钱松屹,张总刚,刘 筠,郭永忠,郭 盛,马中原,杜宇奎,买买提艾力·艾则孜,陶建双,刘 鹏
1中日友好医院心脏血管外科,北京 1000292新疆维吾尔自治区人民医院心外科,乌鲁木齐 830001
·论 著·
经胸微创封堵术治疗继发孔房间隔缺损140例分析
钱松屹1,张总刚2,刘 筠2,郭永忠2,郭 盛2,马中原2,杜宇奎2,买买提艾力·艾则孜2,陶建双2,刘 鹏1
1中日友好医院心脏血管外科,北京 1000292新疆维吾尔自治区人民医院心外科,乌鲁木齐 830001
目的 探讨经胸小切口继发孔房间隔缺损(ASD)微创封堵术的可行性及有效性。方法 回顾性分析2004年8月至2014年7月收治的140例继发孔房间隔缺损患者,其中男47例、女93例,年龄3~63岁,房间隔缺损直径6~36 mm。患者均于静吸复合全麻下,经右前胸第4肋间小切口进胸,在术中经食管超声(TEE)引导下行房缺封堵术。结果 134例患者经封堵器封堵成功。6例患者因封堵不成功,改行体外循环下ASD修补术。封堵失败原因包括:术后封堵伞脱落2例,均为中央型大ASD,以及术中封堵不成功4例,其中术中TEE发现残余分流2例、筛孔状ASD 1例、术中封堵器脱落1例。术后规律随访,随访期间无严重并发症发生。结论 TEE引导下经胸小切口非体外循环下ASD封堵术安全、有效、创伤小、操作简便,有一定推广价值。
经胸小切口;继发孔房间隔缺损;封堵器;经食管超声心动图
ActaAcadMedSin,2016,38(6):650-653
心房间隔缺损(atrial septal defect,ASD)为常见的心脏先天性畸形,可分为继发孔ASD(80%)、原发孔ASD(10%)及静脉窦型(10%)[1],男女发病比例约为1∶2[2]。体外循环下房间隔缺损修补术为治疗ASD的传统方法,术式成熟、效果确切,但是手术创伤大、术中出血多、体外循环并发症可能。经食管超声心动图(trans-esophageal echocardiography,TEE)引导下,经右胸小切口、非体外循环下以封堵器封堵ASD,是近年发展起来的一项治疗继发孔ASD的新术式。为探讨此种术式的可靠性及安全性,新疆维吾尔自治区人民医院心外科于2004年8月至2014年7月采用微创经胸封堵术治疗继发孔ASD 140例,现报道如下。
对象 选取新疆维吾尔自治区人民医院心外科2004年8月至2014年7月采用微创经胸封堵术治疗继发孔ASD患者140例,其中男47例、女93例;年龄3~63岁,中位年龄31岁,体重11~86 kg,中位体重 62.2 kg。术前心功能Ⅱ~Ⅲ级(纽约心脏病协会分级)。术前经胸超声心动图诊断为ASD(继发孔型),未发现其他合并心内畸形。其中中央型ASD 109例、上腔型ASD 19例、下腔型ASD 12例。缺损长径(22.3±9.8) mm(6~36 mm)。入选标准:(1)继发孔ASD,未合并其他心内畸形;(2)超声心动图提示ASD缺损长径≤36 mm,周围残边≥4 mm且较为厚实;(3)体重>10 kg;(4)超声心动图提示ASD左向右分流为主。所有患者均被充分告知手术可能风险及并发症,由本人或其监护人签署知情同意书。
