杂交技术在肌部室间隔缺损治疗中的应用课件

杂交技术在肌部室间隔缺损治疗中的应用课件杂交技术在肌部室间隔缺损治疗中的应用课件杂交技术在肌部室间隔1杂交技术在肌部室间隔缺损治疗中的应用杂交技术在肌部室间隔缺损治疗中的应用安 琪 石应康四川大学华西医院 胸心血管外科杂交技术在肌部室间隔缺损治疗中的应用安 琪 石应康2杂交技术在肌部室间隔缺损治疗中的应用课件3杂交技术在肌部室间隔缺损治疗中的应用课件4杂交技术在肌部室间隔缺损治疗中的应用课件5杂交技术在肌部室间隔缺损治疗中的应用课件6资料与方法肌部VSDNo.Sex(M/F)Age(years)Weight(kg)Diameter(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资料与方法肌部VSDNo.SexAgeWeightDia7No.Sex(M/F)Age(years)Weight(kg)Diameter(mm)/LocationAssociated CHDsMVSD1MVSD2MVSD3MVSD48F9/12610/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 mm)资料与方法肌部VSDNo.SexAgeWeightDiameter(mm)/L8资料与方法封堵技术o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情况o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o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9资料与方法封堵技术切切 口：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 资料与方法封堵技术切 口：10杂交技术在肌部室间隔缺损治疗中的应用课件11杂交技术在肌部室间隔缺损治疗中的应用课件12资料与方法封堵技术o穿刺点选择：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。资料与方法封堵技术穿刺点选择：13杂交技术在肌部室间隔缺损治疗中的应用课件14杂交技术在肌部室间隔缺损治疗中的应用课件15杂交技术在肌部室间隔缺损治疗中的应用课件16资料与方法封堵技术o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。资料与方法封堵技术穿刺及轨道建立17资料与方法封堵器o肌部封堵器o使用PDA封堵器（心尖肌部缺损）资料与方法封堵器18杂交技术在肌部室间隔缺损治疗中的应用课件19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、心律失常资料与方法随访 出院前及出院后6个月时接20结结 果果结 果21结果MVSDo单发VSD使用单枚封堵器7例，同期膜部VSD封堵1例o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o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oMVSD封堵后，CPB下矫治合并畸形4例结果MVSD单发VSD使用单枚封堵器7例，同期膜部VSD22病例1:MVSD2+ASD病例1:MVSD2+ASD23MVSD2+ASD第一枚封堵器释放MVSD2+ASD第一枚封堵器释放24MVSD2+ASD第二根引导钢丝（视频）MVSD2+ASD第二根引导钢丝（视频）25MVSD2+ASD第一枚伞释放后的第二支鞘管MVSD2+ASD第一枚伞释放后的第二支鞘管26MVSD2+ASD两枚VSD、一枚ASD封堵器释放MVSD2+ASD两枚VSD、一枚ASD封堵器释放27病例二:心尖部MVSD2+PVSDo一例合并PVSD的患儿，其心尖部两肌部缺损直径分别为6mm和4mm，相距5mmo术中于非CPB下使用8、6mmPDA封堵器成功关闭两个缺损。o体外循环下修补大的PVSD病例二:心尖部MVSD2+PVSD一例合并PVSD的患儿28结果MVSD2两枚PDA封堵器结果MVSD2两枚PDA封堵器29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病例3：单枚封堵器封堵2个MVSD 该技术在两个相30杂交技术在肌部室间隔缺损治疗中的应用课件31杂交技术在肌部室间隔缺损治疗中的应用课件32病例4：MVSD4+ASDo9月，6kg，重度PHo4个MVSD、合并ASDo使用3枚MVSD封堵器、1枚 ASD封堵器，全部封堵成功o4个MVSD中，有3个缺损彼此相邻病例4：MVSD4+ASD9月，6kg，重度PH33病例4：MVSD4+ASDo需要预先建立两个轨道o第一个鞘管进入并封堵室缺o第二个鞘管进入并封堵室缺o封堵第三个室缺病例4：MVSD4+ASD需要预先建立两个轨道34图中见2枚MVSD伞和ASD伞图中见2枚MVSD伞和ASD伞35图中见3个肌部伞图中见3个肌部伞36手术后X光片见3枚肌部VSD伞和ASD伞手术后X光片见3枚肌部VSD伞和ASD伞37杂交技术在肌部室间隔缺损治疗中的应用课件38讨论o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讨论经皮介入封堵存在的不足39讨论o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；合理选伞讨论心室穿刺封堵术的优势有:40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，减少心律失常的发生讨论41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讨论超声心动图的重要性42超声医生-外科医生的配合保证手术的成功o超声医生对外科的理解o外科医生对图像的理解o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。