成人继发孔型房间隔缺损并发房颤患者三种治疗方法分析

目的介绍成人房间隔缺损（ASD）并发心房颤动（AF）患者的几种治疗方法,并分析其治疗效果。方法：回顾分析本院136例ASD并发有明显临床症状且药物治疗无效的AF病例,其中36例接受介入封堵＋经导管射频消融术（导管射频消融组）,84例体外循环下ASD补术＋改良迷宫术（改良迷宫组）,16例单纯介入封堵术（未行经导管射频消融术,单纯介入封堵组）,术前,术后12月用心脏超声仪评价右心房、右室内径及肺动脉压力和心电图变化。结果：所有病例的术中、术后均未出现严重并发症,所有病例均无死亡,随访12个月,36例接受介入封堵＋经导管射频消融术28例转复为窦性心律,8例仍为AF,后行二次射频消融术转为窦性心律,84例ASD补术＋改良迷宫手术患者中有66例转复窦性,14例失败仍为AF,4例为交界性心律,单纯介入封堵组16例8例成功,8例术后仍为AF,与术前比较,各组心脏超声检查示右心房、右心室内径均较术前明显缩小,肺动脉压力明显下降（均P〈0．05）。各组之间无显著差异。经导管射频消融组和改良迷宫手术组AF治愈率高（对比单纯介入组,均P〈0．05）,患者心慌不适更能得到改善,生活质量更高。结论：介入封堵及外科手术均能安全有效治疗ASD并发AF,每种方法各有利弊,可依据患者临床具体情况选择。     

Electrophysiological determinants of atrial fibrillation in sinus node dysfunction despite atrial pacing.

AIMS: The effectiveness of atrial pacing in reducing the incidence of atrial fibrillation in patients with sinus node dysfunction is incomplete, and the correlation between electrophysiological atrial properties and the effect of permanent atrial pacing has been poorly investigated. Accordingly, the aim of the present study was to correlate electrophysiological data, in terms of atrial refractoriness, conduction parameters, and propensity to atrial fibrillation induction, and the likelihood of atrial fibrillation after DDD device implantation. METHODS AND RESULTS: The authors reviewed electrophysiological data of 41 patients with sinus node dysfunction (mean age 70 +/- 8 years, who were investigated free of anti-arrhythmic treatments before pacemaker implantation. At a drive cycle length of 600 ms, effective and functional refractory periods, S1-A1 and S2-A2 latency, A1 and A2 width, and latent vulnerability index (effective refractory period [ERP] A2), were measured. Atrial fibrillation induction was tested with up to three extrastimuli in 34 patients. Induction of sustained atrial fibrillation (> 1 min) was considered as the end-point. P-wave duration on the surface ECG in lead II/V1 was also measured. Minimal atrial rate was programmed between 60 and 75 bpm (mean: 64 +/- 4 bpm). After implantation, the patients were followed-up for 28 +/- 17 months, and ECG-documented occurrence of atrial fibrillation was determined. Electrophysiological characteristics of patients with (n = 12) or without (n = 29) paroxysmal atrial fibrillation before implantation were similar. When comparing patients with (n = 11) or without (n = 30) post-pacing atrial fibrillation occurrence, no differences were found in age, underlying heart disease, left atrial size, minimal pacing rate, and follow-up duration. Additionally, between the two former groups, there was no significant difference in terms of effective refractory periods (233 +/- 47 ms vs 239 +/- 25 ms), functional refractory periods (280 +/- 48 ms vs 272 +/- 21 ms), S1-A1 (44 +/- 20 ms vs 37 +/- 13 ms) and S2-A2 latency (77 +/- 28 ms vs 66 +/- 22 ms), and A1 duration (60 +/- 23 ms vs 53 +/- 16 ms). In contrast, in patients with post-pacing atrial fibrillation occurrence, the P wave was more prolonged (116 +/- 22 ms vs 98 +/- 13 ms; P < 0.01), A2 was longer (116 +/- 41 ms vs 87 +/- 27 ms; P < 0.01), effective refractory periods/A2 was lower (2.1 +/- 0.4 cm vs 3.1 +/- 1.4 cm; P < 0.05), and rate of atrial fibrillation induction was higher (8/11 patients vs 8/23 patients; P < 0.05). Electrophysiological characteristics of patients free of post-pacing atrial fibrillation with associated (n = 6) or unassociated (n = 24) paroxysmal atrial fibrillation history before implantation were quite similar. In patients with post-pacing atrial fibrillation with associated (n = 6) or unassociated atrial fibrillation history (n = 5) before implantation, effective refractory periods was statistically different (207 +/- 23 ms vs 264 +/- 46 ms; P < 0.05). Values of effective refractory periods < 220 ms were significantly more frequent in patients with post-pacing atrial fibrillation than in patients without (4/11 patients vs 2/30 patients; P < 0.05). When comparing patients with post-pacing atrial fibrillation with effective refractory periods > or = 220 ms (n = 7) and < 220 ms (n = 4), A2 duration was remarkably prolonged (145 +/- 42 ms vs 90 +/- 11 ms; P < 0.05) in those with effective refractory periods > or = 220 ms. By contrast, between the two groups, effective refractory periods/A2 were identical (2.08 +/- 0.6 cm vs 2.15 +/- 0.3 cm; P = n.s.). CONCLUSION: Prolonged atrial refractoriness, lesser degrees of conduction disturbance and a lower rate of atrial fibrillation induction seem to be predictive of stable sinus rhythm. In contrast, patients with persistence of atrial fibrillation despite pacing have a more abnormal and inhomogeneous atrial substrate, as well as a higher rate of atrial fibrillation induction. Prolonged P wave, shortened refractoriness, or remarkably abnormal conduction disturbances in the presence of prolonged refractoriness limit the effectiveness of standard atrial pacing in atrial fibrillation prevention. Identification of predictive criteria of failure of single-site atrial pacing may be used to consider dual-site atrial pacing in such patients with sinus node dysfunction.     

