杂交技术在肌部室间隔缺损治疗中的应用.pptx

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1、研究背景外科直视手术修补肌部室间隔缺（MVSD）存在：显露差、右室切开率高，残余分流的发生率高对于年龄小、体重轻，且缺损较大，需早期干预的患儿，经皮介入封堵受外周血管大小等条件限制 经皮介入封堵肌部室间隔缺（MVSD）具有微创的优势。也存在建立轨道复杂、成功率低等弊端第1页/共93页研究背景 经心室穿刺封堵室缺（perventricular device closure）可能是除传统手术和经皮介入以外，治疗MVSD的第三种选择，使部分病人仍然有机会得到相对的微创手术。第2页/共93页资料与方法2007年5月-2009年7月，12例罹患单发或多发MVSD的先天性心脏病患者，1例心脏刀刺伤导致MV

2、SD，均行经心室穿刺封堵室缺年龄:6月-22岁，平均4.616.8岁 其中 5例1岁，13岁3例第3页/共93页资料与方法肌部VSDo体重：平均15.816.1kg（5-60kg）。o单发肌部VSD 7例，其中，外伤性肌部室缺1例；多发肌部VSD 6例（两处缺损5例，4处缺损1例）。o缺损直径2-10 mm，平均5.42.7mm。第4页/共93页资料与方法肌部VSDNo.Sex(M/F)Age(years)Weight(kg)Diameter(mm)/LocationAssociated CHDs MVSD1MVSD2MVSD3MVSD41F 8/1287/middlePAPVC,ASD(po

3、sterior,12 mm),PVSD(12 mm),TR(moderate)2M3125/middle3M6/125.58/middle4F6/1253/middlePVSD(8 mm)5M10/1288/middle6F143212/middle7M22607/apical第5页/共93页No.Sex(M/F)Age(years)Weight(kg)Diameter(mm)/LocationAssociated CHDsMVSD1MVSD2MVSD3MVSD48F9/12610/anterior6/apicalASD(ostium secundum,6 mm)9F19/129.56/api

4、cal4/apicalPDA(10 mm8 mm),PVSD(15 mm)10M1127.54/posterior2/posteriorPVSD(25 mm),TR(mild)11M4/1276/posterior3/apicalPVSD(15 mm)12M4173/middle3/middle13F9/1263.5/anterior3.5/anterior3/middle3/posteriorASD(ostium secundum,12 mm)资料与方法肌部VSD第6页/共93页资料与方法封堵技术气管插管后常规放入TEE，对室缺的大小、位置、与主动脉瓣的关系再次予以评估，再次检查各瓣膜的开闭

5、情况多发MVSD根据其大小、相互的位置关系，确定封堵的先后顺序、封堵方式、及封堵器的型号单纯肌部MVSD干备体外循环，合并其他需CPB下矫治畸形的MVSD同时准备体外循环第7页/共93页资料与方法封堵技术切 口：1）单纯MVSD，行剑突下3-4 cm小切口，锯开下分胸骨，切开心包并悬吊，显露右心室游离壁。2）如MVSD合并其他需同期矫治畸形，行常规胸骨正中切口 第8页/共93页第9页/共93页第10页/共93页资料与方法封堵技术穿刺点选择：开胸后TEE再次确认VSD位置，外科医生以手指轻压右心室表面，配合TEE上手指图象确定穿刺点及角度。第11页/共93页第12页/共93页第13页/共93页第

6、14页/共93页资料与方法封堵技术穿刺及轨道建立1）所选穿刺点带垫片“U”字缝合一针、20G穿刺针穿刺，右心室导入引导钢丝。在TEE引导下将引导钢丝穿过VSD进入左心室腔建立轨道。2）沿钢丝置入8 F动脉鞘至左心室腔，退出钢丝及内鞘，并将安装好封堵器的装载器接于鞘管尾部，输送封堵器并分别打开左右伞。第15页/共93页资料与方法封堵器肌部封堵器使用PDA封堵器（心尖肌部缺损）第16页/共93页第17页/共93页资料与方法随访 出院前及出院后6个月时接受TTE和心电图检查，记录有无残余分流、新出现的二尖瓣及三尖瓣反流、心律失常第18页/共93页结 果第19页/共93页结果MVSD单发VSD使用单枚

7、封堵器7例，同期膜部VSD封堵1例多发VSD因相距较近，使用单枚封堵器3例。其中一例存在残余分流，同期直视修复使用2枚VSD封堵器3例、3枚VSD封堵器1例，其中2例同时施行了ASD封堵MVSD封堵后，CPB下矫治合并畸形4例第20页/共93页病例1:MVSD2+ASD第21页/共93页MVSD2+ASD第一枚封堵器释放第22页/共93页MVSD2+ASD第二根引导钢丝（视频）第23页/共93页MVSD2+ASD第一枚伞释放后的第二支鞘管第24页/共93页MVSD2+ASD两枚VSD、一枚ASD封堵器释放第25页/共93页病例二:心尖部MVSD2+PVSD一例合并PVSD的患儿，其心尖部两肌部

