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1、杂交技术在肌部室间隔缺损治疗中的应用杂交技术在肌部室间隔缺损治疗中的应用安 琪 石应康四川大学华西医院 胸心血管外科研究背景o外科直视手术修补肌部室间隔缺（MVSD）存在：显露差、右室切开率高，残余分流的发生率高o对于年龄小、体重轻，且缺损较大，需早期干预的患儿，经皮介入封堵受外周血管大小等条件限制 o经皮介入封堵肌部室间隔缺（MVSD）具有微创的优势。也存在建立轨道复杂、成功率低等弊端研究背景 经心室穿刺封堵室缺（perventricular device closure ）可能是除传统手术和经皮介入以外，治疗MVSD的第三种选择，使部分病人仍然有机会得到相对的微创手术。资料与方法o2007
2、年5月-2009年7月，12例罹患单发或多发MVSD的先天性心脏病患者，1例心脏刀刺伤导致MVSD，均行经心室穿刺封堵室缺o年龄: 6月-22岁，平均4.616.8岁 其中 5例1岁，13岁3例资料与方法肌部VSDo体重：平均15.816.1kg（5-60kg）。o单发肌部VSD 7例，其中，外伤性肌部室缺1例；多发肌部VSD 6例（两处缺损5例，4处缺损1例）。o缺损直径2-10 mm，平均5.42.7mm。资料与方法肌部VSDNo.Sex(M/F)Age(years)Weight(kg)Diameter (mm)/LocationAssociated CHDs MVSD1MVSD2MVSD
3、3MVSD41F 8/1287/middlePAPVC, ASD (posterior, 12 mm), PVSD (12 mm), TR (moderate) 2M3125/middle3M6/125.58/middle4F6/1253/middlePVSD (8 mm)5M10/1288/middle6F143212/middle7M22607/apicalNo.Sex(M/F)Age(years)Weight(kg)Diameter (mm)/LocationAssociated CHDsMVSD1MVSD2MVSD3MVSD48F9/12610/anterior6/apicalASD
4、(ostium secundum, 6 mm) 9F19/129.56/apical4/apicalPDA (10 mm8 mm), PVSD (15 mm) 10M1127.54/posterior2/posteriorPVSD (25 mm), TR (mild) 11M4/1276/posterior3/apicalPVSD (15 mm)12M4173/middle3/middle13F9/1263.5/anterior3.5/anterior3/middle3/posteriorASD (ostium secundum, 12 mm) 资料与方法肌部VSD资料与方法封堵技术o气管插管
5、后常规放入TEE，对室缺的大小、位置、与主动脉瓣的关系再次予以评估，再次检查各瓣膜的开闭情况o多发MVSD根据其大小、相互的位置关系，确定封堵的先后顺序、封堵方式、及封堵器的型号o单纯肌部MVSD干备体外循环，合并其他需CPB下矫治畸形的MVSD同时准备体外循环资料与方法封堵技术切切 口：口：1）单纯MVSD，行剑突下3-4 cm小切口，锯开下分胸骨，切开心包并悬吊，显露右心室游离壁。2）如MVSD合并其他需同期矫治畸形，行常规胸骨正中切口 资料与方法封堵技术o穿刺点选择：穿刺点选择： 开胸后TEE再次确认VSD位置，外科医生以手指轻压右心室表面，配合TEE上手指图象确定穿刺点及角度。 资料与
6、方法封堵技术o穿刺及轨道建立1）所选穿刺点带垫片“U”字缝合一针、20G穿刺针穿刺，右心室导入引导钢丝。在TEE引导下将引导钢丝穿过VSD进入左心室腔建立轨道 。2）沿钢丝置入8 F动脉鞘至左心室腔，退出钢丝及内鞘，并将安装好封堵器的装载器接于鞘管尾部，输送封堵器并分别打开左右伞。资料与方法封堵器o肌部封堵器o使用PDA封堵器（心尖肌部缺损）资料与方法随访 出院前及出院后6个月时接受TTE和心电图检查，记录有无残余分流、新出现的二尖瓣及三尖瓣反流、心律失常结结 果果结果MVSDo单发VSD使用单枚封堵器7例，同期膜部VSD封堵1例o多发VSD因相距较近，使用单枚封堵器3例。其中一例存在残余分流
7、，同期直视修复o使用2枚VSD封堵器3例、3枚VSD封堵器1例，其中2例同时施行了ASD封堵oMVSD封堵后，CPB下矫治合并畸形4例病例1: MVSD2+ASDMVSD2+ASD第一枚封堵器释放MVSD2+ASD第二根引导钢丝（视频）MVSD2+ASD第一枚伞释放后的第二支鞘管MVSD2+ASD两枚VSD、一枚ASD封堵器释放病例二: 心尖部MVSD2+PVSDo一例合并PVSD的患儿，其心尖部两肌部缺损直径分别为6mm和4mm，相距5mmo术中于非CPB下使用8、6mmPDA封堵器成功关闭两个缺损。o体外循环下修补大的PVSD结果MVSD2两枚PDA封堵器病例3：单枚封堵器封堵2个MVSD
8、 该技术在两个相邻的肌部室缺中使用病例4：MVSD4+ASDo9月，6kg，重度PHo4个MVSD、合并ASDo使用3枚MVSD封堵器、1枚 ASD封堵器，全部封堵成功o4个MVSD中，有3个缺损彼此相邻病例4：MVSD4+ASDo需要预先建立两个轨道o第一个鞘管进入并封堵室缺o第二个鞘管进入并封堵室缺o封堵第三个室缺图中见2枚MVSD伞和ASD伞图中见3个肌部伞手术后X光片见3枚肌部VSD伞和ASD伞讨论o经皮介入封堵存在的不足）受病人年龄和体重的限制）对外周血管潜在的损伤）室缺靠室隔前份或心尖时，经皮封堵失败的可能性大）存在射线照射对婴幼儿的影响讨论o心室穿刺封堵术的优势有:1）操作灵活、
9、准确放伞2）封堵器收放容易便于选伞3）实时评估疗效，减少残余漏；合理选伞讨论4）合并其他畸形时，如封堵成功，可明显缩短体外循环时间；单纯MVSD可避免体外循环5）避免心室切开，保护右室功能，减少心律失常的发生讨论超声心动图的重要性）术前超声检查；）TEE在穿刺点选择中的引导作用；）TEE在轨道建立过程中的引导作用；）超声在评估中的作用超声医生-外科医生的配合保证手术的成功o超声医生对外科的理解o外科医生对图像的理解o两者的结合：经超声医生的手得到图像 经外科医生的手实施操作。结论o经心室穿刺封堵MVSD是一种安全、有效和微创的治疗手段，其短期效果满意o经心室穿刺与经皮介入封堵肌部室缺相比，基本