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43结论o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o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o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结论44杂交技术在肌部室间隔缺损治疗中的应用课件45杂交技术在肌部室间隔缺损治疗中的应用课件46谢谢 谢谢谢 谢47英文版英文版48The application of hybrid technique for muscular ventricular septal defectsYing-kang Shi,Qi An Department of Thoracic and Cardiovascular SurgeryWest China Hospital,Sichuan UniversityThe application of hybrid tech49BackgroundoSurgical repair of MVSD:poor exposure,chance of ventriculotomy,and high incidence of residual shunt;oTranscatheter closure:limited by vessel condition in young children needing early intervention;oTranscatheter closure:minimally invasive,but hard to establish the pathway and the success rate is lower.BackgroundSurgical repair of M50Background Perventricular device closure(PDC)may be the third choice and probably provides part of the patients a chance to get minimally invasive treatment compared to on-pump surgeryBackground Perventricular d51Patients&MethodsoMay 2007 to July 2009,thirteen patients with single or multiple MVSDs,including a traumatic one(Knife)received PDC;oAge:6M-22Y,average 4.616.8Y 5 cases1Y,3 cases within 1Y to 3YPatients&MethodsMay 2007 to 52Patients&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).Patients&MethodsWeight:15.853Patients&MethodsNo.Sex(M/F)Age(years)Weight(kg)Diameter(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/apicalPatients&MethodsNo.SexAgeWei54No.Sex(M/F)Age(years)Weight(kg)Diameter(mm)/LocationAssociated CHDsMVSD1MVSD2MVSD3MVSD48F9/12610/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 mm)Patients&MethodsNo.SexAgeWeightDiameter(mm)/L55Technique-general considerationoTEE after intubation,evaluate the defect(diameter,location,relationship with AV)and check the valve again;oDecide the device size,process and sequence of closure for multiple MVSDs;oCPB ready for associated CHDs,and just stand by without prime for isolated MVSD.Technique-general considerati56Technique-incisionoSub-xiphoid 3-4 cm incision and partial sternotomy for isolated MVSD;oConventional median sternotomy if with associated CHDs.Technique-incisionSub-xiphoid57杂交技术在肌部室间隔缺损治疗中的应用课件58杂交技术在肌部室间隔缺损治疗中的应用课件59Techniquepuncture locationoUnder continuous TEE monitor,the RV free wall was gently depressed with the 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.Techniquepuncture locationUnd60杂交技术在肌部室间隔缺损治疗中的应用课件61杂交技术在肌部室间隔缺损治疗中的应用课件62杂交技术在肌部室间隔缺损治疗中的应用课件63Techniquepathway establishmentoa purse-string suture at the location,puncture with a 20 gauge needle,guidewire was introduced into the LV through the defect under TEE oA deliver sheath was advanced over the wire into the LV,then the device was delivered through the sheath.Techniquepathway establishmen64Technique-occluderoMuscular occluderoPDA occluder(for apical defect)Technique-occluder65杂交技术在肌部室间隔缺损治疗中的应用课件66Follow-upo TTE and ECG at discharge and 6 months after discharge;oAny residual shunt,arrhythmia or new valve problem would be recorded.Follow-up TTE and ECG at disch67ResultsResults68ResultsoSeven devices for seven single MVSDs(a PVSD PDC simultaneously);oThree single devices for three pairs of nearby defects(one