手术方法 患者仰卧位,静吸复合全麻下,术前经口置入9 mm食管超声(TEE)探头(HP Sonos 7500彩色多普勒超声仪),测量ASD最大直径,并分别测量缺损距上腔静脉、下腔静脉、主动脉后壁、肺静脉开口、冠状静脉窦口、二尖瓣环距离,以及心房、房间隔长度。手术均在非体外循环下进行,右侧胸骨旁线第4肋间水平行4~6 cm纵行切口,女性患者可采用右侧乳房下缘弧形切口,切断肋间肌、注意勿伤右乳内动脉,于第4肋间行2~3 cm横行切口进入胸腔,牵开萎陷肺叶、显露右房面心包,于膈神经前约1.5 cm处切开心包并悬吊、暴露右心房。全身肝素化(1 mg/kg),活化凝血时间>250 s。右房外侧壁牵引固定,缝双层荷包、直径约1.0 cm,根据TEE测量结果选择相应尺寸封堵器(西安中丹康博生物科技有限公司),应用封堵器及其输送系统在双荷包线中心穿刺,在TEE引导下,将封堵器导管送至左心房,先将封堵器的左房侧推出,后撤鞘管、使伞内侧面与房间隔左房侧面紧密贴合,然后释放右房侧伞,于TEE 下确定封堵伞位置,观察心房水平有无残余分流,二、三尖瓣瓣叶开闭是否受限,牵拉牵引线了解封堵伞固定是否牢固,经反复检查无误后,剪断牵引线、完全释放封堵伞,撤出鞘管,结扎荷包缝线,完成封堵。若术中TEE提示封堵器型号或位置不适合,则于完全释放前回收封堵器重新释放或更换适合封堵器,并重复上述步骤,直至手术医师及超声医师确认满意后完全释放封堵器。缝合心包切口,静推鱼精蛋白中和肝素,彻底止血,膨肺后逐层关胸。
术后处理 术后第1日起予阿司匹林,成人100 mg每日1次、儿童按3 mg/kg,规律抗凝3个月。分别于术后即刻、3~5 d及1、3、6、12、18、24、30、36、42、48个月进行随访,行超声心动图及心电图检查。
134例患者经封堵器封堵成功,无手术死亡,术后即刻复查TEE未见残余分流。手术时间(1.4±0.3)h,术中失血量(40.6±11.7)ml,无术中、术后输血。6例患者因封堵不成功,改行体外循环下ASD修补术。封堵失败原因包括,术后封堵伞脱落2例,均为中央型大ASD(>30 mm),经胸壁超声证实后,急诊行体外循环下ASD修补术。术中封堵不成功4例,其中2例术中封堵伞释放后,TEE发现ASD下缘残余分流,改为体外循环下ASD修补术;1例经术中TEE证实为筛孔状ASD,遂放弃行ASD封堵术、改为体外循环下ASD修补术;1例术中封堵伞释放后即刻发生封堵器脱落,经TEE证实封堵伞移位至三尖瓣口,遂扩大右房切口,在TEE引导下以镊子夹持封堵伞边缘取出封堵伞,并改为体外循环下ASD修补术。术后气管插管拔除时间(187.2±16.1) min。ICU停留时间(11.2±2.6) h。住院时间(8.9±3.8) d,术后住院时间(5.3±2.7) d。术后随访122例,随访率91.0%(122/134),随访时间(31.4±5.8)个月(3~48个月),随访方式为门诊或住院检查,分别于术后3个月、6个月,以后每半年1次,复查超声心动图,未见心房水平残余分流,未见封堵伞移位。
经胸微创封堵术优势 ASD为先天性心脏病中发病率最高的类型,缺损造成心房水平的左向右分流,长期肺血流量增加可导致肺动脉高压,如不及时手术,将发生右心功能不全,并最终累及左心功能,影响患者预期寿命[3]。缺损的存在还可导致矛盾栓塞,即静脉系统的栓子通过缺损进入体循环,而造成全身动脉栓塞[4]。传统体外循环下ASD修补术,技术成熟、效果确切,不受发病位置、大小的限制[5],且可同期矫治其他合并心内畸形[6],但是存在需体外循环、手术时间长、创伤大等缺点。而导管介入房缺封堵术,适应证较窄,通常适用于中、小型ASD[7],其导管行径长、可控性差。当缺损直径较大时,封堵伞往往与房间隔呈垂直位,调整、释放困难,对于缺损边缘较窄的大ASD,由于导管由下腔静脉进入,释放封堵伞时易致伞穿越缺损而无法准确定位于ASD两侧,导致操作时间延长,医患双方均需接触放射线,增加了手术风险。若对ASD介入封堵术适应证选择不慎,有发生远期并发症的可能[8]。
