经皮球囊肺动脉瓣成形术治疗先天性肺动脉瓣狭窄的疗效及中远期随访研究

发布时间：2018-04-23 20:08

本文选题：肺动脉瓣狭窄 + 经皮球囊肺动脉瓣成形术　；参考：《南华大学》2012年硕士论文

【摘要】：目的先天性肺动脉瓣狭窄(pulmonary stenosis，PS)是常见的先天性心脏病(con-genital heart defects，CHD)之一，发病率约占CHD的8%-10%。近年来，经皮球囊肺动脉瓣成形术(percutaneous balloon pulmonary valvuloplasty，PBPV)已取代外科手术成为治疗PS的首选方法，国内外大样本的临床报道不断增多，近中期疗效获得一致肯定，但尚缺乏远期随访资料。本研究旨在评价PBPV治疗肺动脉瓣狭窄的中远期疗效；并探讨影响疗效的相关因素。方法收集自1987年至2011年6月住院并实施PBPV的PS患者203例（其中2例为室间隔完整的肺动脉闭锁），其中男118例，女85例，4.27±4.16岁（3月～40岁）。回顾性分析患者手术前、后临床症状体征、心电图（electrocardiogram，ECG）、经胸多普勒超声心动图(transthoracic dopplerechocardiography，TTE)、右心导管检查、右心室造影及PBPV相关资料。根据PBPV术前心导管所测跨肺动脉跨瓣压差将患者分为轻、中、重度三组。行右心室正侧位造影，测量肺动脉瓣瓣环直径，选择合适球囊扩张。扩张术后即刻根据导管所测PTG程度，将PBPV术后即刻疗效分为优、良、差三组，PTG≤25mmHg为优，25mmHgPTG50mmHg为良，≥50mmHg为差。术后1、3、6、12个月及每隔1年随访，到2011年12月平均随访2.88±2.82年，随访内容包括临床症状和体格检查、ECG和TTE。结果 203例患者，术前66例(32.5%)有活动后气促、胸闷、乏力等症状，其中46例(22.7%)伴有紫绀。术前所有患者均可闻及胸骨左缘2-3肋间粗糙的2/6～4/6级收缩期杂音，其中78例（38.4%）可触及肺动脉瓣区收缩期震颤。心电图右室肥厚178例（87.7%）；不完全右束支传导阻滞11例(5.4%)，右房扩大48例(23.6%)。手术成功200例，技术成功率为98.5%，，术后PTG及右室收缩压较术前明显降低((P0.01)，而肺动脉收缩压明显升高(P0.01)，术后即刻疗效总优良率达93%。轻、中、重度三组PS的术后PTG较术前明显下降(P0.01)，三组间疗效不同(P0.01)。不同球囊瓣环内径比的术后PTG较术前均明显下降(P0.01)，各组间疗效无不同（P0.05）。随访3个月～14.75年，97.2%(171/176)患者临床症状消失，所有患者杂音较术前均明显减轻，震颤均消失。术前178例右室肥厚的患者中，术后146例（82%）恢复正常，26例（14.6%）转为不完全右束支传导阻滞，6例(3.4%)无明显变化；术前不完全右束支传导阻滞11例，术后4例恢复正常；术前右房扩大者，除2例余术后均恢复正常。TTE随访术后各时段PTG较术前均明显下降，且呈下降趋势，随访总优良率达98.3%。术后常见并发症包括瓣膜反流、反应性漏斗部狭窄；严重并发症包括右室流出道穿孔、心脏压塞2例、急性左心功能衰竭1例、三尖瓣腱索损伤1例，严重并发症发生率1.97%，总死亡率0.49%。以术后残余PTG为应变量，术前性别、年龄、体重、有无紫绀、是否合并房间隔缺损或卵圆孔未闭、术前导管测PTG、球囊/肺动脉瓣环直径（balloon/pulmonary valve annulus，B/A）比值、V1R电压等进行统计学分析，结果只有术前PTG(狭窄程度)有意义，术前狭窄程度是导致PBPV术后即刻不能达优（PTG25mmHg）的重要影响因素。结论 PBPV治疗PS安全可靠，能有效解除肺动脉瓣狭窄,即刻及中远期疗效满意，严重并发症少，可作为先天性PS的首选治疗方法。术前狭窄程度是影响疗效的重要因素。
[Abstract]:objective
Congenital pulmonary stenosis (pulmonary stenosis, PS) is one of the common congenital heart disease (con-genital heart defects, CHD). The incidence of congenital heart disease (CHD) is about 8%-10%. in CHD. Percutaneous balloon pulmonary valvuloplasty (percutaneous balloon pulmonary) has replaced surgery as the first choice for the treatment of CHD. The clinical reports of large samples are increasing, and the curative effect in the near middle period is unanimous, but the long-term follow-up data are still lacking. The purpose of this study is to evaluate the medium-term efficacy of PBPV for the treatment of pulmonary valve stenosis and to explore the related factors that affect the curative effect.
Method
From 1987 to June 2011, 203 cases of PS patients were hospitalized and performed PBPV (2 cases of ventricular septum intact pulmonary atresia), including 118 males, 85 females, 4.27 + 4.16 years (March to 40 years). Retrospective analysis of the patient's symptoms and signs, electrocardiogram (electrocardiogram, ECG), and transthoracic Doppler echocardiography (transthoracic Dopplerechocardiography, TTE), right cardiac catheterization, right ventriculography and PBPV related data. According to the difference of cross pulmonary artery cross valve pressure measured by the cardiac catheterization before PBPV, the patients were divided into three groups of light, medium and severe. Right ventricle side contrast, pulmonary valve ring diameter was measured, and appropriate balloon dilation was selected. PTG was measured immediately after dilation by catheter. To the extent, the immediate effect of PBPV was divided into three groups: excellent, good and poor, PTG < 25mmHg as excellent, 25mmHgPTG50mmHg was good, and 50mmHg was poor. The postoperative follow-up was 1,3,6,12 months and every 1 years, and the average follow-up was 2.88 + 2.82 years in December 2011. The follow-up contents included clinical symptoms and physical examination, ECG and TTE..
