摘要

目的：评价Amplatzer封堵器治疗动脉导管未闭(PDA)的初步疗效。

方法：自1998年5月～1999年6月，采用美国AGA公司生产的Amplatzer封堵器共施行47例(女37例，男10例)PDA封堵术。平均年龄15.8±13.4岁(0.9～48岁)，平均体重37.3±21.2 kg(6.5～82.0 kg)。3例为PDA结扎术后再通。全部病例均经临床、心电图、X线胸片及超声心动图检查证实为PDA。局麻或全麻下穿刺右股静、动脉，先行右心导管检查及主动脉弓降部造影，以确定PDA的位置、形状及直径。选择大于所测PDA最窄直径2～4 mm的Amplatzer封堵器，于透视下经6 F输送鞘管将其封堵于PDA处。10分钟后重复主动脉造影，若封堵器形状、位置满意，无或仅有微～少量残余分流时，可释放封堵器。重复右心导管检查后撤出导管，压迫止血。术后24～48小时，1～13个月行超声心动图、X线胸片检查，观察残余分流情况、有无再通及封堵器位置等。

结果：主动脉弓降部造影显示PDA属Krichenko A型45例，B型及E型各1例。PDA最窄处直径平均为4.6±1.7 mm(2～8 mm)。肺循环血流量/体循环血流量平均为2.3(1.0～7.7)。肺动脉高压22例，其中轻度增高14例，中度增高5例，重度增高3例。全组47例PDA封堵器均放置成功。造影示无残余分流31例(66.0%)，微量残余分流13例(27.6%),少量残余分流3例(6.4%)。透视时间平均13.6分(6～65)分。术后24～48小时彩色多普勒超声心动图示动脉水平左向右分流完全消失45例(95.7%),微量残余分流2例(4.3%)。其中1例随访2个月后残余分流消失，另1例于封堵术后17小时发生溶血，于54小时后行外科PDA缝合术，余无重要并发症发生。

结论：应用Amplatzer封堵器治疗直径达8 mm的PDA是安全、有效的介入方法，术中应尽量封堵完全，减少残余分流，避免溶血并发症的发生。

Transcatheter Closure of Patent Ductus Arteriosus Using Amplatzer Duct Occluder: Initial Results

Department of Radiology, Cardiovascular Institute and Fu Wai Hospital CAMS and PUMC, Beijing (100037)

Jiang Shiliang, Huang Lianjun, Dai Ruping, et al.

Abstract

Objective: To evaluate the immediate and short-term results of transcatheter closure of patent ductus arteriosus (PDA) using Amplatzer duct occluder (ADO) device.

Methods: From May 1998 to June 1999, forty-seven patients (37 females, 10 males) with PDA were treated by transcatheter closure with ADO. The mean age was 15.8±13.4 years (ranged from 0.9 to 48 years) and the mean weight was 37.3±21.2 kg (ranged from 6.5 to 82.0 kg). Three patients had a previous surgical ligation with clinically evident recanalization. Before catheterization, physical examination, chest radiography, electrocardiography and echocardiography were performed. Conventional right and left heart catheterizations were performed under general or local anesthesia to determine pressure and oxygen saturation levels. A 5F-pigtail catheter was placed in the distal aortic arch. An aortography was performed in the lateral projection to evaluate the morphologic characteristics, position and minimum diameter of the ductus. Each PDA was occluded through the venous side using a 6F long sheath to deliver the ADO. The size of occlusion device was 2 to 4 mm larger than the narrowest diameter of the PDA. Aortography was repeated 10 minutes after the closure to assess the degree of residual shunt and confirm the device position. Once the position of the device was found to be satisfactory and without or with only a trace to small residual shunt was confirmed, the device was released by turning the cable counterclockwise using the pin vise. Right heart catheterization was repeated after the release. In all patients, chest radiography and echocardiography were performed 24 to 48 hours after the procedure. Of the 47 patients, 20 completed a 1 to 13-month follow-up.

