膜部室间隔缺损封堵术后完全性左束支传导阻滞治疗效果分析

摘要 ： 目的 探讨儿童膜部室间隔缺损（VSD）封堵术后完全性左束支传导阻滞（CLBBB）的治疗及预后。方法 回 顾分析 2009 年 2 月至 2019 年 6 月就诊的 18 例 VSD 封堵术后 CLBBB 患儿的临床资料。结果 18 例接受 VSD 封堵术并经心 电图检测确诊 CLBBB 患儿的平均年龄为 5 . 69 ± 2 . 33 岁（3 岁 2 个月 ~ 10 岁 5 个月），男性 11 例、女性 7 例，随访时间中位数 5 年（3 个月 ~ 10 年）。14 例无心力衰竭患儿中 4 例经糖皮质激素治疗 CLBBB 即恢复，随访 3 ~ 6 个月各项指标均无异常 ；8 例 随访 5 ~ 10 年，无不适，心电图无变化，心功能、左室射血分数、心房利钠肽均无异常，但左室舒张末期内径（LVDD）增大 ；2 例接受封堵器取出及 VSD 修补术，1 例术后出现完全性右束支传导阻滞，余无异常，另 1 例术后出现完全性房室传导阻滞， 植入起搏器，随访 1 年 QRS 波时限较术前缩短，心功能无异常，LVDD 增大。4 例合并心力衰竭患儿中 3 例行心脏再同步化 治疗（CRT）植入术，1 例行左室起搏，术后 QRS 波均 < 150 ms ；1 例行 CRT 术后 3 天因急性心力衰竭死亡，另 3 例随访 1 ~ 2 年 心功能明显改善。结论 对于 VSD 封堵术后早期出现 CLBBB 患儿，糖皮质激素可能有效，若无效，可选择手术取出封堵器， 但有发生完全性房室传导阻滞的风险。若合并心力衰竭，CRT 或左室起搏治疗可能有一定效果。
Abstract: Objectives To investigate different treatments and prognosis on complete left bundle branch block (CLBBB) in children after closure of perimembranous ventricular septal defect (VSD). Method Eighteen cases with CLBBB after perimembranous VSD intervention diagnosed from February 2009 to June 2019 were enrolled in this study. The patients were divided into 4 groups according to different treatments such as close follow-up, glucocorticoid treatment, removing closure device and CRT treatment. The follow-up results including clinical signs and symptoms, chest radiography, electrocardiogram (ECG), echocardiography (ECHO) and type B natriuretic peptide (BNP) were analyzed. Results A total of 8 patients accept close follow-up for 5 to 10 years without any symptoms or signs, showed normal cardiac function (NYHA I) and normal left ventricular ejection fraction (LVEF) by ECHO. The left ventricular end-diastolic diameter (LVDD) were larger according to references. There were 4 cases suffered CLBBB on 1 to 4 days after intervention. They recovered after accepting glucocorticoid treatment for 1 week. The ECG, ECHO and BNP tests were normal after 6 month. There were 2 cases admitted to remove the closure device and accepted surgical repair. The first case accepted surgery after 6 months of intervention. The ECG after postoperative 1 week showed complete right bundle branch block until now. The other observation target including ECHO and BNP were normal after one-year follow-up. Another case accepted surgery 7 years after intervention, but complete atrioventricular block occurred after surgery and not recovered 1 week later. The patient accepted double chamber pacemaker implantation and showed normal cardiac function excepting the enlarged LVDD after 1 year follow up. There were 4 cases with heart failure accepted standard medicine therapy for at least six months and had no obvious improvement. Three (3) of them accepted CRT implantation, another case accepted permanent pacemaker implantation (left atrial sensing, left ventricular pacing) for personal reasons. The QRS wave was shorter than 150 millisecond after surgery. One (1) patient accepted CRT implantation died after 3 days because of acute heart
临床儿科杂志 第 38 卷第 2 期 2020 年 2 月 J Clin Pediatr Vol.38 No.2 Feb. 2020
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doi:10.3969/j.issn.1000-左束支传导阻滞治疗效果分析
陈轶维 赵文婥 王顺民 杜欣为 吉 炜 朱荻绮 陈丽君 张志芳 李 奋 上海交通大学医学院附属上海儿童医学中心心脏中心（上海 200127）
关键词 ： 室间隔缺损介入术 ； 完全性左束支传导阻滞 ； 心功能不全 ； 心脏再同步化治疗
Long-term follow-up of different treatment on complete left bundle branch block after closure of perimembranous ventricular septal defect in children CHEN Yiwei, ZHAO Wenchuo, WANG Shunmin, DU Xinwei, JI Wei, ZHU Diqi, CHEN Lijun, ZHANG Zhifang, LI Fen (Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China)