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动脉导管未闭形态与其伸展性的相关性

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探讨动脉导管未闭(PDA)形态与其伸展性的关系。 方法 126例儿童PDA患者,按Krichenko 法分为3组,A组(导管最窄处在肺动脉端)共72例,B组(导管最窄处在主动脉端)共24例,C组(导管呈管状)共30例,均采用国产PDA封堵器治疗。测量PDA最窄直径和封堵术后封堵器腰部最窄直径,PDA最窄径与术后封堵器腰部直径之差反映PDA的伸展性。 结果 126例PDA全部封堵成功,术后即刻造影显示12例(9.5%)有残余分流,20min后重复造影6例分流消失,6例术后3天超声心动图检查分流消失。A组PDA直径为4.97±1.00mm,B组PDA直径为5.28±0.62mm,C组PDA直径为3.78±0.72mm,A组与 B组PDA伸展性无明显差异,A组和B组伸展性明显高于C组(P<0.05)。结论  A型和B型PDA伸展性较大,选择封堵器时应较常规方法偏大;C型PDA伸展性较小,宜选择偏小封堵器。

关键词    动脉导管未闭  介入治疗

Relationship between the Morphologic Characteristics and the Extensibility of Patent Ductus Arteriosus

WANG Zhen, Zhang Mi-lin, Gao Lei, Xie Qi-lian, Zhang Yuan-xiang.

Department of Cardiology,First Affiliated Hospital, Hebei Medical University, Shijiazhuang  050031,China  

Abstract

Objective: To investigate the relationship between the morphologic characteristics and the extensibility of Patent ductus arteriosus PDA.

Methods:  One hundred and twenty-six children with PDA were enrolled in this study and were treated all by domestic duct occluder. All the subjects were divided into three groups according to Krichenko’s classification method. Group A included 72 patients (the narrowest segment of the ductus was near to the pulmonary artery), group B included 24 patients(the narrowest segment of the ductus was near to the descending aortic artery) and group C included 30 patients(the ductus was tubular type).The narrowest diameter of  PDA and the lumbar part of the occluder ( the extensive diameter of the PDA)were measured and the differences of them could reflect the extensibility of PDA.

Results: The occluder was successfully placed in the PDA in all of the 126 patients. Aortographies were performed instantly after the procedure and there was residual shunt in 12 patients(9.5%).The residual shunt flow disappeared completely in 6 patients 20minutes later confirmed by aortography and in others three days after the procedure confirmed by echocardiography. The mean diameter of PDA was 4.97±1.00mm in group A, 5.28±0.62mm in group B and 3.78±0.72mm in group C. There was no significant differences between group A and group B about the extensibility of PDA. The extensibility of PDA was much higher in group A and group B than in group C (P<0.05,respectively).

Conclusion: PDA of type A and type B have higher extensibility, so we should select larger occluder than routine methods for type A and type B but smaller occluder for type C.

Key words:  Patent ductus arteriosus; transcatheter closure

动脉导管未闭(PDA)是临床常见的先天性心脏病,既往手术是唯一治疗方法。外科手术风险大,且术后残余分流及再通率较高。经导管封堵PDA具有操作简便,创伤小,恢复快,适应证广,封闭完全等优点[1],介入治疗PDA的关键在于选择大小合适的封堵器。封堵器的选择主要参考PDA的形态和大小,但PDA具有一定的伸展性,只有准确了解其伸展直径才能选择最合适的封堵器,本研究旨在探讨PDA的形态与其伸展性的关系。

资料与方法

1. 1资料 共入选20048月至20061月期间在我院治疗的儿童PDA患者126例,男36例,女90例,年龄6.36±1.21岁(1 ~16岁)。均经临床、X线、心电图及超声心动图确诊为PDA

1. 2方法 所有入选者PDA封堵治疗所用国产封堵器均由北京华医圣杰有限公司提供。先行主动脉造影,观察PDA形态,按Krichenko法[2]将其入选者分为A、B、C组,A组(导管最窄处在肺动脉端)共72例,B组(导管最窄处在主动脉端)共24例,C组(导管呈管状)共30例,三组间年龄无显著性差异。测量PDA大小,选择合适的封堵器封堵后即刻造影,测量封堵器腰部直径,有残余分流者20min后重复造影,术后3天超声心动图复查。

