超声引导下经胸心间隔缺损封堵术与常规开胸修补手术的对比研究
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摘要
目的:比较食管超声引导下经胸心间隔缺损封堵术与常规开胸修补手术的临床结果。方法:采用前瞻性临床队列研究方法纳入安徽医科大学第一附属医院心脏大血管外科2015年7月至2016年12月通过经胸超声心动图诊断为先天性心间隔缺损(heart septal defects,HSD)的126例先天性心脏病(congenital heart disease,CHD)患者,排除手术禁忌后,有心内直视手术修补或封堵适应证者共79例。其中45例HSD患者行食管超声引导下经胸封堵术(封堵组),另34例行常规开胸修补手术(修补组)。对比两组术中(开胸时间、关胸时间、麻醉时间、手术时间)、术后(术后ICU监护时长、呼吸机支持时长、心纵引流液量、切口长度、术后住院天数、住院总花费围、手术期输血例数)和术后并发症等各项临床指标。结果:封堵组手术成功率为97.8%,修补组为100.0%(P>0.05)。两组术中、术后等各项指标进行比较,封堵组均优于修补组(P<0.05),封堵组患者术后胸腔积液发生率低于修补组(4.5%vs 47.1%,P<0.001),随访期间无死亡病例及严重并发症发生。结论:与常规开胸修补手术相比,超声引导下心间隔缺损封堵术有着手术时长短、创伤小、切口美观、术后恢复快、住院时间短、花费相对较低等优点,是治疗先天性心间隔缺损安全、有效、经济、可行的手术方式。
Objective: To evaluate advantages between transesophageal echocardiography guided transthoracic device closure and conventional correction surgery with cardiopulmonary bypass in heart septal defects. Methods: From July 2015 to December 2016, 126 patients with heart septal defects were treated in the First Affiliated Hospital of Anhui Medical University. A total of 79 patients were enrolled in the cohort after removing surgical contraindication; 45 patients received transesophageal echocardiography guided transthoracic device closure(TEE group) and 34 patients received conventional correction surgery(CPB group), respectively. Perioperative clinical parameters(thoracotomy time, time of sternal closure, anesthesia duration, operation time, length of ICU stay, duration of mechanical ventilation, volume of drainage, operative incision lengths, duration of hospital stay, hospitalization expenses, and number of transfusion cases) and postoperative complications were compared between two groups. Results: Success rate of operation was 97.8% in the TEE group and 100% in the CPB group(P>0.05). All clinical parameters were compared between two groups which TEE group was better than the CPB group(P<0.05). The incidence of postoperative pleural effusion in the TEE group was lower than that in the CPB group(4.5% vs 47.1%, P<0.05). No deaths and serious complications occurred during follow-up period. Conclusion: Relative to conventional correction surgery with CPB, transesophageal echocardiography guided transthoracic device closure in heart septal defects was better in minimal invasiveness, recovering time, safety, reliability and so on. It should be actively promoted in clinical practice.
Objective: To evaluate advantages between transesophageal echocardiography guided transthoracic device closure and conventional correction surgery with cardiopulmonary bypass in heart septal defects. Methods: From July 2015 to December 2016, 126 patients with heart septal defects were treated in the First Affiliated Hospital of Anhui Medical University. A total of 79 patients were enrolled in the cohort after removing surgical contraindication; 45 patients received transesophageal echocardiography guided transthoracic device closure(TEE group) and 34 patients received conventional correction surgery(CPB group), respectively. Perioperative clinical parameters(thoracotomy time, time of sternal closure, anesthesia duration, operation time, length of ICU stay, duration of mechanical ventilation, volume of drainage, operative incision lengths, duration of hospital stay, hospitalization expenses, and number of transfusion cases) and postoperative complications were compared between two groups. Results: Success rate of operation was 97.8% in the TEE group and 100% in the CPB group(P>0.05). All clinical parameters were compared between two groups which TEE group was better than the CPB group(P<0.05). The incidence of postoperative pleural effusion in the TEE group was lower than that in the CPB group(4.5% vs 47.1%, P<0.05). No deaths and serious complications occurred during follow-up period. Conclusion: Relative to conventional correction surgery with CPB, transesophageal echocardiography guided transthoracic device closure in heart septal defects was better in minimal invasiveness, recovering time, safety, reliability and so on. It should be actively promoted in clinical practice.
引文
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8.徐玮泽,叶菁菁,李建华,等.食管超声引导下经皮儿童房间隔缺损封堵术的疗效评价[J].临床小儿外科杂志,2018,17(1):38-42.XU Weize,YE Jingjing,LI Jianhua,et al.Percutaneous transcatheter closure of atrial septal defect under the guidance of transesophageal echocardiography in children[J].Journal of Clinical Pediatric Surgery,2018,17(1):38-42.
