伍成德，劉鵬，林巍，林剛，符芳永

(中南大學(xué)湘雅醫(yī)學(xué)院附屬海口醫(yī)院心胸外一科，海南海口570208)

經(jīng)胸微創(chuàng)封堵與體外循環(huán)治療不同直徑干下型VSD療效分析

伍成德，劉鵬，林巍，林剛，符芳永

(中南大學(xué)湘雅醫(yī)學(xué)院附屬海口醫(yī)院心胸外一科，海南?？?70208)

目的探討干下型室間隔缺損(VSD)直徑大小對手術(shù)療效的影響，對比分析經(jīng)胸微創(chuàng)封堵與體外循環(huán)治療不同直徑干下型室間隔缺損的治療效果。方法對2008年8月至2016年8月中南大學(xué)湘雅醫(yī)學(xué)院附屬海口醫(yī)院心胸外一科收治的63例缺損直徑在3～10 mm的先天性干下型VSD 2～6歲患兒病例資料進(jìn)行回顧性分析，其中男性35例，女性28例。依據(jù)手術(shù)方式的不同將其分為體外組和微創(chuàng)組，再依據(jù)直徑大小差異各分為兩組，經(jīng)胸微創(chuàng)封堵治療34例，男女比例為19/15，其中直徑3～5 mm 13例，＞5 mm 21例；正中切口體外循環(huán)治療29例，男女比例為16/13，其中直徑在3～5 mm 11例，＞5 mm 18例。分別對其手術(shù)成功率、術(shù)中術(shù)后情況及術(shù)后并發(fā)癥進(jìn)行比較，進(jìn)行統(tǒng)計(jì)分析。結(jié)果體外組手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間均較微創(chuàng)組長，兩種手術(shù)方式總體成功率差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。缺損直徑在3～5 mm時(shí)，兩種手術(shù)方式治療干下型室間隔缺損的手術(shù)成功率均為100.00%，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)；缺損直徑在5～10 mm時(shí)，體外組手術(shù)成功率為100.00%，明顯高于微創(chuàng)組的80.95%，差異有統(tǒng)計(jì)學(xué)意義(P=0.045)。手術(shù)失敗患者的缺損直徑均在8～10 mm。兩種手術(shù)治療方式的手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間及手術(shù)成功率均不受缺損直徑大小的影響(P＞0.05)。兩種手術(shù)治療干下型室間隔缺損的術(shù)后早期并發(fā)癥比較差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，但兩種手術(shù)方式治療干下型室間隔缺損的總早期并發(fā)癥發(fā)生率差異有統(tǒng)計(jì)學(xué)意義(P=0.041)，體外組的總體發(fā)生率為5.75%，高于微創(chuàng)組的1.67%。兩種手術(shù)治療方式的早期并發(fā)癥發(fā)生率不受缺損直徑大小的影響(P＞0.05)。結(jié)論VSD缺損直徑大小對不同手術(shù)治療方式的成功率有影響。體外組早期并發(fā)癥發(fā)生率較微創(chuàng)組高，早期并發(fā)癥發(fā)生率不受缺損直徑大小影響；微創(chuàng)組較體外組術(shù)中優(yōu)勢明顯。缺損直徑較小選擇微創(chuàng)封堵優(yōu)勢明顯，缺損直徑越大選擇體外循環(huán)手術(shù)治療優(yōu)勢越明顯。

室間隔缺損；干下型；微創(chuàng)封堵術(shù)

室間隔缺損(ventricular septal defect，VSD)是常見的先天性心血管畸形之一，其發(fā)病率約占先天性心血管疾病的20%～25%[1]。干下型室間隔缺損是室間隔缺損的常見類型，主要位于室間隔漏斗部，緊鄰主、肺動(dòng)脈瓣，位置特殊，該類缺損在亞洲人群中的發(fā)病率較高，約占室間隔缺損的15%[2-4]。VSD的傳統(tǒng)治療方法為體外循環(huán)(cardiopulmonary bypass，CPB)直視修補(bǔ)術(shù)，隨著心血管微創(chuàng)技術(shù)的快速發(fā)展，經(jīng)胸微創(chuàng)封堵術(shù)和介入封堵術(shù)因創(chuàng)傷小、恢復(fù)快、效果好等優(yōu)點(diǎn)，在VSD的治療活動(dòng)中得到廣泛應(yīng)用。介入封堵治療術(shù)禁忌證較多，不適合用于干下型VSD的治療。鄰近主動(dòng)脈瓣下的VSD導(dǎo)管介入封堵術(shù)操作復(fù)雜，并發(fā)癥較多[5]，成功率低，是經(jīng)皮導(dǎo)管封堵術(shù)的相對禁忌證[6]。故該法不適用于干下型VSD的治療，本文不予以討論。本研究對經(jīng)胸微創(chuàng)封堵術(shù)和CPB直視修補(bǔ)術(shù)2種治療干下型VSD方法進(jìn)行比較，探討兩種手術(shù)方法在不同缺損直徑干下型VSD治療中的療效差異，為臨床制定最佳治療方案提供理論依據(jù)。