1.3统计学处理

   所有数据用SPSS11.0统计软件处理,计量资料采用均数±标准差表示,组间比较采用方差分析,P< 0.05为有统计学意义。

结果

126PDA全部封堵成功,术后即刻造影显示12例(9.5%)有残余分流,20min6例分流消失,6例术后3天超声心动图检查分流消失,所有PDA术后 封堵器均固定良好,无明显移位及脱落,无主、肺动脉血流受阻。手术成功率100%

APDA直径为4.97±1.00mm,BPDA直径为5.28±0.62mmCPDA直径为3.78±0.72mmPDA最窄径与封堵器腰部直径的差值A组为1.18±0.39mm,B组为1.07±0.19mmC组为0.64±0.18  mm A组与BPDA伸展性无明显差异,A组和B组伸展性明显高于C组(P<0.05.

讨论

PDA是儿童常见的先天性心脏病,一般较房间隔缺损、室间隔缺损更易合并肺动脉高压,且进展迅速,若不及时治疗常可危及生命。外科方法风险大,且术后残余分流及再通率较高。PDA封堵治疗具有操作简便,创伤小,恢复快,适应证广,封闭完全等优点,自1967Porstman应用塑料泡沫塞子封堵PDA获得成功以来,先后发展了Rashkind双面伞、Sideris纽扣补片法、弹簧圈法及Amplatzer用于PDA介入治疗[3-6]Porstman法早已淘汰,Rashkind双面伞和Sideris纽扣补片法由于其残余分流发生率较高及并发症较多其临床应用亦受到限制,对于PDA最小直1~2mm之间者可用弹簧圈堵塞法封堵,而对于PDA最小直径≥2mm者目前最常用的方法是应用Amplatzer法封堵[7]因此精确测量PDA的大小、形态,了解其伸展性,在确定适宜的介入方法及选择大小合适的封堵器方面有重要作用。由于PDA与主动脉常呈30度角,而PDA封堵器的固定盘与腰部呈90度角,所以PDA封堵器将部分深入主动脉或肺动脉内,从而可能导致主动脉或肺动脉血流阻塞,因此封堵器的恰当选择显得尤为重要。本研究中,采用的国产PDA封堵器为镍钛记忆合金编织而成,具有自膨胀性,封堵器撑开时PDA最窄处被扩张,封堵器被PDA狭窄处所重塑,重塑程度取决于PDA的伸展性。本研究结果显示,A组与BPDA伸展性无明显差异, A组和B组伸展性明显高于C组(P<0.05)。在PDA的介入治疗中应充分考虑其伸展性,为了封堵充分并避免主动脉或肺动脉血流受阻,C型病变选择封堵器应偏小,而A型和B型病变选择封堵器应偏大。

总之,应用国产封堵器治疗PDA时,准确测量PDA大小,并根据PDA形态估计其伸展性,选择大小合适的封堵器,是手术成功和减少并发症的关键。

 

[参考文献]

[1] Masura J,Walsh KP,Thanopoulous B,et al.Catheter closure of moderate to large-sized patent ductus arteriosus using the new Amplatzer Duct Occluder:Immediate and short-term results.J Am Coll Cardiol,1998.31:878-882.

[2] Krichenko A, Benson LN, Burrows P, et al. Angiographic classification of the isolatedpersistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol,1989,63:877-880.

 [3] Porstmann W,Wiemy L,Warnke H,et al.Catheter closure of patent ductus arteriosus:62 cases treated without thoracotomy.Radiol Clin North Am,1971,9:203-218.

[4] Tynan M.Transcatheter occlusion of persistent arterial duct:report of the European regiatry. Lancet, 1992, 340: 1062-1066.

[5] Rao PS,Haddad J,et al.Follow-up results of transcatheter occlusion of patent ductus arteriosus with adjustable buttoned device. J Am Coll Cardiol,1995,25:332A.

[6] Hijazi Z, Lloyd TR, Beekman RH, et al. Transcatheter closure with single or multiple Gianturco coils of patent ductus arteriosus in infants weighing8kg: retrograde versus antegrade approach. Am Heart J,1996,132:827-835.

[7] 中华儿科杂志编辑委员会先天性心脏病经导管介入治疗指南中华儿科杂志,2004, 42: 234-239.

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