9.张蕾,周达新,赵维鹏,等.多发性房间隔缺损经导管封堵治疗中封堵器的个体化运用[J].中国介入心脏病学杂志,2017,25(3):138-143.ZHANG Lei,ZHOU Daxin,ZHAO Weipeng,et al.Individualized application of occluder in transcatheter closure of multi-fenestrated atrial septal defects[J].Chinese Journal of Interventional Cardiology,2017,25(3):138-143.
10.Rigatelli G,Dell'Avvocata F,Cardaioli P,et al.Five-year follow-up of intracardiac echocardiography-assisted transcatheter closure of complex ostium secundum atrial septal defect[J].Congenit Heart Dis,2012,7(2):103-110.
11.Praz F,Wahl A,Schmutz M,et al.Safety,feasibility,and longter m results of perc utaneous closure of atr ial septal defects using the A mplatzer septal occluder w ithout per iprocedural echocardiography[J].J Invasive Cardiol,2015,27(3):157-162.
12.Kijima Y,Akagi T,Nakagawa K,et al.Three-dimensional echocardiography guided closure of complex multiple atrial septal defects[J].Echocardiography,2014,31(10):E304-E306.
13.Gil-Jaurena JM,González-López MT,Pérez-Caballero R,et al.15 years of minimally invasive paediatric cardiac surgery;development and trends[J].An Pediatr(Barc),2016,84(6):304-310.
14.Chu MW,Losenno KL,Fox SA,et al.Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair[J].Can J Surg,2014,57(3):E75-E81.
15.Ma ZS,Dong MF,Yin QY,et al.Totally thoracoscopic repair of atrial septal defect without robotic assistance:A single-center experience[J].J Thorac Cardiovasc Surg,2011,141(6):1380-1383.
16.Hill KD,Wang C,Einstein AJ,et al.Impact of imaging approach on radiation dose and associated cancer risk in children undergoing cardiac catheterization[J].Catheter Cardiovasc Interv,2016,89(5):888-897.
17.杨学永,周启宇,王振国,等.不同微创介入治疗在房间隔缺损中的应用[J].中华实用儿科临床杂志,2012,27(13):1044-1045.YANG Xueyong,ZHOU Qiyu,WANG Zhenguo,et al.Application of minimally invasive lnterventional treatment for atrial septal defect in children[J].Journal of Applied Clinical Pediatrics,2012,27(13):1044-1045.
18.钱松屹,张总刚,刘筠,等.经胸微创封堵术治疗继发孔房间隔缺损140例分析[J].中国医学科学院学报,2016,38(6):650-653.QIAN Songyi,ZHANG Zonggang,LIU Jun,et al.Effectiveness of secundum atrial septal defect occlusion with the septal occluder through right-chest small incision:clinical analysis of 140 cases[J].Acta Academiae Medicinae Sinicae,2016,38(6):650-653.
19.Sharafuddin MJ,Gu X,Titus JL,et al.Transvenous closure of secundum atrial septal defects:preliminary results with a new selfexpanding nitinol prosthesis in a swine model[J].Circulation,1997,95(8):2162-2168.
20.Guo Z,Zhang C,Wang H,et al.Peratrial device closure of atrial septal defect undertransesophageal echocardiographic guidance without fluoroscopy compared toconventional on-pump surgical closure[J].Braz J Cardiovasc Surg,2017,32(1):38-42.
2.King TD,Thompson SL,Steiner C,et al.Secundum atrial septal defect.Nonoperative closure during cardiac catheterization[J].JAMA,1976,235(23):2506-2509.
3.Michel-Behnke I,Ewert P,Koch A,et al.Device closure of ventricular septal defects by hybrid procedures:a multicenter retrospective study[J].Catheter Cardiovasc Interv,2011,77(2):242-251.
4.孙俊杰,彭帮田,范太兵,等.食管超声引导下经胸微创外科封堵治疗先天性心脏病研究[J].中华实用诊断与治疗杂志,2014,28(10):964-965.SUN Junjie,PENG Bangtian,FAN Taibing,et al.Transesophageal echocardiography guided surgical minimally invasive occlusion operation for congenital heart disease[J].Journal of Chinese Practical Diagnosis and Therapy,2014,28(10):964-965.
5.Xing Q,Pan S,An Q,et al.Minimally invasive perventricular device closure of per imembranous ventr icular septal defect w ithout cardiopulmonary bypass:multicenter experience and mid-term followup[J].J Thorac Cardiovasc Surg,2010,139(6):1409-1415.
