm(范围4.00~8.40 mm),主动脉侧缺损平均直径(5.92±0.63)mm(范围5.00~7.00 mm);两组的封堵器大小分别为(7.63±1.67)mm(范围6.00~12.00 mm)和(6.83±1.34)mm(范围6.00~10.00 mm),数据差异无统计学意义。随访结果显示,并未有封堵器脱落、心律失常及残余分流等并发症发生。结论 经胸及经皮微创封堵婴儿期大型PDA均是安全有效的治疗方式,对于体质量低、低月龄患儿,若外周血管纤细、穿刺及置管困难的,可采用经胸微创封堵的手术路径。

Objective To evaluate the clinical efficacy of minimally invasive perpulmonary and percutaneous closure of the patent ductus arteriosus(PDA)in infants.Methods A retrospective analysis was performed on 145 infants diagnosed with a large PDA≥4.0 mm in diameter.Data on PDA size,left ventricular end-diastolic diameter and operation-related parameters were collected for each patient.Based on the different interventional approaches,the infants were divided into two groups:the DSA-guided percutaneous closure group(n=95)and the Echo-guided perpulmonary closure group(n=50).The clinical efficacy of both groups was evaluated.Results Both groups achieved a high success rate of 100%in the Echo-guided perpulmonary closure group and 100%in the percutaneous approach.In the DSA-guided perpulmonary closure group for the patients aged from 7 to 12 months,the mean minimum diameter of PDA at the pulmonary end was(5.80±1.29)mm(range,4.00-10.00 mm),the mean maximum diameter of PDA at the aortic end was(8.14±2.16)mm(range,5.20-15.00 mm),and the size of the implanted device was(8.12±1.65)mm(range,6.00-12.00 mm).Similarly,in the DSA-guided percutaneous closure group,the mean minimum and maximum diameters of PDA were(5.14±0.94)mm(range,4.00-9.50 mm)and(6.66±1.25)mm(range,4.00-12.70 mm),respectively.The implanted device size was(7.83±1.93)mm(range,6.00-10.00 mm).The above data and the postoperative pulmonary artery systolic pressure(PASP)of both groups were lower than before surgery(P<0.05).In the Echo-guided perpulmonary closure group for the patients aged from 0 to 6 months,the mean minimum diameter of PDA at the pulmonary end was(5.14±1.51)mm(range,4.00-10.00 mm),and the mean maximum diameter of PDA at the aortic end was(6.68±1.80)mm(range,4.00-10.00 mm).Similarly,in the DSA-guided percutaneous closure group,the mean minimum and maximum diameters of PDA were(5.11±1.24)mm(range,4.00-8.40 mm)and(5.92±0.63)mm(range,5.00-7.00 mm),respectively.The implant device size was(7.63±1.67)mm(range,6.00-12.00 mm)and(6.83±1.34)mm(range,6.00-10.00 mm)in the two groups,respectively;there were no statistical differences between the two groups.The follow-up results showed that there were no complications such as device dislodgement,arrhythmia,or residual shunt.Conclusion Both the perpulmonary and percutaneous approaches for the closure of large PDA devices in infants are safe and effective.The perpulmonary approach is particularly suitable for low-birth-weight and preterm infants,especially in cases with limited accessibility and peripheral vascular challenges.