摘要
目的观察宽间距(两个有封堵意义的缺损间距>7 mm)多发孔房间隔缺损(MHASD)封堵术中经右胸—右心房入路食管超声引导下“穿刺单伞法”的安全性和有效性。方法纳入12例宽间距MHASD(4例合并上腔或下腔型房间隔缺损),术前采用彩色多普勒超声诊断仪行经胸超声心动图(TTE)或经食管超声心动图(TEE)检查,按所含每个房间隔缺损大小定义为大(>15 mm)、中(5~15 mm)、小(<5 mm),并分为S-S型(两个小缺损)、M-S型(1个中缺损伴1个或多个小缺损)、M-M型(两个中缺损,可伴小缺损)、Cribriform型(不含大房缺的非对称性筛孔状房缺,房缺个数≥5个)。采用右胸—右心房入路,在TEE引导下于两个拟封堵缺损的中间处穿刺房间隔,由此置入单个封堵器,通过伞盘覆盖MHASD,达到完全封堵。观察封堵器置入后即刻完全封堵情况,记录心内操作时间、手术时间、封堵器大小,以及有无残余分流(RS)、术中并发症;术后第4天复查TTE、胸片、心电图,观察有无房室传导阻滞等并发症及封堵器位置有无移位;术后1、3、6、12个月时均复查TTE、心电图,12个月后每年复查1次TTE、心电图,记录术前及术后第4天、6个月时的右心房内径(RA)、右心室前后径(RV)、左心房内径(LA)、左心室舒张末内径(LV)。结果12例MHASD患者中,分型为S-S、M-S、M-M、Cribriform型各3例,4例合并腔静脉型房缺(上腔型房缺1例、下腔型房缺3例)。患者均成功封堵,封堵器尺寸(26.4±7.7)mm,心内操作时间(22±8)min,手术时间(80±19)min;其中术中即刻完全封堵8例(67%),术中更换封堵器4例,1例穿刺2次完成封堵;术后疼痛轻微,术后第3~5天出院,出院时4例存在RS(均<3 mm)。术后患者均获随访,随访12个月时仅1例RS<3 mm。术后第4天、6个月RA、RV较术前缩小(P均<0.05),而术后6个月较术后第4天比较差异无统计学意义;与术前比较,术后第4天、6个月LA、LV差异无统计学意义。在随访期间,所有患者封堵器位置固定,形态良好,均未发现与封堵器相关的手术并发症。结论经右胸—右心房入路食管超声引导下“穿刺单伞法”封堵术可实现宽间距MHASD完全封堵,且无封堵相关并发症。
Objective To observe the safety and effectiveness of using the"Inter-defect septal puncture technique"to occlude wide-spaced(the distance between two defects intended to occlude is>7 mm)multi-hole atrial septal defect(MHASD)under the guidance of transesophageal echocardiography through peratrial approach.Methods Twelve cases of wide-spaced MHASD(4 cases with superior or inferior vena cava type of atrial septal defect)were included.Transthoracic echocardiography(TTE)or transesophageal echocardiography(TEE)were performed by color Doppler ultrasound before operation.ASDs were categorized by per size as large(>15mm),moderate(>5-≤15mm)and small(≤5mm)ASDs.MHASDs were divided into the S-S type(two small defects),M-S type(one medium defect with one or more small defects),M-M type(two medium defects,which can be accompanied by small defects),and cribriform type(asymmetric sieve shaped MHASD without large ASD,the number of defects≥5).Through peratrial approach and under the guidance of TEE,the atrial septum was punctured in the middle of the two defects which were intended to be occluded so as to implant a single occluder into the implanting hole and cover the periphery holes to achieve complete closure.The immediate complete occlusion rate after the placement of the occlude was observed,and the intracardiac manipulation time,operation time,occluder size,residual shunt(RS)and intraoperative complications was recorded.On the 4th day after operation,TTE,chest film,and ECG were rechecked to observe whether there were complications such as atrioventricular block and whether the position of occluder was shifted.TTE and ECG were reexamined at 1,3,6 and 12 months of follow-up.TTE and ECG were reexamined once a year after 12 months.The right atrial diameter(RA),right ventricular anterior posterior diameter(RV),left atrial diameter(LA)and left ventricular end diastolic diameter(LV)were recorded before operation and on the 4th days and 6th months after operation.Results Among the 12 patients with MHASD,there were 3 cases of S-S type,3 cases of M-S type,3 cases of M-M type,and 3 cases of cribriform type,respectively,and 4 cases with vena cava ASD(1 case with superior vena cava ASD and 3 cases with inferior vena cava ASD).All patients were successfully occluded.The occluder size was(26.4±7.7)mm,the intracardiac manipulation time was(22±8)min,and the operation time was(80±19)min.Among them,8 cases(67%)were completely occluded immediately during operation,4 cases replaces occluder during operation,and 1 case was punctured twice.The postoperative pain was mild,and the patients were discharged from hospital on the 3rd to 5th day after operation.Residual shunt was found in 4 cases(all<3 mm)when discharged.All patients were followed up.At 12 months of follow-up,only 1 case had RS(<3 mm).RA and RV decreased on the 4th days and 6th months of follow-up(all P<0.05),but there was no significant difference between the 6th month and the 4th days of follow-up.Compared with preoperative data,there was no significant difference in LA or LV on the 4th day and 6th month after operation.During the follow-up period,all occluders were stable and with good shape,and no occluder-related surgical complications were found.Conclusions Using the"Inter-defect septal puncture technique"to occlude wide-spaced MHASD under the guidance of transesophageal echocardiographic through peratrial approach is feasible.No operation-related ccomplications are recorded.
作者
孙跃坤
李红昕
孙士彬
李海峰
吕蒙
王海燕
厉泉
陈善良
米怀雪
SUN Yuekun;LI Hongxin;SUN Shibin;LI Haifeng;LYU Meng;WANG Haiyan;LI Quan;CHEN Shanliang;MI Huaixue(Department of Cardiovascular Surgery,Shandong Provtncial Qianfoshan Hospital,Cheeloo College of Medicine,Shandong University,Jinan 250013,China;不详)
出处
《山东医药》
CAS
2022年第17期33-38,共6页
Shandong Medical Journal
基金
山东省自然科学基金项目(ZR2013HM063)
山东省重点研发项目(2018GSF118058)。
关键词
多发房间隔缺损
经右胸—右心房手术入路
房间隔穿刺
封堵器
超声引导
介入治疗
multi-hole atrial septal defect
transesophageal echocardiographic through peratrial approach
septal puncture
occluder
ultrasonic guidance
interventional therapy
