不同年龄段房间隔缺损封堵对心脏重构及心功能的影响

目的:观察各年龄段继发孔型房间隔缺损经导管介入封堵治疗后对心脏几何形态学及右心功能变化的影响.方法:回顾性分析,998-06/2008-10贵州省人民医院心内科收治的房间隔缺损患者109例,男53例,女56例,年龄3.5-70岁.按年龄段分为儿童组(年龄≤7岁,n=31),青少年组(年龄8-18岁,n=42)和成人组(年龄＞18岁,n=36).应用经胸超声心动图分别测量各年龄段房间隔缺损患者经导管房间隔缺损封堵治疗前和治疗后6个月收缩末期左房横径、右房横径、右房横径左房横径、右心室舒张末期内径、左心室舒张末期内径、右心室舒张末期内径左心室舒张末期内径、肺动脉内径及左右心室射血分数的变化.结果:与术前相比,各组房间隔缺损封堵后6个月,右房、右室内径、肺动脉内径缩小,右房横径/左房横径和右心室舒张末期内径/左心室舒张末期内径明显下降,左房、左室内径增大,左、右室射血分数明显改善(P< 0.05-0.01);但儿童组心脏重构逆转及心功能改善程度明显大于青少年组及成人组(P<0.05),青少年组和成人组相比,差异无显著性意义(P＞0.05).结论:继发孔型房间隔缺损介入治疗对不同年龄患者均能有效逆转心脏重构、改善心功能,但儿童阶段效果更好.     

Transcatheter closure of atrial septal defects

Transcatheter closure of atrial septal defects has evolved significantly over the last 20 years. Transcatheter closure has replaced surgical closure for the treatment of most secundum atrial septal defectsat the current time. A major reason for this is the lower morbidity of transcatheter closure procedures. Several closure devices have come into clinical use. The Amplatzer septal occluder (AGA Medical Co.) currently has the largest reported experience and subsequently the best-established safety and efficacy features. Clinically challenging situations, such as larger atrial septal defects, atrial septal defects with deficient rims and multiple atrial septal defects, are increasingly being addressed using the transcatheter approach, with improved results. The incidence of most complications has significantly reduced over time, and serious side effects are relatively uncommon. In this review, the literature is summarized regarding the current role of transcatheter closure, the evolution of the different available devices for clinical use and the complications that occur with their use. A comparison is also made with surgical closure techniques.     

Transcatheter closure of atrial septal defects

Transcatheter closure of atrial septal defects has evolved significantly over the last 20 years. Transcatheter closure has replaced surgical closure for the treatment of most secundum atrial septal defectsat the current time. A major reason for this is the lower morbidity of transcatheter closure procedures. Several closure devices have come into clinical use. The Amplatzer^® septal occluder (AGA Medical Co.) currently has the largest reported experience and subsequently the best-established safety and efficacy features. Clinically challenging situations, such as larger atrial septal defects, atrial septal defects with deficient rims and multiple atrial septal defects, are increasingly being addressed using the transcatheter approach, with improved results. The incidence of most complications has significantly reduced over time, and serious side effects are relatively uncommon. In this review, the literature is summarized regarding the current role of transcatheter closure, the evolution of the different available devices for clinical use and the complications that occur with their use. A comparison is also made with surgical closure techniques.     

Interventional closure of atrial septal defects without fluoroscopy in adult and pediatric patients

Background

Interventional closure of atrial septal defects (ASDs) with a transcatheter device is the preferred strategy in children and adults. This procedure has been proven in numerous studies, but X-ray and contrast agent exposure is still a major side effect. The aim of this study was to clarify whether the interventional closure of ASDs is possible and safe if it is guided by transesophageal echocardiography (TEE) alone.

Methods and results

We retrospectively selected and studied pediatric and adult patients with interventional closure of ASDs at the Deutsches Herzzentrum Berlin (DHZB) without fluoroscopy between 1999 and 2010. We included 330 out of 1,605 patients; 254 had an ASD II, 30 a PFO and 46 multiperforated atrial septum. Median age was 8.92 (0.96–76.3)?years and median body weight 32.6 (8.3–156)?kg. Median stretched defect size was 13 (5–29)?mm. Median procedure time was 50 (20–170)?min. Closure was performed in the majority of patients with the Amplatzer^? septal occluder or Amplatzer^? PFO occluder. The procedure succeeded in 98.2?% of cases and closure rate was 94.9?% after 48?h. Complication rate was low and procedure time was similar to that necessary with studies using fluoroscopy.

