经导管标记房室传导参数与室间隔缺损封堵术后传导阻滞关系的研究
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摘要
研究背景和目的：过去二十年间,室间隔缺损(VSD)经皮微创介入封堵治疗取得巨大进步,同时也一直存在着争议。早期阶段研发的封堵器系统的设计缺陷直接导致介入手术的低成功率以及较高的并发症发生率,在对膜周部室间隔缺损(pm-VSD)的封堵治疗中,封堵术后并发症房室传导阻滞尤其受到关注。
随着国产封堵器的研发,介入治疗膜周部室间隔缺损的手术成功率明显提高,并且主要并发症明显下降,但房室传导阻滞(AVB)仍然受到极大关注。早期研究学者多从流行病学、解剖学、力学等方面对心脏传导阻滞发生机制提出诸多假设,却鲜有从侵入性心脏电生理角度探索室间隔缺损介入封堵前后房室传导功能改变及与心脏阻滞发生关系的研究。
本研究纳入符合先心病室间隔缺损介入治疗指针患者,在介入封堵手术前及术后即刻行腔内希氏束(His)电图标测,研究室间隔缺损介入封堵前后房室传导参数改变,并结合体表心电图(ECG)深入探讨VSD介入封堵术与房室传导功能改变的关系。
研究对象与方法：(1)病例收集：纳入膜周部室间隔缺损患者32例,患者平均年龄10.9±11.2岁,术前所有患者心电图均为窦性心律,无明显心脏传导阻滞心电图表现。
(2)封堵器及传送系统：所有患者均接受国产封堵器治疗,输送系统由输送鞘、扩张管、推送导管、推送螺杆及装载器组成。
(3)封堵方法：①建立血管通路；②行左右心导管检查测定各房室、腔压力；③随后行左室及升主动脉造影明确缺损室间隔位置、大小及主动脉瓣功能；④建立经VSD的股动、静脉的导丝轨道；⑤沿轨道经股静脉放置输送鞘,经输送鞘将室间隔缺损封堵器送至缺损室间隔处打开,经超声及造影观察后释放封堵器。
(4)电生理检查：①侵入性电生理检查：分别于左右心导管检查术开始前及封堵伞释放后即刻两次标记腔内His电图,测量A-H、H-V、A-V间期；观察VSD封堵术前后希氏束各参数值改变,判断术中及术后可能发生AVB的机会及预防发生AVB可能性。；②体表心电图描记：分别记录术前及术后5-7日心电图测量PR间期,观察QRS波形态。
(5)随访：患者于出院后1月、3月、6月及1年复查心电图及经胸心脏超声(TTE),观察心脏传导阻滞发生或改变、封堵器位置形态、瓣膜结构及功能、残余分流等。结果：(1)本研究共30例患者完成手术前后腔内His电图标测,无电极导管操作相关严重并发症；
(2)30例患者在封堵器释放后AV间期、AH间期、HV间期均值均有不同程度延长,但差异无统计学意义(P值>0.1)；
(3)术后AV、HV间期较基础测量值延长(≥15%)患者15例,其中6体表心电图有房室或室内传导阻滞改变；传导参数未延长15例患者中仅2例发生心脏传导阻滞,但差异无统计学意义(P=0.215)；
(4)≤10岁年龄组术后AV间期均值较术前延长(130.9±28.4ms：119.3±15.8ms),差异有统计学意义(P=0.048)。在年龄>10岁组手术前后AH、HV、AV间期均无明显改变(P>0.1);
(5)室间隔膜部瘤、VSD直径、封堵器直径/VSD直径与术后传导阻滞关系无显著相关(P>0.1)。
结论：(1)室间隔缺损介入封堵手术前行腔内His电图标测,可提早发现VSD房室传导功能异常,对VSD介入封堵术后发生AVB的潜在可能性有预测价值。
(2)VSD介入封堵手术前后传导参数的改变,可预测术后房室传导阻滞发生,并指导VSD介入治疗手术、预防房室传导阻滞发生。
(3)VSD介入试封堵时,行His标测可选择封堵术释放与否。
Background and Objective:Progress have been made significantly since the fist device closure of ventricular septal defect(VSD), and controversies surrounding such techniques persist. The early types of devices developed for VSD closure were associated with low success rates and high morbidity, and the fact that the devices were not specifically designed for peri-membranous(pm-VSD) contributes to conduction disturbance and atrioventricular(AV) block, which represents a main concern.
