经导管介入封堵治疗儿童动脉导管未闭合并二尖瓣反流疗效评价

doi:10.12372/jcp.2022.21e1493

摘要/Abstract

摘要：

目的分析单纯经导管介入封堵治疗儿童动脉导管未闭（PDA）合并中、重度二尖瓣反流（MR）的中长期疗效,探究其安全性及可行性。方法回顾 2013年3月至2019年3月诊断PDA合并中、重度MR并单纯行经导管介入封堵治疗患儿的临床资料。结果共纳入121例患儿,男27例、女94例,年龄19.8（8.0~28.0）月;合并中度MR 94例,重度MR 27例。超声下PDA直径（6.4±1.8）mm。患儿术前,术后24 h,术后1、3、6、12、24月的主肺动脉（MPA）直径、左心房（LA）直径、左心室舒张末期直径（LVEDD）、左心室收缩末期直径（LVESD）差异均有统计学意义（P<0.05）。与术前相比,术后各随访时间点MPA直径、LA直径、LVEDD和LVESD均缩短,差异有统计学意义（P<0.05）。随访期间120例（93.4%）患儿MR程度较术前减轻。所有患儿术前,术后24 h,术后1、3、6、12及24月的MR面积差异有统计学意义（P<0.05）,术后各随访时间点MR面积均较术前缩小,差异有统计学意义（P<0.05）,但术后12与24个月之间MR面积差异无统计学意义（P>0.05）。结论 PDA合并中、重度MR患儿在严格把握手术指征的前提下,单纯行经导管介入封堵治疗可改善MR程度、降低左心负荷,该方法安全有效。

关键词: 二尖瓣反流, 动脉导管未闭, 经导管封堵术, 先天性心脏病

Abstract:

Objective To analyze the medium - and long-term efficacy of simple transcatheter closure in the treatment of children with patent ductus arteriosus (PDA) complicated with moderate and severe mitral regurgitation (MR), and to explore its safety and feasibility. Methods Clinical data of children diagnosed with PDA complicated with moderate and severe MR and treated with transcatheter closure from March 2013 to March 2019 were retrospectively analyzed. Results A total of 121 children (27 boys and 94 girls) with a median age of 19.8 (8.0-28.0) months were included. There were 94 cases with moderate MR and 27 cases with severe MR. Echocardiography showed that the diameter of PDA was (6.4±1.8) mm. There were statistically significant differences in the main pulmonary artery (MPA) diameter, left atrium (LA) diameter, left ventricular end diastolic diameter (LVEDD) and left ventricular end systolic diameter (LVESD) among different time points (preoperative, postoperative 24 h, postoperative 1, 3, 6, 12 and 24 months) (P<0.05). Compared with pre-operation, MPA diameter, LA diameter, LVEDD and LVESD were all shortened at each follow-up time point after surgery, with statistical significance (P<0.05). During the follow-up period, 120 children (93.4%) had less MR than pre-operation. There were statistically significant differences in MR areas of all children among different time points (preoperative, postoperative 24 h, postoperative 1, 3, 6, 12 and 24 months) (P<0.05). The postoperative MR area at each follow-up time point was significantly smaller than that before surgery (P<0.05), but there was no significant difference in MR area between 12 and 24 months after surgery (P>0.05). Conclusions On the premise of strictly grasping the surgical indications, simple transcatheter closure can improve MR degree and reduce left heart load in PDA combined with moderate and severe MR in children, which is safe and effective.

Key words: mitral regurgitation, patent ductus arteriosus, transcatheter closure, congenital heart disease

陈艳华, 尹丹, 郑敏, 吕铁伟, 易岂建, 李谧, 向平. 经导管介入封堵治疗儿童动脉导管未闭合并二尖瓣反流疗效评价[J]. 临床儿科杂志, 2022, 40(7): 517-521.

CHEN Yanhua, YIN Dan, ZHENG Ming, LYU Tiewei, YI Qijian, LI Mi, XIANG Ping. Efficacy evaluation on transcatheter closure of patent ductus arteriosus with mitral regurgitation in children[J]. Journal of Clinical Pediatrics, 2022, 40(7): 517-521.