8、缺损直径分别为6mm和4mm，相距5mm术中于非CPB下使用8、6mmPDA封堵器成功关闭两个缺损。体外循环下修补大的PVSD第26页/共93页结果MVSD2两枚PDA封堵器第27页/共93页病例3：单枚封堵器封堵2个MVSD 该技术在两个相邻的肌部室缺中使用第28页/共93页第29页/共93页第30页/共93页病例4：MVSD4+ASD9月，6kg，重度PH4个MVSD、合并ASD使用3枚MVSD封堵器、1枚 ASD封堵器，全部封堵成功4个MVSD中，有3个缺损彼此相邻第31页/共93页病例4：MVSD4+ASD需要预先建立两个轨道第一个鞘管进入并封堵室缺第二个鞘管进入并封堵室缺封堵第三个室

9、缺第32页/共93页图中见2枚MVSD伞和ASD伞第33页/共93页图中见3个肌部伞第34页/共93页手术后X光片见3枚肌部VSD伞和ASD伞第35页/共93页第36页/共93页讨论经皮介入封堵存在的不足）受病人年龄和体重的限制）对外周血管潜在的损伤）室缺靠室隔前份或心尖时，经皮封堵失败的可能性大）存在射线照射对婴幼儿的影响第37页/共93页讨论心室穿刺封堵术的优势有:1）操作灵活、准确放伞2）封堵器收放容易便于选伞3）实时评估疗效，减少残余漏；合理选伞第38页/共93页讨论4）合并其他畸形时，如封堵成功，可明显缩短体外循环时间；单纯MVSD可避免体外循环5）避免心室切开，保护右室功能，减少心

10、律失常的发生第39页/共93页讨论超声心动图的重要性）术前超声检查；）TEE在穿刺点选择中的引导作用；）TEE在轨道建立过程中的引导作用；）超声在评估中的作用第40页/共93页超声医生-外科医生的配合保证手术的成功超声医生对外科的理解外科医生对图像的理解两者的结合：经超声医生的手得到图像 经外科医生的手实施操作。第41页/共93页结论经心室穿刺封堵MVSD是一种安全、有效和微创的治疗手段，其短期效果满意经心室穿刺与经皮介入封堵肌部室缺相比，基本不受患儿年龄及缺损位置限制，且选伞灵活其远期效果，如心律失常、心室功能的远期影响尚有待进一步观察第42页/共93页第43页/共93页第44页/共93页谢

11、 谢第45页/共93页英文版第46页/共93页The application of hybrid technique for muscular ventricular septal defectsYing-kang Shi,Qi An Department of Thoracic and Cardiovascular SurgeryWest China Hospital,Sichuan University第47页/共93页BackgroundSurgical repair of MVSD:poor exposure,chance of ventriculotomy,and high inci

12、dence of residual shunt;Transcatheter closure:limited by vessel condition in young children needing early intervention;Transcatheter closure:minimally invasive,but hard to establish the pathway and the success rate is lower.第48页/共93页Background Perventricular device closure(PDC)may be the third choic

13、e and probably provides part of the patients a chance to get minimally invasive treatment compared to on-pump surgery第49页/共93页Patients&MethodsMay 2007 to July 2009,thirteen patients with single or multiple MVSDs,including a traumatic one(Knife)received PDC;Age:6M-22Y,average 4.616.8Y 5 cases1Y,3 cas

14、es within 1Y to 3Y第50页/共93页Patients&MethodsoWeight:15.816.1 kg(range 5.0-60 kg);oSeven single MVSDs(including the traumatic one)and six multiple MVSDs(five with two defects and one with four);oDiameter of defect:5.22.7 mm(range 2-12 mm).第51页/共93页Patients&MethodsNo.Sex(M/F)Age(years)Weight(kg)Diamete

15、r(mm)/LocationAssociated CHDs MVSD1MVSD2MVSD3MVSD41F 8/1287/middlePAPVC,ASD(posterior,12 mm),PVSD(12 mm),TR(moderate)2M3125/middle3M6/125.58/middle4F6/1253/middlePVSD(8 mm)5M10/1288/middle6F143212/middle7M22607/apical第52页/共93页No.Sex(M/F)Age(years)Weight(kg)Diameter(mm)/LocationAssociated CHDsMVSD1MV

