Echo-guided Minimally Invasive Device Closure Of Ventricular Septal Defects Via Right Infra-axillary Approach

Background:Ventricular septal defect is common congenital heart disease,whose therapy includes open heart repair and percutaneous intervention closure.Though open heart surgery repair has merits of better exposure of operation field and wider indications,it need median sternotomy with great trauma and more bleedings,which delay recovery time and need cardiopulmonary bypass and transfusion,and postoperative sternum deformatoin and incison scar lead to psychogical barriar,resulting worse long-life prognosis.Percutaneous intervention closure avoid surgical trauma and cardiopulmonary bypass,but this technique is often performed under radiation,which do harm to both performers and patients,and charactered as narrower indition,limitation to age,more complications,longer circuit,harder manipulation,expensive DSA device.Therefore,its necessary to explore a new techinque to overcome the drawbacks of above two treatments,to manipulate and spread easily.For what’s described above,we started to explore make small incision on infra-axillary,and perform the minimally invasive device closure of ventricular septal defect under guidance of TEE.This research is going to apply minimally invasive device closure to patients who meet the inclusions,to appraise its clinical feasibility.Besides,the results is compared with that of open heart surgery during same period,to evalate its safety and efficiency.The research was divided into two sections,as followings:Section I Exploration and method of Minimally Invasive Device Closure via Right Infra-axillary ApproachObjective:To investigate the feasibility and safety of minimally invasive device closure via right infra-axillary approach.Methods:From January 2014 to December 2017,428 patients,diagnosed as ventricular septal defect at out-patient,were enrolled in this study.Under TEE guidance,the minimal incision is made along mid-axillary line between third and fifth intercosta,and part pericardium is opened and suspended to expose RA,and purse-string is sew on RA.The guiding bar is advanced into RA,subsquently crossing TV,RV,VSD,LV to build delivery pathway.The device is opened and released after TEE show no influence on surrounding tissue and stability.The evaluation difference between supine and lateral position,successful rate,postoperative complications are recorded,the follow-up is administrated at discharge,3month,6month,1year,2year,3year,4year after discharge by ECG and TTE.Results:There is no significant difference between supine and lateral position.The immediate successful rate was 98.6%,6 cases failed and converted open heart surgery.3 remained trivial residual shunt,and 20 trivial TR were detected and 15 preoperative moderate to severe TR were reduced to trivial TR after operation.IRBBB happened in 23,and there no complete AVB.2 cases were diagnosed as pleural effussion.During follow-up of 6month to 4year,2 residual shunts disappeared,20 new TR and 23 IRBBB reduced,and no other major complications happened.Occlusion:Minimally invasive device closure via right infra-axillary approach performs easily and safely,with cosmetic incision,high success rate and no evident complications.Section II Clinical results comparison between Minimally Invasive Device Closure via Right Infra-axillary Approach and open heart surgeryObjective:To investigate the theraputic advantages of minimally invasive device closure via right infra-axillary approach by comparing its clinical results with that of open heart surgery.Methods:A total of 801 patients were enrolled in this study.The study group was givenminimally invasive device closure with sub-axillary longitude mini-incision and the control group was underwent open-heart surgical repair with cardiopulmonary bypass.The operation time,postoperative auxiliary time,postoperative 24-h drainage flow and postoperative hospital stay and follow-up were used to evaluate the effect of two different intervention methods.Results:Compared with the control group,the operative time(58.0± 12.1 min),postoperative auxiliary ventilation time(2.5±1.2 h),postoperative 24-h drainage flow(0)and postoperative hospital time(4.0±1.2d)were shorter significantly in study group than that in control group[(91.3±21.1min)、(5.4±2.3 h)、(67.5±12.2 ml)、(7.0±1.5 d)].During follow-up,the occurrence of residual shunting and new valve insufficiency was not significantly difference,however,abnormal EKG results happened more frequently in study group than that in control group.Conclusion:Compared with open heart surgery,minimally invasive device closure has a same success rate,and advantages of short operation time,rapid postoperative revovery,less complications,which could be regarded as a efficient alternative treatment to open heart surgery.