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1、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,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 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,2007年5月-2009年7月，12例罹患
2、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VSD,体重：平均15.816.1kg（5-60kg）。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）。缺损直径2-10 mm，平均5.42.7mm。,资料与方法肌部VSD,资料与方法肌部VSD,资料与方法封堵技术,气管插管后常规放入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多发MVSD根据其大小、相互的位置关系，确定封堵的先后顺序、
3、封堵方式、及封堵器的型号单纯肌部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 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,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。,资料与方法封堵技术,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
4、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,肌部封堵器使用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 果,结果MVSD,单发VSD使用单枚封堵器7例，同期膜部VSD封堵1例多发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，同期直视修复使用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MVSD封堵后，CPB下矫治合并畸形4例,病例1:MVSD2+ASD,MVSD2+A
5、SD,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+PVSD,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5mm术中于非CPB下使用8、6mmPDA封堵器成功关闭两个缺损。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,该技术在两个相邻的肌部室缺中使用,病例4：MVSD4+ASD,9月，6kg，重度PH4个MVSD、合并ASD使用3枚MVSD封堵器、1枚 ASD封堵器，全部封
6、堵成功4个MVSD中，有3个缺损彼此相邻,病例4：MVSD4+ASD,需要预先建立两个轨道第一个鞘管进入并封堵室缺第二个鞘管进入并封堵室缺封堵第三个室缺,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,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,心室穿刺封堵术的优势有:1）操作灵活、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
7、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,超声医生对外科的理解外科医生对图像的理解两者的结合：经超声医生的手得到图像 经外科医生的手实施操作。,结论,经心室穿刺封堵MVSD是一种安全、有效和微创的治疗手段，其短期效果满意经心室穿刺与经皮介入封堵肌部室缺相比，基本不受患儿年龄及缺损位置限制，且选伞灵活其远期效果，如心律失常、心室功能的远期影响尚有待进一步观察,谢 谢,英文版,The application of
8、hybrid technique for muscular ventricular septal defects,Ying-kang Shi,Qi An Department of Thoracic and Cardiovascular SurgeryWest China Hospital,Sichuan University,Background,Surgical repair of MVSD:poor exposure,chance of ventriculotomy,and high incidence of residual shunt;Transcatheter closure:li
9、mited by vessel condition in young children needing early intervention;Transcatheter closure:minimally invasive,but hard to establish the pathway and the success rate is lower.,Background,Perventricular device closure(PDC)may be the third choice and probably provides part of the patients a chance to
10、 get minimally invasive treatment compared to on-pump surgery,Patients&Methods,May 2007 to July 2009,thirteen patients with single or multiple MVSDs,including a traumatic one(Knife)received PDC;Age:6M-22Y,average 4.616.8Y 5 cases1Y,3 cases within 1Y to 3Y,Patients&Methods,Weight:15.816.1 kg(range 5.
11、0-60 kg);Seven single MVSDs(including the traumatic one)and six multiple MVSDs(five with two defects and one with four);Diameter of defect:5.22.7 mm(range 2-12 mm).,Patients&Methods,Patients&Methods,Technique-general consideration,TEE after intubation,evaluate the defect(diameter,location,relationsh
12、ip with AV)and check the valve again;Decide the device size,process and sequence of closure for multiple MVSDs;CPB ready for associated CHDs,and just stand by without prime for isolated MVSD.,Technique-incision,Sub-xiphoid 3-4 cm incision and partial sternotomy for isolated MVSD;Conventional median
13、sternotomy if with associated CHDs.,Techniquepuncture location,Under continuous TEE monitor,the RV free wall was gently depressed 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.,Techniquep
14、athway establishment,a purse-string suture at the location,puncture with a 20 gauge needle,guidewire was introduced into the LV through the defect under TEE A deliver sheath was advanced over the wire into the LV,then the device was delivered through the sheath.,Technique-occluder,Muscular occluderP
15、DA occluder(for apical defect),Follow-up,TTE and ECG at discharge and 6 months after discharge;Any residual shunt,arrhythmia or new valve problem would be recorded.,Results,Results,Seven devices for seven single MVSDs(a PVSD PDC simultaneously);Three single devices for three pairs of nearby defects(
16、one residual shunt,conventional repaired later);Three cases using two devices,and one case with three devices(two ASD PDC simultaneously)Four cases received on-pump surgery for their associated CHDs.,Case 1:MVSD2+ASD,MVSD2+ASD,Release of the first device,MVSD2+ASD,The second guidewire(video),MVSD2+A
17、SD,The second sheath after the release of the first device,MVSD2+ASD,Two MVSD devices and one ASD device(video),Case 2:two apical MVSDs+PVSD,Two apical MVSDs(6mm and 4mm),5mm apart;Closed by two PDA occluders(8mm and 6mm)without CPB.The big PVSD received on-pump repaire,MVSD2,Two PDA occluders,Case
18、3:single device for two MVSDs,This technique is applicable for two nearby defects,Case 4:MVSD4+ASD,9M girl,6kg,severe PHMVSD4 plus one ASDAll defects were closed successfully with three MVSD devices and one ASD device;Three out of the four muscular defects were closed to each other.,Case 4:MVSD4+ASD
19、,Two pathways should be established in advanceThe first sheath in and MVSD closedThe second sheath in and MVSD closedThe third MVSD be closed,Two MVSD devices and one ASD device,Three MVSD devices,Three MVSD devices and one ASD device were seen on the post-surg X-ray,Discussion,Disadvantages of tran
20、scatheter closureLimited by patient age and weight;Potential vessel damage;Hard to establish a pathway in apical or anterior MVSDsUndesirable radiation(esp.for small babies),Discussion,Advantages of PDC Easy and precise handling;Easy retrieve allowing better device choice;In-time assessment,less res
21、idual shunt and rational device picking;,Discussion,4)No CPB for isolated MVSD and shorter CPB time for those with associated CHDs5)No ventriculotomy,better RV function and less arrythmia.,Discussion,The importance of EchoTTE before operation;TEE for puncture location;TEE guiding for pathway establi
22、shment;Echo assessment,Echocardiographer-Surgeon teamwork,How the echocardiographer understands the procedure;How the surgeons understands the image Teamwork：Pictures form echocardiographer Operation under surgeons hand,Conclusion,PDC of MVSDs was safe and efficacious,short-time results was acceptable;PDC was not limited by patients age and weight;The long-time follow-up(ventricular function,arrhythmia)was necessary.,Thank you,
