室间隔缺损经导管介入治疗与外科手术治疗的对比分析

发布时间：2018-05-01 07:48

本文选题：室间隔缺损 + 介入治疗　；参考：《山东大学》2016年硕士论文

【摘要】：研究背景与目的：先天性心脏病(Congenital Heart Disease, CHD),是儿童心脏病中最常见的,而室间隔缺损(Ventricular Septal Defect, VSD),是小儿先天性心脏病中最常见的类型。虽然外科手术是治疗室间隔缺损常规且成熟的方法,但因进行外科手术治疗需要开胸并依赖于体外循环、输血、气管插管等,对机体造成损伤较大,并且可能有比较严重的手术并发症,为患者带来身心上的损伤。20世纪初,室间隔缺损介入治疗在临床开展,在应用初期因封堵器的设计和手术操作方式并不完善,并未在临床大规模开展。但随着介入器械的不断改进和逐渐普及,以及封堵技术的不断成熟优化,介入治疗安全、简单、微创的优点逐渐凸显,成为国内外应用及研究的热点。我国介入治疗的发展,是随着国产封堵器的发展而来。国产封堵器对进口封堵器进行了改进,分为对称型、偏心型、零边和小腰大边型,比Amplatzer封堵器成功率更高,能适合更多情况的VSD。因此,2004年国内即发布了先天性心脏病经导管介入治疗指南,认可了介入治疗的是VSD治疗的选择。也因此这段时间是介入治疗与外科治疗对比研究的高峰时期。当时,介入治疗技术仍处于发展期,技术不够成熟,并发症仍较多,且由于封堵器价格较高而使介入手术费用较高,让许多人在治疗方式的选择上产生了犹豫。近几年,随着介入治疗的广泛开展,封堵器研发技术的持续进步,使介入治疗费用较往年有所降低,且成功率大幅提高。因此,两种治疗方法的具体特点与效果已有所改变,两种方法的对比分析也会不同。本研究旨在通过对2014年1月1日至2015年12月31日于山东省立医院小儿心脏和心外科住院的室间隔缺损病例进行对比分析研究,在介入治疗长足发展的今天,通过对比患者的一般情况,室间隔缺损大小,术中情况及术后情况,探究室间隔缺损两种治疗方法的对比分析的改变情况。方法：本研究选择2014年1月1日至2015年12月31日于山东省立医院小儿心脏科和心外科住院进行治疗的膜周部室间隔缺损病例(介入治疗组85例、外科传统手术组80例)。以上病例,患者都经过了常规体检、心电图、胸部正侧位片、经胸超声心动图(TTE)等检查确诊。病例纳入标准为：1.膜周部室间隔缺损,未合并其他的需要经过手术矫正的心脏畸形；2.无重度肺动脉高压,无心内赘生物,无感染性心内膜炎,无主动脉瓣脱垂。3.介入组使用封堵器均为国产封堵器。比较两组的术前一般情况(性别、年龄、体重、压差等),室间隔缺损大小,术中情况(麻醉方式、输血、体外循环(CPB)、手术时间等),术后情况(手术成功率、住院时间、住院费用等)及并发症(感染、气胸、胸腔、心包积液、残余漏、心律失常等)。全部统计学处理使用SPSSI 22.0软件包。结果：两组均无死亡病例,两组的一般情况无统计学意义,但外科组年龄范围较介入治疗组大。室间隔缺损大小差别较大,外科组明显大于介入治疗组,具有统计学意义,但介入治疗组最大缺损大小较前有所增加。介入组和外科组的缺损直径在TTE和术中所测得的值虽然不尽相同,但P值均大于0.05,无统计学意义。术中情况均有统计学意义：介入治疗大部分采用全麻,外科治疗均为气管插管下全麻,全麻率差异无统计学意义,但两者使用的药物和气管插管率不同。介入治疗和外科治疗在治疗成功率方面无显著差异,但在手术时间和输血率上有明显区别。外科手术所需时间明显大于介入治疗所需的时间。外科手术均需要输血,输血率为100%,远大于介入治疗。外科手术治疗的成功率为98.7%,失败1例,原因为：术后行超声心动图示：补片边缘两处分流,修补失败,再次手术修补。介入治疗的成功率为97.6%,失败2例,原因分别为：术中封堵器边缘较多分流,更换封堵器也无法改善和术中出现Ⅲ度房室传导阻滞。介入治疗需要在CT透视下进行,而外科手术治疗需要依赖体外循环,且术后气管插管时间较长。术后情况：介入治疗组及外科手术组成功率均高,差别无统计学意义；介入治疗组住院时间短,但两者的住院费用差别无统计学意义；外科手术组严重并发症的发生率较高,但介入治疗组术后心律失常的发生率较高高,并且其他较轻的并发症较外科手术组少。结论：1.VSD介入封堵治疗与外科手术治疗相比,无需开胸,无需使用体外循环机,外科治疗不需要在CT透视下进行,且适应症较广,年龄、缺损大小、缺损形状范围等均比介入封堵治疗要宽泛。2.两种治疗方式的术后并发症均减少。但介入治疗的改变更为突出,近几年严重并发症尤其是严重房室传导阻滞极少发生。3.随着室间隔缺损封堵器价格的下降,介入治疗的治疗费用相对下降,而手术费用相对增多。
[Abstract]:Background and Objective : Congenital heart disease ( CHD ) is the most common type in children ' s heart disease , and ventricular septal defect ( VSD ) is the most common type in children ' s congenital heart disease . By comparing the general situation of the patients , the size of the ventricular septal defect , the situation of operation and the postoperative situation , the authors explored the change of the comparative analysis of the two methods of treatment of ventricular septal defect . Methods : This study selected the cases of perimembranous ventricular septal defect ( 85 cases in the interventional therapy group , 80 cases in the traditional operation group ) in the pediatric cardiac department and the cardiac surgery hospital in Shandong Province from January 1 , 2014 to December 31 , 2015 . All the above cases were confirmed by routine physical examination , electrocardiogram , chest positive side panel , thoracic echocardiography ( TTE ) , etc . The cases were included in the standard : 1 . Ventricular septal defect of membranous perimembranous ventricular septal defect , no other heart deformity requiring surgical correction ;
2 . There were no severe pulmonary hypertension , incardiac neoplasm , no infective endocarditis , no aortic valve prolapse , 3 . The use of occluder in the intervention group was the domestic occluder . The preoperative general conditions ( sex , age , weight , pressure difference , etc . ) , ventricular septal defect size , intraoperative situation ( anesthesia mode , blood transfusion , cardiopulmonary bypass ( CPB ) , operation time , etc . ) and complications ( infection , pneumothorax , thoracic cavity , pericardial effusion , residual leakage , arrhythmia , etc . ) were compared between the two groups . Results : There was no significant difference in the operative time and blood transfusion rate . The success rate of interventional therapy was higher than that in interventional therapy group .
The hospitalization time of interventional therapy group was shorter , but there was no significant difference between the hospitalization expenses .
Conclusion : 1 . Compared with surgical treatment , there is no need to open the chest , and there is no need to use extracorporeal circulation machine . The surgical treatment need not be carried out in the perspective of CT , but the change of interventional therapy is more prominent . In recent years , the serious complications especially the serious atrioventricular block rarely occur . 3 . With the decrease of the price of ventricular septal defect occluder , the treatment cost of interventional therapy is relatively decreased , and the surgical cost is relatively increased .

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R726.5

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