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The Application of Transesophageal Echoeardiography for Atrial Septal Defect Blockade Operation

【摘要】 目的 评价经食管超声心动图(TEE) 监测房间隔缺损封堵术的临床价值。 方法 手术前应用经胸超声心动图(TTE)及TEE筛选符合条件的100例单纯房间隔缺损(ASD)患者行封堵术;手术中TEE监测整个封堵过程和引导封堵伞的放置;手术后评价封堵效果、残余分流或并发症等。 结果 100例患者均应用TTE和TEE确诊,导引和监测成功闭合房间隔缺损。技术成功96例,成功率96%;4例失败,失败率4%。手术后复查无1例残余分流,3例胸腔积液。经胸超声心动图与TEE诊断结果完全一致率40%,TEE诊断对手术前TTE诊断做出补充或修正诊断的有60例(60%)。结论 TEE对选择适合行封堵术者、选择封堵器大小、指导封堵器的释放、以及疗效评价均具有重要的作用。【Abstract】 Objective To evaluation the clinical role of transesophageal echocardiography (TEE) for atrial septal defect (ASD) blockade operation. Method The 100 patients with ASD were selected on transthoracic echocardiography (TTE) and TEE. During operation, TEE was applied to monitor the procedure of occlusion, to guide the occluder cites, to evaluate the effects and to make sure if there were peripheral residual shunts around the occlusion and other complications. Results All of the patients were exactly diagnosed by TTE and TEE，guiding and evaluating the successful closed ASD. The successful rate of occlusion was 96%，the failure rate was 4%. The review after surgery showed that, there were no residual review, pleural effusion in three patients. The concordance rate of TTE and TEE diagnosis result is 40%. TEE diagnosis amend the preoperative TTE diagnosis in 60 patients (60%). Conclusions TEE plays an important role in select inpatients，determining the size of the occluder，correctly before occlusion operation, guiding the placement of the occluder in operation and evaluating the effect after operation.

经胸微创封堵房间隔缺损术后并发症研究

目的:总结对继发孔型房间隔缺损微创封堵治疗术后并发症监护治疗的经验。方法:6例继发孔型房间隔缺损心脏病患者均采用经由胸小切口,直视超声引导下置入CardiacureTM封堵器。结果:全组患者无死亡,5例1次封堵成功,1例术后2h发现封堵伞脱落,立即给予2次开胸封堵。1例术后出现频发室性多源早搏,伴短阵室速。1例由术前的不完全右束支传导阻滞转成完全右束支传导阻滞,2例术后有少到中量胸腔积液。结论:虽然微创封堵术手术创伤小,但术后监护有其特殊性,ICU医师应引起重视。

动脉导管未闭合并重度肺动脉高压患者的介入与外科治疗

目的 探讨动脉导管未闭(PDA)合并重度肺动脉高压(PH)患者外科手术治疗与介入封堵治疗的适应证和治疗效果。 方法 回顾分析1998年5月至2008年5月我科收治的30例PDA患者的临床资料，其中男14例，女16例；年龄14～41岁，平均年龄25.8岁。18例行外科手术治疗，12例行介入封堵治疗。 结果 经外科手术和介入封堵治疗患者术后即刻的肺动脉收缩压(608±120 mm Hg vs. 100.2±14.2 mm Hg; 60.3±11.6 mm Hg vs. 108.4±17.6 mm Hg)和平均肺动脉压(401±98 mm Hg vs. 76.1±11.3 mm Hg; 40.2±10.5 mm Hg vs. 79.5±13.6 mm Hg)均较术前明显降低（Plt;0.05）。术后4例手术患者中有2例出现声音嘶哑，2例残余分流；介入封堵治疗患者术后未出现明显并发症。随访29例，随访时间3个月~2年；1例失访。随访期间患者无明显胸闷、气促等，超声心动图检查大动脉水平未探及残余分流，1例术前伴有心房颤动的患者在封堵术后2个月时猝死，死亡原因不明。28例患者术后90 d复查超声心动图提示：肺动脉收缩压均较术前明显降低（Plt;0.05），两种治疗方法的疗效差异无统计学意义（Pgt;0.05）。 结论 介入封堵治疗PDA合并重度PH的患者与外科手术治疗相比较具有创伤小、风险小、并发症少和恢复快等优点，尤其是介入封堵治疗可行试验性封堵，对鉴别动力性和阻力性PH具有不可替代的优越性。但一些特殊类型的PDA患者仍需外科手术治疗。

