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目的:总结外科微创非体外循环下经胸右心室穿刺室间隔缺损(VSD)封堵术的临床经验。方法:取19例VSD患者行微创非体外循环、食管超声(TEE)指引下经胸右心室穿刺VSD封堵治疗。膜周部VSD14例,干下型VSD3例,肌部VSD1例。缺损直径2.5～12(5.49±2.90)mm,膜周部VSD中2例形成膜部瘤。手术方法采用全麻,根据VSD位置选择切口位置,干下型VSD患者选择左侧胸骨旁第Ⅱ肋间切口,其余患者均选择胸骨正中中下1/3切口。TEE指引下安放VSD封堵器来封堵VSD。封堵器较缺损范围大1～2mm,干下型缺损选择偏心封堵器。结果:1例干下型VSD因封堵器释放后TEE显示主动脉瓣反流增加,经调整位置后无明显改善,遂改行常规体外循环修补VSD。其余18例封堵成功,其中16例应用等边封堵器,2例应用偏心(0mm)封堵器(均为干下型VSD),封堵器直径5～12mm,术后呼吸机辅助时间均小于5h,平均住院时间约为5d。所有封堵成功患者均未输血,术后第2天常规口服阿司匹林3mg.kg-1.d-1(最大100mg/d)。全组均未出现Ⅲ度房室传导阻滞及残余分流等并发症。结论:外科微创非体外循环下经胸右心室穿刺VSD封堵术是一种新的治疗方法,具有创伤小、恢复快、术后并发症少、避免受放射线的损伤等优点。但是合适的适应证选择仍是提高手术成功率的关键。
OBJECTIVE: To summarize the clinical experience of transcatheter closure of transthoracic ventricular septal defect (VSD) under minimally invasive surgery without cardiopulmonary bypass. Methods: Nineteen patients with VSD underwent minimally invasive off-pump or transthoracic ventricular puncture (VSD) under the guidance of esophageal ultrasound (TEE). 14 cases of peritoneal VSD, 3 cases of dry type VSD and 1 case of muscular VSD. The diameter of defect was 2.5-12 (5.49 ± 2.90) mm, and 2 cases of membranous tumor formed in VSD. The method of surgery was general anesthesia. The incision location was selected according to the position of the VSD. The left parasternal intercostal space Ⅱ intercostal incision was selected for the patients undergoing dry-type VSD. The rest of the patients were selected for the mid-lower third of the sternal incision. TEE guidance placed VSD occluder to block the VSD. Occluder than the defect range of 1 ~ 2mm, dry type defect selection eccentric occluder. Results: In 1 case of dry type VSD, the TEE showed aortic valve regurgitation increased after the occluder was released, and no significant improvement was found after adjusting the position. Then, conventional cardiopulmonary bypass was used to repair the VSD. The remaining 18 cases were successfully blocked, of which 16 cases were treated with equilateral occluder, 2 cases with eccentric (0mm) occluder (all under-performed VSD), occluder diameter of 5 ~ 12mm, postoperative ventilator aided time Less than 5h, the average length of stay was about 5d. All patients with successful occlusion were not transfused. Aspirin 3 mg.kg-1.d-1 (maximally 100 mg / d) was routinely given on the second postoperative day. The whole group did not appear Ⅲ degree atrioventricular block and residual shunt and other complications. CONCLUSIONS: Surgical minimally invasive trans-thoracic-ventricular puncture VSD occlusion under cardiopulmonary bypass is a new treatment method with the advantages of less trauma, faster recovery, less postoperative complications, and avoiding radiation damage. However, the right choice of indications is still the key to improving the success rate of surgery.