Fu Xingpeng,Ye Jingjing,Yu Jin,et al.Comparative analysis of perimembranous and high ventricular septal defects closure via an ultra-minimal trans-intercostal incision guided by transesophageal echocardiography in children[J].Journal of Clinical Pediatric Surgery,2023,22(05):412-418.[doi:10.3760/cma.j.cn101785-202212030-003]
食管超声引导下经肋间超微切口封堵小儿膜周部和高位室间隔缺损的对比研究
- Title:
- Comparative analysis of perimembranous and high ventricular septal defects closure via an ultra-minimal trans-intercostal incision guided by transesophageal echocardiography in children
- Keywords:
- Heart Septal Defects; Ventricular; Septal Occluder Device; Ultrasonography; Doppler; Surgical Procedures; Operative; Child
- 摘要:
- 目的 比较食管超声引导(transesophageal echocardiography,TEE)下经肋间超微切口(即左侧胸骨旁肋间超微切口长度≤1 cm)封堵小儿膜周部和高位(流出道及膜高位)室间隔缺损(ventricular septal defect,VSD)的临床特点和预后,为此类微创手术的开展提供参考。方法 本研究为回顾性研究,选取2015年1月至2021年12月浙江大学医学院附属儿童医院收治的344例TEE下经胸骨旁左肋间超微切口行VSD封堵术的患儿作为研究对象,根据VSD的位置将其分为膜周部VSD和高位VSD两组,其中膜周部VSD 组239例(239/344,69.5%),高位VSD 组105例(105/344,30.5%);比较两种不同类型VSD的手术过程、手术时间、术后并发症及预后资料。结果 膜周部VSD组封堵成功229例(229/239,95.8%),高位VSD组封堵成功100例(100/105,95.2%),两组成功率差异无统计学意义(P＞0.05);膜周部VSD组手术时间[24~170(58.8±27.2)min]长于高位VSD组[20~98(48.8±17.9)min],差异有统计学意义(P＜0.05)。两组VSD直径均与封堵器直径呈正相关(P＜0.05),但与手术时间无显著相关性(P＞0.05)。在239例膜周部VSD患儿和105例高位VSD患儿中,分别有12例(12/239,5.0%)和5例(5/105,4.8%)经调整或更换封堵器后再次封堵成功,两组再次封堵成功率的差异无统计学意义(P＞0.05)。膜周部VSD组共10例封堵失败,包括术中导丝不能通过VSD 7例,封堵器脱落2例,发生室颤1例;高位VSD组共5例封堵失败,包括术中导丝不能通过VSD 1例,术中及术后封堵器移位各1例,主动脉瓣反流加重1例,血压明显下降1例。膜周部VSD组在术后1~4 d的随访中,发现1例新增二尖瓣轻度反流、4例新增三尖瓣轻中度反流,随访6个月后均情况稳定;高位VSD组在术后1~4 d随访中,1例出现右室流出道梗阻,随访6个月后发现流速下降。两组共发现残余轻微分流19例,心包积液19例,胸腔积液4例,均在6个月的随访过程中自愈。结论 TEE下经肋间超微切口封堵小儿膜周部和高位VSD成功率高且术后患儿恢复佳,其中高位VSD的手术耗时较膜周部VSD短,VSD直径并不是影响手术时间的唯一决定性因素。
- Abstract:
- Objective To explore the characteristics and prognoses of perimembranous and high ventricular septal defects (VSD) closure via a ultra-minimal trans-intercostal incision (i.e.left parasternal intercostal ultra-minimal incision≤1 cm) in children guided by transesophageal echocardiography (TEE) and provide references for such mini-invasive surgery.Methods From January 2015 to December 2021,344 cases of VSD closure via a left parasternal ultra-minimal trans-intercostal incision in children guided by TEE.According to the location of VSD,they were divided into two groups of perimembranous VSD (239/344,69.5%) and high VSD (outflow tract & high membrane)(105/344,30.5%).Operative procedures,operative duration,postoperative complications,prognoses and other relevant data of two groups were compared.Results Among them,229 cases (229/239,95.8%) of perimembranous VSD and 100 cases (100/105,95.2%) of high VSD were successfully occluded.No significant difference existed in success rate (P>0.05).However,operative duration of perimembranous VSD was longer than that of high VSD (P<0.05).In both groups,diameter of VSD was correlated positively with diameter of occluder,but not with operative duration.Among 239 cases of perimembranous VSD and 105 cases of high VSD,12 cases (12/239,5.0%) and 5 cases (5/105,4.8%) were successfully re-occluded after adjusting or replacing occluder.No significant inter-group difference existed in success rate of re-occlusion (P>0.05).A total of 10 children in perimembranous VSD group failed to occlude,including 7 cases (7/239,2.9%) in which guide wire could not pass through VSD,2 cases (2/239,0.8%) in which occluder slipped off and 1 case of ventricular fibrillation.There were 5 cases of occlusion failure in high VSD group,including 1 case in which guide wire could not pass through VSD during operation (1/105,1.0%),1 case with occluder displacement during operation and 1 case post-operation (2/105,1.9%),1 case with aggravation of aortic regurgitation and 1 case with marked decrease in blood pressure.There was no significant inter-group difference in failure rate when guide wire could not pass through VSD and occluder slipped off or shifted(P>0.05).During a follow-up period of (1-4) days in perimembranous VSD group,there were 1 case of mild mitral regurgitation and 4 cases of mild-to-moderate tricuspid regurgitation.No change occurred during 6-month follow-ups.During a follow-up period of (1-4) days in high VSD group,one case developed right ventricular outflow tract obstruction and flow velocity declined during 6-month follow-ups.There were residual slight shunt (n=19),pericardial effusion (n=19) and pleural effusion (n=4) in two groups.They were self-cured during 6-month follow-ups.Conclusion Through a ultra-minimal trans-intercostal incision guided by TEE,perimembranous and high VSD closure offers a high success rate and an excellent postoperative recovery in children.Although operative duration of high VSD is shorter,diameter of VSD is not a sole influencing factor of operative duration.
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备注/Memo
收稿日期:2022-12-13。
基金项目:浙江省公益技术应用研究项目(LGF22H180002)
通讯作者:谈林华,Email:chtlh@zju.edu.cn