Conclusion

Interventional closure of ASDs is safe and effective if guided with TEE alone. The results can compete with those with the use of fluoroscopy. TEE-guided closure of ASD should be considered in more catheter laboratories to avoid unnecessary radiation exposure for the patient and the examiner.     

Impact of transcatheter closure of atrial septal defects on cardiac function

Purpose

The purpose of this study was to investigate the effects of transcatheter closure of atrial septal defects (ASD) on left ventricular function.

Methods

Conventional and three-dimensional echocardiographic methods (3D) were performed in 20 patients who underwent ASD closure. Diastolic and systolic volumes (LVVd and LVVs) and ejection fractions (EF) were determined by 3D methods. Doppler and tissue Doppler indices were also measured before and 1?day after the procedure. We determined the predictors of patients with a mitral early Doppler/tissue Doppler velocity ratio (E/E′) ≥8 after closure.

Results

Ejection fraction decreased (from 70?±?8 to 63?±?8%, p?=?0.005) after the procedure because of an equivalent increase in LVVs and LVVd maintaining the same cardiac output. Among the echocardiographic variables before ASD closure that correlated with E/E′ after closure, the receiver operating characteristic curve of E′ gave the largest area under the curve with E′ of 12.2?cm/s as the best predictor of patients with E/E′ ≥8 after ASD closure.

Conclusion

Atrial septal defect closure decreased EF on the surface, thereby maintaining the same stroke volume and cardiac output. Patients with diastolic dysfunction before closure might have a higher risk of developing congestive heart failure after ASD closure.     

超声心动图在房间隔及室间隔缺损介入治疗中的作用

经心导管微创介入性治疗先天性心脏病是目前医学领域的研究热点之一,近几年发展极其迅速,并已逐渐形成一门新兴的学科分支。经心导管介入性治疗的先天性心脏病包括:房间隔缺损、室间隔缺损、动脉导管未闭、冠状动脉瘘、主动脉窦瘤破裂、肺动脉瓣狭窄等。超声心动图在先天性心脏     

Echocardiographic characteristics of secundum-type atrial septal defects in adult patients: implications for percutaneous closure using Amplatzer septal occluders.

The aim of the study was to analyze echocardiographic characteristics of isolated secundum-type atrial septal defects (ASD II) in adult patients and their implications for percutanous closure using Amplatzer septal occluders. The study population consisted of 64 consecutive adult patients with isolated ASD II (mean age 43.6 +/- 15.9 years). Patients were evaluated using both transthoracic and transesophageal echocardiography. Defects in 29 of 64 patients (45.3%) fulfilled the echocardiographic criteria for percutaneous closure. The mean defect diameter in the study was 22.2 +/- 9.5 mm. In all, 13 morphologic variations of ASD II were detected. A statistically significant correlation between defect size and the number of deficient defect rims was found. Less than 50% of ASD II in adult patients fulfilled the echocardiographic criteria for percutaneous closure using Amplatzer septal occluders. Because others have demonstrated growth of ASD II over time, we presume that in some patients, defect growth is associated with attenuation or even disappearance of defect rims causing changing defect morphology with increasing defect size.     

Migraine with aura related to closure of atrial septal defects

A 27-year-old woman had a history of migraine with aura (MWA) since aged 13 years with mostly two attacks per year. After transcutaneous closure of a secundum atrial septal defect (ASD) she suffered from almost daily recurring migraine attacks with prolonged aura symptoms. Exacerbation and new appearance of migraine attacks with aura after transcutaneous closure of ASD have been described previously.     

Percutaneous closure of atrial septal defects leads to normalisation of atrial and ventricular volumes

Background

Percutaneous closure of atrial septal defects (ASDs) should potentially reduce right heart volumes by removing left-to-right shunting. Due to ventricular interdependence, this may be associated with impaired left ventricular filling and potentially function. Furthermore, atrial changes post-ASD closure have been poorly understood and may be important for understanding risk of atrial arrhythmia post-ASD closure. Cardiovascular magnetic resonance (CMR) is an accurate and reproducible imaging modality for the assessment of cardiac function and volumes. We assessed cardiac volumes pre- and post-percutaneous ASD closure using CMR.