1 資料與方法

1.1 一般資料2008年8月至2016年8月中南大學(xué)湘雅醫(yī)學(xué)院附屬海口醫(yī)院心胸外一科經(jīng)超聲心動(dòng)圖確診63例2～6歲先天性單純干下型室間隔缺損的患兒，其中男性35例，女性28例，年齡2～6歲，體質(zhì)量7～16 kg。經(jīng)胸微創(chuàng)封堵治療34例，男女比例為19/15；正中切口體外循環(huán)治療29例，男女比例為16/13。術(shù)前同每位患者家屬溝通并簽署知情同意書，該研究經(jīng)醫(yī)院倫理委員會(huì)審批通過[2016(科研倫審-017)]。

1.2 納入標(biāo)準(zhǔn)患兒無其他重要臟器先天性畸形或功能不全、染色體病、先天性和繼發(fā)性免疫抑制或缺陷等；術(shù)前經(jīng)胸超聲心動(dòng)圖提示無肺動(dòng)脈高壓者及中重度主動(dòng)脈瓣脫垂或關(guān)閉不全；患兒均為竇性心律；VSD直徑≤10 mm且≥3 mm；病歷資料完整；術(shù)中使用封堵器為先健科技(深圳)有限公司生產(chǎn)，型號及規(guī)格為XJFVM04-16(批準(zhǔn)文號：國械注準(zhǔn)20163770339)。

1.3 方法根據(jù)研究目的收集患兒相關(guān)資料：(1)基本信息(年齡、性別、體質(zhì)量)；(2)輔助檢查結(jié)果(超聲心動(dòng)圖、心電圖、術(shù)中經(jīng)食道超聲)；(3)手術(shù)記錄(術(shù)式、體外循環(huán)時(shí)間、手術(shù)時(shí)間、輸血量)；(4)住院病歷信息(ICU氣管插管時(shí)間、ICU監(jiān)護(hù)天數(shù)、住院天數(shù)及手術(shù)早期并發(fā)癥情況)。將收集到的資料依據(jù)手術(shù)方式不同分為體外循環(huán)組和微創(chuàng)組；參照國際室間隔分類標(biāo)準(zhǔn)[7-8]，再將每組病例資料按其缺損直徑大小分為＞5 mm組和3～5 mm組，對比分析兩種治療方法在不同組中的療效，微創(chuàng)組術(shù)中失敗患者則改為體外循環(huán)直視手術(shù)，體外循環(huán)手術(shù)失敗患者則視為患者死亡。

1.4 統(tǒng)計(jì)學(xué)方法釆用SPSS17.0軟件對所收集數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料符合正態(tài)分布者采用獨(dú)立樣本t檢驗(yàn)，結(jié)果以均數(shù)±標(biāo)準(zhǔn)差(x-±s)表示；計(jì)數(shù)資料釆用χ2檢驗(yàn)或Fisher's確切檢驗(yàn)，結(jié)果以百分比表示。P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 術(shù)前基本情況體外循環(huán)組和微創(chuàng)組兩組患兒在年齡、性別、體質(zhì)量及VSD直徑等基線資料比較差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，見表1～表3。

表1 兩組術(shù)前基本資料比較

表2 兩組數(shù)據(jù)內(nèi)部VSD直徑缺損程度分布情況(例)

表3 兩組數(shù)據(jù)VSD直徑分布情況比較(x-±s)

2.2 兩組術(shù)中和術(shù)后早期結(jié)果體外組手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間均較微創(chuàng)組長，但不同直徑兩組間手術(shù)成功率差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。缺損直徑為3～5 mm時(shí)，兩種手術(shù)方式治療干下型室間隔缺損的手術(shù)成功率均為100.00%，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)；缺損直徑為5～10 mm時(shí)，體外組手術(shù)成功率為100.00%，明顯高于微創(chuàng)組的80.95%，差異有統(tǒng)計(jì)學(xué)意義(χ2=4.021，P=0.045)，手術(shù)失敗病例均為缺損直徑8～10 mm的患者，見表4。不同直徑干下型室間隔缺損對兩種手術(shù)治療方式組內(nèi)在手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間及手術(shù)成功率方面比較差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，見表5。