Clinical Application of Minimally Invasive Transthoracic Occlusion in Ventricular Septal Defect

目的探讨临床应用微创经胸小切口封堵术治疗室间隔缺损（ventricular septal defect，VSD）的初步经验 方法回顾性分析我院心外科2006年4月至2013年12月施行微创经胸小切口封堵术治疗205例VSD患者的临床资料。其中，男112例、女93例，年龄4个月～62（10.2± 12.5）岁，无合并其它心内畸形，术前经胸超声心动图筛查，术中经食管超声心动图监测、引导，胸骨下段小切口或左胸第3肋间胸骨旁小切口行VSD封堵术。术后密切随访病情，定期随访心电图、胸部X线片（后前位+左侧位）、超声心动图。 结果全组患者无死亡。封堵成功200例（97.6%），封堵失败转行体外循环下手术修补5例，术后并发VSD残余漏3例，无新发主动脉瓣及三尖瓣反流、封堵伞脱落、二次开胸、完全性房室传导阻滞、溶血等并发症。 结论微创经胸小切口VSD封堵术安全、有效，技术日臻成熟，临床应用值得推广，但仍需注意团队医师间配合以及指征把握。

食管超声心动图监测下经胸微创房间隔缺损封堵术

目的评价经食管超声心动图（TEE）监测经胸微创房间隔缺损（ASD）封堵术的临床价值。方法本组16例ASD患者术前均经胸超声心动图检查粗筛，符合封堵条件后在全身麻醉下插入经食管超声探头，于手术开始前，根据ASD最大直径选择合适的封堵器。在手术开始后，监测整个封堵过程，引导封堵伞的放置，评价即刻封堵效果，确认是否有残余分流或并发症。结果16例患者中15例封堵成功，TEE显示封堵器与ASD边缘吻合紧密，无残余分流；1例直径31mm的ASD患者，封堵器放置后发现其后下缘存在残余分流，随即改行体外循环ASD修补术。随访3个月，效果满意。结论TEE对选择适合行封堵术的的ASD患者、选择封堵器大小、指导封堵器的释放、以及疗效评价均具有重要的作用。

Analysis of Failure of Perventricular Device Closure of Ventricular Septal Defect

摘要:目的:分析微创外科室间隔缺损(ventricular septal defect,VSD)封堵失败原因,以期提高术前超声心动图筛查水平。方法:回顾性分析25例微创外科VSD封堵失败改行修补术病例,对比超声表现及手术所见,归纳总结产生并发症的原因。结果:残余分流与VSD假性膜部瘤右室面具有多个出口和低估VSD大小密切相关;VSD合并主动脉瓣右冠瓣脱垂是主动脉瓣反流的主要原因;封堵器移位与低估VSD大小且使用偏心封堵器有关;原有三尖瓣反流加重和发生Ⅲ度房室传导阻滞VSD均位于隔瓣下方;封堵失败组较封堵成功组缺损偏大,差异具有统计学意义(Plt;0.05)。结论:超声心动图对VSD及其毗邻结构的细致评估,有助于严格适应证,提高手术成功率。 Abstract: Objective:To analyze the failure of perventricular closure of ventricular septal defect (VSD), in order to improve the preoperative echocardiography examination. Methods: Twentyfive cases underwent surgical repair after failure of perventricular closure of VSD were included in this study. With combination of echocardiographic and surgical findings, retrospective analysis of the failure of perventricular closure of VSD were attempted to summarize the cause of complications.Results: Residual ventricular communication was due to underestimation of size of VSD and pseudomembranous aneurysm resulting in multiple outlets of VSD on the right ventricle side; preoperative prolapse of rightcoronary cusp was the main reason for mild or greater than mild aortic valve regurgitation after eccentric device closure of VSD; Underestimation of the size of VSD and using eccentric occluder device were responsible for the displacement of VSD occluder device. Postoperative aggravated tricuspid regurgitation and Ⅲ°atrialventricular block (AVB) were attributed to VSDs located under the septal leaflet of tricuspid valve. The size of VSD in group of failed perventricular device closure of VSD was larger than that in group of successful device closure of VSD,and the difference was significant(Plt;0.05). Conclusion: Echocardiography vividly reveals VSD and adjacent structures, which should be used in accessing the anomaly and defect and formulating surgical plans to reduce surgical morbidity and mortality.