residual shunt,conventional repaired later);oThree cases using two devices,and one case with three devices(two ASD PDC simultaneously)oFour cases received on-pump surgery for their associated CHDs.ResultsSeven devices for seven69Case 1:MVSD2+ASDCase 1:MVSD2+ASD70MVSD2+ASDRelease of the first deviceMVSD2+ASDRelease of the first71MVSD2+ASDThe second guidewire(video)MVSD2+ASDThe second guidewire72MVSD2+ASDThe second sheath after the release of the first deviceMVSD2+ASDThe second sheath af73MVSD2+ASDTwo MVSD devices and one ASD device(video)MVSD2+ASDTwo MVSD devices and74Case 2:two apical MVSDs+PVSDoTwo apical MVSDs(6mm and 4mm),5mm apart;oClosed by two PDA occluders(8mm and 6mm)without CPB.oThe big PVSD received on-pump repaireCase 2:two apical MVSDs+PVSDT75MVSD2Two PDA occludersMVSD2Two PDA occluders76Case 3:single device for two MVSDs This technique is applicable for two nearby defectsCase 3:single device for two 77杂交技术在肌部室间隔缺损治疗中的应用课件78杂交技术在肌部室间隔缺损治疗中的应用课件79Case 4:MVSD4+ASDo9M girl,6kg,severe PHoMVSD4 plus one ASDoAll defects were closed successfully with three MVSD devices and one ASD device;oThree out of the four muscular defects were closed to each other.Case 4:MVSD4+ASD9M girl,6kg80Case 4:MVSD4+ASDoTwo pathways should be established in advanceoThe first sheath in and MVSD closedoThe second sheath in and MVSD closedoThe third MVSD be closedCase 4:MVSD4+ASDTwo pathways81Two MVSD devices and one ASD deviceTwo MVSD devices and one ASD d82Three MVSD devicesThree MVSD devices83Three MVSD devices and one ASD device were seen on the post-surg X-rayThree MVSD devices and one ASD84杂交技术在肌部室间隔缺损治疗中的应用课件85DiscussionoDisadvantages 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)DiscussionDisadvantages of tra86DiscussionoAdvantages of PDC 1)Easy and precise handling;2)Easy retrieve allowing better device choice;3)In-time assessment,less residual shunt and rational device picking;DiscussionAdvantages of PDC 87Discussion4)No CPB for isolated MVSD and shorter CPB time for those with associated CHDs5)No ventriculotomy,better RV function and less arrythmia.Discussion4)No CPB for isolat88DiscussionThe importance of Echo1)TTE before operation;2)TEE for puncture location;3)TEE guiding for pathway establishment;4)Echo assessmentDiscussionThe importance of E89Echocardiographer-Surgeon teamworkoHow the echocardiographer understands the procedure;oHow the surgeons understands the image oTeamwork：Pictures form echocardiographer Operation under surgeons handEchocardiographer-Surgeon tea90ConclusionoPDC of MVSDs was safe and efficacious,short-time results was acceptable;oPDC was not limited by patients age and weight;oThe long-time follow-up(ventricular function,arrhythmia)was necessary.Conclusion91杂交技术在肌部室间隔缺损治疗中的应用课件92杂交技术在肌部室间隔缺损治疗中的应用课件93Thank youThank you9466、节制使快乐增加并使享受加强。德谟克利特67、今天应做的事没有做，明天再早也是耽误了。裴斯泰洛齐68、决定一个人的一生，以及整个命运的，只是一瞬之间。歌德69、懒人无法享受休息之乐。拉布克70、浪费时间是一桩大罪过。卢梭66、节制使快乐增加并使享受加强。德谟克利特95