2.3 術(shù)后早期并發(fā)癥兩種手術(shù)治療干下型室間隔缺損的術(shù)后早期單一并發(fā)癥發(fā)生率差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，但兩種手術(shù)方式治療干下型室間隔缺損早期并發(fā)癥總發(fā)生率差異有統(tǒng)計(jì)學(xué)意義(χ2=4.164，P=0.041)，體外組的總體發(fā)生率為5.75%，高于微創(chuàng)組的1.67%，見表6。不同缺損直徑VSD兩種手術(shù)方式治療早期并發(fā)癥組間比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)，見表7。不同缺損直徑干下型室間隔缺損對兩種手術(shù)治療方式早期并發(fā)癥發(fā)生率差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)，見表8。

表4 不同缺損直徑VSD兩種手術(shù)治療術(shù)中及術(shù)后情況組間比較(x-±s)

表5 不同缺損直徑VSD組內(nèi)術(shù)中及術(shù)后情況組內(nèi)比較

表6 兩種手術(shù)治療方法早期并發(fā)癥總體比較[例(%)]

表7 不同缺損直徑VSD兩種手術(shù)治療早期并發(fā)癥組間比較[例(%)]

表8 不同缺損直徑VSD早期并發(fā)癥組內(nèi)比較[例(%)]

3 討論

1954年，Lillehei及其團(tuán)隊(duì)[9]開展了世界上首例VSD直視修補(bǔ)術(shù)，隨著手術(shù)適應(yīng)證的嚴(yán)格控制、早期手術(shù)和術(shù)后監(jiān)護(hù)水平的提高，目前體外直視修補(bǔ)術(shù)死亡率低，術(shù)后并發(fā)癥也非常少。體外直視修補(bǔ)術(shù)已成為VSD治療的金標(biāo)準(zhǔn)。1998年經(jīng)胸微創(chuàng)封堵術(shù)治療VSD開始用于臨床[10]，相關(guān)研究報(bào)道療效確切[11-12]。本研究主要通過分析VSD直徑大小對體外和微創(chuàng)兩種手術(shù)治療室間隔缺損療效差異，旨在為臨床醫(yī)師制定手術(shù)方案提供參考依據(jù)。

本研究將VSD缺損直徑大小作為研究的主要指標(biāo)，觀察VSD缺損直徑大小對微創(chuàng)及體外循環(huán)兩種手術(shù)治療室間隔缺損組間及組內(nèi)療效差異。通過對兩種手術(shù)方法的手術(shù)成功率進(jìn)行對比分析，我們發(fā)現(xiàn)不同直徑兩組間手術(shù)成功率存在差異，在VSD缺損直徑為3～5 mm時(shí)，兩種手術(shù)方式治療干下型室間隔缺損的手術(shù)成功率均為100.00%，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)；但缺損直徑為5～10 mm時(shí)，體外組手術(shù)成功率為100.00%，明顯高于微創(chuàng)組的80.95%，差異有統(tǒng)計(jì)學(xué)意義(χ2=4.021，P=0.045)，微創(chuàng)組手術(shù)失敗者缺損直徑均在8～10 mm。目前，室間隔缺損微創(chuàng)封堵傘的直徑規(guī)格為4～12 mm，在對VSD患者進(jìn)行封堵傘封堵時(shí)要求缺損直徑小于封堵傘2～4 mm，根據(jù)需要適當(dāng)選擇封堵器的規(guī)格[13]。因此，本文僅對缺損直徑≤10 mm的患者進(jìn)行進(jìn)行研究。有研究表明缺損直徑越大，封堵傘所承受的壓力越大，穩(wěn)定性越差，手術(shù)成功率越低，這一理論在我們的實(shí)驗(yàn)結(jié)果中得到了印證[14-18]。

通過術(shù)中和術(shù)后情況比較，我們發(fā)現(xiàn)體外組手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間均較微創(chuàng)組長；但兩種手術(shù)治療方式組不同缺損直徑干下型室間隔缺損的手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間、術(shù)后住院時(shí)間及手術(shù)成功率差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)。方舒等[19]研究表明，微創(chuàng)手術(shù)具有創(chuàng)傷小、ICU內(nèi)氣管插管時(shí)間短、住院時(shí)間短、輸血比例小的優(yōu)點(diǎn)。

將兩種手術(shù)治療干下型室間隔缺損的術(shù)后早期并發(fā)癥進(jìn)行比較，我們發(fā)現(xiàn)兩種手術(shù)治療干下型室間隔缺損的各單一并發(fā)癥差異均無統(tǒng)計(jì)學(xué)意義(P＞0.05)，但兩種手術(shù)方式治療干下型室間隔缺損的總早期并發(fā)癥發(fā)生率差異有統(tǒng)計(jì)學(xué)意義(χ2=4.164，P=0.041)，體外組的總體并發(fā)癥發(fā)生率為5.75%，明顯高于微創(chuàng)組的1.67%。不同缺損直徑干下型室間隔缺損對兩種手術(shù)治療方式的早期并發(fā)癥發(fā)生率的影響差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)，而張剛成等[20]研究表明微創(chuàng)手術(shù)較開胸手術(shù)并發(fā)癥明顯減少。