经胸微创膜部室间隔缺损封堵术围术期炎症因子的变化

Clinical investigation of percutaneous closure of patent ductus arteriosus under echocardiography guidance

Objective To assess the efficacy and safety of percutaneous closure of patent ductus arteriosus (PDA) solely under echocardiography guidance. Methods We retrospectively analyzed the clinical data of 200 patients who received the percutaneous closure of PDA under echocardiography guidance in Fuwai Hospital from August 2013 to April 2016. According the different approach, they were divided into 2 groups: a femoral artery approach group (n=143) and a femoral vein approach group (n=57). In the femoral artery approach group, there were 42 males and 101 females aged 3.20±5.63 years. In the femoral vein group, there were 10 males and 47 females aged 7.30±11.36 years. All Patients were treated by percutaneous PDA closure solely under echocardiography guidance. The follow-up was performed at one month after the operation by echocardiography, chest radiograph and electrocardiogram. Results All 200 patients were successfully treated with percutaneous closure of PDA. The patients’ gender, in-hospital stay, rates of occluder detachment were similar between the two groups (P>0.05). Compared with the femoral vein approach group, the femoral artery approach group had a younger age (3.20±5.63 yearsvs. 7.30±11.36 years, P<0.001), less body weight (14.25±11.54 kgvs. 24.25±19.14 kg, P<0.001) and shorter diameter of PDA (3.06±0.79 mmvs. 5.93±0.68 mm, P<0.001) and PDA occluders (5.43±1.00 mmvs. 12.14±0.54 mm, P<0.001), but had higher hospitalization expenses (32 108.2±3 100.2 yuanvs.25 120.7±3 534.1 yuan, P<0.001). In the femoral vein approach group, one patient was closed under radiation guidance because guide wires could not pass through PDA. One patient in the femoral artery approach group suffered from occluder detachment at one day after operation and was cured by transthoracic minimally invasive PDA occlusion. There were no complications of occluder detachment, residual shunt, pericardial effusion or left pulmonary stenosis during the follow-up. Conclusion Echocardiography-guided percutaneous PDA closure is safe and effective, while the proper interventional approach should be chosen by the anatomical features of PDA.

应用全 3D 经食管超声心动图精确引导房间隔缺损经皮封堵治疗的可行性研究

目的探讨应用全 3D 经食管超声心动图（TEE）在精确引导房间隔缺损（ASD）经皮封堵治疗中的应用。方法纳入 2017 年 7 月至 2018 年 6 月间诊断 ASD，并于我院行全 3D-TEE 引导经皮介入封堵患者 17 例，男 4 例、女 13 例，平均年龄（27.1±8.0）岁。手术过程采用全 3D-TEE 引导经皮 ASD 封堵技术。记录手术时间、成功率、3D 超声图像质量、封堵器更换率及手术相关并发症等。结果经 TEE 示房间隔缺损直径（15.8±2.7）mm，3D-TEE 测量房间隔缺损前后径（17.4±2.4）mm，上下径（17.9±5.3）mm，缺损周长折算径（18.0±3.5）mm。手术成功率 100.0%，平均 ASD 封堵器型号（23.1±3.5）mm，无封堵器脱落，明显残余分流，心内结构损伤等严重不良事件，平均导管操作时间（30.7±5.5）min，封堵器换伞率 11.8%（2/17）。15（88.2%）例患者图像佳并采用全 3D-TEE 引导。结论应用全 3D-TEE 精确引导房间隔缺损经皮封堵治疗安全、有效，具有无辐射及引导精准的优势。

Transcatheter closure of congenital heart disease under the guidance of transthoracic echocardiography

Objective To explore the feasibility of transcatheter closure of congenital heart disease (CHD) under the guidance of transthoracic echocardiography (TTE). Methods A total of 37 patients with CHD who received transcatheter closure under the guidance of transthoracic echocardiography from November 2013 through November 2015 in our hospital were recruited. There were 15 males and 22 females, aged 1 to 16 years. Among them 32 patients suffered atrial septal defect and 5 patients had patent ductus arteriosus. The transcatheter closure of CHD was performed under the guidance of TTE. The patients underwent echocardiography follow-up at one, three and six months after surgery. Results Closure devices were successfully implanted in 37 patients under TTE guidance. The procedure was simple and safe. During the follow-up, no severe complication such as valvular injury, pericardial effusion, residual shunt and peripheral vascular injury occurred. Conclusion Transcatheter closure of CHD under TTE guidance is a feasible method and worth further clinical application.