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经胸骨旁入路微创室间隔缺损封堵手术245例

Minimally invasive technique of device closure of ventricular septal defect through parasternal approach

摘要:

目的 探讨在食管超声引导下,经胸骨旁入路微创封堵室间隔缺损(VSD)手术的效果和安全性,并比较3种入路方法的优缺点.方法 2012年1月至2015年7月,294例患儿采用不同穿刺入路行微创封堵VSD.经胸骨左缘-右心室入路(A组)209例,于胸骨左缘第3或第4肋间,1.0~2.0 cm切口入胸,右心室表面荷包中心穿刺,在食管超声引导下,直接将输送管和封堵器一起送入VSD完成封堵,也可用尖端折弯成“L”型输送系统进入VSD后,再推入封堵器完成封堵.经胸骨右缘-右心房入路(B组)36例,于胸骨右缘第4或第3肋间,1.0~2.0 cm切口入胸,右心房表面荷包中心穿刺,在食管超声引导下,插入“S”型中空探条,经三尖瓣后先将探条尖端送入VSD口,再经中空探条置入导丝,建立轨道后完成封堵.经胸骨下段正中-右心室穿刺入路(C组)49例,于胸骨下段正中1.5~3.0 cm切口,锯开胸骨下段入胸,后续方法与A组相同.3组间年龄、体质量、VSD直径和封堵器大小等差异无统计学意义,但VSD部位不同.结果 A组封堵成功205例(98.1%,205/209),B组35例(97.2%,35/36),C组48例(97.9%,48/49),组间差异无统计学意义.心内操作时间A组(10±6)min、C组(7±5) min,均少于B组(19±11) min;切-缝皮时间A组(40±15) min、B组(43±17) min,均少于C组(55±21)min.住院时间A组(5.9±2.2)天、B组(5.5±2.7)天,均少于C组(8.3±3.6)天.随访l~ 43个月,3组患儿均无明显残余漏、瓣膜关闭不全、严重心律失常和封堵器脱落等并发症.结论经胸骨旁微创封堵VSD安全、有效,较胸骨正中入路创伤小,患儿恢复更快.经食管超声心动图对VSD的判断非常重要,应根据VSD的大小、部位、走行路径、左向右分流方向等因素,个体化的选择手术入路.

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abstracts:

Objective To evaluate the safety aod efficacy of device closure of ventricular septal defect (VSD) through parasternal approach,and to compare the advantages and disadvantages of three approaches.Methods Between Jan 2012 and Jul 2015,209 cases(Group A) underwent per-ventricular device closure of VSD through a left parasternal approach,and 36 cases(Group B) underwent per-atrial device closure of VSD through a fight parasternal approach,and 49 cases(Group C) underwent per-ventricular device closure of VSD through a median sternotomy approach.In group A,a 1.0 to 2.0 cm left parasternal iucision was made in the fourth or third intercostal space.Press the right ventricular(RV) free wall to select the puncture point.After securing double purse-string suture around the optimal puncture site,the occluder was introduced via a sheath inserted directly into the RV and navigation and positioning of the device guided by transesophageal echocardiography(TEE).In group B,a 1.0 to 2.0 cm right parasternal incision was made in the fourth or third intercostal space.After securing double purse-string suture at the right atrium near the atrioventricular groove,a specially designed hollow probe was inserted into the right atrium and was passed through the tricuspid valve into the right ventricle.The tip of the probe was manipulated to aim at or cross VSD,and a spring guide-wire was inserted into the left veotricle(LV) through the channel of the probe under TEE guidance.Then the delivery sheath was positioned into LV passing over the wire,and the device was pushed into the sheath and was deployed to finish closure.In group C,after a 1.5 to 3.0 cm median sternal incision was made,the closure of VSD was finished as the same procedure as in group A.Results There was no significant differences at the age and weight between 3 groups,as well as the size of VSD and devices.But the position of VSD varied between 3 groups.The rate of successful closure in group A (98.1%,205/209) and B (97.2%,35/36) was similar to group C (97.9%,48/49).The mean intracardiac manipulating time was shorter in group A(10 ± 6) min and group C (7 ± 5) min than in group B(19 ± 11) min.The mean time of skin cut to suture was shorter in group A(40 ± 15) min and group B(43 ± 17) min than in group C(55 ±21) min.And the average hospitalization time in group A (5.9 ± 2.2) days and group B (5.5 ± 2.7) days was shorter than in group C (8.3 ± 3.6) days.During the follow-up period of 1 to 40 months,no obvious residual leakage,arrhythmia or valvular inadequacy were found in all cases,and no device dropped out.Conclusion Minimally invasive technique of device closure of VSD through parasternal approach appears to be safe and effective,further reducing trauma and recovering faster than median sternal approach.Accurate and all-round TEE evaluation is very important to case selection of VSD.Individually procedure approach should be performed according to the size,position,and path and flow direction of VSD.

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