本术式采用胸骨旁小切口、女性患者可采用乳房下切口,较为美观,术中无需体外循环,手术操作简便、时间短、创伤较小、术后恢复快、住院时间短[9]。与导管介入封堵相比,该术式应用范围有所扩大,TEE显示ASD更为直观,封堵伞尺寸选择更为精确,手术径路短,操作准确性高,且释放不满意尚可回收。因不受静脉内径限制,故该术式对于婴幼儿患者亦适用。术中无需使用造影剂,亦不接触放射线。若术中发生并发症或意外情况,方便转为体外循环下ASD修补术,提高了手术安全性。较之胸腔镜或机器人辅助下胸腔镜房缺修补术,此种手术具备设备要求低、操作简便、易于掌握、学习曲线短等优点[10]。
手术操作要点 合适适应证的选择是提高ASD微创封堵术成功率及降低并发症的首要前提。中央型继发孔ASD适合行ASD封堵术,而上腔型、下腔型及混合型ASD,因缺少边缘、封堵伞固定不稳,均不宜接受封堵术。本研究1例术中发生封堵伞滑脱,即为下腔型ASD。选择封堵伞型号即封堵伞腰部直径是术中的重要决策。一般根据TEE测得缺损最大直径,在此基础上增加4~6 mm、选择相应型号的封堵器。对于柔软边缘,应视同缺损范围。对于大直径ASD(>30 mm),若边缘完整且宽度>4 mm,可考虑行封堵术,若TEE提示ASD存在1条及以上边缘缺乏,则放弃行ASD封堵术,改行体外循环下ASD修补术。TEE对于术中判断ASD分型、直径、边缘宽度、与瓣膜关系,以决定术式及选择适当型号封堵伞,以及术后即刻判断有无脱落、移位、残余分流等均有重要意义。故术中手术医师与超声医师的配合,对于封堵伞释放的精确性、稳定性非常重要。针对幼儿或成人大型ASD,可在右房壁与封堵伞边缘缝合1针,以防封堵伞脱落后移位至瓣膜口或心室流出道,导致急性心功能不全或继发血栓形成、栓子脱落栓塞等可能危及生命的并发症。
术后注意事项 术后听诊心脏杂音消失,术后每日查体心脏听诊,若杂音复现、提示封堵伞脱落可能。术后1周内复查超声心动图,观察封堵伞位置有无改变,之后按计划规律复查超声心动图。因切口小、术中出血量少,常规不放置胸腔引流管,术中止血彻底,术后常规行半坐位床旁胸片,观察有无胸腔及心包积液征象;术后应用阿司匹林肠溶片规律抗血小板治疗3个月,预防血栓形成。
综上,经胸小切口房缺修补术作为复合手术,结合开放手术与介入治疗的优势、克服了二者各自的不足,具有操作简便、效果确切、创伤小、术后恢复快等优点,经中长期随访效果肯定,具备推广的价值。
[1]Eduardo DC,Dunbar I,James J, et al. Pediatric and congenital cardiology, cardiac surgery and intensive care[M]. London: Springer-Verlag, 2014: 1439- 1454.
[2]Feldt RH, Avasthey P, Yoshimasu F, et al. Incidence of congenital heart disease in children born to residents of Olmsted County, Minnesota, 1950- 1969 [J]. Mayo Clin Proc, 1971,46(12):794- 799.
[3]Lange SA, Braun MU, Schoen SP, et al. Latent pulmonary hypertension in atrial septal defect: dynamic stress echocardiography reveals unapparent pulmonary hypertension and confirms rapid normalisation after ASD closure [J]. Neth Heart J, 2013,21(7- 8): 333- 343.
