Bentham James R, Gujral Arjun, Adwani Satish, Archer Nick, Wilson Neil
Department of Paediatric Cardiology, John Radcliffe Hospital, Oxford, United Kingdom.
Cardiol Young. 2011 Jun;21(3):271-80. doi: 10.1017/S1047951110002039. Epub 2011 Feb 1.
To describe the difficulties and differing techniques in the transcatheter placement of amplatz ventricular septal defect devices to close perimembranous ventricular septal defects and place these in the context of the expanding literature on ventricular septal defect catheter closure.
Surgery remains the established first-line therapy for closure of haemodynamically significant perimembranous ventricular septal defects. Transcatheter techniques appeared to promise a possible alternative, obviating the need for cardiac surgery. However, significant technical and anatomical constraints coupled with ongoing reports of a high incidence of heart block have prevented these hopes from being realised to any significant extent. It is likely that there are important methodological reasons for the high complication rates observed. The potential advantages of transcatheter perimembranous ventricular septal defect closure over surgery warrant further exploration of differing transcatheter techniques.
Between August, 2004 and November, 2009, 21 patients had a perimembranous ventricular septal defect closed with transcatheter techniques. Of these, 14 were closed with a muscular amplatz ventricular septal defect device. The median age and weight at device placement were 8 years, ranging from 2 to 19 years, and 18.6 kilograms, ranging from 10 to 21 kilograms, respectively.
There were 25 procedures performed on 23 patients using 21 amplatz ventricular septal defect devices. Median defect size on angiography was 7.8 millimetres, ranging from 4 to 14.3 millimetres, with a median device size of 8 millimetres, ranging from 4 to 18 millimetres, and a defect/device ratio of 1.1, with a range from 0.85 to 1.33. Median procedure time was 100 minutes, with a range from 38 to 235 minutes. Adverse events included device embolisation following haemolysis in one, and new aortic incompetence in another, but there were no cases of heart block. Median follow-up was 41.7 months, with a range from 2 to 71 months.
Evaluating transcatheter closure of perimembranous ventricular septal defect using amplatz ventricular septal defect devices remains important, if a technically feasible method with low and acceptable complication rates is to be identified. Incidence of heart block may be minimised by avoiding oversized devices, using muscular devices, and accepting defeat if an appropriately selected device pulls through. Given the current transcatheter technologies, the closure of perimembranous ventricular septal defects should generally be performed in children when they weigh at least 10 kilograms.
描述经导管置入Amplatzer室间隔缺损封堵器关闭膜周部室间隔缺损的困难及不同技术，并将其置于室间隔缺损导管封堵不断扩充的文献背景中。
手术仍是有血流动力学意义的膜周部室间隔缺损封堵的既定一线治疗方法。经导管技术似乎有望成为一种替代方法，从而无需进行心脏手术。然而，严重的技术和解剖学限制，以及持续报道的高心脏传导阻滞发生率，使得这些希望在很大程度上未能实现。观察到的高并发症发生率可能有重要的方法学原因。经导管膜周部室间隔缺损封堵相对于手术的潜在优势值得进一步探索不同的经导管技术。
2004年8月至2009年11月期间，21例患者采用经导管技术关闭膜周部室间隔缺损。其中，14例采用肌部Amplatzer室间隔缺损封堵器关闭。置入封堵器时的中位年龄和体重分别为8岁（范围2至19岁）和18.6千克（范围10至21千克）。
对23例患者进行了25次操作，使用了21个Amplatzer室间隔缺损封堵器。血管造影显示缺损大小中位数为7.8毫米（范围4至14.3毫米），封堵器大小中位数为8毫米（范围4至18毫米），缺损/封堵器比例为1.1（范围0.85至1.33）。操作时间中位数为100分钟（范围38至235分钟）。不良事件包括1例溶血后封堵器栓塞，另1例出现新的主动脉瓣关闭不全，但无心脏传导阻滞病例。中位随访时间为41.7个月（范围2至71个月）。
如果要确定一种技术上可行且并发症发生率低且可接受的方法，评估使用Amplatzer室间隔缺损封堵器经导管关闭膜周部室间隔缺损仍然很重要。通过避免使用过大的封堵器、使用肌部封堵器以及在合适选择的封堵器无法通过时接受失败，可将心脏传导阻滞的发生率降至最低。鉴于当前的经导管技术，膜周部室间隔缺损的封堵一般应在儿童体重至少10千克时进行。
