超声引导PDA封堵治疗.ppt

改良动脉导管未闭导管封堵法改良动脉导管未闭导管封堵法 Transcatheter closing PDA guided by transthoracic echocardiography:Feasibility and safety福建医科大学附属协和医院心内科福建医科大学附属协和医院心内科福建省冠心病研究所福建省冠心病研究所陈良龙陈良龙Fighting CVD背景背景/Background/Background l传统的导管封堵治疗传统的导管封堵治疗PDAPDA法通常需穿刺股动、静脉，以建立法通常需穿刺股动、静脉，以建立输送轨道；并做降主动脉造影，以确定输送轨道；并做降主动脉造影，以确定PDAPDA形态、大小及选形态、大小及选择合适的封堵器。择合适的封堵器。lConventionally,trans-catheter closing PDA usually needs puncturing both the femoral artery and the femoral vein to create an occluder delivering track,and performing aorta-angiography to determine the morphology and size of PDA in order to select a proper occluder.局限性局限性/Limitations/Limitations l通常，穿刺股动脉及股静脉并不困难；但是婴幼儿或体重通常，穿刺股动脉及股静脉并不困难；但是婴幼儿或体重低于低于4KG4KG者，穿刺股动脉或者，穿刺股动脉或/和股静脉可能会有困难；对于和股静脉可能会有困难；对于直径小的股动脉进行穿刺及插管操作可能造成血管损伤及直径小的股动脉进行穿刺及插管操作可能造成血管损伤及相关并发症。相关并发症。lNormally,puncturing the femoral vessels is easy,but it may be difficult if the patients are infants or their weight is 4 Kg;moreover,puncturing and operation manipulating may damage the femoral artery or introduce complications.局限性局限性/Limitations/Limitations l主动脉造影时需要注射造影剂，造影剂剂量较大时具有肾主动脉造影时需要注射造影剂，造影剂剂量较大时具有肾毒性；同时，毒性；同时，X X线造影时患者需要接受较高剂量的线造影时患者需要接受较高剂量的X X线辐射。线辐射。这对患者尤其是儿童是十分不利的。这对患者尤其是儿童是十分不利的。lOpacification medium injected for aorta-angiography has renal toxicity if used at high dosages;meanwhile,patients have to receive extra X-Ray radiation during aorta-angiography.These may be harmful for patients especially for children.替代方法替代方法/Alternative/Alternativel鉴此，传统的导管鉴此，传统的导管PDAPDA封堵术是否有改良或替代方法？封堵术是否有改良或替代方法？不必穿刺股动脉不必穿刺股动脉不需做不需做X X线主动脉造影线主动脉造影仅穿刺股静脉仅穿刺股静脉lIn view of the facts，are there any modified techniques for substitution traditional methods for closing PDA?No femoral artery punctureNo aorta-angiographyOnly femoral vein punctureA case demo病例介绍病例介绍Fighting CVD技术操作技术操作-PDA-PDA测量、轨道建立测量、轨道建立 技术操作技术操作-封堵器定位、残余分流观察封堵器定位、残余分流观察技术操作技术操作-封堵器主、肺动脉无占位封堵器主、肺动脉无占位技术操作技术操作-封堵器主动脉占位？封堵器主动脉占位？技术操作技术操作-封堵器释放后封堵器释放后Initiate experience初步经验初步经验Fighting CVD临床资料临床资料/Patients data/Patients datalPDAPDA患儿患儿2727例，男例，男1212例，女例，女1515例，年龄例，年龄4.64.62.92.9岁（岁（1 1 8 8）岁，体重岁，体重13.113.15.4Kg5.4Kg（3.73.7 23.5Kg23.5Kg）。其中，）。其中，2 2岁以下婴岁以下婴幼儿幼儿6 6例，体重例，体重8.28.23.1Kg3.1Kg（3.73.7 13.8Kg13.8Kg）。）。lTwenty-seven pts with PDA(12 males and 15 females,aged at 4.6 2.9 years,weighted at 13.1 5.4 Kg)were included in the study,among whom 6 pts are infants with weight of 8.23.1Kg(3.7 13.8Kg).临床资料临床资料/Patients data/Patients datal二维超声心动图封堵前测量二维超声心动图封堵前测量PDAPDA最窄处直径为最窄处直径为5.95.91.5mm 1.5mm(3.2(3.2 7.8mm)7.8mm)，PDAPDA长度长度9.79.73.6mm(6.73.6mm(6.7 13.2mm)13.2mm)。PDAPDA具具有较典型的漏斗部、且彩色多普勒血流显像提示有较典型的漏斗部、且彩色多普勒血流显像提示PDAPDA分流分流方向指向肺动脉外侧壁或中部。方向指向肺动脉外侧壁或中部。l lPreoperatively,the narrowest PDA diameter wasPreoperatively,the narrowest PDA diameter was 5.91.5mm with the PDA length of 9.73.6mm measured by 2DE,andmeasured by 2DE,and CDFI revealed the typical PDA shunting in all patients.方法方法/Methods/Methodsl仅穿刺股静脉、不穿刺股动脉，在仅穿刺股静脉、不穿刺股动脉，在X X线透视下建立输送轨道；线透视下建立输送轨道；按术前超声测量的按术前超声测量的PDAPDA最窄处直径的最窄处直径的2 2倍选择倍选择AmplatzerAmplatzer封堵封堵器，并根据术中器，并根据术中CDFICDFI实时监测结果进行适当调整。实时监测结果进行适当调整。lWe only punctured the femoral vein as an approach for building up an occluder delivering track under fluoroscopy;the Amplatzer occluder was selected based on the narrowest diameter of PDA determined by 2DE and adjusted by real-time CDFI monitoring when the delivering catheter was crossing PDA.