By the development of domestic-made VSD-occluder, the success rate and complications related to this procedure are acceptable. Complete AV block, however, remains a preoccupying concern. Mechanisms underlying this complication are still unclear, and hypothesis have been proposed in several ways except invasive electrophysiology.
This study focus on patients who underwent attempted transcathter closure of pm-VSD within the indication guided by Chinese Academy of Cardiovascular Sciences. Invasive parameters of His electrocardiogram were recorded prior to and following VSD closure during the procedure in each patient, to explore how transcathter closure techniques affect AV conductions and its relationship with AV block after the procedure.
Material and Methods:(1) Patients population:32patients had an attempted transcathter pm-VSD closure in one insitituion. Mean age was10.9±11.2years (range3.0-52years). All patients are with normal sinus rhythm in surface ECG recording and had no significant AV block.
(2) VSD-occluder and Adnexa: All patients accept domestic VSD-occluder. Adnexa package include transport sheathe, dilator, transport cable and loading sheathe.
(3) Pocedure:All patients underwent right and left cardiac catheterization and angiography under X-ray guidance. The technique for pm-VSD closuring has been previously reported:①Vessel access was create fist;②then arteriovenous guide wire track through VSD was build;③placing transport sheathe;④pushing VSD-occluder through transport sheathe to VSD and open the two discs;⑤release the occluder when a proper position was proved by transthoracic echocardiography and angiography.
(4) Electrophysiological study (EPS):①Invasive EPS recording:Invasive His bundle electrograph recording was performed prior to cardiac catheterization and following the release of VSD-occluder during the procedure, and AH, HV, AV intervals were measured. Possibility of the occurrence AVB was estimated during the procedure based on changing of the basic His intervals.②Surface ECG monitoring: recording patients surface ECG before and5to7days after the procedure, and PR intervals, configuration of QRS complex were recorded.
(5) Follow-ups:Patients underwent ECG monitoring and TTE at1,3,6, and12month after discharge and yearly thereafter. Adverse events were ascertained at each assessment on the basis of clinical evaluation.
Result:(1) Invasive His bundle recording was performed in32patients, no severe complications related to electrode catheter manipulation.
(2)30out of32patients had a success release of VSD-occluder. No significant change for AH, HV or AV measurement was observed in those patients(P>0.1).
(3) EPS parameters with an increased measurement of15%or more were observed in15/30patients,6among them had AV or intraventricular block, and only2had AV or intraventricular block in the left15patients respectively.
(4) With respect to EPS changes, the only detectable risk factor was procedure age. More precisely, AV interval recored after the procedure prolonged significantly than basic recording in patient under10[(130.9±28.4)ms:(119.3±15.8)ms, p=0.048], while no significant change with AH, HV or AV measurement was observed in the other group.
(5) With respect to the occurrence of new onset conduction disturbances on surface ECG, there were no identifiable relationships with septal aneurysm(P>0.5), VSD diameters(P>0.5), device/VSD ratio(P>0.6).
Conclusion:(1) His mapping in transcathter closure of pm-VSD can detect AV conduction disturbance more precisely, and possesses important clinical value on prediction of potential possibility of AV block after the procedure.
(2) Transcathter closure of pm-VSD promotes relative changes in the electrophysiologic parameters of the AV conduction system. These changes had suggestive predictivity of new conduction abnormalities in or after the procedure of VSD closure, thus would be helpful to VSD treatment protocol.
(3) In attempting VSD closuring, His bundle mapping provide important clinical value on deciding release VSD-occluder or not during the procedure.
