应用Amplatzer封堵器关闭32例膜部室间隔缺损

Catheter closure of membranous ventricular septal defects using a new Amplatzer membranous VSD occluder

目的 观察Amplatzer膜部室间隔缺损封堵器关闭膜部室间隔缺损的临床疗效及安全性。方法 经超声心动图及临床表现诊断为膜部室间隔缺损患者 ,如有临床症状但没有右向左分流 ,且膜部室间隔缺损的局部解剖结构满足以下条件 :(1)膜部室间隔缺损离主动脉瓣至少 1mm ,离三尖瓣隔瓣至少 3mm ;(2 )室间隔缺损的最窄直径小于 14mm ;(3)伴膜部室间隔瘤形成时 ,瘤体未影响右心室流出道 ;(4 )外科手术关闭膜部室间隔缺损后遗留的室间隔缺损 ,且对心脏的血流动力学有影响。在局部或全身麻醉下对患者行经导管Amplatzer双面伞膜部室间隔缺损的关闭治疗 ,手术中连续经胸或经食管超声心动图和X线监测。术后随访 3个月。结果 自 2 0 0 2年 6月至 2 0 0 3年 3月共有 32例患者行经导管Amplatzer双面伞膜部室间隔缺损的关闭治疗 ,其中男 17例 ,女 15例。超声测定膜部室间隔缺损直径为 3～ 8mm(平均 5 1mm) ,左心室造影测定膜部室间隔缺损的直径为 3～ 8mm(平均 4 4mm) ,所选Amplatzer膜部室间隔缺损封堵器直径为 4～ 12mm(平均 7 6mm)。堵闭操作技术成功率为 10 0 %。超声心动图示术后即刻残余分流为 11 5 % (少量分流 3 8% ,微量 7 7% ) ,2 4h后残余分流为 7 7% (为微量 ) ,3个月后有 3 8%的微量分流。

Objective To evaluate the effectiveness and safety of transcatheter closure of membranous ventricular septal defect (MVSD) using Amplatzer membranous VSD occluder (AMVSO). Methods The patients, who were clinically diagnosed with VSD were recommended for further transthoracic echocardiographic assessment using multiple standard views. If there were left to right shunts across ventricular septum, the margin of defects to the aortic valve was more than 1mm and that to tricuspid valve was more than 3 mm. If there was an aneurysm, it should not interfere with the function of outlet of right ventricule. Finally, if the diameter of VSDs wasless than 14mm, catheter closure of VSDs was suggested in these patients. The patients, having residual shunt after surgical closure of VSD, were included. All procedures were performed under local or general anesthesia. Transthorac echocardiography and X ray were used continuously to monitor the procedure. Transthoracic echocardiography was performed immediately after the release of devices, 24 hours, and 3 months after the procedure, respectively.Results From June 2002 to March 2003, 32 consecutive patients (15 females), underwent transcatheter closure of MVSD. The mean diameters of VSDs measured by echocardiography was 5.1 mm (3～8 mm) and, while that by angiography was 4.4 mm (3～8 mm). The mean size of the occluder was 7.6 mm(4～12 mm). The successful rate of device implantation was 100% (32/32). The residual shunt immediately after the closure was 11.5%, whereas after 24 hours it was only 7.7%, which was not serious. After 3 months′ follow-up, only 3.8% trivial residual shunt existed. No death occurred during and after the procedure. Atrial tachycardia, ventricular tachycardia, and bundle (right and left bundle) branch block, which was considered to relate to catheter manipulation inside the chamber of ventricle, were common and transient. One aortic regurgitation and tricuspid insufficiency became severe after the procedure, but they were not serious. One patient developed III degree A-V block 24 hours after the procedure, and EKG became LBBB 3 days after the temporary pace making. Hemolysis was observed in one patient, and he recovered 7days after the medication therapy. Conclusion Transthoracic echocardiography was very much effective in catheter closure of MVSD. The asymmetric self-expanding nitinol double-disc Amplatzer device designed for the transcatheter closure of MVSD is implanted easily and stably. Due to low ratio of residual shunt and few serious complications, the Amplatzer device is a good choice for the transcatheter closure of MVSD.