摘要
目的
对比分析经导管封堵术、外科微创封堵术和开胸体外循环下修补术三种方法治疗小儿继发孔型房间隔缺损(ASD)的适应证、疗效、并发症和费用等。
方法
选择2004年2月-2009年12月分别在我院心外科和小儿心脏科住院治疗的继发孔型房间隔缺损患儿共310例,患儿年龄介于1-12岁之间,其中男129人,女181人。经导管封堵者(介入组)164例,外科微创封堵者(微创组)29例,开胸体外循环下修补者(开胸组)117例。应用回顾性研究方法对同期内三种治疗方法的适应证、手术成功率、手术时间、术后并发症、住院天数及治疗费用等进行对比分析。
结果
①三种治疗方法的成功率分别为介入组97.0%、微创组96.5%、开胸组100%,三种方法手术成功率无明显差异(p＞0.05)。
②介入组ASD直径为8～33mm(15.75±8.05)；微创组10～36mm(17.11±9.32)；开胸组6-40mm(20.00±10.62),开胸组ASD直径大于前两组(p均＜0.05)。介入组封堵伞为8-38mm(17.9±8.2)；微创组为12-40mm(19.4±8.9),二者无明显差异。
③介入组术后2例出现房性期前收缩、1例Ⅰ度房室传导阻滞,并发症发生率为1.8%；微创组术后1例发生心房颤动、1例房性期前收缩、1例心包积液,并发症发生率为10.3%；开胸组出现并发症者共34例,包括心房颤动、不完全右束支传导阻滞、完全右束支传导阻滞、呼吸道感染、手术切口感染、胸腔积液及心包积液,并发症发生率为29.1%。介入组并发症发生率明显低于后两组(p均＜0.05)。
④介入组和微创组中均无需输血,开胸组51例患儿需要输血,平均输血量为(280.56±104.51)ml。
⑤介入组手术时间为30-90min(49.8±15.0)；微创组为50-105min(61.4±20.8)；开胸组为130-210min(173.1±42.7)。介入组手术时间明显低于后两组(p均＜0.01)。
⑥介入组的治疗费用显著高于开胸组(p＜0.05),治疗费用分别为介入组(2.48±0.25)万元、微创组(2.39±0.32)万元、开胸组(1.72±0.36)万元。
⑦介入组平均住院天数为(6.13±0.92)d,微创组为(6.21±1.83)d,开胸组为(13.42±2.08)d,介入和微创组住院天数明显短于开胸组(p均＜0.05)。
⑧介入组于术后24h即可下床活动,微创组及开胸组术后分别在ICU监护24h,微创组术后2天、开胸组术后5天可下床活动,介入组与微创组术后恢复时间明显短于开胸组。
⑨介入组无手术疤痕,微创组胸部手术疤痕长2.5-3.5cm,开胸组胸部手术疤痕长15-20cm。
⑩介入组采用静脉麻醉或局麻,微创组与开胸组均需在气管插管全身麻醉下进行,开胸组还需体外循环支持。
结论
①经导管封堵房间隔缺损疗效确切、并发症低、创伤小、恢复快、无手术疤痕,宜作为继发孔型房间隔缺损的首选治疗方法。
②外科微创封堵术在适应证、成功率及费用等方面与经导管封堵相近,虽无X线辐射,但恢复较慢、有胸部手术疤痕。
③开胸修补术适应证广、成功率高、费用低,但需体外循环支持、创伤大、需输血、手术时间长、并发症多、恢复慢、胸部疤痕长,宜作为继发孔型房间隔缺损的次选治疗方法。
Objective To compare the indications.efficacy, complication and cost of transcatheter closure, minimal intraoperative closure and open heart surgical repair of secundum atrial septal defect in children.
Methods
310 patients (including 129 male and 181 female with age range from 1 to 12 years) with secundum atrial septal defect admitted to Shandong Provincial Hospital during 2004 Feb. and 2009 Dec.164 of 310 patients were treated by transcatheter closure (interventional group),29 of 310 by minimal intraoperative closure (mini-invasive group) and 117 of 310 by open heart surgical repair (open heart group). To compare their indications, success rate, operation time, complications, hospital stay and cost.
Results
①The success rate was 97.0% in interventional group,96.5% in mini-invasive group and 100% in open heart group, respectively. There's no significant difference in success rate among the three methods (p>0.05)
②The diameters of atrial septal defect were 8-33mm (15.75±8.05) in interventional group,10～36mm (17.11±9.32) in mini-invasive group and 6-40mm (20.00±10.62) in open heart group, respectively. The diameters of ASD in open heart group were larger than that in the other two groups (p both<0.05).The diameters of occluder in interventional group were (17.9±8.2) mm and (19.4±8.9) mm in mini-invasive group。There were no significant difference between the two groups (p>0.05).
③The complication rate was 1.8% in interventional group including 2 cases with atrial premature contraction and 1 case with first degree atrioventricular block. The complication rate was 10.3% in the mini-invasive group including 1 case with atrial fibrillation,1 case with atrial premature contraction and 1 case with pericardial effusion. The complication rate was 29.1%(34/117) in the open heart group including atrial fibrillation, incomplete right bundle branch block, complete right bundle branch block, respiratory infection, surgical wound infection, pleural effusion and pericardial effusion. The complication rate in the interventional group was much lower than that of the other two groups(p both<0.05).
④51 patients in the open heart group accepted blood transfusion of mean volume (280.56±104.51)ml. No patients need blood transfusion in the interventional group and mini-invasive group.
⑤The operation time was 30 to 90 min (49.8±15.0) in the intervention group, 50 to 105 min (61.4±20.8) in the mini-invasive group and 130 to 210 min (173.1±42.7) in the open heart group, respectively. The operation time of interventional group was much shorter than that of the other two groups (p both <0.01).
⑥The costs were (24,800±2,500) RMB in the interventional group, (23,90013,200) RMB in the mini-invasive group and (17,20013,600) RMB in the open heart group, respectively. The cost in the interventional group was more expensive then that of the other two group (p both<0.05).
⑦The mean lengths of hospital stay were (6.1310.92)days in the interventional group, (6.21±1.83)days in the mini-invasive group and (13.42±2.08)days in the open heart group, respectively. The open heart group had the longest time of hospital stay (p both<0.05).
⑧The patients in the interventional group got out of bed after 24h post procedure, while the patients in the mini-invasive group and the open heart group required intensive care in the ICU for 24h post operation. The patients in the mini-invasive group got out of bed after 2 days post operation and the open heart group needed 5 days. The patients in the first two groups had significantly shorter recovery time than the third one.
⑨There was no skin scar on in the interventional group. The patients had the skin scar of 2.5～3.5 cm on chest in the mini-invasive group and chest scare of 15-20 cm in the open heart group.
⑩atients in the interventional group received local anesthesia or intravenous anesthesia without tracheal intubation. The patients in the mini-invasive group and the open heart group required general anaesthesia with tracheal intubation. And the open heart group also required cardiopulmonary bypass support.
Conclusion
①Transcatheter closure had an curative effect, low complications, rapid recovery and no skin scar, which is proper to be the first choice for the children with ASD.
②Minimal intraoperative closure is similar with transcatheter closure in the indications, success rate and cost, etc. Although it has no X-ray radiation, but has relatively slow recovery and chest scar.
③Open heart surgical repair had wide indications, high success rate and low cost. However, it had cardiopulmonary bypass support needed, blood transfusion needed, high complication rate, major trauma, long operation time, slow recovery and large chest scar, which is proper to be the secondary choice for the children with ASD.
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