随着国产封堵器的研发,介入治疗膜周部室间隔缺损的手术成功率明显提高,并且主要并发症明显下降,但房室传导阻滞(AVB)仍然受到极大关注。早期研究学者多从流行病学、解剖学、力学等方面对心脏传导阻滞发生机制提出诸多假设,却鲜有从侵入性心脏电生理角度探索室间隔缺损介入封堵前后房室传导功能改变及与心脏阻滞发生关系的研究。
本研究纳入符合先心病室间隔缺损介入治疗指针患者,在介入封堵手术前及术后即刻行腔内希氏束(His)电图标测,研究室间隔缺损介入封堵前后房室传导参数改变,并结合体表心电图(ECG)深入探讨VSD介入封堵术与房室传导功能改变的关系。
研究对象与方法：(1)病例收集：纳入膜周部室间隔缺损患者32例,患者平均年龄10.9±11.2岁,术前所有患者心电图均为窦性心律,无明显心脏传导阻滞心电图表现。
(2)封堵器及传送系统：所有患者均接受国产封堵器治疗,输送系统由输送鞘、扩张管、推送导管、推送螺杆及装载器组成。
(3)封堵方法：①建立血管通路；②行左右心导管检查测定各房室、腔压力；③随后行左室及升主动脉造影明确缺损室间隔位置、大小及主动脉瓣功能；④建立经VSD的股动、静脉的导丝轨道；⑤沿轨道经股静脉放置输送鞘,经输送鞘将室间隔缺损封堵器送至缺损室间隔处打开,经超声及造影观察后释放封堵器。
(4)电生理检查：①侵入性电生理检查：分别于左右心导管检查术开始前及封堵伞释放后即刻两次标记腔内His电图,测量A-H、H-V、A-V间期；观察VSD封堵术前后希氏束各参数值改变,判断术中及术后可能发生AVB的机会及预防发生AVB可能性。；②体表心电图描记：分别记录术前及术后5-7日心电图测量PR间期,观察QRS波形态。
(5)随访：患者于出院后1月、3月、6月及1年复查心电图及经胸心脏超声(TTE),观察心脏传导阻滞发生或改变、封堵器位置形态、瓣膜结构及功能、残余分流等。结果：(1)本研究共30例患者完成手术前后腔内His电图标测,无电极导管操作相关严重并发症；
(2)30例患者在封堵器释放后AV间期、AH间期、HV间期均值均有不同程度延长,但差异无统计学意义(P值>0.1)；
(3)术后AV、HV间期较基础测量值延长(≥15%)患者15例,其中6体表心电图有房室或室内传导阻滞改变；传导参数未延长15例患者中仅2例发生心脏传导阻滞,但差异无统计学意义(P=0.215)；
(4)≤10岁年龄组术后AV间期均值较术前延长(130.9±28.4ms：119.3±15.8ms),差异有统计学意义(P=0.048)。在年龄>10岁组手术前后AH、HV、AV间期均无明显改变(P>0.1);
(5)室间隔膜部瘤、VSD直径、封堵器直径/VSD直径与术后传导阻滞关系无显著相关(P>0.1)。
结论：(1)室间隔缺损介入封堵手术前行腔内His电图标测,可提早发现VSD房室传导功能异常,对VSD介入封堵术后发生AVB的潜在可能性有预测价值。
(2)VSD介入封堵手术前后传导参数的改变,可预测术后房室传导阻滞发生,并指导VSD介入治疗手术、预防房室传导阻滞发生。
(3)VSD介入试封堵时,行His标测可选择封堵术释放与否。
Background and Objective:Progress have been made significantly since the fist device closure of ventricular septal defect(VSD), and controversies surrounding such techniques persist. The early types of devices developed for VSD closure were associated with low success rates and high morbidity, and the fact that the devices were not specifically designed for peri-membranous(pm-VSD) contributes to conduction disturbance and atrioventricular(AV) block, which represents a main concern.
