超聲引導(dǎo)PDA封堵治療

改良動(dòng)脈導(dǎo)管未閉導(dǎo)管封堵法

TranscatheterclosingPDAguidedbytransthoracicechocardiography:Feasibilityandsafety福建醫(yī)科大學(xué)附屬協(xié)和醫(yī)院心內(nèi)科

福建省冠心病研究所

陳良龍UUFightingCVD背景/Background

傳統(tǒng)的導(dǎo)管封堵治療PDA法通常需穿刺股動(dòng)、靜脈，以建立輸送軌道；并做降主動(dòng)脈造影，以確定PDA形態(tài)、大小及選擇合適的封堵器。Conventionally,trans-catheterclosingPDAusuallyneedspuncturingboththefemoralarteryandthefemoralveintocreateanoccluderdeliveringtrack,andperformingaorta-angiographytodeterminethemorphologyandsizeofPDAinordertoselectaproperoccluder.局限性/Limitations

通常，穿刺股動(dòng)脈及股靜脈并不困難；但是嬰幼兒或體重低于4KG者，穿刺股動(dòng)脈或/和股靜脈可能會(huì)有困難；對(duì)于直徑小的股動(dòng)脈進(jìn)行穿刺及插管操作可能造成血管損傷及相關(guān)并發(fā)癥。Normally,puncturingthefemoralvesselsiseasy,butitmaybedifficultifthepatientsareinfantsortheirweightis

4Kg;moreover,puncturingandoperationmanipulatingmaydamagethefemoralarteryorintroducecomplications.局限性/Limitations

主動(dòng)脈造影時(shí)需要注射造影劑，造影劑劑量較大時(shí)具有腎毒性；同時(shí)，X線造影時(shí)患者需要接受較高劑量的X線輻射。這對(duì)患者尤其是兒童是十分不利的。Opacificationmediuminjectedforaorta-angiographyhasrenaltoxicityifusedathighdosages;meanwhile,patientshavetoreceiveextraX-Rayradiationduringaorta-angiography.Thesemaybeharmfulforpatientsespeciallyforchildren.替代方法/Alternative鑒此，傳統(tǒng)的導(dǎo)管PDA封堵術(shù)是否有改良或替代方法？不必穿刺股動(dòng)脈不需做X線主動(dòng)脈造影僅穿刺股靜脈Inviewofthefacts，arethereanymodifiedtechniquesforsubstitutiontraditionalmethodsforclosingPDA?NofemoralarterypunctureNoaorta-angiographyOnlyfemoralveinpunctureAcasedemo

病例介紹UUFightingCVD技術(shù)操作-PDA測(cè)量、軌道建立

技術(shù)操作-封堵器定位、殘余分流觀察技術(shù)操作-封堵器主、肺動(dòng)脈無(wú)占位技術(shù)操作-封堵器主動(dòng)脈占位？技術(shù)操作-封堵器釋放后Initiateexperience

初步經(jīng)驗(yàn)UUFightingCVD目的/Objectives探討在超聲心動(dòng)圖引導(dǎo)下、不需做X線主動(dòng)脈造影、不必穿刺股動(dòng)脈、僅穿刺股靜脈封堵治療PDA的可行性及安全性。Weintroducedanovelmethodwhichrequirednoaorta-angiographyandnofemoralarterypuncture,onlyneededfemoralveinpunctureandechocardiographyguidingduringPDAclosingWetestedthefeasibilityandsafetyforthismethods.臨床資料/PatientsdataPDA患兒27例，男12例，女15例，年齡4.6±2.9歲（1

8）歲，體重13.1±5.4Kg（3.7

23.5Kg）。其中，2歲以下嬰幼兒6例，體重8.2±3.1Kg（3.7

13.8Kg）。Twenty-sevenptswithPDA(12malesand15females,agedat4.62.9years,weightedat13.15.4Kg)wereincludedinthestudy,amongwhom6ptsareinfantswithweightof8.2±3.1Kg(3.7