總之，VSD缺損直徑大小對體外手術(shù)及微創(chuàng)手術(shù)治療的手術(shù)成功率存在一定的影響，缺損直徑為3～5 mm時(shí)，兩種手術(shù)方式成功率差異無統(tǒng)計(jì)學(xué)意義，但缺損直徑為5～10 mm時(shí)，體外循環(huán)手術(shù)成功率較高。兩種手術(shù)方式治療干下型VSD，體外循環(huán)組并發(fā)癥較微創(chuàng)組高，但兩種手術(shù)方式早期并發(fā)癥發(fā)生率均不受缺損直徑大小影響；體外循環(huán)手術(shù)較微創(chuàng)手術(shù)在手術(shù)時(shí)間、輸血總量、機(jī)械通氣時(shí)間、術(shù)后重癥監(jiān)護(hù)時(shí)間及術(shù)后住院時(shí)間長。直徑缺損為3～5 mm的干下型室間隔缺損選擇微創(chuàng)手術(shù)優(yōu)勢明顯，直徑缺損在5～10 mm時(shí)，選擇微創(chuàng)手術(shù)需慎重，尤其是對缺損直徑在8～10 mm的患者。缺損直徑越大選擇體外循環(huán)手術(shù)治療優(yōu)勢越明顯。

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Curative effect of transthoracic mini-invasive occlusion and cardiopulmonary bypass on subpulmonic ventricular septal defect of different diameters.

WU Cheng-de,LIU Peng,LIN Wei,LIN Gang,FU Fang-yong.Cardiothoracic DepartmentⅠ,Central South University Xiangya School of Medicine Affiliated Haikou Hospital,Haikou 570208,Hainan,CHINA

ObjectiveTo investigate the effect of diameter of subpulmonic ventricular septal defect(VSD)on the curative effect of operation,and to compare the curative effect of transthoracic mini-invasive occlusion and cardiopulmonary bypass on subpulmonic VSD of different diameters.MethodsThe clinical data of 64 children with the diameter of 3-10 mm congenital subpulmonic VSD,including 35 males and 28 females,who admitted to Cardiothoracic Department of Central South University Xiangya School of Medicine Affiliated Haikou Hospital from August 2008 to August 2016,were retrospectively analyzed.The patients were divided intoin vitroand mini-invasive group according to the different surgical methods,and then were divided into two groups according to their differences in diameter.There were 34 cases in the mini-invasive group with male to female ratio of 19/15,with 13 cases of 3-5 mm diameter and 21 cases of more than 5 mm.There were 29 cases of median incision cardiopulmonary bypass(in vitrogroup)with male to female ratio of 16/13,with 11 cases of 3-5 mm diameter,18 cases of more than 5 mm.The operative success rate,intraoperative and postoperative complications were compared and analyzed statistically.ResultsThe operative time,total blood transfusion,mechanical ventilation time,postoperative intensive care time and postoperative hospitalization time of in vitrogroup were significantly longer than those of mini-invasive group(P＜0.05).There was a significant difference in the overall success rate between the two surgical methods(P＜0.05).There was no significant difference in the success rate between the two groups in the 3-5 mm diameter of the defect(100.00%vs100.00%,P＞0.05).When the diameter of the defect was 5-10 mm,the success rate ofin vitrogroup was 100.00%,which was significantly higher than 80.95%of the mini-invasive group(χ2=4.021,P=0.045).All failed patients had a defective diameter of 8 mm to 10 mm.The operative time,total blood transfusion,mechanical ventilation time,postoperative intensive care time,postoperative hospital stay and operation success rate were not affected by the diameter of the defect(P＞0.05).There was no significant difference in the early complications of the two types of surgical treatment of subpulmonic VSD(P＞0.05).However,there were statistically significant differences in the incidence of early complications between the two surgical methods for thetreatment of subpulmonic VSD(P=0.041).The overall incidence of thein vitrogroup was 5.75%,which was significantly higher than 1.67%of mini-invasive group.The incidence of early complications of both surgical treatments was not affected by diameter(P＞0.05).ConclusionThe diameter of VSD has an effect on the success rate of different surgical methods.The incidence of early complications in the cardiopulmonary bypass(in vitro)group was higher than that in the mini-invasive group,and the incidence of early complication was not affected by the diameter of the defect.The minimally invasive group has obvious advantages than the cardiopulmonary bypass group.For the defect with the smaller diameter,the mini-invasive occlusion has obvious advantages.Otherwise,cardiopulmonary bypass has obvious advantages.

Ventricular septal defect(VSD);Subpulmonic;Mini-invasive occlusion

R541.1

A

1003—6350（2017）18—2974—05

2017-04-05)

10.3969/j.issn.1003-6350.2017.18.014

林剛。E-mail：3125007420@qq.com