By the development of domestic-made VSD-occluder, the success rate and complications related to this procedure are acceptable. Complete AV block, however, remains a preoccupying concern. Mechanisms underlying this complication are still unclear, and hypothesis have been proposed in several ways except invasive electrophysiology.
This study focus on patients who underwent attempted transcathter closure of pm-VSD within the indication guided by Chinese Academy of Cardiovascular Sciences. Invasive parameters of His electrocardiogram were recorded prior to and following VSD closure during the procedure in each patient, to explore how transcathter closure techniques affect AV conductions and its relationship with AV block after the procedure.
Material and Methods:(1) Patients population:32patients had an attempted transcathter pm-VSD closure in one insitituion. Mean age was10.9±11.2years (range3.0-52years). All patients are with normal sinus rhythm in surface ECG recording and had no significant AV block.
(2) VSD-occluder and Adnexa: All patients accept domestic VSD-occluder. Adnexa package include transport sheathe, dilator, transport cable and loading sheathe.
(3) Pocedure:All patients underwent right and left cardiac catheterization and angiography under X-ray guidance. The technique for pm-VSD closuring has been previously reported:①Vessel access was create fist;②then arteriovenous guide wire track through VSD was build;③placing transport sheathe;④pushing VSD-occluder through transport sheathe to VSD and open the two discs;⑤release the occluder when a proper position was proved by transthoracic echocardiography and angiography.
(4) Electrophysiological study (EPS):①Invasive EPS recording:Invasive His bundle electrograph recording was performed prior to cardiac catheterization and following the release of VSD-occluder during the procedure, and AH, HV, AV intervals were measured. Possibility of the occurrence AVB was estimated during the procedure based on changing of the basic His intervals.②Surface ECG monitoring: recording patients surface ECG before and5to7days after the procedure, and PR intervals, configuration of QRS complex were recorded.
(5) Follow-ups:Patients underwent ECG monitoring and TTE at1,3,6, and12month after discharge and yearly thereafter. Adverse events were ascertained at each assessment on the basis of clinical evaluation.
Result:(1) Invasive His bundle recording was performed in32patients, no severe complications related to electrode catheter manipulation.
(2)30out of32patients had a success release of VSD-occluder. No significant change for AH, HV or AV measurement was observed in those patients(P>0.1).
(3) EPS parameters with an increased measurement of15%or more were observed in15/30patients,6among them had AV or intraventricular block, and only2had AV or intraventricular block in the left15patients respectively.
(4) With respect to EPS changes, the only detectable risk factor was procedure age. More precisely, AV interval recored after the procedure prolonged significantly than basic recording in patient under10[(130.9±28.4)ms:(119.3±15.8)ms, p=0.048], while no significant change with AH, HV or AV measurement was observed in the other group.
(5) With respect to the occurrence of new onset conduction disturbances on surface ECG, there were no identifiable relationships with septal aneurysm(P>0.5), VSD diameters(P>0.5), device/VSD ratio(P>0.6).
Conclusion:(1) His mapping in transcathter closure of pm-VSD can detect AV conduction disturbance more precisely, and possesses important clinical value on prediction of potential possibility of AV block after the procedure.
(2) Transcathter closure of pm-VSD promotes relative changes in the electrophysiologic parameters of the AV conduction system. These changes had suggestive predictivity of new conduction abnormalities in or after the procedure of VSD closure, thus would be helpful to VSD treatment protocol.
(3) In attempting VSD closuring, His bundle mapping provide important clinical value on deciding release VSD-occluder or not during the procedure.
引文
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[34]Tucker EM, Pyles LA, Bass JL, et al. Permanent pacemaker for atrioventricular conduction block after operative repair of perimembranous ventricular septal defect. Journal of the American College of Cardiology, 2007,50(12): 1196-1200.
[35]Batra AS, Wells WJ, Hinoki KW, et al. Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block associated with surgery for congenital heart disease. The Journal of Thoracic and Cardiovascular Surgery, 2003, 125(6): 1291-1293.
