發(fā)布時(shí)間：2018-04-23 20:08

  本文選題：肺動(dòng)脈瓣狹窄 + 經(jīng)皮球囊肺動(dòng)脈瓣成形術(shù)��； 參考：《南華大學(xué)》2012年碩士論文

【摘要】：目的 先天性肺動(dòng)脈瓣狹窄(pulmonary stenosis，PS)是常見(jiàn)的先天性心臟病(con-genital heart defects，CHD)之一，發(fā)病率約占CHD的8%-10%。近年來(lái)，經(jīng)皮球囊肺動(dòng)脈瓣成形術(shù)(percutaneous balloon pulmonary valvuloplasty，PBPV)已取代外科手術(shù)成為治療PS的首選方法，國(guó)內(nèi)外大樣本的臨床報(bào)道不斷增多，近中期療效獲得一致肯定，但尚缺乏遠(yuǎn)期隨訪(fǎng)資料。本研究旨在評(píng)價(jià)PBPV治療肺動(dòng)脈瓣狹窄的中遠(yuǎn)期療效；并探討影響療效的相關(guān)因素。 方法 收集自1987年至2011年6月住院并實(shí)施PBPV的PS患者203例（其中2例為室間隔完整的肺動(dòng)脈閉鎖），其中男118例，女85例，4.27±4.16歲（3月～40歲）�；仡櫺苑治龌颊呤中g(shù)前、后臨床癥狀體征、心電圖（electrocardiogram，ECG）、經(jīng)胸多普勒超聲心動(dòng)圖(transthoracic dopplerechocardiography，TTE)、右心導(dǎo)管檢查、右心室造影及PBPV相關(guān)資料。根據(jù)PBPV術(shù)前心導(dǎo)管所測(cè)跨肺動(dòng)脈跨瓣壓差將患者分為輕、中、重度三組。行右心室正側(cè)位造影，測(cè)量肺動(dòng)脈瓣瓣環(huán)直徑，選擇合適球囊擴(kuò)張。擴(kuò)張術(shù)后即刻根據(jù)導(dǎo)管所測(cè)PTG程度，將PBPV術(shù)后即刻療效分為優(yōu)、良、差三組，PTG≤25mmHg為優(yōu)，25mmHgPTG50mmHg為良，≥50mmHg為差。術(shù)后1、3、6、12個(gè)月及每隔1年隨訪(fǎng)，到2011年12月平均隨訪(fǎng)2.88±2.82年，隨訪(fǎng)內(nèi)容包括臨床癥狀和體格檢查、ECG和TTE。 結(jié)果 203例患者，術(shù)前66例(32.5%)有活動(dòng)后氣促、胸悶、乏力等癥狀，其中46例(22.7%)伴有紫紺。術(shù)前所有患者均可聞及胸骨左緣2-3肋間粗糙的2/6～4/6級(jí)收縮期雜音，其中78例（38.4%）可觸及肺動(dòng)脈瓣區(qū)收縮期震顫。心電圖右室肥厚178例（87.7%）；不完全右束支傳導(dǎo)阻滯11例(5.4%)，右房擴(kuò)大48例(23.6%)。手術(shù)成功200例，技術(shù)成功率為98.5%，，術(shù)后PTG及右室收縮壓較術(shù)前明顯降低((P0.01)，而肺動(dòng)脈收縮壓明顯升高(P0.01)，術(shù)后即刻療效總優(yōu)良率達(dá)93%。輕、中、重度三組PS的術(shù)后PTG較術(shù)前明顯下降(P0.01)，三組間療效不同(P0.01)。不同球囊瓣環(huán)內(nèi)徑比的術(shù)后PTG較術(shù)前均明顯下降(P0.01)，各組間療效無(wú)不同（P0.05）。隨訪(fǎng)3個(gè)月～14.75年，97.2%(171/176)患者臨床癥狀消失，所有患者雜音較術(shù)前均明顯減輕，震顫均消失。術(shù)前178例右室肥厚的患者中，術(shù)后146例（82%）恢復(fù)正常，26例（14.6%）轉(zhuǎn)為不完全右束支傳導(dǎo)阻滯，6例(3.4%)無(wú)明顯變化；術(shù)前不完全右束支傳導(dǎo)阻滯11例，術(shù)后4例恢復(fù)正常；術(shù)前右房擴(kuò)大者，除2例余術(shù)后均恢復(fù)正常。TTE隨訪(fǎng)術(shù)后各時(shí)段PTG較術(shù)前均明顯下降，且呈下降趨勢(shì)，隨訪(fǎng)總優(yōu)良率達(dá)98.3%。術(shù)后常見(jiàn)并發(fā)癥包括瓣膜反流、反應(yīng)性漏斗部狹窄；嚴(yán)重并發(fā)癥包括右室流出道穿孔、心臟壓塞2例、急性左心功能衰竭1例、三尖瓣腱索損傷1例，嚴(yán)重并發(fā)癥發(fā)生率1.97%，總死亡率0.49%。以術(shù)后殘余PTG為應(yīng)變量，術(shù)前性別、年齡、體重、有無(wú)紫紺、是否合并房間隔缺損或卵圓孔未閉、術(shù)前導(dǎo)管測(cè)PTG、球囊/肺動(dòng)脈瓣環(huán)直徑（balloon/pulmonary valve annulus，B/A）比值、V1R電壓等進(jìn)行統(tǒng)計(jì)學(xué)分析，結(jié)果只有術(shù)前PTG(狹窄程度)有意義，術(shù)前狹窄程度是導(dǎo)致PBPV術(shù)后即刻不能達(dá)優(yōu)（PTG25mmHg）的重要影響因素。 結(jié)論 PBPV治療PS安全可靠，能有效解除肺動(dòng)脈瓣狹窄,即刻及中遠(yuǎn)期療效滿(mǎn)意，嚴(yán)重并發(fā)癥少，可作為先天性PS的首選治療方法。術(shù)前狹窄程度是影響療效的重要因素。
[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.

【學(xué)位授予單位】：南華大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類(lèi)號(hào)】：R725.4

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