10、不受患儿年龄及缺损位置限制，且选伞灵活o其远期效果，如心律失常、心室功能的远期影响尚有待进一步观察谢谢 谢谢英文版The application of hybrid technique for muscular ventricular septal defectsYing-kang Shi, Qi An Department of Thoracic and Cardiovascular SurgeryWest China Hospital, Sichuan UniversityBackgroundoSurgical repair of MVSD: poor exposure, chance o
11、f ventriculotomy, and high incidence of residual shunt;oTranscatheter closure: limited by vessel condition in young children needing early intervention;oTranscatheter closure: minimally invasive, but hard to establish the pathway and the success rate is lower.Background Perventricular device closure
12、 (PDC) may be the third choice and probably provides part of the patients a chance to get minimally invasive treatment compared to on-pump surgeryPatients & MethodsoMay 2007 to July 2009, thirteen patients with single or multiple MVSDs, including a traumatic one (Knife) received PDC;oAge: 6M-22Y, av
13、erage 4.616.8Y 5 cases1Y, 3 cases within 1Y to 3YPatients & MethodsoWeight: 15.816.1 kg (range 5.0-60 kg); oSeven single MVSDs (including the traumatic one) and six multiple MVSDs (five with two defects and one with four);oDiameter of defect: 5.22.7 mm (range 2-12 mm).Patients & MethodsNo.Sex(M/F)Ag
14、e(years)Weight(kg)Diameter (mm)/LocationAssociated CHDs MVSD1MVSD2MVSD3MVSD41F 8/1287/middlePAPVC, ASD (posterior, 12 mm), PVSD (12 mm), TR (moderate) 2M3125/middle3M6/125.58/middle4F6/1253/middlePVSD (8 mm)5M10/1288/middle6F143212/middle7M22607/apicalNo.Sex(M/F)Age(years)Weight(kg)Diameter (mm)/Loc
15、ationAssociated CHDsMVSD1MVSD2MVSD3MVSD48F9/12610/anterior6/apicalASD (ostium secundum, 6 mm) 9F19/129.56/apical4/apicalPDA (10 mm8 mm), PVSD (15 mm) 10M1127.54/posterior2/posteriorPVSD (25 mm), TR (mild) 11M4/1276/posterior3/apicalPVSD (15 mm)12M4173/middle3/middle13F9/1263.5/anterior3.5/anterior3/
16、middle3/posteriorASD (ostium secundum, 12 mm) Patients & MethodsTechnique-general considerationoTEE after intubation, evaluate the defect (diameter, location, relationship with AV) and check the valve again;oDecide the device size, process and sequence of closure for multiple MVSDs;oCPB ready for as
17、sociated CHDs, and just stand by without prime for isolated MVSD.Technique-incisionoSub-xiphoid 3-4 cm incision and partial sternotomy for isolated MVSD;oConventional median sternotomy if with associated CHDs. Techniquepuncture locationoUnder continuous TEE monitor, the RV free wall was gently depre
18、ssed with the surgeon index finger. This depression of the RV free wall could be clearly visualized by TEE, and its spacial relationship to the defect was determined. Techniquepathway establishmentoa purse-string suture at the location, puncture with a 20 gauge needle, guidewire was introduced into
