儿童继发孔型房间隔缺损的介入治疗_高伟

·论著·作者单位:200127上海第二医科大学附属新华医院上海儿童医学中心心内科儿童继发孔型房间隔缺损的介入治疗

高伟　周爱卿　余志庆　李奋　张玉奇　孙锟　钟玉敏 【摘要】　目的　探讨儿童继发孔型房间隔缺损(atrialseptaldefect,ASD)封堵术的指征、方法学和并发症的预防。方法　1998年10月～2003年1月,119例继发孔型ASD患儿,根据家属意愿接受了经导管应用Amplatzer房间隔封堵器的介入治疗。年龄0.8～17.0岁,平均(7.5±2.8)岁,体重6.7～88.0kg,平均(23.7±7.8)kg。所有病例术前检查被证实均为继发孔型ASD。按ASD球囊伸展直径或大于1～2mm选择封堵器进行堵塞。其中3例为多发ASD。6例合并动脉导管未闭(patentductusarteriosus,PDA)或肺动脉瓣狭窄(pulmonarystenosis,PS)者应用其他封堵装置和球囊扩张治疗合并的畸形。术后定期行心脏超声及临床检查随访。结果　119例患儿术前经食道超声(transesophagealechocardiography,TEE)或经胸超声(trans-thoracicechocardiography,TTE)检测ASD平均直径(12.9±5.6)mm(6.5～34.5mm),肺动脉平均压力为(29.0±5.0)mmHg(25.0～62.0mmHg),球囊伸展直径为(15.7±4.8)mm(8.0～38.0mm)。所选封堵器直径平均为(15.0±5.0)mm(8.0～38.0mm)。112例封堵成功。3例多发ASD也选用单一封堵器。6例合并PDA或PS者同时完成介入治疗。112例堵塞后即刻封堵率为93.8%(105/112);堵塞1个月后的封堵率97.3%(109/112),堵塞1年后的封堵率98.2%(110/112),仅2例存在少量左向右分流。有5例(4.5%)在堵塞后24h内出现偶发房性早搏,1d后消失。有1例(0.9%)出现Ⅱ度1型房室传导阻滞,1个月后恢复正常。随访时间为1个月～4.3年,无封堵器移位需外科干预者,也无栓塞及心内膜炎等并发症的发生。结论　AmplatzerASD封堵器在儿童继发孔型ASD治疗中可作为外科手术修补的替代治疗。【关键词】　房间隔缺损;　治疗

Transcatheterclosureofsecundumatrialseptaldefectinchildren　GAOWei,ZHOUAi-qing,YUZhi-qing,LIFen,ZHANGYu-qi,SUNKun,ZHONGYu-min.DepartmentofCardiology,ShanghaiXinhuaHospital,ShanghaiChildren'sMedicalCenter,ShanghaiSecondMedicalUniversity,Shanghai200127,China

【Abstract】　Objective　Thisstudywasundertakentoinvestigatetheindication,methodologyandcomplicationoftranscatheterclosureofsecundumatrialseptaldefect(ASD).ASDtranscatheterocclusiontechniqueshavebecomealternativetosurgicalprocedures.AnumberofdifferentdevicesareavailablefortranscatheterASDclosure.Thetypeandincidenceofcomplicationsdependpartiallyupondifferentdevices.Methods　AretrospectiveanalysiswasperformedonthepatientstreatedfromOctober1998toJanuary2003.TranscatheterclosureofASDwithAmplatzerseptaloccluder(ASO)wasperformedin119patients,ofwhom3patientsweremultipleASD,3associatedwithpulmonarystenosis(PS)and3patentductusarteriosus(PDA).Theageofthecasesrangedfrom0.8to17years(mean7.5±2.8years)andthebodyweightrangedfrom6.7to88kg(mean23.7±7.8kg).Theyallmetwithcriteriafortranscatheterclosure.Theballoon-stretcheddiameterofASDwasdeterminedwithfluoroscopy,ultrasoundandmeasuringplate.Achoiceofdevicesizewasidenticaltoor1～2mmlargerthanthestretcheddiameter(SD).AsimultaneousPDAclosurewithdeviceorballoondilationwasdoneinsixcasesassociatedwithPDAorPS,respectively.Follow-upwasperformedbasedontheechocardiographicandclinicalfindings.Results　In119casesexaminedwithtransesophagealechocardiography(TEE)ortrans-thoracicechocardiography(TTE),ASDmeandiameterwas(12.9±5.6)mm(6.5-34.5mm),pulmonarymeanpressurewas(29.0±5.0)mmHg(25.0-62.0mmHg),andSDwas(15.7±4.8)mm(8.0-38.0mm).Thediametersofthesedeviceswere(15.0±5.0)mm(8-38mm).Thedevicesweresuccessfullyimplantedin112cases.Ofthem,3patientshadmultipleASDwithonedeviceocclusion.6casesassociatedwithPDAorPSweretreatedsuccessfullywithPDAocclusionorballoondilatation,respectively.Theimmediate,onemonthandoneyearcompleteocclusionrateswere93.8%(105/112),97.3%(109/112)