Result
In 203 patients, 66 (32.5%) before operation (32.5%) had symptoms of postoperative breath, chest tightness, and fatigue, of which 46 (22.7%) had cyanosis. All patients before the operation could smell the 2/6 to 4/6 systolic murmur of the 2-3 intercostal intercostal intercostals of the sternum, of which 78 (38.4%) could touch the systolic tremor in the pulmonary valve region. The ECG right ventricular hypertrophy was 178 cases (87.7%), and the right ventricular hypertrophy (87.7%); and incomplete right 11 cases of bundle branch block (5.4%) and 48 cases of right atrial enlargement (23.6%). The success rate of 200 cases was 98.5%. The postoperative PTG and right ventricular systolic pressure were significantly lower than before operation (P0.01), and pulmonary systolic pressure increased significantly (P0.01). The total excellent rate of postoperative immediate effect reached 93%. light, moderate and severe three groups of PS decreased significantly (P0.01), three after operation (P0.01), three The curative effect was different between the groups (P0.01). The postoperative PTG was significantly lower than that before the operation (P0.01). The curative effect was no different in each group (P0.05). Follow up 3 months to 14.75 years, 97.2% (171/176) patients' clinical symptoms disappeared, all patients' murmurs were significantly less than before operation and the tremor disappeared. 178 cases of right ventricular hypertrophy before operation, 146 after operation Cases (82%) were restored to normal, 26 cases (14.6%) turned to incomplete right bundle branch block, 6 cases (3.4%) had no obvious change, 11 cases of incomplete right bundle branch block before operation, 4 cases recovered normal after operation. Before operation, all the right atrial enlargement, except 2 cases, all recovered to normal.TTE follow up, and the PTG decreased obviously, and showed a decline trend, follow up total. The common complications after 98.3%. were valvular reflux, reactive funnular stenosis, severe complications including right ventricular outflow tract perforation, cardiac tamponade in 2 cases, acute left heart failure in 1 cases, three apical chordae tendineae injury in 1 cases, severe complication rate 1.97%, total mortality 0.49%. with residual PTG as a variable, preoperative sex, age, Body weight, cyanosis, atrial septal defect or oval foramen, preoperative catheterization PTG, balloon / pulmonary artery ring diameter (balloon/pulmonary valve annulus, B/A) ratio, V1R voltage and so on were statistically analyzed. Only before operation PTG (degree of stenosis) was intentional, preoperative stenosis was caused immediately after PBPV (PTG25mm). The important influence factors of Hg).
conclusion
PBPV is safe and reliable for the treatment of PS. It can effectively relieve the stenosis of pulmonary artery valve. The immediate and middle and remote effects are satisfactory, and the serious complications are few. It can be used as the first choice for the treatment of congenital PS. The degree of preoperative stenosis is an important factor affecting the curative effect.

【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R725.4

【参考文献】