[36]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010, 139(6); 1409-1415.
[37]Michel - Behnke I, Ewert P, Koch A, et al. Device closure of ventricular septal defects by hybrid procedures: A multicenter retrospective study. Catheterization and cardiovascular interventions, 2011,77(2):242-251.
[38]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010,139(-6) 1409-1415.
[39]马淑英.传导系统不同部位的文氏现象.实用心电学杂志,2008,17(5)：396-398.
[40]王永权.双侧束支主干阻滞的心电图分析.临床心电学杂志,2007,16(5)：388-394.
[41]宋志远,李永华,柴红.室间隔缺损介入治疗围术期发生心脏传导阻滞患者的随访研究.中华心血管病杂志,2009,37(11)：990-993.
[42]Szkutnik M, Qureshi SA, Kusa J. et al. Use of the Amplatzer muscular ventricular septal defect occluder for closure of perimembranous ventricular septal defects. Heart, 2007, 93(3): 355.
[43]Wu H, Qin Y, Zhao X, et al. Transcatheter closure of multi-hole perimembranous VSD with aneurysm: 3-year follow-up study. Clinical research in cardiology, 2009,98(9) : 563-569.
[1]Visconti KJ, Bichell DP, Jonas RA, et al. Developmental outcome after surgical versus interventional closure of secundum atrial septal defect in children. Circulation, 1999, 100(suppl 2):Ⅱ-145-Ⅱ-150.
[2]Lock J, Block P, McKay R, et al. Transcatheter closure of ventricular septal defects. Circulation, 1988,78(2):361-368.
[3]Thanopoulos BVD, Tsaousis GS, Konstadopoulou GN, et al. Transcatheter closure of muscular ventricular septal defects with the amplatzer ventricular septal defect occluder: initial clinical applications in childrenl. Journal of the American College of Cardiology,1999,33(5):1395-1399.
[4]Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defect with Amplatzer septal occluders. The American journal of cardiology, 2005,96(12):52-58.
[5]Liu J, You X, Zhao X, et al. Outcome of transcatheter closure of perimembranous ventricular septal defect with modified double-disk occluder device. Zhonghua xin xue guan bing za zhi [Chinese journal of cardiovascular diseases],2010, 38(4):321.
[6]Chessa M, Butera G, Negura D, et al. Transcatheter closure of congenital ventricular septal defects in adult: Mid-term results and complications. International journal of cardiology, 2009, 133(1): 70-73.
[7]Kalra GS, Verma PK, Dhall A, et al. Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up. American heart journal, 1999, 138(2): 339-344.
[8]Pedra CAC, Pedra SRF, Chaccur P, et al. Perventricular device closure of congenital muscular ventricular septal defects. Expert Review of Cardiovascular Therapy, 2010, 8(5):663-674.
[9]Diab KA, Cao QL and Hijazi ZM. Device closure of congenital ventricular septal defects. Congenital heart disease, 2007, 2(2):92-103.
[10]Qin Y, Chen J, Zhao X, et al. Transcatheter closure of perimembranous ventricular septal defect using a modified double-disk occluder. The American journal of cardiology, 2008, 101(12): 1781-1786.
[11]Holzer R, de Giovanni J, Walsh KP, et al. Transcatheter closure of perimembranous ventricular septal defects using the Amplatzer membranous VSD occluder: immediate and midterm results of an international registry. Catheterization and cardiovascular interventions, 2006, 68(4):620-628.
[12]秦永文,赵仙先,吴弘,et al国产室间隔缺损封堵器的安全性和疗效评价.中国循环杂志,2005,20(001)：10-13.
[13]刘璟,游晓华,赵仙先,et al国产封堵器治疗先天性膜周部室间隔缺损的疗效评估.中华心血管病杂志,2010,38(004)：321-325.
[14]王治平,王庸晋,周胜华et al国产封堵器经导管介入治疗膜周部室间隔缺损379例.心脏杂志,2008,20(4)：F0002-F0002.
