【作者】 杨倩；

【导师】 杨岷；

【作者基本信息】 大连医科大学 ， 外科学（专业学位）， 2019， 硕士

【摘要】 目的:对房间隔缺损(atrial septal defect,ASD)、室间隔缺损(ventricular septal defect,VSD)经超声引导下封堵术与传统外科手术两种手术方式进行回顾性对比研究。探讨经超声引导下心脏间隔缺损封堵术的适应证、安全性及可行性,为超声引导下封堵治疗房间隔缺损和室间隔缺损提供理论依据。方法:选取自2013年7月至2018年7月于苏北人民医院心脏外科行ASD及VSD外科治疗病例共64例:传统手术共45例(ASD:38例,VSD:7例);超声引导下封堵19例(ASD:15例,VSD:4例)。所选病例术前均行经胸超声心动图、常规检查、心电图、胸部CT或胸部正侧位片等检查确诊并排除手术禁忌,部分老年患者术前常规行冠脉造影检查排除冠心病。病例纳入标准主要有:1.继发孔型房间隔缺损、室间隔缺损,未合并其他需要外科手术治疗的心脏疾病;2.所选患者术前及术后的护理记录、病程记录等数据均能够如实查到,超声心动图的复查也在我院完成;3.封堵治疗组所用封堵器均由上海形状记忆合金材料公司生产。排除标准:1.患者临床资料不完全或检查由外院进行;2.患者合并其他需要外科治疗的心脏畸形。比较两组患者术前情况(性别,年龄,体重,房、室间隔缺损大小等),术中一般情况(手术时间、切口长度、体外循环时间、动脉阻断时间、出血量、输血量、呼吸机通气时间等),术后恢复情况(术后下床时间、手术成功率、术后住院天数、住院费用等)及术后并发症(残余漏、气胸、心包积液、胸腔积液及切口液化等)。统计数据均用SPSS 21.0统计软件进行处理。结果:传统手术组与封堵治疗组相比,术前体重方面有差异,封堵治疗组体重(49.5±22.2)Kg,传统治疗组体重(55.5±15.0)Kg;封堵治疗组年龄(30.3±20.9)岁,传统手术组年龄(36.7±17.7)岁。术前超声心动图检查见封堵组治疗缺损直径(ASD:9.2±3.0 mm,VSD:2.4±0.6 mm);传统手术组缺损直径(ASD:22.2±9.9 mm,VSD:9.1±4.7 mm)。传统手术组术中常规行全麻下体外循环手术治疗,术中阻断主动脉,据凝血指标输注血小板等改善术后凝血情况,出血量封堵治疗组(15.8±9.9)ml,传统手术组出血量(358.7±187.2)ml;封堵治疗组术中均无输血,传统手术组输血量(719.4±452.6)ml。术后常规进入重症医学科观察,封堵治疗组呼吸机通气时间(5.5±4.2)h;传统手术组呼吸机辅助时间(20.5±7.0)h。两组患者均无死亡,封堵治疗组1例封堵失败,另择期行开胸手术治疗,手术成功率94.8%,较传统手术组成功率(100%)低,分析原因为主动脉瓣侧缺损边缘不足。传统手术1例因术后大出血再次开胸止血治疗;封堵治疗组术后无残余分流,传统手术组房间隔及室间隔术后各有1例少量残余分流,残余分流率4.4%,均行保守治疗,并定期随访。传统手术组术后出现气胸、切口液化、胸腔积液等并发症明显高于封堵组。两组患者在术后住院时间、住院费用方面存在统计学差异。结论:房间隔及室间隔经超声引导下封堵治疗与传统外科手术相比,无需行体外循环,术中无大量血液丢失,无需输血改善患者凝血及贫血,手术安全性更高,风险更小。与传统手术相比,封堵治疗无需开胸,切口更小,术后无切口脂肪液化,无胸廓畸形,更符合当代人们对于美的追求,在一定程度上能够减少患者身心负担。封堵治疗组手术时间短,术后恢复快,手术费用更加低廉,在严格掌握适应证的情况下优于外科手术组治疗。随着封堵技术提高、封堵材料的进步,超声引导下封堵治疗必将为间隔缺损的治疗提供更理想的方案。更多还原

