Heart Center, Children's Hospital, Qingdao University, Qingdao, China.
Ann Thorac Surg. 2012 Dec;94(6):2070-5. doi: 10.1016/j.athoracsur.2012.05.070. Epub 2012 Aug 24.
Surgical repair of doubly committed subarterial ventricular septal defect (VSD) under cardiopulmonary bypass has been the gold standard with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from cardiopulmonary bypass. Perventricular device closure of muscular and then perimembranous VSD on beating heats with a small subxiphoid or inferior sternotomy has been attempted in the past few years with good results. We have tried perventricular closure of doubly committed subarterial VSD through a left anterior minithoracotomy as an alternative procedure with a modified occluder.
Between January 2008 and December 2010, 6 selected patients with doubly committed subarterial VSD were recruited for modified device closure on beating hearts without cardiopulmonary bypass through left anterior minithoracotomy involving a short incision through the third intercostal space. Their ages ranged from 18 to 46 months and their body weights from 11 to 23 kg. A single per-right ventricular "U" like suture under pulmonic annulus was established, and a delivery system was introduced, aided by an 18G trocar, including a guidewire, delivery sheath, and loading sheath. A proper device was selected according to the VSD size established by transesophageal echocardiography (TEE), and then the device was released under real-time monitoring of TEE if no residual shunt, increased aortic prolapse or regurgitation, abnormal atrioventricular valvular motion appeared.
In 5 of the 6 children, the device was successfully closed through a left minithoracotomy with satisfactory cosmetic effects. In the other child, the procedure was converted to conventional open-heart repair because the relatively larger occluder induced significantly increased aortic regurgitation. There was no operative or late mortality or major morbidity. All children were followed up for 10 to 21 months. No residual shunt, increased aortic prolapse or regurgitation, or serious atrioventricular block was recorded until the most recent follow-up.
Selected doubly committed subarterial VSD can be safely closed with a proper occluder through left anterior minithoracotomy. The Cosmetic results are highly satisfactory.
在体外循环下进行完全正中切开的心脏手术修复双重冠状下室间隔缺损（VSD）一直是金标准，但会导致皮肤瘢痕形成，并可能因体外循环而导致死亡率和发病率增加。过去几年，尝试使用经皮室间隔缺损封堵器在跳动的心脏上通过小胸骨下或下胸骨切开术来闭合肌性和膜周 VSD，取得了良好的效果。我们尝试通过左侧前小开胸术作为替代手术，使用改良的封堵器进行双重冠状下 VSD 的经皮闭合。
2008 年 1 月至 2010 年 12 月，我们为 6 例双重冠状下 VSD 患者选择了经左侧前小开胸术在跳动的心脏上进行改良器械闭合，不使用体外循环，仅通过第三肋间的小切口。他们的年龄在 18 至 46 个月之间，体重在 11 至 23 公斤之间。在肺动脉瓣环下建立单个经右心室“U”型缝线，引入输送系统，在 18G 套管针的辅助下，包括导丝、输送鞘和装载鞘。根据经食管超声心动图（TEE）确定的 VSD 大小选择合适的器械，然后在 TEE 实时监测下释放器械，如果没有残余分流、主动脉瓣脱垂或反流增加、房室瓣运动异常出现。
在 6 例患儿中，有 5 例通过左侧小开胸术成功闭合，美容效果满意。在另一名患儿中，由于相对较大的封堵器导致主动脉瓣反流显著增加，手术改为常规心脏直视修复。没有手术或晚期死亡或重大并发症。所有患儿均随访 10 至 21 个月。在最近的随访中，没有记录到残余分流、主动脉瓣脱垂或反流增加或严重房室传导阻滞。
通过左侧前小开胸术，使用合适的封堵器可以安全地闭合选择的双重冠状下 VSD。美容效果非常满意。
