经皮血管支架置入治疗复杂先心病外科术后分支肺动脉狭窄  

Endovascular stent implanttation to rehabilitate residual branch pulmonary artery stenosis in children after surgical repair with complex congenital heart disease

作　　者：谢育梅[1] 张智伟[1] 钱明阳[1] 李俊杰[1] 石继军[1] 王树水[1] 孙凌[1] 梁小碧 

机构地区：[1]广东省人民医院、广东省医学科学院、广东省心血管病研究所心儿科,广州510010 [2]广州市妇儿中心

出　　处：《中华胸心血管外科杂志》2015年第8期449-452,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：2011年国家科技支撑计划（2011BAIllB22）

摘　　要：目的 探讨经皮血管支架置入治疗儿童复杂先天性心脏病外科术后分支肺动脉狭窄的可行性和有效性.方法 17例患儿男14例,女3例;年龄1.2～14.0岁,平均（6.5±4.1）岁;体质量8～46 kg,平均（19.3±9.2） kg.诊断法洛四联症9例,肺动脉闭锁伴室间隔缺损6例,右心室双出口和大动脉转位各1例.外科根治术后超声心动图及心脏螺旋CT均显示左肺动脉开口及近端不同程度狭窄,CT显示左肺动脉起始部狭窄内径1.0～4.9 mm,平均（3.2±1.3） mm,同侧肺血减少.术前右心室收缩压（RVSP） （75.9 ±20.3）mmHg（1 mmHg =0.133 kPa）,跨狭窄处压差（51.6±13.9） mmHg.右心室造影和选择性肺动脉造影显示左肺动脉近段明显狭窄,其中3例同时合并右肺动脉轻中度狭窄.根据狭窄最窄径和长度置入合适支架,再次行左肺动脉选择性造影和/或主肺动脉造影、测压,评估支架置入效果;3例合并右肺动脉轻中度狭窄病例同时行经皮球囊右肺动脉成形术.术后24 h使用低分子肝素抗凝,术后3个月同时口服氯吡格雷和阿斯匹林,3个月后改为单服阿斯匹林至术后6个月.随访3～ 46月,平均10.2月.术后24 h、1、3、6、12个月行超声心动图、心电图和X线胸片随访,术后3～6月复查心脏CT.结果 2例年长儿分别置入12 mm和16 mm美国NuMED自膨胀裸支架,2012年至2014年置入15例,选用球囊直径为6～10 mm颈内动脉支架或肾动脉支架.术后患侧肺血明显改善,右心室压力明显下降,术后RVSP（46.2±17.8） mmHg（t =6.881,P＜0.001）,跨狭窄处压差（21.0±15.6） mmHg（t=12.213,P＜0.001）,术后血管内径（8.3±2.2） mm（t=-10.509,P＜0.001）.所有患儿均未发生血管夹层、心包压塞、严重心律失常等并发症.随访期内无死亡病例.其中2000年1例最早置入支架患儿术后1年发现支架内再狭窄,随后行肺动脉支架取出及狭窄矫治术.其余病例随访期内未发现再狭窄、支架内栓塞、支架�Objective Discuss the feasibility and effectiveness of percutaneous stent implantation treatment of surgical postoperative pulmonary branches stenosis in children.Methods From April 2000 to January 2014,17 pediatric patients underwent implantation of stents for branch pulmonary artery stenosis following surgical repair.Median age was（6.5 ±4.1） years （range,1.2-14.0） and median weight was （19.3 ± 9.2） kg（range,8-46）.Patient diagnoses were tetralogy of Fallot （nine）,pulmonary atresia with ventricular septal defect（PA/VSD） （six）,double outlet right ventricle（one）,transposition of the great arteries with ventricular septal defect（TGA/VSD） （one）.Cardiac spiral computed tomography（CT） had shown the proximal left pulmonary artery had moderate to severe stenosis,with the mean diameter of the stenotic vessels was （3.2 ± 1.3） mm.Angiograms were obtained in compounded views of the stenotic vessel after baseline hemodynamics measured.Platelet anti-aggregation therapy with aspirin or clopidogrel was prescribed for 6 months after stent implantation.Results Twelve of ExpressTM Vascular premounted stents（Boston Scientific）,three of Cordis premounted stents through a 6Fr or 7Fr long vascular sheath and to the area of stenosis in the proximal LPA.Two of CP stents were implanted in the LPA.Mean peak systolic gradient recorded across the stenotic prestenting was（51.6 ± 13.9） mmHg and fell to（21.0 ± 15.6） mmHg（P 〈 0.01） following stent implantation RVSP was （75.9 ± 20.3） mmHg and fell to （46.2 ± 17.8） mmHg （P 〈 0.05） obtained by right cardiac catheter examination.All stents were implanted in the desired location.There were no instances of malposition or embolization.Stent embolization occurred in one patient of CP stent implantation and addressed surgically at six month after the procedure.The median follow-up was ten months with a range between three months and 46 months.There was no mortality associated with stent implantation.Conclusion Premount

关 键 词：心脏缺损 先天性 肺动脉狭窄 支架 

分 类 号：R543.5[医药卫生—心血管疾病]