继发孔型房间隔缺损患者心律失常的临床研究

目的 心律失常是继发孔型房间隔缺损（ASD）的常见并发症,本研究探讨未行介入封堵术和外科修复术治疗的ASD患者心律失常的发生情况及其可能危险因素,以期为指导心律失常的防治工作提供理论依据。 方法 所有患者行18导联常规心电图、24小时动态心电图（Holter）、床旁心电监护检查,记录心律失常类型。经胸超声心动图（TTE）测 ASD 最大径、右室与左室内径比值（RV/LV）、三尖瓣反流法估测肺动脉收缩压（PASP）等临床资料进行统计分析。 结果 共收集77例患者,年龄57.19±15.59岁,女性51人（66.2%）。29例（37.6%）患者ASD最大径＞20 mm;47例（48.1%）患者肺动脉收缩压＞50 mmHg;29例（37.6%）患者右室明显增大,右室内径/左室内径比例≥1.0。心律失常类型共计19种,患者发病年龄大多分布在60岁以上（48.1%）。其中多源室性期前收缩（室早）（r = 6.506,P = 0.039）、心房颤动（r = 9.109,P = 0.011）、成对房性期前收缩（房早）（r = 6.241,P = 0.044）及非持续性房性心动过速（房速）（r = 9.653,P = 0.008）随年龄增大发病率有增加的趋势。随着年龄增大,心律失常发生种类有增多的趋势（z = -3.168, P = 0.002）;随着ASD最大径的增大,室性心律失常发病率有增加的趋势（?2 = 3.983,P = 0.046）。结论 继发孔型房间隔缺损未行手术修补或介入封堵治疗的患者,当ASD最大径＞20 mm,肺动脉收缩压＞50 mmHg,RV/LV≥1.0,年龄大于60岁时心律失常的发生率明显增加,病情加重,临床应当引起重视。     

