經(jīng)導(dǎo)管同期介入治療兒童復(fù)合型先天性心臟病8例分

經(jīng)導(dǎo)管同期介入治療兒童復(fù)合型性心臟病8例分析及隨ysisandFollow-upStudyon8ChildrenCaseswithCombinedCongenitalHeartDiseaseTreatedwithSimultaneousTranscatheter少,本研究2例合并三種畸形,6例合并兩種畸形,均介入治療成功,最長隨5?通訊及第一作者:成勝單位:西安第四西京醫(yī)院兒通信地址:西安樂西路15號:經(jīng)導(dǎo)管同期介入治療兒童復(fù)合型性心臟病8例分析及隨成勝權(quán) 劉建平 1 2 2 21 牛永春(1.第四西京醫(yī)院兒科;2.第四西京醫(yī)院超聲診斷科,陜西西安【】目的探討兒童性心臟病(CHD)復(fù)合畸形(復(fù)合型CHD)經(jīng)導(dǎo)管介入治療的方法及療效?方法應(yīng)用經(jīng)導(dǎo)管介入治療方法同期封堵治療8例兒童復(fù)合型CHD,其中男4例?女4例,平均(6.1±2.9)歲,其中房間隔缺損(ASD)伴室間隔1例,卵原孔未閉(PFO)伴PS1例,ASD伴PS4例?經(jīng)導(dǎo)管介入治療的原則是:ASD術(shù);PFO伴PS和ASD伴PS者,先行PBPV糾正PS,其次行PFO或ASD封堵術(shù)?結(jié)果本組例復(fù)合型CHD均1次治療成功,術(shù)中未發(fā)生任何嚴(yán)重并發(fā)癥?余分流,跨瓣壓差均在通常標(biāo)準(zhǔn)良好的范圍內(nèi),無任何并發(fā)癥發(fā)生?結(jié)論經(jīng)導(dǎo)管【】兒童;心臟缺損,性;心臟導(dǎo)管插入術(shù);封堵器;隨訪研【號】 【文獻(xiàn)標(biāo)識嗎】ysisandFollow-upStudyon8ChildrenCaseswithCombinedCongenitalHeartDiseaseTreatedwithSimultaneousCHENGSheng-quan1,LIUJian1,SUNxin1,LIJun2,ZHANGJun2,LIULi-wen2,DENGYue-lin1,NIUYong-Chun11DepartmentofPediatrics,2DepartmentofUltrasound,XijingHospital,FourthMilitaryMedicalUniversity,Xi'an710032,China:quanyi@ 】ObjectiveToinvestigatethemethodsandefficiencyofinterventionaltreatmentforchildren’scombinedcongenitalheartdiseases(CHD).MethodsEightpatients(4boysand4girls)withcombinedcongenitalheartdiseaseunderwentsimultaneoustranscathetertherapy.Theirmeanagewas6.1±2.9yearsold.Thetypesofthecongenitalheartdefectcombinationwereasfollows:1casewithatrialseptalventricularseptaldefect(VSD),andpatentductusarteriosus(PDA);1casewithASD,PDA,andpulmonarystenosis(PS);1casewithASDPDA;1casewithpatentforamenovale(PFO)andPS;4caseswithASDandPS.Themethodsoftranscatheterinterventionwere:forcaseswithASD,VSD,andPDA,theocclusionofVSDwasperformedfirst,thatofPDAsecond,andthatofASDthird;forcaseswithASD,PDA,andPS,theocclusionofpercutaneousballoonpulmonaryvalvuloplasty(PBPV)wasperformedfirst,thatofPDAsecond,andthatofASDthird;forcaseswithPFOandPS,theocclusionofPBPVwasperformedfirst,andthatofPFOfollowed;forcaseswithASDandPS,theocclusionofPBPVwasperformedfirst,andthatofASDfollowed.ResultsEachpatientwastreatedsuccessfullywithonlyoneoperation.Nocomplicationsoccurredduringtheoperations.Noresidualshuntandalltheocclusiondeviceswerefoundinthesuitablesites,judgedbytransthoracicechocardiography(TTE)andX-rayrightaftertheoperations.For6patientscombinedwithPS,thesystolicpressureacrossthepulmonaryvalvedecreasedfrom(75.3±15.6)mmHgbeforetheoperationsto(14.0±5.6)mmHgaftertheoperations(P<0.05).With3.4±1.2yearsfollow-up,noresidualshuntoccurredandgradientsacrossvalveorcoarctationsiteswerewithinthelimitofsatisfactoryresults.Nocomplicationswereobserved.ConclusionComparedwithsimplecongenitalheartdisease,transcatheterinterventionforcombineddefectsismoredifficult,However,followedbytheprincipleofeasieroperationsfirst,satisfactoryresultscanbeobtainedfromsuitableindications,propermethods,andstandardizedmanipulations. 】children;heartdefects;congenital;heartcatheterization;occluder;follow-upstudies兒童性心臟病(congenitalheartdisease,CHD)復(fù)合畸形(復(fù)合型CHD)既往外科手術(shù)是唯一的治療方法?近年來經(jīng)導(dǎo)管治療兒童CHD在臨得到日益廣CHD,如室間隔缺損(ventricularseptaldefect,VSD)?間隔缺損(atrialseptaldefect,ASD)?動脈導(dǎo)管未閉(patentarteriosus,PDA)?肺動脈瓣狹窄(pulmonarystenosis,PS)等均可通過經(jīng)導(dǎo)管封或兩種以上畸形的CHD,同時經(jīng)導(dǎo)管介入治療的較少?我科自2002年3月以8CHD?資料與方20023200758CHD療,其中男4例,女4例,平均(6.1±2.9)歲?術(shù)前進(jìn)行血尿便常規(guī)?肝腎功凝血功能?心電圖?X?復(fù)合畸形種類:VSDASD?PDA1,ASDPDA?PS1,ASDPDA1孔未閉(patentforamenovale,PFO)PS1,ASDPS4?1?1221%利多卡因局部麻醉(Percutaneousballoonpulmonaryvalvuloplasty,PBPV)VSD?ASD?PDA?ASD封堵術(shù);ASDPDA?PS者,先行PBPV糾正PS,再次行PDA封堵術(shù),最后行ASDVSD?ASD和PDA封堵器均為華醫(yī)圣杰公司產(chǎn)品,PBPV所用擴(kuò)張球囊為NUMED術(shù)中靜脈注入肝素按100U/kg體重,靜脈注射地塞5mg?所有患兒術(shù)后常規(guī)靜脈用抗生素三天預(yù)防,復(fù)查心電圖及超聲心動圖,術(shù)后次日開始口服阿司匹術(shù)后1?3?6個月,1?2?3?4及5年門診或隨訪,復(fù)查心電圖?超聲心動圖及胸統(tǒng)計學(xué)處理計量資料數(shù)據(jù)以X±S表示結(jié)8CHD11,2,3-A?B?C,4-A?B?術(shù)VSD?ASDPDA,6PS球囊選擇以球囊/瓣環(huán)的比值為1.2～1.4為原則?VSD?ASD及PDA封堵器(傘)的選擇以大于最窄直徑2～6mm,不防礙瓣膜的開放和關(guān)閉?無返流?不造成狹窄為原則?1?