19、the LV through the defect under TEE oA deliver sheath was advanced over the wire into the LV, then the device was delivered through the sheath.Technique-occluderoMuscular occluderoPDA occluder (for apical defect)Follow-upo TTE and ECG at discharge and 6 months after discharge;oAny residual shunt, ar
20、rhythmia or new valve problem would be recorded.ResultsResultsoSeven devices for seven single MVSDs (a PVSD PDC simultaneously);oThree single devices for three pairs of nearby defects (one residual shunt, conventional repaired later);oThree cases using two devices, and one case with three devices(tw
21、o ASD PDC simultaneously)oFour cases received on-pump surgery for their associated CHDs.Case 1: MVSD2+ASDMVSD2+ASDRelease of the first deviceMVSD2+ASDThe second guidewire (video)MVSD2+ASDThe second sheath after the release of the first deviceMVSD2+ASDTwo MVSD devices and one ASD device (video)Case 2
22、: two apical MVSDs+PVSDoTwo apical MVSDs (6mm and 4mm), 5mm apart;oClosed by two PDA occluders (8mm and 6mm) without CPB.oThe big PVSD received on-pump repaireMVSD2Two PDA occludersCase 3: single device for two MVSDs This technique is applicable for two nearby defectsCase 4: MVSD4+ASDo9M girl, 6kg,
23、severe PHoMVSD4 plus one ASDoAll defects were closed successfully with three MVSD devices and one ASD device;oThree out of the four muscular defects were closed to each other.Case 4: MVSD4+ASDoTwo pathways should be established in advanceoThe first sheath in and MVSD closedoThe second sheath in and
24、MVSD closedoThe third MVSD be closedTwo MVSD devices and one ASD deviceThree MVSD devicesThree MVSD devices and one ASD device were seen on the post-surg X-rayDiscussionoDisadvantages of transcatheter closure1)Limited by patient age and weight;2)Potential vessel damage;3)Hard to establish a pathway
25、in apical or anterior MVSDs4)Undesirable radiation (esp. for small babies)DiscussionoAdvantages of PDC 1)Easy and precise handling;2)Easy retrieve allowing better device choice;3) In-time assessment, less residual shunt and rational device picking;Discussion4) No CPB for isolated MVSD and shorter CP
26、B time for those with associated CHDs5) No ventriculotomy, better RV function and less arrythmia.DiscussionThe importance of Echo1)TTE before operation;2)TEE for puncture location;3)TEE guiding for pathway establishment;4)Echo assessmentEchocardiographer-Surgeon teamworkoHow the echocardiographer un
27、derstands the procedure;oHow the surgeons understands the image oTeamwork： Pictures form echocardiographer Operation under surgeons handConclusionoPDC of MVSDs was safe and efficacious, short-time results was acceptable;oPDC was not limited by patients age and weight;oThe long-time follow-up (ventricular function, arrhythmia) was necessary.Thank you