16、SD2MVSD3MVSD48F9/12610/anterior6/apicalASD(ostium secundum,6 mm)9F19/129.56/apical4/apicalPDA(10 mm8 mm),PVSD(15 mm)10M1127.54/posterior2/posteriorPVSD(25 mm),TR(mild)11M4/1276/posterior3/apicalPVSD(15 mm)12M4173/middle3/middle13F9/1263.5/anterior3.5/anterior3/middle3/posteriorASD(ostium secundum,12

17、 mm)Patients&Methods第53页/共93页Technique-general considerationTEE after intubation,evaluate the defect(diameter,location,relationship with AV)and check the valve again;Decide the device size,process and sequence of closure for multiple MVSDs;CPB ready for associated CHDs,and just stand by without prim

18、e for isolated MVSD.第54页/共93页Technique-incisionSub-xiphoid 3-4 cm incision and partial sternotomy for isolated MVSD;Conventional median sternotomy if with associated CHDs.第55页/共93页第56页/共93页第57页/共93页Techniquepuncture locationUnder continuous TEE monitor,the RV free wall was gently depressed with the

19、surgeon index finger.This depression of the RV free wall could be clearly visualized by TEE,and its spacial relationship to the defect was determined.第58页/共93页第59页/共93页第60页/共93页第61页/共93页Techniquepathway establishmenta purse-string suture at the location,puncture with a 20 gauge needle,guidewire was

20、introduced into the LV through the defect under TEE A deliver sheath was advanced over the wire into the LV,then the device was delivered through the sheath.第62页/共93页Technique-occluderMuscular occluderPDA occluder(for apical defect)第63页/共93页第64页/共93页Follow-up TTE and ECG at discharge and 6 months af

21、ter discharge;Any residual shunt,arrhythmia or new valve problem would be recorded.第65页/共93页Results第66页/共93页ResultsSeven devices for seven single MVSDs(a PVSD PDC simultaneously);Three single devices for three pairs of nearby defects(one residual shunt,conventional repaired later);Three cases using

22、two devices,and one case with three devices(two ASD PDC simultaneously)Four cases received on-pump surgery for their associated CHDs.第67页/共93页Case 1:MVSD2+ASD第68页/共93页MVSD2+ASDRelease of the first device第69页/共93页MVSD2+ASDThe second guidewire(video)第70页/共93页MVSD2+ASDThe second sheath after the releas

23、e of the first device第71页/共93页MVSD2+ASDTwo MVSD devices and one ASD device(video)第72页/共93页Case 2:two apical MVSDs+PVSDTwo apical MVSDs(6mm and 4mm),5mm apart;Closed by two PDA occluders(8mm and 6mm)without CPB.The big PVSD received on-pump repaire第73页/共93页MVSD2Two PDA occluders第74页/共93页Case 3:single

24、 device for two MVSDs This technique is applicable for two nearby defects第75页/共93页第76页/共93页第77页/共93页Case 4:MVSD4+ASD9M girl,6kg,severe PHMVSD4 plus one ASDAll defects were closed successfully with three MVSD devices and one ASD device;Three out of the four muscular defects were closed to each other.

25、第78页/共93页Case 4:MVSD4+ASDTwo pathways should be established in advanceThe first sheath in and MVSD closedThe second sheath in and MVSD closedThe third MVSD be closed第79页/共93页Two MVSD devices and one ASD device第80页/共93页Three MVSD devices第81页/共93页Three MVSD devices and one ASD device were seen on the

26、post-surg X-ray第82页/共93页第83页/共93页DiscussionDisadvantages of transcatheter closure1)Limited by patient age and weight;2)Potential vessel damage;3)Hard to establish a pathway in apical or anterior MVSDs4)Undesirable radiation(esp.for small babies)第84页/共93页DiscussionAdvantages of PDC 1)Easy and precise

27、 handling;2)Easy retrieve allowing better device choice;3)In-time assessment,less residual shunt and rational device picking;第85页/共93页Discussion4)No CPB for isolated MVSD and shorter CPB time for those with associated CHDs5)No ventriculotomy,better RV function and less arrythmia.第86页/共93页DiscussionT

28、he importance of Echo1)TTE before operation;2)TEE for puncture location;3)TEE guiding for pathway establishment;4)Echo assessment第87页/共93页Echocardiographer-Surgeon teamworkHow the echocardiographer understands the procedure;How the surgeons understands the image Teamwork：Pictures form echocardiograp

29、her Operation under surgeons hand第88页/共93页ConclusionPDC of MVSDs was safe and efficacious,short-time results was acceptable;PDC was not limited by patients age and weight;The long-time follow-up(ventricular function,arrhythmia)was necessary.第89页/共93页第90页/共93页第91页/共93页Thank you第92页/共93页感谢您的观看！第93页/共93页