并發(fā)癥的發(fā)生及處理:6PS當(dāng)心率低于55次/分,用稀釋好的阿托品(常規(guī)備用)靜推,按每次0.03～0.05mg/kg給予,心率很快回復(fù)正常;7例術(shù)中出現(xiàn)過陣發(fā)性室上型心動過速,2例出現(xiàn)早搏,退出導(dǎo)管即可?隨訪結(jié)果:所有患兒均于術(shù)后1?3?6個月及1年來院檢查;隨訪2年有24年3例,隨訪5年3例?經(jīng)胸超聲心動圖檢查示所有患者各水平分流均,擴(kuò)大的內(nèi)徑進(jìn)行性縮小,所有封堵器位置固定良好,無移位及脫落;X均明顯減少,心臟大小均明顯恢復(fù);心電圖檢查無傳導(dǎo)阻滯及左右束支阻滯;討CHD治療的重要和根治的,因其較之外科有不用開胸?住院時間短?小及療的可行性及療效如何,國內(nèi)外尚不多?本研究對8例兒童復(fù)合型CHD進(jìn)行同期介入治療,其中合并三種畸形2例,兩種畸形6例,均介入治療成功,說明一?復(fù)合型性心臟病介入治療原復(fù)合型CHD的介入治療是在單純型CHD介入治療的基礎(chǔ)上發(fā)展起來的,雖說前者的簡單疊加?CHD了以下的治療策略:對于VSDASD?PDA者,我們先行VSD封堵術(shù),再次行PDA封堵術(shù),最后行ASD封堵術(shù);ASDPDA?PS者PBPV糾正PS,再次行PDAASD;PFOPS?ASDPSPBPVPS,PFOASD?的畸形不能同時完成而再送外科手術(shù)?②后期操作不影響前面治療VSD伴PDA或/和ASD是性心臟病中最常見的組合畸形之一?VSD非常適PDA→VSD→ASD內(nèi)操作次數(shù),避免影響VSD或/和ASD封堵器的穩(wěn)定性,但如果估計VSD介入治療較,則需先完成VSD封堵,成功后再作PDA或/和ASD封堵,否則將是PDAASD作了介入封堵,而VSD再送外科手術(shù)治療的尷尬?對于VSD伴ASD?PDAVSD→PDA→ASD,VSD雜,通過右心房和左系統(tǒng),應(yīng)該先行封堵,PDA封堵后再行ASD封堵操作,則PDAASD,PDA,PDAASDVSD或ASD伴PS,在VSD或ASD有指征能完成介入治療的前提下,是否做聯(lián)合囊擴(kuò)張效果欠佳,應(yīng)以外科手術(shù)為主?PBPV→VSDASD先不,端管沿鋼絲至肺總動脈,交換彎頭硬鋼絲為J型軟鋼絲,探查PDA后,端管沿鋼絲至降主動脈,交換J型軟鋼絲為彎頭硬鋼絲,端管,PDAASDPFOPSPBPV,ASDPFO,PBPV導(dǎo)管和導(dǎo)絲不再經(jīng)過,不對肺動脈瓣造成影響?對于ASD?PDA伴PS者,先PBPV,PDA→ASD?二?仔細(xì)準(zhǔn)確的心臟超聲檢查是選擇適應(yīng)癥的重要形,嚴(yán)格掌握適應(yīng)證?例如型ASD的伸展徑以≤34mm為宜,缺損邊緣至冠狀靜脈竇?瓣及左上肺靜脈應(yīng)≥5mm;肺動脈瓣狹窄應(yīng)為瓣膜型狹窄,無流關(guān)閉不全;對PDA的封堵,只要PDA內(nèi)徑≥2mmPDA封堵器封堵等PS?ASDPDA1～41～4復(fù)合型CHD1VSDASD、PDA2ASD伴PDA3-A、B、CASDPDA、PS，圖4-A、B為ASDPS成功率近100%?由于VSD剖結(jié)構(gòu)的復(fù)雜性和缺損變異的多樣性,其適應(yīng)證的選擇及操作過程尚待不斷完善?即使術(shù)前嚴(yán)格超聲檢查篩選VSD患者,仍不可避免地有極少部分患者手術(shù)不成功,或封堵器置入后會影響主動脈瓣或啟閉,嚴(yán)重者只能回收封堵器,放棄封堵,轉(zhuǎn)外科手術(shù)治療?這種情況下就沒有必要行其余畸形的糾治?另外,手術(shù)方案還體現(xiàn)了后期操作不影響前面治療的思想?以ASD合并其他心臟畸形為例,先糾正其他畸形,最后行ASD封堵,可避免先行ASDASDASDVSDCHD?總之,在治療過程中我們的總原則是先做技術(shù)難度大的,后作簡單的手術(shù),后期操作不影響前面的治療效果?CHD24-3-24-3-14-3-3-18CHD號別編性 超聲診斷(缺口/瓣環(huán)大小mm) 號別4882男4882男722-3女4女818-5男5822-6男22-7女822-8男22-[參考文獻(xiàn)成勝權(quán),劉建平,,等.國產(chǎn)雙盤狀封堵器治療兒童膜周部室間隔缺損的效果及隨訪研究.中國循證兒科,2007,2(1):27－31.HilaziZM,HakimF,HawelehAA,etal.Cathetercl