·287·中华儿科杂志2004年4月第42卷第4期　ChinJPediatr,April2004,Vol42,No.4and98.2%(110/112),respectively.Residualshuntremainedin2cases.NocomplicationoccurredexcepttransientatrialprematurebeatsandgradeⅡtype1A-Vblockin5cases(4.5%)and1cases(0.9%),respectively.Thewholetimeperiodoftheprocedurerangedfrom25to68minutes.Thetotalfollowupperiodwasfromonemonthto4.3years.Nounsatisfactorydevicepositionorembolizationorclinicalevidenceofbacterialarteritiswasfoundduringthefollow-upperiod.Conclusion　TranscatheterclosureofsecundumASDusingtheASOisasafeandeffectivealternativetosurgicalrepair.TranscatheterclosureofsecundumASDassociatedwithsmallanterior,inferiororposteriorrimisfeasibleusingASO.ASOcanbeperformedininfantsandyoungchildrenonlyifthediameterofdiskissmallerthanthediameterofatrialseptum.MultipleASDisnotthecontraindicationforintervention.IfthediameterofASDisover36mm,thedevicechoiceshoulddependonthemaximumdiameterofASDdeterminedwithechocardiography.TTEissuitableforthesmallerASDandTEEforthebiggerASD.Itisveryimportanttoavoidairembolismandatrialperforationduringtheprocedure.【Keywords】　Heartseptaldefects,atrial;　Therapy

尽管经导管成功封堵继发孔型房间隔缺损(atrialseptaldefect,ASD)的报道已有25年了,但该技术得到广泛发展和应用是在近3～4年,故对病例的选择、操作技术及封堵手术中、手术后并发症等,都在不断摸索和总结,且目前对于大样本儿童继发孔型ASD介入治疗的报道还很少。我院于1998年10月～2003年1月为119例继发孔型ASD儿童施行了介入治疗,总结如下。对象与方法一、对象1998年10月～2003年1月根据家属意愿,119例继发孔型ASD患儿接受了经导管应用Amplatzer房间隔封堵器(Amplatzerseptaloccluder,ASO)的介入治疗。其中男52例,女67例;年龄0.8～17.0岁,平均(7.5±2.8)岁。体重6.7～88.0kg,平均(23.7±7.8)kg。所有病例均于术前经体格检查、心电图、X线胸片及经胸超声心动图(trans-thoracicechocardiography,TTE)证实为继发孔型ASD。其中3例合并动脉导管未闭(patentductusarteriosus,PDA),3例合并肺动脉瓣狭窄(pulmonarystenosis,PS)。二、方法1.介入治疗方法:选取美国AGA公司制造的Amplatzer房间隔封堵器系统。在全麻或局麻下穿刺股静脉并行肝素化(125U/kg),行常规右心导管术,测定肺循环/体循环比值和肺动脉压力。选择性右上肺静脉肝锁位造影,判断ASD的大小和位置,观察造影剂经肺循环后的肺静脉回流,并排除心室水平分流和主动脉弓的病变。造影后再沿已插入左上肺静脉或左心室的交换导丝插入球囊测量导管并骑跨于房间隔上,以稀释造影剂充盈球囊,在胸透下调整球囊测量大小及位置。当球囊测量导管出现腰凹切迹及经食道超声心动图(transesophagealechocardiography,TEE)或TTE监测下已无分流时停止充盈。在透视(后前位)和超声屏幕上直接测量球囊腰凹切迹直径,然后将球囊测量导管撤至体外,再以同样剂量的造影剂在体外充盈球囊后在测量板上测量ASD伸展直径,最后分析上述3种测量所得ASD伸展直径结果并选定一直径数值,按该ASD伸展直径或较其大1～2mm选择封堵器,沿8～12F输送鞘在透视和超声监测下将封堵器送入左房,释放左房盘后,回撤整个递送系统使左房盘与房间隔相贴,固定输送导丝,回撤外鞘管,释放出封堵器的腰部及右房盘,并抖动输送导丝证实封堵器位置稳定与否,经超声和透视证实封堵器位置合适后再释放封堵器,撤除整个递送系统,完成封堵术。如有合并PDA或PS,则先封堵PDA或球囊扩张PS,再完成ASD封堵术。通常术前3d至术后3个月给予肠溶阿司匹林3～5mg/(kg·d),如所选封堵器较大,则可延长到6个月。术前1d至术后2d静脉给予抗生素预防感染。2.随访:(1)即刻随访:术后2h作TTE检查,观察封堵器情况及有无心包积液并测定左心室收缩功能(射血分数,ejectionfraction,EF;缩短分数,fractionshortening,FS)等。(2)常规随访:术后1、3、6个月及1年作心电图及超声心动图检查,观察封堵器情况及有无心律失常表现。以后再根据情况每半年或1年随访1次。