图/表 3

表1

图1

表2

参考文献 22

[1]	Jain A, Shah PS. Diagnosis, evaluation, and management of patent ductus arteriosus in preterm neonates[J]. JAMA Pediatr, 2015, 169(9): 863-872. doi: 10.1001/jamapediatrics.2015.0987
[2]	Khoo NS, Smallhorn JF. Mechanism of valvular regurgitation[J]. Curr Opin Pediatr, 2011, 23(5): 512-517. doi: 10.1097/MOP.0b013e32834aa56a pmid: 21900780
[3]	Hamrick SEG, Sallmon H, Rose AT, et al. Patent ductus arteriosus of the preterm infant[J]. Pediatrics, 2020, 146(5): e20201209. doi: 10.1542/peds.2020-1209
[4]	潘翠珍, 潘文志, 周达新. 二尖瓣反流介入治疗的超声心动图评价中国专家共识[J]. 中国介入心脏病学杂志, 2019, 27(1): 6-12.
[5]	Yasuhara J, Kuno T, Kumamoto T, et al. Comparison of transcatheter patent ductus arteriosus closure between children and adults[J]. Heart Vessels, 2020, 35(11): 1605-1613. doi: 10.1007/s00380-020-01639-4 pmid: 32494943
[6]	Baruteau AE, Hascoët S, Baruteau J, et al. Transcatheter closure of patent ductus arteriosus: past, present and future[J]. Arch Cardiovasc Dis, 2014, 107(2): 122-132. doi: 10.1016/j.acvd.2014.01.008
[7]	孙锟, 李奋, 张智伟, 等. 儿童常见先天性心脏病介入治疗专家共识[J]. 中华儿科杂志, 2015, 53(1): 17-24.
[8]	Grayburn PA, Thomas JD. Basic principles of the echocardiographic evaluation of mitral regurgitation[J]. JACC Cardiovasc Imaging, 2021, 14(4): 843-853. doi: 10.1016/j.jcmg.2020.06.049 pmid: 33454273
[9]	Lancellotti P, Tribouilloy C, Hagendorff A, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging[J]. Eur Heart J Cardiovasc Imaging, 2013, 14(7): 611-644. doi: 10.1093/ehjci/jet105 pmid: 23733442
[10]	Little SH. Three-dimensional echocardiography to quantify mitral valve regurgitation[J]. Curr Opin Cardiol, 2012, 27(5): 477-484. doi: 10.1097/HCO.0b013e3283562d67
[11]	Zoghbi WA, Adams D, Bonow RO, et al. Recom-mendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance[J]. J Am Soc Echocardiogr, 2017, 30(4): 303-371. doi: 10.1016/j.echo.2017.01.007
[12]	Krichenko A, Benson LN, Burrows P, et al. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion[J]. Am J Cardiol, 1989, 63(12): 877-880. pmid: 2929450
[13]	Vida VL, Zanotto L, Carrozzini M, et al. Repair techniques for mitral valve insufficiency in children[J]. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu, 2018, 21: 41-45. doi: 10.1053/j.pcsu.2017.11.004
[14]	Chemtob RA, Wierup P, Mick S, et al. Choosing the "Best" surgical techniques for mitral valve repair: lessons from the literature[J]. J Card Surg, 2019, 34(8): 717-727. doi: 10.1111/jocs.14089
[15]	Moore RA, Wierup P, Burns DJP, et al. Early failure after non-resectional mitral valve repair with artificial chordae[J]. J Card Surg, 2020, 35(9): 2432-2435. doi: 10.1111/jocs.14817
[16]	Kheiwa A, Ross RD, Kobayashi D. Reversal of severe mitral regurgitation by device closure of a large patent ductus arteriosus in a premature infant[J]. Cardiol Young, 2017, 27(1): 189-192. doi: 10.1017/S1047951116000998 pmid: 28281414
[17]	Wang Z, Chen T, Chen L, et al. Safety and efficacy of transcatheter closure of patent ductus arteriosus with severe mitral regurgitation in adults[J]. Invasive Cardiol, 2016, 28(1): 30-33.
[18]	Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology[J]. J Am Soc Echocardiogr, 2005, 18(12): 1440-1463. doi: 10.1016/j.echo.2005.10.005
[19]	Nappi F, Avatar Singh SS, Santana O, et al. Functional mitral regurgitation: an overview for surgical management framework[J]. J Thorac Dis, 2018, 10(7): 4540-4555. doi: 10.21037/jtd.2018.07.07
[20]	Hou M, Qian W, Wang B, et al. Echocardiographic prediction of left ventricular dysfunction after transcatheter patent ductus arteriosus closure in children[J]. Front Pediatr, 2019, 7: 409. doi: 10.3389/fped.2019.00409
[21]	Abdel-Bary M, Abdel-Baseer KA, Abdel-Latif AF, et al. Left ventricular dysfunction postsurgical patent ductus arteriosus ligation in children: predictor factors analysis[J]. J Cardiothorac Surg, 2019, 14(1): 168. doi: 10.1186/s13019-019-0990-z pmid: 31533759
[22]	Agha HM, Hamza HS, Kotby A, et al. Predictors of transient left ventricular dysfunction following transcatheter patent ductus arteriosus closure in pediatric age[J]. J Saudi Heart Assoc, 2017, 29(4): 244-251. doi: 10.1016/j.jsha.2017.02.002

项目	术前	术后24 h	术后1月	术后3月	术后6月	术后12月	术后24月	F值	P
MPA/mm	20.3±3.8	19.5±3.7¹⁾	16.4±2.9¹⁾	15.8±2.3¹⁾	16.0±3.1¹⁾	16.0±2.1¹⁾	15.8±3.4¹⁾	41.47	<0.001
LA/mm	23.1±3.9	22.5±4.0¹⁾	19.3±3.5¹⁾	17.6±3.2¹⁾	17.6±3.0¹⁾	17.2±2.9¹⁾	16.8±2.6¹⁾	94.85	<0.001
LVEDD/mm	41.5±6.5	39.6±6.3¹⁾	33.9±6.6¹⁾	31.2±5.2¹⁾	30.8±5.0¹⁾	30.6±4.9¹⁾	30.7±4.9¹⁾	122.32	<0.001
LVESD/mm	26.5±5.3	26.6±4.9	23.3±5.2¹⁾	20.2±4.2¹⁾	19.7±4.0¹⁾	19.8±3.7¹⁾	20.2±3.8¹⁾	80.20	<0.001
LVEF/%	63.3±4.8	63.7±4.0	63.2±4.2	63.4±4.5	63.2±3.9	63.2±3.9	63.1±4.0	0.63	0.707

时间	MR面积/cm²
术前	2.9(2.5~3.7)
术后24 h	2.3(1.7~3.1)¹⁾
术后1月	1.5(1.0~2.3)¹⁾²⁾
术后3月	1.1(0.8~2.0)¹⁾²⁾³⁾
术后6月	1.0(1.0~1.8)^1)2)3)4)
术后12月	0.9(0.6~1.6)^1)2)3)4)5)
术后24月	0.9(0.6~1.5)^1)2)3)4)5)
H值	317.25
P	<0.001