Methods

Consecutive patients (n = 23) underwent CMR pre- and 6 months post-ASD closure. Steady state free precession cine CMR was performed using contiguous slices in both short and long axis views through the ASD. Data was collected for assessment of left and right atrial, ventricular end diastolic volumes (EDV) and end systolic volumes (ESV). Data is presented as mean ± SD, volumes as mL, and paired t-testing performed between groups. Statistical significance was taken as p < 0.05.

Results

There was a significant reduction in right ventricular volumes at 6 months post-ASD closure (RVEDV: 208.7 ± 76.7 vs. 140.6 ± 60.4 mL, p < 0.0001) and RVEF was significantly increased (RVEF 35.5 ± 15.5 vs. 42.0 ± 15.2%, p = 0.025). There was a significant increase in the left ventricular volumes (LVEDV 84.8 ± 32.3 vs. 106.3 ± 38.1 mL, p = 0.003 and LVESV 37.4 ± 20.9 vs. 46.8 ± 18.5 mL, p = 0.016). However, there was no significant difference in LVEF and LV mass post-ASD closure. There was a significant reduction in right atrial volumes at 6 months post-ASD closure (pre-closure 110.5 ± 55.7 vs. post-closure 90.7 ± 69.3 mL, p = 0.019). Although there was a trend to a decrease in left atrial volumes post-ASD closure, this was not statistically significant (84.5 ± 34.8 mL to 81.8 ± 44.2 mL, p = NS).

Conclusion

ASD closure leads to normalisation of ventricular volumes and also a reduction in right atrial volume. Further follow-up is required to assess how this predicts outcomes such as risk of atrial arrhythmias after such procedures.     

超声心动图对房间隔缺损介入治疗后随诊观察

目的：评价超声心动图对继发孔型房间隔缺损（ASD）介入治疗的近期及远期疗效。方法：继发孔型ASD患者778例，男276例，女502例；男：女=1：1．8，年龄2-74岁，平均（29．6±9．6）岁；其中中央型765例，多发孔型13例，合并畸形91例。使用仪器：东芝6000型，Philips IE33彩色超声诊断仪（TIE）及1500型食道超声心动图（TEE）。探头频率分别为2．5MHz和5MHz。介入术后复查TTE，主要记录各心腔内径，包括右室流出道（RVOT）及右室内径（RV）。观察闭合器的位置、有无残余分流、瓣膜反流及心包积液和心功能状态。出院后1个月、3个月、半年及1年，TTE随诊。TTE选择切面为心尖四腔心及胸骨旁四腔心，剑突下四腔心及两房心切面，大动脉短轴及剑突下短轴切面。结果：超声检出介入手术并发症发生率2．3％。其中闭合器脱落5例，脑梗死2例，心包积液5例，残余分流4例，肺动静脉瘘1例。结论：超声对ASD介入治疗近期和远期疗效的判定有临床意义。     

Effects of transcatheter closure of atrial septal defects on heart rate variability

This study evaluated heart rate variability and its changes in 30 patients before and after transcatheter closure of secundum atrial septal defects. Heart rate variability data from 30 healthy volunteers with normal echocardiographic parameters and no history of atrial septal defects were included as controls. Values for the SD of all the normal RR intervals (SDNN), the SD of the means of all the 5-min segment normal RR intervals (SDANN), and the mean of all the 5-min SDs of normal RR intervals during the 24-h period (SDNN index) in patients with atrial septal defects before transcatheter closure were statistically significantly different from controls. At 6 months after closure of the defects these values were not statistically different from controls. It is concluded that transcatheter closure of secundum atrial septal defects had positive effects on heart rate variability and, consequently, may contribute to less mortality and morbidity.     

