先天性心脏病术后残余室间隔缺损介入治疗及中长期随访

目的 评价先天性心脏病（先心病）术后残余室间隔缺损（VSD）介入治疗的效果及中长期随访结果。 方法 回顾性分析2002年9月至2014年5月复旦大学附属儿科医院介入治疗的先心病术后残余VSD患者的临床资料，对辅助检查、介入治疗情况和随访行描述性分析。结果 21例患者进入分析，男11例，女10例，平均年龄8.8（2.7～21）岁,平均体重26.3（10.5～53.5） kg。13例为VSD修补术后残余漏，其中2例合并主动脉弓缩窄修补术后再缩窄；5例为法洛四联症（TOF）术后残余VSD，其中1例合并频发室性早搏及短阵室性心动过速；2例为右室双出口术后残余VSD；1例为完全性大动脉转位术后残余VSD。介入治疗距离外科手术时间为11～80个月。①介入治疗中左心室造影测得VSD右心室面直径为(3.73±1.56) mm，4例右室面有多处分流，1例为左室-右房瘘；肺循环与体循环血流量之比为1.53±0.23；无中度以上肺动脉高压者。②21例患者中，1例介入治疗中建立轨道时反复发生Ⅲ度房室传导阻滞而放弃堵闭行外科手术治疗；20例（95.2%）封堵成功，其中1例应用2个堵闭器。1例合并频发室性早搏及短阵室性心动过速患儿同时行射频消融治疗成功；2例合并主动脉弓再缩窄患儿经球囊扩张后缩窄解除。介入治疗中无不良事件发生。介入治疗后即刻造影和经胸超声心动图显示少量残余分流3例。ECG均无异常发现。③20例随访1～79个月，均无明显临床症状。2例在1年随访中ECG分别出现不完全性右束支传导阻滞及Ⅰ度房室传导阻滞，继续随访6~12个月无改变；2/3例即刻有残余分流患儿在随访中残余分流消失，1例介入治疗后20个月时仍有残余分流3.4 mm，心腔大小和功能正常；无新发的三尖瓣或主动脉瓣反流，3例堵闭前存在的中重度三尖瓣反流在随访中反流均为轻度；未见堵闭器移位、脱落或血栓形成。结论 经导管堵闭介入治疗先心病手术后残余VSD是一项安全、有效和易行的方法，介入治疗后即刻和中长期随访效果好，应成为此类患儿首选的治疗方法。

The efficacy and its mid-to long-term follow-up of transcathter closure of post-surgery residual ventricular septal defect of congenital heart disease

Objective To evaluate the safety and efficacy of transcatheter closure of post-surgery residual ventricular septal defect (VSD) and its mid- to long-term follow-up results.Methods The clinical data of patients with post-surgery residual VSD who underwent an attempt of percutaneous device closure from September 2002 to December 2013 in Children's Hospital of Fudan University were summarized. Results 21 patients (11 males and 10 females) with post-surgery residual VSD underwent an attempt of percutaneous device closure in our center. The mean age was 8.8 years (2.7-21 years) and the mean weight was 26.3 kg (10.5-53.5 kg). Among these 21 patients, their previous surgery procedures were VSD repair in 13 cases, repair of tetralogy of Fallot (TOF) in 5 cases, repair of double outlet right ventricle (DORV) in 2 cases, and repair of complete transposition of great arteries (TGA) with VSD in 1 case. In addition, 1 patient of post-TOF repair was associated with frequently premature ventricular contraction and ventricular tachycardia, 2 patients of post VSD repair were associated with recoarctation of the aorta. The duration between previous surgery and transcathter device closure was 11-80 months. The mean diameter of VSDs in right ventricle (RV) side was 3.73 mm (1.6-6.3 mm) by angiogram. There were multiple shunts in RV side in 4 patients, and one patient was left ventricle to right atrium shunt. The QP/Qs ratio was 1.53±0.23, and there was no pulmonary hypertension more than moderate. Amplatzer devices were successfully deployed in all cases except for 1 failure case due to a repeat complete block during the arterial-venous loop establishing, and 2 devices were used in 1 patient. The median device size was 6.5 mm (4-12 mm). A radio-frequency ablation and 2 balloon dilatations were successfully finished for the associated defects in the same procedure. There was no procedure-related adverse events. Mild residual shunt was showed by angiogram and transthoracic echocardiography (TTE) immediate after closure in 3 patients. Three patients with moderate to severe tricuspid regurgitation before device closure improved significantly after closure. All patients were doing well clinically in a mean 22.2 months (1- 79 months) follow up. Minor arrhythmia was observed in 2 patients in the first year follow-up ECG including incomplete right bundle branch and first-degree atrioventricular block, and remained the same in another 6 months to 1 year follow-up. All 3 residual shunts disappeared in the follow-up echocardiography except for a 3.4 mm residual shunt still existed in 1 patient with normal heart size and function. No new onset tricuspid or aortic regurgitation was showed. There was no device malposition or embolization, or thrombosis formation.Conclusion Transcatheter closure of post-surgery residual ventricular septal defect is safe, effective and less trauma. The mid- to long-term follow-up results of these cases are promising.