超声心动图在成人房间隔缺损治疗决策中的作用

目的　探讨超声心动图在成人房间隔缺损(ASD)治疗决策中的作用 ,选择适合的病例进行经皮导管堵闭治疗。方法　本组资料来源于 2 0 0 2年 8月至 2 0 0 3年 8月广东省心血管病研究所 ,12 8例患者经胸超声心动图 (TTE)诊断为继发孔型ASD ,使用TTE筛选和患者同意的 5 2例进行导管堵闭治疗 ,78例患者进行了外科手术治疗。结果　经超声心动图筛选的病例 ,导管介入治疗能有效地关闭 96 %(5 0 /5 2 )的继发孔型ASD ,外科手术修补房间隔缺损的成功率为 10 0 % ,超声心动图显示的房间隔缺损分型与外科术中分型的差异无显著的统计学意义 (P >0 0 5 )。结论　经胸超声心动图能准确的显示成人ASD解剖变异和确定分型 ,经皮导管介入治疗能成功地堵闭绝大多数经超声心动图筛选的患者     

Percutaneous closure of atrial septal defect type ostium secundum using the new Intrasept occluder: initial experience.

We report the first experience obtained with the new Intrasept device. We attempted to treat 35 patients with a mean age of 43 +/- 21 years. The mean size of the defect was 17/15 mm. It was successfully closed in 31 patients. In the remaining four the device could not be stabilized because of excessive defect size. A small residual shunt was present immediately following implantation in three patients. No complications occurred during the procedure and at 6 months, 31 patients had an uneventful outcome. Only one patient had a small residual shunt. No thrombus, embolization, or device fracture was documented during a mean follow-up of 17 +/- 11 months. Percutaneous closure of ASD ostium secundum is feasible with the Intrasept device with a high success rate and very good medium-term outcome. Our initial experience and results were excellent with small to medium size defects, however, large defects (>20 mm) remain challenging.     

Familial recurrence of congenital heart disease in patients with ostium secundum atrial septal defect.

AIMS: Ostium secundum atrial septal defect (osASD) is one of the most common cardiac malformations. Few data are available on the familial recurrence of congenital heart disease (CHD), in particular, in a large group of patients with isolated osASD. The aim is to investigate the familial recurrence of CHD in up to third-degree relatives from a large sample of consecutively enrolled patients with osASD, taking into account the influence of degree of relatedness (as number of relatives). METHODS AND RESULTS: From January 1998 to December 2002, we enrolled 583 patients with osASD and 408 healthy subjects, referred to our tertiary centre. We hypothesized that a positive family history required at least one relative with CHD to constitute a risk factor. In this model of analysis, the null hypothesis is a similar familial history between cases and controls. Among 583 patients with osASD, 109 (19%) had at least one relative with CHD. Among the 408 healthy subjects studied, only 23 (6%) had a family history of CHD. A familial recurrence of CHD was demonstrated in 72 of 312 (23%) patients with isolated osASD and in 37 of 271 (13.6%) patients with non-isolated osASD. Familial recurrence of isolated osASD was demonstrated in 22 of 312 patients (7%) with an isolated osASD and only in six of 271 patients (2.2%) with non-isolated osASD. The familial recurrence risk of isolated osASD in patients with isolated osASD was higher in sibs, especially in sisters (33.3%). CONCLUSION: This study underscores the role of genetic factors in the determination of CHD, particularly osASD. Our results could represent the basis for further studies to calculate a 'value of family history' to adapt the familial recurrence to the real size of each family group. In this way, we could select families with a 'tendency' to develop CHD, particularly osASD. In these families, we could analyse the genetic pattern to establish abnormalities and the bases of CHD.     

Nonobstructive asymmetrical septal hypertrophy and ostium secundum-type atrial septal defect

We report a 36-year-old woman with hypertrophic cardiomyopathy with asymmetric septal hypertrophy without outflow tract obstruction associated with an ostium secundum-type atrial septal defect with significant hemodynamic repercussion. Diagnosis was established with transesophageal echocardiography. This is the second case of this rare association reported in the literature and the first evaluated by transesophageal echocardiography.     