Contemporary clinical management of atrial septal defects in the adult

Patients with simple congenital heart disease, such as isolated atrial septal defects (ASDs), are rapidly becoming a relatively large population with a variety of clinical problems that are often missed by pediatric physicians or grown-up congenital heart disease specialists and may involve different adult health professionals, such as general cardiologists or internists. A Medline search was performed to search for randomized trials, prospective cohort studies, meta-analysis, reviews and practice guidelines regarding different aspects of ASD in adults over a 6 year period. Isolated ASD are common (7% of all cardiac anomalies) and can present at any age, sometimes in conjunction with other genetic disorders such as Down syndrome or in a familiar form. The diagnosis is often accidental: Doppler echocardiography and, more recently, MRI are mandatory to assess types and significance of ASDs. Surgical or percutaneous repair should be offered at any age unless associated with pulmonary vascular disease: percutaneous closure should be preferred in isolated secundum ASD with sufficient rims on transesophageal echocardiography, whereas surgery remains the only option for primum and sinus defects. Follow-up of operated patients is based on Holter ECG and echocardiography, which should be scheduled every 2 years for secundum and sinus defects and every year for primum defect with valve repair. ASDs in adolescents and adults may be suspected in any physician’s office and doctors should be acquainted with innovative imaging techniques and contemporary therapeutic options in order to deliver proper care to different types of ASDs and assist them after repair with appropriate follow-up strategies.     

Contemporary clinical management of atrial septal defects in the adult

Patients with simple congenital heart disease, such as isolated atrial septal defects (ASDs), are rapidly becoming a relatively large population with a variety of clinical problems that are often missed by pediatric physicians or grown-up congenital heart disease specialists and may involve different adult health professionals, such as general cardiologists or internists. A Medline search was performed to search for randomized trials, prospective cohort studies, meta-analysis, reviews and practice guidelines regarding different aspects of ASD in adults over a 6 year period. Isolated ASD are common (7% of all cardiac anomalies) and can present at any age, sometimes in conjunction with other genetic disorders such as Down syndrome or in a familiar form. The diagnosis is often accidental: Doppler echocardiography and, more recently, MRI are mandatory to assess types and significance of ASDs. Surgical or percutaneous repair should be offered at any age unless associated with pulmonary vascular disease: percutaneous closure should be preferred in isolated secundum ASD with sufficient rims on transesophageal echocardiography, whereas surgery remains the only option for primum and sinus defects. Follow-up of operated patients is based on Holter ECG and echocardiography, which should be scheduled every 2 years for secundum and sinus defects and every year for primum defect with valve repair. ASDs in adolescents and adults may be suspected in any physician's office and doctors should be acquainted with innovative imaging techniques and contemporary therapeutic options in order to deliver proper care to different types of ASDs and assist them after repair with appropriate follow-up strategies.     

房间隔缺损Amplatzer封堵术后右心形态和功能改变的超声心动图观察

目的探讨房间隔缺损行Amplatzer封堵器封堵术后右心形态和功能变化.方法对25例继发孔房间隔缺损患者,分别于术前、术后48～72 h及3个月后行经胸超声心动图检查,测量缺损大小、右心室壁厚度、房室腔径及容积、每搏输出量及射血分数等,并进行比较.结果缺损直径为(2.2±0.6)cm,所有患者均在经胸超声心动图监控下成功植入Amplatzer封堵器;术后48～72 h超声心动图复查,除2例患者残存微量左向右分流外,余患者心房水平分流完全消失;13例患者术后3～6个月复查,原2例残存分流完全消失;术后48～72 h超声心动图检查发现,右心房最大长径及横径,右心室舒张末期长径、横径及前后径,主肺动脉根部内径均明显缩小,右心室舒张末期容积、每搏输出量及射血分数较术前明显减低(P<0.01);术后3个月超声心动图复查发现,患者右心房内径、右心室舒张末期内径及容积、右心室收缩末期横径及容积术后3个月进行性缩小,右心室每搏输出量及射血分数与术后早期相比差异无统计学意义,室间隔异常运动消失.结论房间隔缺损封堵术后右心室前负荷的降低对右心形态有明显影响,右心内径及容积进行性回复,室间隔异常运动消失,代偿增强的右心室每搏输出量、射血分数下降,但并不是持续性降低,而是在新的前负荷水平上达到新平衡,保持右心收缩功能.     

Residual sinus venosus atrial septal defect after surgical closure of atrial septal defect.

We describe residual atrial septal defects in 3 patients who had previous surgical repair. The residual defects were the sinus venosus type near the orifice of the inferior vena cava. Preoperative and intraoperative transesophageal echocardiography may aid in the detection and facilitate the successful repair of these defects.     

