应用不同封堵装置封堵动脉导管未闭的临床评价

Clinical evaluation of transcatheter closure of PDA with different type of devices

摘要:

目的：评价应用不同封堵装置治疗儿童动脉导管未闭（Patent ductus arteriosus，PDA）的可行性和临床效果。方法：2009年3月至2011年9月间确诊为PDA并接受介入治疗的患儿共443例，男218例，女225例，平均年龄7.8岁（0.6~13岁），平均体重17.5 kg（5.3~48 kg），合并其他畸形者均排除。根据PDA大小分别选择弹簧圈、PDA封堵器和室间隔缺损（Ventricular sep－tal defect，ＶＳＤ）封堵器治疗。根据PDA的形态和大小分别采用经股动脉逆行或经股静脉顺行释放。结果：431例（97.3%）成功封堵。4例因释放前存在主动脉缩窄，3例存在左肺动脉狭窄而放弃，5例大PDA合并肺动脉高压者封堵试验阳性而放弃。心导管检查肺动脉平均压32.5 mmHg（23~67 mmHg），Qp/Qs：1.62（1.4~3.2）。其中45例采用弹簧圈封堵，53例应用动脉导管未闭封堵器－Ⅱ（Amplatzer duct occluder-Ⅱ，ADO-Ⅱ），12例为膜部ＶＳＤ封堵器，其余均采用ADO进行封堵。25例（5.8%）术后出现少量残余分流，18例1月随访时消失，3月随访时全部消失。6例（1.3%）术后出现主动脉轻度狭窄，压差<10 mmHg，无需处理，随访无进展。2例（0.46%）术后出现血小板降低，对症治疗2周后出院，随访无异常发现。1例出现术后溶血。1例随访出现三尖瓣中度返流。结论：对不同类型和大小的PDA可应用不同装置进行封堵，术中操作仔细，避免损失三尖瓣，部分大PDA封堵后可存在残余分流、主动脉狭窄和血小板变化，随访时需密切观察。

Abstract:

Objective：To evaluate the feasibility，clinical outcome and resource utilization of transcatheter closure of patent ductus arteriosus（PDA） in children. Methods：From March 2009 to September 2011，successful transcatheter implantation of the Amplatzer duct occluder（ADO） was performed in 443 children（218 males and 225 females）；the median age was 7.8 years old（0.6-13 years） and the median weight was 17.5 kg（5.3-48 kg）. All of them were confirmed with PDA by echocardiography without any other defects. Some patients with small PDA were closed with coils，some with medium or large PDA were treated with ADO，ADO-Ⅱ or ventricular septal defect（VSD） occluder. The devices were released by retrograde or antegrade way based on the configuration and size of PDA. Results：Successful implantation of the device was achieved in 431 patients（97.3%）. Acute aortic stenosis resulting in occluder removal occurred in 4 cases，3 cases gave up treatment due to left pulmonary branch arterial stenosis，5 cases（large PDA complicated with pulmonary hypertension） gave up treatment due to positive results of experimental occlusion. Median pulmonary artery pressure was 32.5 mmHg（23-67 mmHg） and Qp/Qs was 1.62（1.4-3.2）. Forty-five patients with diameter of PDA<2 mm were treated with coils，53 patients were closed with ADO-Ⅱ，12 patients with diameter of PDA>2 mm were treated with VSD occluder，the others were closed with ADO. Twenty-five（5.8%） patients had trivial residual leak postoperatively and the symptom disappeared in 18 of them after 1 month during the follow-up and the symptom disappeared in all patients after 3 months. Six patients（1.3%） had mild aortic stenosis，however，the pressure gradient was less than 10 mmHg and remained unchanged in the follow-up. Two patients（0.46%） had rhrombocytopenia postoperatively，recovered after being treated for two weeks and remained in stable condition in the follow-up. One patient was found with hemolysis. One patient was found with mild tricuspid regurgitation in the follow-up. Conclusions：PDA with different sizes and morphology can be treated with different kinds of occluders. Carefulness is needed during the operation to avoid the impairment of tricuspid valve. Some patients with large PDA may have complications of residual shunt，aortic stenosis and platelet changes，therefore，more attention should be paid to.