[15]王志远,金梅Amplatzer与国产封堵器经皮介入治疗室间隔缺损的临床应用现状.心肺血管病杂志,2010,001：77-80.
[16]宣斌,秦永文,胡建强,et al双侧无铆型房间隔缺损封堵器的实验研究.介入放射学杂志,2007,15(11)：683-685.
[17]方臻飞,李丽,沈向前,et al生物陶瓷膜先天性心脏病封堵器与普通镍钛合金封堵器的比较：随机对照.中国组织工程研究与临床康复,15(34)：6296-6301.
[18]Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. European heart journal,2007, 28(19):2361-2368.
[19]胡大一.心血管疾病防治指南和共识2009,常见先天性心脏病介入治疗中国专家共识[M].北京；人民卫生出版社,2009,63.
[20]程应樟,吴清华,程晓曙,et al国产封堵器治疗嵴内型室间隔缺损的临床研究.2008,
[21]解启莲,高磊,周谨,et al隔瓣后型室间隔缺损的介入治疗.临床荟萃,2007,22(17)：1270-1271.
[22]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010, 139(6):1409-1415.
[23]Michel I, Ewert P, Koch A, et al. Device closure of ventricular septal defects by hybrid procedures: A multicenter retrospective study. Catheterization and cardiovascular interventions, 2011,77(2): 242-251.
[24]Amin Z, Danford DA, Lof J, et al. Intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass:preliminary results with the perventricular technique. The Journal of Thoracic and Cardiovascular Surgery, 2004, 127(1):234-241.
[25]Bacha E, Cao QL, Galantowicz M, et al. Multicenter experience with perventricular device closure of muscular ventricular septal defects. Pediatric cardiology, 2005,26(2):169-175.
[26]Breur J, Visser G, Kruize A, et al. Treatment of fetal heart block with maternal steroid therapy: case report and review of the literature. Ultrasound in obstetrics & gynecology, 2004, 24(4): 467-472.
[27]Bacha EA, Cao QL, Starr JP, et al. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. Journal of thoracic and cardiovascular surgery, 2003,126(6):1718-1723.
[2]Scully BB, Morales DLS, Zafar F, et al. Current expectations for surgical repair of isolated ventricular septal defects. The Annals of Thoracic Surgery, 2011,89(2):544-551.
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[6]Lock J, Block P, McKay R, et al. Transcatheter closure of ventricular septal defects. Circulation, 1988,78(2):361-368.
[7]Sideris EB, Walsh KP, Haddad JL, et al. Occlusion of congenital ventricular septal defects by the buttoned device." Buttoned device" Clinical Trials International Register. Heart, 1997, 77(3): 276-279.
[8]Kalra GS, Verma PK, Dhall A, et al. Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up. American heart journal, 1999,138(2): 339-344.
[9]Thanopoulos BVD, Tsaousis GS, Konstadopoulou GN, et al. Transcatheter closure of muscular ventricular septal defects with the amplatzer ventricular septal defect occluder: initial clinical applications in childrenl. Journal of the American College of Cardiology, 1999, 33(5): 1395-1399.
[10]Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defect with Amplatzer septal occluders. The American journal of cardiology, 2005,96(12): 52-58.
[11]Liu J, You X, Zhao X, et al. Outcome of transcatheter closure of perimembranous ventricular septal defect with modified double-disk occluder device. Zhonghua xin xue guan bing za zhi [Chinese journal of cardiovascular diseases],2010, 38(4):321.
[12]Chessa M, Butera G, Negura D, et al. Transcatheter closure of congenital ventricular septal defects in adult: Mid-term results and complications. International journal of cardiology, 2009, 133(1): 70-73.
[13]秦永文,赵仙先,李卫萍.应用自制封堵器经导管闭合膜部室间隔缺损.介入放射学杂志,2002,11(2)：130-130.
[14]王治平,王庸晋,周胜华,et al国产封堵器经导管介入治疗膜周部室间隔缺损379例.心脏杂志,2008,20(4)：F0002-F0002.