成人继发孔型房间隔缺损形态学特点及其对经导管封堵术的影响

目的探讨成人继发孔型房间隔缺损(ASD)边缘形态学特点及其对封堵术的影响。方法收集本院1997年9月—2005年12月符合封堵治疗适应证的272例40岁以上成人继发孔型ASD,采用Amplatzer法封堵ASD。封堵前均采用经胸超声心动图(TTE)和经食管超声心动图(TEE)对缺损形态学进行全面评价,按照残存边缘条件进行分组。分别对两组的缺损大小、边缘形态和长短、封堵器直径、成功率,残余分流率和并发症等指标进行分析。结果本组全部272例中存在短边者96例,占35.3%;薄边者61例,占22.4%。短边以前缘最常见69例(71.9%),长度(1.4±1.4)mm;薄边以后下缘最常见,占59.0%(36例),长度2～23mm,平均长度(6.7±6.3)mm。A组[短边和(或)薄边]共135例,占49.6%,B组(边缘良好)共137例,占50.4%。A、B两组在性别、年龄方面差异均无统计学意义,两组技术成功率、残余分流和并发症发生率等差异亦无统计学意义。但两组缺损TTE径[(18.9±5.5)mm和(16.5±4.8)mm,P<0.01]、TEE径[(22.7±5.0)mm和(20.0±5.5)mm,P<0.01]、所选用的封堵器直径[(29.1±5.7)mm和(26.0±5.9)mm,P<0.01]以及肺动脉收缩压[(36.9±11.9)mmHg(1mmHg=0.133kPa)和(32.6±9.1)mmHg,P<0.01]差异均有统计学意义,A组均高于B组。A、B两组封堵器直径与TTE和TEE所测量的直径之间均具有较好的相关性(A组TTE:r=0.709,TEE:r=0.850;B组TTE:r=0.716,TEE:r=0.915)。B组均高于A组,而且两组中封堵器直径与TEE值的相关性均高于与TTE的相关性。结论成人继发孔型ASD近一半合并边缘短缺和(或)边缘变薄,但选择直径更大的封堵器仍可以成功实施封堵治疗。而根据TTE和TEE,特别是后者所测量的直径能够准确地选择合适的封堵器。     

经导管介入治疗婴幼儿继发孔型房间隔缺损110例

目的探讨经导管介入治疗继发孔型房间隔缺损(atrial septal defect,ASD)在婴幼儿中应用的安全性及有效性。方法回顾性分析110例继发孔型ASD婴幼儿患者经导管介入治疗的临床资料,着重分析治疗方法、结果、并发症情况及随访结果。比较治疗前、后主要观察指标的变化,心律失常发生与否与观测指标之间的多因素分析采用偏相关分析。结果患者ASD直径(13.5±4.3)mm,选择ASD封堵器直径(15.9±4.1)mm,全部110例患儿中,有108例成功封堵,总的手术成功率98.2%;封堵术后右心房舒张末期内径和三尖瓣反流面积较术前缩小,差异有统计学意义[(20.1±6.5)mmvs.(22.7±5.8)mm,P0.05;(0.5±0.6)cm2vs.(1.0±0.9)cm2,P0.05];偏相关分析显示,心律失常发生与患儿的体质量(r=0.546,P=0.060)、年龄(r=-0.427,P=0.078)、选择封堵器直径(r=-0.242,P=0.115)之间不存在相关。随访至2009年12月,全部患儿无血栓栓塞、感染性心内膜炎等并发症出现。结论婴幼儿继发孔型ASD经导管介入治疗安全,可靠,并发症少,值得推广应用。     

Combined percutaneous pulmonary valvuloplasty and atrial septal defect closure for pulmonary valvular stenosis and associated secundum atrial septal defect in an adult.

Percutaneous balloon valvuloplasty is the treatment of choice for congenital pulmonary valve stenosis, and percutaneous closure of secundum atrial septal defects has become a promising alternative to surgery in selected patients. We report a case of combined percutaneous pulmonary valvuloplasty and secundum atrial septal defect occlusion in an adult patient.     

