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摘要
目的：采用Amplatzer封堵器经皮穿刺静脉治疗动脉导管未闭，并对其疗效、安全性及并发症进行评价。
方法：25例患者，年龄8.47±6.51(0.9～38.0)岁，体重28.03±21.04(7.0～69.5)kg。经静脉使用6 F传送器置入Amplatzer封堵器，听诊无杂音后10分钟行胸主动脉造影。术前术后均行血液动力学测定，术后24小时、3个月、6个月行超声心动图及X线胸片检查。
结果：全组技术成功率100%。术后即刻所有患者心前区双期连续性杂音消失，10分钟后胸主动脉造影示24例完全堵闭(96%)，仅1例存在极少量残余分流，且48小时后超声心动图示该分流消失。动脉导管最窄径4.09±1.07(1.5～6.0)mm,透视时间6.8±2.1(3.1～14.5)分。除1例患者术后短暂胸部不适外均无任何并发症。随访7.5±2.2(3～12)个月未发生装置移位、再通或肺动脉狭窄。
结论：应用Amplatzer方法经导管治疗动脉导管未闭安全简便，创伤小，适应证广，成功率高，疗效可靠，可用于新生儿，是目前治疗动脉导管未闭最理想的方法。
Transcatheter Closure of Patent Ductus Arteriosus with Amplatzer Occluder
Catheterization Laboratory, Institute of Beijing Heart, Lung and Blood Vessel Disease, An Zhen Hospital, PLA., Beijing (100029)
Li Zhizhong, Han Ling, Jin Mei, et al.
Abstract
Objective: To evluate the efficiency, safety and complications in the application of Amplatzer occluder to the percutaneous closure of patent ductus arteriosus (PDA).
Methods: Twenty-five patients with mean age of 8.47±6.51 (ranging from 0.9～38.0) years and body weight of 28.03±21.04 (ranging from 7.0～69.5) kg underwent percutaneous closure of PDA with Amplatzer occluder led by 6F delivery system. Ten minutes after the procedure aortographies were made to evaluate the efficiency. Hemodynamics was performed before and after the procedure. Echocardiography and X-ray were performed at 24 hours, 3 months and 6 months after the procedure.
Results: The success rate was 100%, no continuous murmur was heard in all patients instantly after the procedure. Aortographies showed that the patent ductus were closed completely (96%), in 24 cases only one case remained a little residual shunt 10 minutes after the procedure. Echocardiography revealed that the residual shunt disappeared 48 hours later. The mean narrowest diameter of PDA was 4.09±1.07 (ranging from 1.5～6.0) mm, the mean fluroscopy time was 6.8±2.1 (3.1～14.5) minutes. Not any complication was found in all patients except one who felt transient discomfort. In 7.5±2.2 months′ follow-up, no devices displacement, recanalization and pulmonary stenosis happened.
Conclusions: Transcatheter closure of PDA using Amplatzer occluder device is safe and efficient, the success rate is high, indication is wide, trauma is little and it can also be used in neonates. Thus it is the most ideal procedure in the treatment of PDA at present.
Key words Patent ductus arteriosus; Transcatheter closure
自1967年Porstmann等［1］首次非开胸成功治疗动脉导管未闭(PDA)以来，国内外学者对经导管治疗PDA的方法、材料和传送器材进行了不懈的研究，到目前为止，介入性治疗PDA取得了很大进展。随着Rashkind双面伞、Sideris纽扣补片、Cook和Pfm弹簧圈，到现在的Amplatzer封堵器的应用，使PDA的介入治疗迈向了一个新台阶。我院近期采用Amplatzer方法治疗25例PDA，现报告如下。
1 材料和方法
临床资料：患者25例，男9例，女16例，年龄8.47±6.51(0.9～38)岁，体重28.03±21.04(7.0～69.5)kg。24例经临床、心电图、X线胸片及超声心动图检查证实为PDA，其中1例合并有1.5 mm的心室间隔缺损。所有病例胸骨左缘第2～3肋间闻及双期连续性杂音。心电图示左心室肥厚20例。右心导管检查肺循环血流量/体循环血流量(QP/QS):2.85±0.75(1.22～5.56),左向右分流量(45.7±17.51)%(18.26%～88.81%),肺动脉压正常10例，轻度增高6例，中度增高8例，重度增高1例，肺动脉平均压24.8±9.87(8～52)mmHg(1 mmHg=0.133 kPa)。
Amplatzer封堵系统结构组成：Amplatzer封堵器是美国AGA公司制造，由镍钛合金丝编织成的网状、具有自膨胀性能的蘑菇状封堵器，内缝3层高分子聚酯片。按“腰部”直径分为4～6 mm、6～8 mm、8～10 mm、10～12 mm、12～14 mm 5种规格，其中前后数字分别为近肺动脉侧和近主动脉侧的“腰部”直径。传送系统由装载鞘、传送鞘和主控钢丝组成，主控钢丝顶端有螺纹，末端带一旋转柄，外鞘直径5F～7F。
操作方法：①局麻或全麻后分别穿刺右股动、静脉。沿静脉送入6F端孔导管完成常规右心导管后，将260 cm的交换钢丝经PDA送入降主动脉。②PDA的定位和测量。沿股动脉送入5F或6F猪尾导管于主动脉弓降部行侧位造影，观察和测量PDA位置、形态、大小(最窄径、最大径和长度)及与气管前壁相对位置。将传送鞘沿导丝送入降主动脉，撤除导丝和内鞘。③选择封堵器堵闭PDA。根据测量PDA各参数，选择较PDA最窄径大2 mm的Amplatzer封堵器，在生理盐水中将气泡排净，旋在主控钢丝顶端并回旋半圈，由主控钢丝收入装载鞘中，送入传送鞘。将封堵器“腰部”准确放在PDA最窄处，听诊无杂音后10分钟重复主动脉造影，确认位置合适，逆时针旋转主控钢丝将其释放。沿途取血、测压后撤除所有鞘管，局部加压包扎6小时，平卧20小时。术中静脉注射肝素0.5～1.0 mg/kg,术前、术后3天静脉用抗生素。术后24小时行超声心动图和X线胸片检查。