[15]王志远,金梅Amplatzer与国产封堵器经皮介入治疗室间隔缺损的临床应用现状.心肺血管病杂志,2010,001：77-80.
[16]秦永文,赵仙先,吴弘,et al国产室间隔缺损封堵器的安全性和疗效评价.中国循环杂志,2005,20(001)：10-13.
[17]刘璟,游晓华,赵仙先et al国产封堵器治疗先大性膜周部室间隔缺损的疗效评估.中华心血管病杂志,2010,38(004)：321-325.
[18]王成山.心脏传导系统基础与临床.清华大学出版社,2009.
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[22]Kramoh E, Dahdah N, Fournier A, et al. Invasive measurements of atrioventricular conduction parameters prior to and following ventricular septal defect closure with the amplatzer device. The Journal of invasive cardiology, 2008,20(5):212-216.
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[24]Butera G, Carminati M, Chessa M, et al. Percutaneous closure of ventricular septal defects in children aged< 12:early and mid-term results. European heart journal, 2006, 27(23): 2889-2895.
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[33]Pacileo G, Pisacane C, Russo MG, et al. Left ventricular mechanics after closure of ventricular septal defect: influence of size of the defect and age at surgical repair. Cardiology in the Young, 1998,8(3): 320-328.
[34]Tucker EM, Pyles LA, Bass JL, et al. Permanent pacemaker for atrioventricular conduction block after operative repair of perimembranous ventricular septal defect. Journal of the American College of Cardiology, 2007,50(12): 1196-1200.
[35]Batra AS, Wells WJ, Hinoki KW, et al. Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block associated with surgery for congenital heart disease. The Journal of Thoracic and Cardiovascular Surgery, 2003, 125(6): 1291-1293.
[36]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010, 139(6); 1409-1415.
[37]Michel - Behnke I, Ewert P, Koch A, et al. Device closure of ventricular septal defects by hybrid procedures: A multicenter retrospective study. Catheterization and cardiovascular interventions, 2011,77(2):242-251.
[38]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010,139(-6) 1409-1415.
[39]马淑英.传导系统不同部位的文氏现象.实用心电学杂志,2008,17(5)：396-398.
[40]王永权.双侧束支主干阻滞的心电图分析.临床心电学杂志,2007,16(5)：388-394.
[41]宋志远,李永华,柴红.室间隔缺损介入治疗围术期发生心脏传导阻滞患者的随访研究.中华心血管病杂志,2009,37(11)：990-993.
[42]Szkutnik M, Qureshi SA, Kusa J. et al. Use of the Amplatzer muscular ventricular septal defect occluder for closure of perimembranous ventricular septal defects. Heart, 2007, 93(3): 355.
[43]Wu H, Qin Y, Zhao X, et al. Transcatheter closure of multi-hole perimembranous VSD with aneurysm: 3-year follow-up study. Clinical research in cardiology, 2009,98(9) : 563-569.
[1]Visconti KJ, Bichell DP, Jonas RA, et al. Developmental outcome after surgical versus interventional closure of secundum atrial septal defect in children. Circulation, 1999, 100(suppl 2):Ⅱ-145-Ⅱ-150.
[2]Lock J, Block P, McKay R, et al. Transcatheter closure of ventricular septal defects. Circulation, 1988,78(2):361-368.
[3]Thanopoulos BVD, Tsaousis GS, Konstadopoulou GN, et al. Transcatheter closure of muscular ventricular septal defects with the amplatzer ventricular septal defect occluder: initial clinical applications in childrenl. Journal of the American College of Cardiology,1999,33(5):1395-1399.
[4]Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defect with Amplatzer septal occluders. The American journal of cardiology, 2005,96(12):52-58.
[5]Liu J, You X, Zhao X, et al. Outcome of transcatheter closure of perimembranous ventricular septal defect with modified double-disk occluder device. Zhonghua xin xue guan bing za zhi [Chinese journal of cardiovascular diseases],2010, 38(4):321.