方法方法/Methods/Methodsl封堵器离到位后若封堵器离到位后若X X线透视下有明显的线透视下有明显的“堆形腰堆形腰”、2DE2DE显示显示封堵器呈封堵器呈“工字形工字形”且主、肺动脉侧均无占位，即开始应用且主、肺动脉侧均无占位，即开始应用CDFICDFI连续监测分流阻断情况；通常封堵到位后即刻至连续监测分流阻断情况；通常封堵到位后即刻至3030分钟分钟内，内，CDFICDFI显示显示PDAPDA分流逐步至完全消失，此时可释放封堵器。分流逐步至完全消失，此时可释放封堵器。lAfter well positioning the occluder,if X-ray showed it a tapered waist,2DE&CDFI revealed it an I I-shaped appearance without any occupation of aorta or pulmonary artery,CDFI was used for continously monitoring the shunting alterations.If shunting disappeared gradually in 30 Min,the occluder could be safely released.方法方法/Methods/Methodsl在下列情况下，需要更换封堵器：在下列情况下，需要更换封堵器：1 1、封堵器到位后、封堵器到位后X X线透线透视下无明显的视下无明显的“堆形腰堆形腰”，或封堵器严重变形，或轻度推，或封堵器严重变形，或轻度推拉即发生封堵器移位；拉即发生封堵器移位；2 2、彩色多普勒血流显像显示封堵器、彩色多普勒血流显像显示封堵器边缘性分流宽度边缘性分流宽度 2mm2mm、持续时间、持续时间 30Min30Min。lIn case of the following situations，the occluder should be replaced：if no tapered waist or severe deformed was found；and if the marginal shunting was 2 mm and/or lasting 30min。结果结果/Results/Results l本方法对本方法对2727例例PDAPDA患儿封堵治疗的技术成功率患儿封堵治疗的技术成功率100%100%，无，无围手围手围手围手术期严重并发症。超声引导术期严重并发症。超声引导术期严重并发症。超声引导术期严重并发症。超声引导PDAPDAPDAPDA封堵治疗在封堵器选择、定封堵治疗在封堵器选择、定封堵治疗在封堵器选择、定封堵治疗在封堵器选择、定位、分流监测方面准确可行，安全可靠。位、分流监测方面准确可行，安全可靠。位、分流监测方面准确可行，安全可靠。位、分流监测方面准确可行，安全可靠。lThe technical success rate for closing PDA by the new method was 100%in 27 patients without any peri-and post-procedural complications.And echocardiography guiding for device selecting and positioning,and shunt monitoring is accurate,feasible and safe.结果结果/Results/Results l l在封堵尝试中，首次封堵器选择太小而需要更换较大封堵在封堵尝试中，首次封堵器选择太小而需要更换较大封堵在封堵尝试中，首次封堵器选择太小而需要更换较大封堵在封堵尝试中，首次封堵器选择太小而需要更换较大封堵器者器者器者器者4 4 4 4例次（例次（例次（例次（14.8%14.8%14.8%14.8%），首次封堵器选择太大而需要更换较），首次封堵器选择太大而需要更换较），首次封堵器选择太大而需要更换较），首次封堵器选择太大而需要更换较小封堵器者小封堵器者小封堵器者小封堵器者2 2 2 2例次（例次（例次（例次（7.4%7.4%7.4%7.4%）。）。）。）。lBased on echocardiographic criteria,requirement of device replacing due to incorrect or improper selection was 22.2%,with 14.8%of selection of too smaller an occluder and 7.4%of selection of too bigger an occluder.讨论讨论/Discussion/Discussionl超声心动图可替代超声心动图可替代X X线造影线造影:lPDAPDA大小测量及封堵器选择大小测量及封堵器选择l封堵器定位、形态判断封堵器定位、形态判断l残余分流监测、封堵器更换残余分流监测、封堵器更换l主动脉、肺动脉占位主动脉、肺动脉占位lEchocardiography substitution for angiography:Echocardiography substitution for angiography:lMeasuring PDA diameter and selecting an Measuring PDA diameter and selecting an occluderoccluderlPositioning the Positioning the occluderoccluder and viewing its shape and viewing its shapelMonitoring residual shunting,determining replacement of Monitoring residual shunting,determining replacement of an an occluderoccluderlInterrogating Interrogating occluderoccluder occupation in aorta and pulmonary occupation in aorta and pulmonary arteryartery结论结论/Conclusion/Conclusionl超声心动图引导、无超声心动图引导、无X X线造影的经股静脉线造影的经股静脉PDAPDA导管封堵术是安全可行的；导管封堵术是安全可行的；l因无需因无需X X线造影，无造影剂毒副作用、线造影，无造影剂毒副作用、X X线辐射减少；线辐射减少；l无需穿刺股动脉，适合在低体重或无需穿刺股动脉，适合在低体重或/和婴幼儿中应用，可最大程度减轻和婴幼儿中应用，可最大程度减轻手术损伤。手术损伤。lEchocardiography guiding for PDA closing is feasible and safe lThe advantages of the new method includes lowest X-ray radiation,no requirement of angiography,no opacification agent toxicity,and no femoral artery puncture.lThanks for your attention Thanks for your attention Fighting CVD