【Abstract】 OBJECTIVE:The objective of this research is to retrospectively contrast research on atrial septal defect(ASD)and ventricular septal defect(VSD),by utilizing ultrasound-guided closure with the traditional surgery in our hospital.Furthermore,the research also aims at exploring the indications,safety,and feasibility of ultrasound-guided closure,and providing the basis for clinical treatment selection.METHODS:A collection of 64 medical cases of ASD and VSD(45 cases of traditional surgery:38 cases of ASD,7 cases of VSD and 19 cases of ultrasound-guided occlusion:15 cases of ASD,4 cases of VSD)were treated in the cardiac surgery department of Su Bei Hospital from 2013.07 to 2018.07.All the selected cases were confirmed and contraindicated by preoperative transthoracic echocardiography(TTE),routine examination,electrocardiogram,chest CT or positive and lateral chest radiography,and some elderly patients were routinely excluded from coronary artery disease by preoperative coronary angiography.As this experiment is a retrospective analysis,the inclusion criteria for cases is as follows:1.Secondary ASD and ventricular septal defect were not associated with other heart diseases requiring surgical treatment.2.The preoperative and postoperative nursing records,the course of the disease and other data of the selected patients can be found truthfully,and the review of echocardiography is completed in our hospital.3.All the plugging devices in the occlusion group were made of Shanghai Shape Memory Alloy Materials Company.Exclusion criteria:1.Incomplete clinical data of the patient or the examination was conducted by other hospitals;2.Patients with other complications A deformity requiring surgical treatment.Two groups in preoperative condition(gender,age,weight,septal defect size...),general intraoperative(operation time,length of incision,Cardiac Pulmonary Bypass(CPB)and Aortic occlusion(AO)...),and postoperative recovery,(postoperative bed time,success rate of surgery,postoperative hospitalization days...)and postoperative complications(residual leakage,pneumothorax,pericardial effusion and pleural effusion...)were compared.Then,Statistical data were all processed by SPSS 21.0 statistical software.RESULTS:There was a difference in preoperative body weight between the traditional surgery group and the occlusion group.Body weight in occlusion group was(49.5±22.2)Kg,while in the conventional treatment group was(55.5±15.0)Kg,Age of the occlusion occlusion group was(30.3±20.9)years old,which of the traditional operation group was(36.7±17.7)years old.Preoperative echocardiography showed that the diameter of defect in occlusion group was(ASD:9.2±3.0 mm,VSD:2.4±0.6 mm)and traditional operation group was(ASD:22.2±9.9 mm,VSD:9.1±4.7 mm).The traditional operation group received routine operation under general anesthesia and cardiopulmonary bypass,the aorta was blocked during the operation and platelet was transfused according to the coagulation index to improve the coagulation after operation The amount of bleeding in the occlusion group was(15.8±9.9)ml,that in the traditional operation group was(358.7±187.2)ml,and there was no blood transfusion in the occlusion group,while in the traditional group the volume of blood transfusion was(719.4±452.6)ml.After operation,the patients were routinely observed in the intensive care department.The ventilation time of ventilator in the occlusion group was(5.5±4.2)h,and that of the traditional operation group was(20.5±7.0)h.There was no death in both groups,one patient in the group failed to occlude and open thoracic surgery was performed at another time.The success rate of operation was 94.8%,which was lower than that of surgical operation(100%),The reason was that the margin of aortic valve defect was insufficient.One case underwent reoperation for hemostasis due to massive hemorrhage after operation in the traditional operation group.There was no residual shunt in the occlusion treatment group;In the traditional operation group a small residual shunt was found,The residual shunt rate was 4.4%.All patients were treated conservatively and followed up regularly.Complications such as pneumothorax,incision liquefaction and pleural effusion in surgical group were significantly higher than those in interventional group.There were statistical differences in Postoperative hospitalization days and hospitalization expenses between the two groups.CONCLUSION:Compared with traditional surgical operations,atrial and ventricular septum therapy were guided by ultrasound does not need to destroy the sternal structure,carry out extracorporeal circulation,or improve the patient’s blood coagulation without blood transfusion,so the operation is safer and less risky.Compared with the traditional surgical incision,the ultrasound-guided sealing has smaller incision size,no radiation exposure risk and no postoperative fat liquefaction,which is more in line with the contemporary pursuit of beauty and can reduce the patient’s physical and mental burden to a certain extent.The occlusion group had shorter operation time,faster postoperative recovery and was superior to the surgical group in terms of indications.With the improvement of sealing technology and the progress of sealing materials,the Sonically-guided occlusion therapy will certainly provide a more ideal scheme for the treatment of congenital heart disease.更多还原