摘要
目的前瞻性随机对照研究经胸微创封堵与右腋下小切口直视修补治疗婴幼儿膜周部室间隔缺损（PmVSD）的疗效和随访结果。方法2010年1月至2013年1月，530例限制性PmVSD患儿纳入研究，年龄〈3岁，体质量〈15kg。应用随机数字表法随机分为两组：微创封堵组265例，采用胸骨下端小切口非体外循环经食管超声（TEE）引导，穿刺右心室游离壁，应用改良封堵器直接闭合VSD；右腋下小切口直视修补组265例，在常规体外循环（CPB）下采用右腋下小切口直视修补VSD。对比两组患儿手术成功率、手术时间、用血量、失血量、呼吸机辅助时间、ICU滞留时间、住院时间以及并发症发生率和医疗费用等指标。结果两组患儿全部得到有效治疗，均无死亡和危及生命的严重并发症。微创封堵组中10例（3．77％）封堵失败，适当延长原切口后中转常规直视手术成功修补；255例（96．23％）一次性封堵成功者中术后发生心律失常30例（11．76％），包括不完全左支传导阻滞（ILBB）3例（1．18％）、完全右束支传导阻滞（CRBB）3例（1．18％）、不完全右束支传到阻滞（IRBB）16例（6．27％）、Ⅰ度房室传导阻滞（AVB）8例（3．14％），微到少量残余分流（RS）18例（7．06％），新增三尖瓣少量反流（TR）29例（11．37％）。右腋下小切口直视修补组患儿全部成功（100％），术后心律失常116例（43．77％），包括CRBB61例（23．02％）、IRBB52例（19．62％）、临时性完全性房室传导阻滞（CAVB）和ILBB各2例（0．75％）、交界性异位心动过速（JET）1例（0．38％）；微到少量RS16例（6．04％），新增少量TRll例（4．15％），心功能不全17例（6．42％）。所有患儿随访12个月以上，无新增或加重的瓣膜反流，无迟发的CAVB以及其他并发症。两组比较，最终疗效相仿。微创封堵组住院天数、手术时间、用血量、失血量、呼吸机辅助时间、ICU滞留时间、住院时间及费用等结果明显低于右腋下小切口直视修补组（P〈0．05），TR病例多于右腋下小切口直视修补组（P〈0．05）；右腋下小切口直视修补组右束支传导阻滞发生率高于微创封堵组（P〈0．05），切口长度大于微创封堵组，但是其隐蔽性更好；微创封堵组无需体外循环，但术后需服用抗凝药物3～6个月。结论经胸微创封堵和右腋下小切口直视修补术都是膜周部室间隔缺损有效治疗方式。微创封堵虽然有一定的局限性，但其操作简单、创伤小、恢复快、并能节约大量医疗资源，对于有治疗适应证的患儿可作为治疗首选。
Objective To compare the treatment outcomes between minimally invasive perventricuIar device occlusion （MIPDO） and fight subaxillary incision surgical repair（RSISR） on perimembranous ventricular septal defect（PmVSD） in children less than 15 kilograms. Methods From January, 2010 to January, 2013, a total of 530 infants（age 〈3 years, weigh 〈 15 kg） with PmVSD enrolled and they were divided into two groups according to different treatment methods at random. Group 1 （ 265 cases） was arranged perventricular device closure with modified occluders through a lower partial median sternotomy under transesophageal echocardiography（TEE） guidance; group 2（265 cases） was arranged surgical repair on cardiopulmonary bypass（CPB） through a right subaxillary small incision. A prospective randomized controlled study was performed between two groups on success rate, operation time, volume of blood loss and transfusion, length of intubation and ICU stay, complications, expenses and follow-up results etc. Results All patients in two groups obtained effective treatment with no death or serious life-threatening complications. Group 1：255 cases（96.23% ） underwent successfully MIPDO. The remainder 10 cases（ 3. 77% ） who failed in attempt were successfully converted to conventional open heart operation by extending the original incision. Different arrhythmias arose in 30 cases （11.76% ）, including incomplete left bundle branch block （ILBB） in 3 cases （1. 18% ）, complete right bundle branch block（CRBB） in 3 cases（ 1.18% ）, incomplete right bundle branch block（IRBB） in 16 cases（6.27% ）, Ⅰ° atrioventricular block（Ⅰ°AVB） in 8 cases（3.14% ） ; trivial residual shunt（RS） in 18 cases（7.06% ） ; newly arose trivial tricuspid regurgitation（TR） in 29 cases（ 11.37% ）. Group 2 ： All the patients（ 100% ） underwent successful surgical repair through right subaxillary incision. Different arrhythmias occurred in 116 cases （43.77%）, including transient complete atrioventricular block （CAVB） and ILBB in 2 cases respective （0.75 % ）, junctional ectopic tachycardia（JET） in 1 cases（0.38% ）, CRBB in 61 cases（23.02% ）, IRBB in 52 cases（ 19.62% ） ; trivial RS in 16 cases （6.04%） ; newly arose trivial TR in 11 cases（4.15% ） ; heart dysfunction in 17 patients（6.42% ）. All patients were followed up for more than 12 months, and there were no newly happened or aggravated valve regurgitation or late onset CAVB in two groups. The final treatment effects are similar in both groups. But group 1 was significantly superior to group 2 in the aspects of operation time, volume of blood loss and consumption, length of intubation and ICU stay, hospitalizations and costs（ all P 〈0. 05 ）. The incidence of TR is higher in group 1 （ P 〈 0.05 ）, and that of right bundle branch block was higher in group 2 （ P 〈 0.05 ）. The incision is longer in group 2, but in a less exposed location. CPB is not needed in group 1, but anticoagulant drug is required for 3-6 months. Conclusion Both RSISR and MIPDO are effective treatment methods of PmVSD. Though having some limitations, MIPDO which characterized by simple procedure, minimal invasion, quick recovery, saving of medical resources could not only minimize the surgical trauma to patients, but also ensure the safety of operation to the maximum extent. However, the patient selection is vital. For selected patients, especially those of moderate PmVSDs with obvious clinical symptoms but no cardiac valve regurgitation, it is an ideal approach.
出处
《中华胸心血管外科杂志》
CSCD
2015年第9期527-532,共6页
Chinese Journal of Thoracic and Cardiovascular Surgery
关键词
室间隔缺损
封堵
封堵器
心脏外科手术
婴幼儿
心肺转流术
Ventrical septal defect Closure Occlusion device Cardiac Surgical operation Infant Cardiopulmonary bypass