6.Zhang S,Zhu D,Qi A,et al.Minimally invasive perventricular device closure of doubly committed sub-arterial ventricular septal defects:single center long-term follow-up results[J].J Cardiothorac Surg,2015,10:119.
7.沈晟,贾兵,陈张根,等.经胸杂交封堵技术治疗小儿肌部室间隔缺损18例[J].临床小儿外科杂志,2013,12(2):132-134.SHEN Sheng,JI A Bing,CHENG Zhanggen,et al.Treatment experience of hybrid approaches for eighteen children with muscular ventricular septal defects[J].Journal of Clinical Pediatric Surgery,2013,12(2):132-134.
8.徐玮泽,叶菁菁,李建华,等.食管超声引导下经皮儿童房间隔缺损封堵术的疗效评价[J].临床小儿外科杂志,2018,17(1):38-42.XU Weize,YE Jingjing,LI Jianhua,et al.Percutaneous transcatheter closure of atrial septal defect under the guidance of transesophageal echocardiography in children[J].Journal of Clinical Pediatric Surgery,2018,17(1):38-42.
9.张蕾,周达新,赵维鹏,等.多发性房间隔缺损经导管封堵治疗中封堵器的个体化运用[J].中国介入心脏病学杂志,2017,25(3):138-143.ZHANG Lei,ZHOU Daxin,ZHAO Weipeng,et al.Individualized application of occluder in transcatheter closure of multi-fenestrated atrial septal defects[J].Chinese Journal of Interventional Cardiology,2017,25(3):138-143.
10.Rigatelli G,Dell'Avvocata F,Cardaioli P,et al.Five-year follow-up of intracardiac echocardiography-assisted transcatheter closure of complex ostium secundum atrial septal defect[J].Congenit Heart Dis,2012,7(2):103-110.
11.Praz F,Wahl A,Schmutz M,et al.Safety,feasibility,and longter m results of perc utaneous closure of atr ial septal defects using the A mplatzer septal occluder w ithout per iprocedural echocardiography[J].J Invasive Cardiol,2015,27(3):157-162.
12.Kijima Y,Akagi T,Nakagawa K,et al.Three-dimensional echocardiography guided closure of complex multiple atrial septal defects[J].Echocardiography,2014,31(10):E304-E306.
13.Gil-Jaurena JM,González-López MT,Pérez-Caballero R,et al.15 years of minimally invasive paediatric cardiac surgery;development and trends[J].An Pediatr(Barc),2016,84(6):304-310.
14.Chu MW,Losenno KL,Fox SA,et al.Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair[J].Can J Surg,2014,57(3):E75-E81.
15.Ma ZS,Dong MF,Yin QY,et al.Totally thoracoscopic repair of atrial septal defect without robotic assistance:A single-center experience[J].J Thorac Cardiovasc Surg,2011,141(6):1380-1383.
16.Hill KD,Wang C,Einstein AJ,et al.Impact of imaging approach on radiation dose and associated cancer risk in children undergoing cardiac catheterization[J].Catheter Cardiovasc Interv,2016,89(5):888-897.
17.杨学永,周启宇,王振国,等.不同微创介入治疗在房间隔缺损中的应用[J].中华实用儿科临床杂志,2012,27(13):1044-1045.YANG Xueyong,ZHOU Qiyu,WANG Zhenguo,et al.Application of minimally invasive lnterventional treatment for atrial septal defect in children[J].Journal of Applied Clinical Pediatrics,2012,27(13):1044-1045.
18.钱松屹,张总刚,刘筠,等.经胸微创封堵术治疗继发孔房间隔缺损140例分析[J].中国医学科学院学报,2016,38(6):650-653.QIAN Songyi,ZHANG Zonggang,LIU Jun,et al.Effectiveness of secundum atrial septal defect occlusion with the septal occluder through right-chest small incision:clinical analysis of 140 cases[J].Acta Academiae Medicinae Sinicae,2016,38(6):650-653.
19.Sharafuddin MJ,Gu X,Titus JL,et al.Transvenous closure of secundum atrial septal defects:preliminary results with a new selfexpanding nitinol prosthesis in a swine model[J].Circulation,1997,95(8):2162-2168.
20.Guo Z,Zhang C,Wang H,et al.Peratrial device closure of atrial septal defect undertransesophageal echocardiographic guidance without fluoroscopy compared toconventional on-pump surgical closure[J].Braz J Cardiovasc Surg,2017,32(1):38-42.