13.8Kg).臨床資料/Patientsdata二維超聲心動(dòng)圖封堵前測(cè)量PDA最窄處直徑為5.9±1.5mm(3.2

7.8mm)，PDA長(zhǎng)度9.7±3.6mm(6.7

13.2mm)。PDA具有較典型的漏斗部、且彩色多普勒血流顯像提示PDA分流方向指向肺動(dòng)脈外側(cè)壁或中部。

Preoperatively,thenarrowestPDAdiameterwas

5.9±1.5mmwiththePDAlengthof9.7±3.6mmmeasuredby2DE,andCDFIrevealedthetypicalPDAshuntinginallpatients.方法/Methods僅穿刺股靜脈、不穿刺股動(dòng)脈，在X線透視下建立輸送軌道；按術(shù)前超聲測(cè)量的PDA最窄處直徑的2倍選擇Amplatzer封堵器，并根據(jù)術(shù)中CDFI實(shí)時(shí)監(jiān)測(cè)結(jié)果進(jìn)行適當(dāng)調(diào)整。Weonlypuncturedthefemoralveinasanapproachforbuildingupanoccluderdeliveringtrackunderfluoroscopy;theAmplatzer

occluderwasselectedbasedonthenarrowestdiameterofPDAdeterminedby2DEandadjustedbyreal-timeCDFImonitoringwhenthedeliveringcatheterwascrossingPDA.方法/Methods封堵器離到位后若X線透視下有明顯的“堆形腰”、2DE顯示封堵器呈“工字形”且主、肺動(dòng)脈側(cè)均無(wú)占位，即開始應(yīng)用CDFI連續(xù)監(jiān)測(cè)分流阻斷情況；通常封堵到位后即刻至30分鐘內(nèi)，CDFI顯示PDA分流逐步至完全消失，此時(shí)可釋放封堵器。Afterwellpositioningtheoccluder,ifX-rayshoweditataperedwaist,2DE&CDFIrevealeditanI-shapedappearancewithoutanyoccupationofaortaorpulmonaryartery,CDFIwasusedforcontinouslymonitoringtheshuntingalterations.Ifshuntingdisappearedgraduallyin30Min,theoccludercouldbesafelyreleased.

方法/Methods在下列情況下，需要更換封堵器：1、封堵器到位后X線透視下無(wú)明顯的“堆形腰”，或封堵器嚴(yán)重變形，或輕度推拉即發(fā)生封堵器移位；2、彩色多普勒血流顯像顯示封堵器邊緣性分流寬度

2mm、持續(xù)時(shí)間

30Min。Incaseofthefollowingsituations，theoccludershouldbereplaced：ifnotaperedwaistorseveredeformedwasfound；andifthemarginalshuntingwas

2mmand/orlasting30min。

結(jié)果/Results

本方法對(duì)27例PDA患兒封堵治療的技術(shù)成功率100%，無(wú)圍手術(shù)期嚴(yán)重并發(fā)癥。超聲引導(dǎo)PDA封堵治療在封堵器選擇、定位、分流監(jiān)測(cè)方面準(zhǔn)確可行，安全可靠。ThetechnicalsuccessrateforclosingPDAbythenewmethodwas100%in27patientswithoutanyperi-andpost-proceduralcomplications.Andechocardiographyguidingfordeviceselectingandpositioning,andshuntmonitoringisaccurate,feasibleandsafe.結(jié)果/Results

在封堵嘗試中，首次封堵器選擇太小而需要更換較大封堵器者4例次（14.8%），首次封堵器選擇太大而需要更換較小封堵器者2例次（7.4%）。Basedonechocardiographiccriteria,requirementofdevicereplacingduetoincorrectorimproperselectionwas22.2%,with14.8%ofselectionoftoosmalleranoccluderand7.4%ofselectionoftoobiggeranoccluder.討論/Discussion超聲心動(dòng)圖可替代X線造影:PDA大小測(cè)量及封堵器選擇封堵器定位、形態(tài)判斷殘余分流監(jiān)測(cè)、封堵器更換主動(dòng)脈、肺動(dòng)脈占位Echocardiographysubstitutionforangiography:MeasuringPDAdiameterandselectinganoccluderPositioningtheoccluderandviewingitsshapeMonitoringresidualshunting,determiningreplacementofanoccluderInterrogatingoccluderoccupationinaortaandpulmonaryartery結(jié)論/Conclusion超聲心動(dòng)圖引導(dǎo)、無(wú)X線造影的經(jīng)股靜脈PDA導(dǎo)管封堵術(shù)是安全可行的；因無(wú)需X線造影，無(wú)造影劑毒副作用、X線輻射減少；無(wú)需穿刺股動(dòng)脈，適合在低體重或/和嬰幼兒中應(yīng)用，可最大程度減輕手術(shù)損傷。Echocardiogr