[6]Chessa M, Butera G, Negura D, et al. Transcatheter closure of congenital ventricular septal defects in adult: Mid-term results and complications. International journal of cardiology, 2009, 133(1): 70-73.
[7]Kalra GS, Verma PK, Dhall A, et al. Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up. American heart journal, 1999, 138(2): 339-344.
[8]Pedra CAC, Pedra SRF, Chaccur P, et al. Perventricular device closure of congenital muscular ventricular septal defects. Expert Review of Cardiovascular Therapy, 2010, 8(5):663-674.
[9]Diab KA, Cao QL and Hijazi ZM. Device closure of congenital ventricular septal defects. Congenital heart disease, 2007, 2(2):92-103.
[10]Qin Y, Chen J, Zhao X, et al. Transcatheter closure of perimembranous ventricular septal defect using a modified double-disk occluder. The American journal of cardiology, 2008, 101(12): 1781-1786.
[11]Holzer R, de Giovanni J, Walsh KP, et al. Transcatheter closure of perimembranous ventricular septal defects using the Amplatzer membranous VSD occluder: immediate and midterm results of an international registry. Catheterization and cardiovascular interventions, 2006, 68(4):620-628.
[12]秦永文,赵仙先,吴弘,et al国产室间隔缺损封堵器的安全性和疗效评价.中国循环杂志,2005,20(001)：10-13.
[13]刘璟,游晓华,赵仙先,et al国产封堵器治疗先天性膜周部室间隔缺损的疗效评估.中华心血管病杂志,2010,38(004)：321-325.
[14]王治平,王庸晋,周胜华et al国产封堵器经导管介入治疗膜周部室间隔缺损379例.心脏杂志,2008,20(4)：F0002-F0002.
[15]王志远,金梅Amplatzer与国产封堵器经皮介入治疗室间隔缺损的临床应用现状.心肺血管病杂志,2010,001：77-80.
[16]宣斌,秦永文,胡建强,et al双侧无铆型房间隔缺损封堵器的实验研究.介入放射学杂志,2007,15(11)：683-685.
[17]方臻飞,李丽,沈向前,et al生物陶瓷膜先天性心脏病封堵器与普通镍钛合金封堵器的比较：随机对照.中国组织工程研究与临床康复,15(34)：6296-6301.
[18]Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. European heart journal,2007, 28(19):2361-2368.
[19]胡大一.心血管疾病防治指南和共识2009,常见先天性心脏病介入治疗中国专家共识[M].北京；人民卫生出版社,2009,63.
[20]程应樟,吴清华,程晓曙,et al国产封堵器治疗嵴内型室间隔缺损的临床研究.2008,
[21]解启莲,高磊,周谨,et al隔瓣后型室间隔缺损的介入治疗.临床荟萃,2007,22(17)：1270-1271.
[22]Xing Q, Pan S, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass:Multicenter experience and mid-term follow-up. The Journal of Thoracic and Cardiovascular Surgery, 2010, 139(6):1409-1415.
[23]Michel I, Ewert P, Koch A, et al. Device closure of ventricular septal defects by hybrid procedures: A multicenter retrospective study. Catheterization and cardiovascular interventions, 2011,77(2): 242-251.
[24]Amin Z, Danford DA, Lof J, et al. Intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass:preliminary results with the perventricular technique. The Journal of Thoracic and Cardiovascular Surgery, 2004, 127(1):234-241.
[25]Bacha E, Cao QL, Galantowicz M, et al. Multicenter experience with perventricular device closure of muscular ventricular septal defects. Pediatric cardiology, 2005,26(2):169-175.
[26]Breur J, Visser G, Kruize A, et al. Treatment of fetal heart block with maternal steroid therapy: case report and review of the literature. Ultrasound in obstetrics & gynecology, 2004, 24(4): 467-472.
[27]Bacha EA, Cao QL, Starr JP, et al. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. Journal of thoracic and cardiovascular surgery, 2003,126(6):1718-1723.
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