[4]Chatterjee T, Aeschbacher BC, Meier B. Ischemic attacks and patent foramen ovale:transcatheter closure of patent foramen ovale in adults with cryptogenic systemic embolism [J]. J Interv Cardiol,1999,12(1):59- 64.
[5]Kubota S,Hoashi T,Kagisaki K,et al. The outcomes of surgical ASD closure in the era of catheter ASD closure; experience of single institute [J]. J Cardiothorac Surg,2013,8(Suppl 1):141.
[6]Clifton L,Daniel B,Richard S,et al. Robotic repair of sinus venosus atrial septal defect with partial anomalous pulmonary venous return and persistent left superior vena cava [J]. Innovations,2014,9(5):388- 390.
[7]Petit CJ, Justino H, Pignatelli RH, et al. Percutaneous atrial septal defect closure in infants and toddlers: predictors of success [J]. Pediatr Cardiol,2013,34(2):220- 225.
[8]Hill K,Christian K,Kavanaugh-Mchugh A,et al. Right-sided pulmonary venous obstruction between a right aortic arch and an amplatzer septal occlusion device following closure of a secundum atrial septal defect [J]. Pediatr Cardiol,2009,30(6):855- 857.
[9]Guo QK,Lu ZQ,Cheng SF,et al. Off-pump occlusion of trans-thoracic minimal invasive surgery (OPOTTMIS) on simple congenital heart diseases (ASD, VSD and PDA) attached consecutive 210 cases report: a single institute experience [J]. J Cardiothorac Surg,2011,6(12):48- 56.
[10]Bonaros N,Schachner T,Oehlinger A,et al. Development of a robotically assisted totally endoscopic ASD repair program [J]. Surg Laparosc Endosc Percutan Tech,2006,16(4):298.
Effectiveness of Secundum Atrial Septal Defect Occlusion with the Septal Occluder through Right-chest Small Incision: Clinical Analysis of 140 Cases
QIAN Song-yi1,ZHANG Zong-gang2, LIU Jun2,GUO Yong-zhong2,GUO Sheng2,MA Zhong-yuan2,DU Yu-kui2,MAI MAI TI AI LI·AI Ze-zi2,TAO Jian-shuang2,LIU Peng1
1Department of Cardiac and Vascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China2Department of Cardiovascular Surgery, Xinjiang Uygur Autonomous Region People’s Hospital, Urumchi 830001, China
QIAN Song-yi Tel:010- 84205089,E-mail:theme2@163.com
Objective To evaluate the feasibility and effectiveness of secundum atrial septal defect(ASD)occlusion with the septal occluder through right-chest small incision. Methods The clinical data of 140 secundum ASD patients (47 males and 93 females) aged 3- 63 years who were treated in our center from August 2004 to July 2014 were retrospectively analyzed. The diameter of ASD was 6 to 36 mm. Under general anesthesia, all patients underwent intraoperative transtsophageal echocardiography (TEE), during which no associated cardiac deformity was found. All patients received ASD occlusion via a small incision (3- 4 cm) at the right anterior chest. The occluders were released with the help of TEE. Results The atrial septal defect closure was successfully completed in 134 cases. Six cases received surgical closure of ASD after the failure of occlusion. The reasons of conversion included postoperative dislodgement of occlusion device (n=2, both were central type with large size) and technically unsuitable for occlusion (n=4, in whom residual shunt was found in 2 case, sieve pore type in 1 case, and intraoperative dislodgement in 1 case). All of these 6 patients were treated surgically under cardiopulmonary bypass. No dislocation of the device or atrial shunt was found within 3 to 48 months after the operation. Conclusion Occlusion via small chest incision of ASD under TEE guidance without cardiopulmonary bypass is a safe, minimally invasive, effective, and convenient treatment and worth clinical application.
small chest incision;secundum atrial septal defect;occluder;transesophageal echocardiography
钱松屹 电话:010- 84205089,电子邮件:theme2@163.com
R541.1;R65.2
A
1000- 503X(2016)06- 0650- 04
10.3881/j.issn.1000- 503X.2016.06.005
2015- 11- 30)