Results: According to the classification adopted by Krichenko et al, 45 patients had PDA of type A (conical with an ampulla of sufficient length), 1 of type B (conical with a very short ductal ampulla), and 1 of type E (long conical with the narrowest point remote from the trachea). The mean PDA diameter at its narrowest segment was 4.6±1.7 mm (ranged from 2.0 to 8.0 mm). The mean pulmonary/systemic blood flow ratio was 2.3 (ranged from 1.1 to 7.9). Twenty-two patients had pulmonary hypertension. The device was successfully placed in the PDA in all patients. Angiography showed that 31 patients (66.0%) had complete immediate closure, 13 (27.6%) had a trace shunt (foaming through the device with no contrast jet), and 3 (6.4%) had a small shunt (with a contrast jet). The fluoroscopy time was 13.6 minutes (ranged from 6 to 65 minutes). Color Doppler revealed complete closure in 45 patients (95.7%). A trace residual shunt in 2, one of them had complete elimination of the residual shunt flow 2 months after the procedure; the other one developed symptomatic hemolysis 17 hours after the procedure and surgical closure of the ductus arteriosus was subsequently performed. No other complications were found.

Conclusion: Transcatheter closure is a safe and effective interventional procedure in the treatment of PDA with a minimum diameter up to 8 mm using Amplatzer duct occluder. To avoid the complication of hemolysis, we should achieve complete or nearly complete closure of the ductus and reduce any residual shunt.

Key wordsPatent ductus arteriosus; Transcatheter closure

动脉导管未闭(PDA)是常见的先天性心脏病之一，30年来已有多种介入治疗法先后应用于临床。我院自1998年5月在我国率先引进Amplatzer封堵器治疗PDA，至1999年6月共完成47例，现报道如下。

1材料和方法

临床资料：全组共47例，女37例，男10例；年龄0.9～48岁，平均15.8±13.4岁；体重6.5～82.0 kg,平均37.3±21.2 kg。3例为PDA结扎术后再通。全部病例均经临床、心电图、X线胸片及超声心动图检查证实为PDA。

封堵器及输送器：Amplatzer封堵器由美国AGA公司生产，由具有自膨胀性的固定盘及与之相连接的“腰部”组成，呈蘑菇状，固定盘及“腰部”均系镍钛记忆合金丝编织而成，内充三层高分子聚酯材料，封堵器长7 mm,“腰部”的直径主动脉侧分别为6、8、10、12及14 mm,肺动脉侧分别为4、6、8、10及12 mm 5种型号。输送器由传送导丝和外鞘组成，传送导丝顶端有螺旋纹，末端附带一旋转柄，鞘管外径为6F。

介入治疗：局麻或全麻下行常规右心导管检查，然后经右股动脉送入5F猪尾导管行主动脉弓降部侧位造影并录象，以确定PDA的位置、形态及大小。将输送导管自主肺动脉侧经PDA送入降主动脉。选择比所测PDA最窄直径＞2～4 mm的Amplatzer封堵器，将其安装于传送导丝的顶端，透视下经输送鞘管将封堵器送至降主动脉。待封堵器的固定盘完全张开后，再将输送鞘管及传送导丝一齐回撤至PDA的的主动脉一侧，使“腰部”完全卡于PDA内。10分钟后重复主动脉弓降部造影，若证实封堵器形状、位置满意，无或仅有微～少量残余分流时，可操纵旋转柄将封堵器释放，行升主动脉→降主动脉和左肺动脉→主肺动脉连续测压及重复常规右心导管检查后撤出导管，压迫止血。术中静脉注射肝素(0.5～1 mg/kg)。术后24～48小时，1～13个月行超声心动图及X线胸片检查，观察残余分流情况、有无再通及封堵器位置等。

2结果

主动脉弓降部造影显示PDA属Krichenko^［1］A型45例，B型及E型各1例。PDA最窄处直径平均为4.6±1.7 mm(2～8 mm)。肺循环血流量/体循环血流量(QP/QS)平均为2.3(1.0～7.7)。肺动脉高压22例，其中轻度增高14例，中度增高5例，重度增高3例。全组47例封堵器均放置成功。14例轻度及4例中度肺动脉高压患者术后均降至正常，1例中度及2例重度肺动脉高压者均降为轻度，另1例重度肺动脉高压者降至中度。造影示无残余分流31例(66.0%),微量残余分流13例(27.6%),少量残余分流3例(6.4%)。术后所有病例行升主动脉→降主动脉及左肺动脉→主肺动脉连续测压，均无收缩压差。听诊胸骨左缘第2～3肋间双期连续性杂音全部消失，其中3例仅闻及轻度收缩期杂音。4例术后即刻主动脉压较术前有不同程度的增高，最高1例达165/110 mmHg(1 mmHg=0.133 kPa),但24小时内均降至正常。透视时间平均13.6分(6～65分)。术后24～48小时彩色多普勒超声心动图示动脉水平左向右分流完全消失者45例(95.7%),微量残余分流者2例(4.3%)。其中1例随访2个月后残余分流消失，另1例于封<