经食管实时三维超声在成人房间隔缺损封堵术术前评估中的应用

目的 探讨经食管实时三维超声心动图(RT-3D-TEE) 在成人房间隔缺损(ASD)封堵术前评估中的应用价值。方法 43例经胸二维超声(2D-TTE)拟诊为继发孔型ASD的成人患者进行了RT-3D-TEE检查,重点观察ASD缺损口的形态,测量ASD最大径、缺损口形态及各方位的残缘及与腔静脉的距离。筛选可封堵的病例行经导管ASD封堵术,分析缺损最大径与封堵器型号的平均绝对误差,以评价各种成像方法测量的准确性。结果 3例ASD过大,RT-3D-TEE未能获得完整的三维重建图、1例经TEE诊为原发孔型ASD未入组;39 例RT-3D-TEE 显示满意,确诊为继发孔型ASD(以下简称ASD),其中 27 例ASD形态为椭圆形,6 例为类圆形,1 例为筛孔型,5例为不规则型;16例ASD各方位有较完整的残缘,23例存在一侧以上的残缘缺失;临床根据RT-3D-TEE检查ASD大小、形态及各方位残缘等条件筛选后,有23例进行了经导管ASD封堵术,成功21例(成功率91.3%,21／23),未成功的2例及未进行封堵术的6例(共8例)进行了外科修补术,11例出院择期治疗或放弃治疗。RT-3D-TEE测量的缺损最大径和封堵器直径的平均绝对差值小于TTE、TEE-Xplane(经食管双平面成像)这两种方法的结果,且差异有统计学意义( p<0.05)。结论 RT3D-TEE能清晰显示ASD的三维重建切面,逼真地显示ASD的形状,直观、精准测量缺损口的各种径线,在封堵术前评估内科导管介入封堵和外科修补治疗方案选择中有更重要的指导价值。     

经导管室间隔缺损封堵术患者的护理

为了总结Amplatzer封堵器介入治疗室间隔缺损(VSD)患者的护理及预防并发症的方法,对18例接受介入治疗的VSD患者进行回顾性分析,并针对各自的并发症实施相应护理.结果18例患者介入治疗技术成功率100%,术后1例发生血肿及腓肠静脉血栓,1例发生传导阻滞,经治疗护理均痊愈.认为准确的术前决策,充分的术前准备,积极的术中、术后监护处理,对保证患者手术顺利、预防或减少并发症发生有重要意义.     

经食管超声心动图在经胸微创房间隔和室间隔缺损封堵术中的应用

目的 探讨经食管超声心动图(TEE)在经胸微创房、室间隔缺损封堵治疗中的应用价值.方法 经胸超声心动图(TTE)粗筛34例房间隔缺损(ASD)患者和38例室间隔缺损(VSD)患者,拟行经胸微创封堵治疗.术中行TEE根据缺损位置、类型、大小选择合适的封堵器;引导封堵器放置,评价即刻封堵效果;术后1周内复查.结果 32例ASD和29例VSD患者封堵成功.术后I周内超声随访,封堵器位置均正常,3例ASD患者微量残余分流,患者心室重构改善,瓣膜反流程度减轻,肺动脉压力下降.结论 TEE对选择适合行经胸微创封堵的ASD、VSD患者、选择合适的封堵器、协助封堵器的释放,评价疗效均有重要的作用.经胸微创封堵ASD、VSD安全、有效.     

房间隔缺损Amplatzer封堵器封堵术后左心血流动力学改变的超声心动图观察

目的探讨房间隔缺损经Amplatzer封堵器封堵术后左心形态和血流动力学的变化。方法65例继发孔型房间隔缺损患者,45例3个月后进行了随访。经胸超声心动图检查分别于术前、术后48~72 h及3个月后进行,测量缺损大小、左室前后径、横径、二尖瓣及主动脉瓣瓣口血流脉冲及组织多普勒流速曲线的相关参数,计算Tei指数和TeiTDI指数。结果房间隔缺损平均孔径(2.5±0.3)cm,舒张末期左室前后径于术后早期和中期扩大,横径于中期扩大,每搏输出量和射血分数迅即持续增加;代偿增强的左室后壁运动幅度恢复。术后早期和中期左室收缩期血流峰值速度均较术前增快,但射血时间无明显延长,术后中期左室血流充盈时间延长。心率、Tei指数及TeiTDI指数封堵术前后无明显变化。结论房间隔缺损封堵术纠正了解剖畸形,使左、右心室的前后负荷回复正常,左心室的解剖构型、舒张和收缩功能迅速得到纠正,血流动力学快速改善,前负荷的变化对心率无影响。