The incidence of congenital heart disease is high in Qinghai area, and congenital heart disease (CHD): Patent ductus arteriosus PDA is one of the common congenital heart diseases. We used the domestic memory alloy PDA blocking umbrella to block the giant PDA (the narrowest part of PDA is greater than or equal to 10mm) in 105 patients, and achieved good treatment results, and the clinical experience is summarized as follows. Pang Yunfeng, Department of Cardiac Surgery, Qinghai Cardiovascular Disease Specialist Hospital
1 Object and method
1.1 Subjects
In this group, 105 patients, 37 males and 68 females, aged 9-57 years old, weighing 25Kg-75Kg, were clearly diagnosed by clinical, ECG, X-ray and echocardiography, and all were diagnosed as giant arteriovenous ductus arteriosus with a diameter of 13mm-22mm. 82 cases of continuous mechanical murmur, 23 cases of grade II-III systolic murmur, and the second pulmonary artery sound could be heard between the 2 ribs at the left edge of the sternum on examination. The second pulmonary artery sound was hyperactive, and systolic tremor was palpable in 90 cases. Echocardiographic examination: left ventricular end-diastolic anteroposterior diameter (LVEDD): 58±5.6 mm on average; right ventricular end-diastolic anteroposterior diameter: 28±3.2 mm on average before surgery; mean pulmonary artery pressure (MPAP): 63.5±3.9 mmHg, including 58 cases with combined moderate pulmonary hypertension and 47 cases with combined severe pulmonary hypertension; QP/QS: <1.3 in 87 cases. 87 cases, QP/QS: >1.3 in 18 cases, arterial oxygen saturation: 89%-93% in 55 cases: 94%-96% in 50 cases, and cardiothoracic ratio: C/T>0.6 in 35 cases.
1.2 Operation method
Under local anesthesia or intravenous basic anesthesia, the femoral artery and femoral vein were punctured, heparin was given intravenously at 100 U/Kg, and a pigtail catheter was fed through the femoral artery, and contrast was injected for digital subtraction. mmHg, the guidewire channel of femoral vein-right atrium-right ventricle-pulmonary artery-PDA-descending aorta was established, and a domestic blocking umbrella with a diameter greater than 5-7 mm at the narrowest part of the PDA was selected and fed to the descending aorta according to the conventional method. Release the blocking umbrella to the descending aorta, release the anterior disc of the blocking umbrella, pull back to make it close to the aortic side of the PDA, perform blocking test, observe the changes of pulmonary artery pressure, aortic pressure, oxygen saturation and heart rate, if the blocking is satisfactory, perform descending aortography again after 30 minutes, there is no or only a small amount of residual shunt, release the blocking umbrella and repeat right heart catheterization, the mean pulmonary artery pressure decreases by more than 20%, postoperative use of sodium nitroprusside to control Systolic pressure was ≤120 mmHg.
2 Results
All 105 cases were successfully inserted with no postoperative complications. Postoperative angiography showed that the PDA was completely blocked, and 7 cases had a small amount of residual shunt. The mean pulmonary artery pressure, anteroposterior left ventricular end-diastolic diameter, anteroposterior right ventricular end-diastolic diameter, and oxygen saturation were measured by echocardiography at 1 week postoperatively, and the comparison of the results before and after blocking is shown in Table 1. The postoperative echocardiography showed that 98 patients had no shunt, 7 patients had a small residual shunt, and 82 patients had a decrease in pulmonary artery systolic pressure below 50 mmHg.
3 Discussion
Qinghai is located in the eastern part of the Qinghai-Tibet Plateau, with an altitude of 2226-4200m (average 3500m). Due to the unfavorable factors such as hypoxia, cold and dryness, the incidence of congenital heart disease is high, and the incidence of patent ductus arteriosus (PDA) is as high as 7%. Due to poor medical and economic conditions, many patients with PDA do not come to the clinic until they have severe symptoms in adulthood, when they are often combined with moderate or severe pulmonary hypertension, which leads to increased brittleness and aneurysmal dilatation of the duct wall, significantly increasing the risk of surgery. At present, interventional blocking of PDA is the treatment of choice. Conventional surgery produces inflammatory mediators due to extracorporeal circulation, which can lead to higher pulmonary artery pressure, lower body circulation pressure, increased myocardial oxygen consumption, lower cardiac output, and severe pulmonary hypertension crisis. Interventional occlusion of PDA avoids the complications of extracorporeal circulation. In this group of cases, the postoperative pulmonary artery pressure decreased significantly and the postoperative recovery was good.
Severe pulmonary hypertension with right-to-left shunt is an absolute contraindication to interventional blocking of PDA, and the interventional treatment of PDA with severe pulmonary hypertension is still controversial. The degree of pulmonary artery disease caused by aortic shunts cannot be accurately determined from clinical and catheter data alone, and interventional occlusion should be performed with caution in this group of patients. If the pulmonary artery pressure drops by more than 30 mmHg after experimental occlusion and there is no systemic reaction, the occluder can be released and permanent occlusion can be performed. Intraoperative PDA blocking test is an effective method. If the pulmonary artery pressure decreases by 20% or pulmonary artery pressure decreases by more than 30 mmHg, and the aortic pressure and arterial oxygen saturation do not decrease significantly, the aortic pressure exceeds the pulmonary artery pressure, and the patient has no discomfort reaction, it is suggested to be dynamic pulmonary hypertension. ideal indication for occlusion. A more obvious decrease in aortic pressure and arterial oxygen saturation, unsatisfactory decrease or no change in pulmonary artery systolic pressure, suggesting pulmonary artery lesions as resistance changes, poor prognosis, should give up blocking; when huge type PDA blocking, large blocker placement needs to be carefully operated, advocating the release of the anterior umbrella and part of the waist in the relatively thick part of the descending aorta near the PDA, which can make the blocker anterior disc fully expanded, when retracting the system The blocker is more likely to fit tightly with the edge of the PDA and can avoid damage to the descending aorta during retraction of the huge anterior disc. It is best to place the large blocker once successfully, not easy to place it repeatedly, and to prevent arterial entrapment when the blocker must be retracted. Postoperative oral cardiotonic, pulmonary artery pressure lowering, diuretic and other drugs for 3 to 6 months, and close postoperative follow-up.
Therefore, only by strictly mastering the indications, fully assessing the degree of pulmonary hypertension, precise interventional operation and strengthening postoperative treatment can we ensure the medium and long-term efficacy and benefit more patients.