介入治疗房间隔缺损并发肺动脉瓣狭窄的临床评价

目的:评价介入治疗房间隔缺损并发肺动脉瓣狭窄的近中期疗效。方法:11例患者,年龄3～53（16±15）岁。超声心动图测量房间隔缺损最大直径为8～38（21.7±10.8）mm,1例心房水平显示双向分流,10例呈左向右分流,均并发有不同程度的肺动脉瓣狭窄。先行球囊肺动脉瓣成形术（PBPV）,其中6例采用肺动脉瓣单球囊,5例采用Inoue二尖瓣球囊扩张;而后置入Amplatzer型房间隔缺损封堵器闭合缺损,选择的封堵器直径为10～40（22.9±11.5）mm。结果:同期行介入治疗均成功,PBPV术后即刻右室收缩压由术前77±18mmHg降至39±7mmHg,肺动脉至右心室跨瓣压差由术前47±18mmHg降至9±5mmHg（P<0.01）。术后超声心动图随访3～67个月,疗效满意,房间隔未见残余分流。结论:介入方法治疗房间隔缺损并肺动脉瓣狭窄安全、有效。     

Transcatheter closure of ruptured sinus of valsalva aneurysm and secundum atrial septal defect with limited inferior rim

We report a case of a 33-year-old man with Down syndrome and ruptured sinus of Valsalva aneurysm (SOVA) plus large ostium secundum atrial septal defect (ASD) with attenuated inferior rim. He underwent successful transcatheter closure of both defects at two separate procedures with transesophageal echocardiography (TEE) guidance. The combination of these two procedures has not been previously reported. Transgastric echocardiographic views which mimic transthoracic subcostal echocardiographic views provide high quality useful images of the anatomy, hemodynamics, and device placement.     

成人房间隔缺损介入治疗对右心功能的影响

目的探讨超声心动图技术评估成人房间隔缺损介入治疗对右心功能的影响。方法选择60例成人房间隔缺损患者设为治疗组,另外选择30名健康成人作为对照组。治疗组患者在术前、术后1d、术后6个月通过超声心动图技术测量三尖瓣收缩期位移（TAPSE）、三尖瓣环收缩期峰值速度（S’）、右心室收缩末面积（AreaES）、右心室舒张末面积（AreaED）、右心室面积变化率（RVFAC）,以及在同等条件下测出健康成人对照组的上述数据,并对两组数据进行统计分析。结果两组年龄比较,差异无统计学意义[（40．10±13．9）岁vs.（40．87±15．5）岁,P=0．849]。治疗组术前右心室收缩末面积、右心室舒张末面积、三尖瓣收缩期位移、三尖瓣环收缩期峰值速度大于对照组,差异有统计学意义[（15．28±4．30）cm^2 vs.（7．27±2．41）cm^2,P=0．000;（28．98±6．68）cm^2 vs.（15．15±3．63）cm^2,P〈0．001;（2．58±0．67）cm vs．（2．25±0．45）cm,P=0．045;（16．5±0．3）cm／s vs．（14．2±2．9）cm/s．P=0．0041．而RVFAC小于对照组,差异有统计学意义（47．34％±7．26％vs.52．63％±6．77％,P=0．007）。治疗组介入治疗后第1天三尖瓣收缩期位移、三尖瓣环收缩期峰值速度与治疗前比较,差异有统计学意义[（2．32±0．46）cm vs．（2．58±0．67）cm,P〈0．01;（12．7±2．6）cm／svs.（16．5±0．3）cm／s,P〈0．01];术后6个月RVFAC与治疗前比较,差异才有统计学意义（50．76％±3．56％vs．47．34％±7．26％,P〈0．05）。结论房间隔缺损早期已经出现右心功能受限,介入治疗后右心功能逐渐恢复至正常成人水平,超声心动图评估成人房间隔缺损右心功能需要不同指标的综合评价。     

Pulmonary vascular disease in secundum atrial septal defect in childhood: an unusual evolution

Reported is a case of a 16-month-old girl with an isolated atrial septal defect in whom severe pulmonary hypertension has developed in 26 months in spite of an important functional gradient across the pulmonic valves at a first catheterization. Individual susceptibility to an increased pulmonary blood flow is evoked.     

Closure of ostium secundum atrial septum defect with the Atriasept occluder: Early European experience

Objectives : This multicentre study sought to report the safety and efficacy of the ATRIASEPT septal occluder to repair atrial septal defect (ASD). Background : The ATRIASEPT is a low profile, flexible, double disk occluder with centering system specifically designed for closure of ostium secundum ASD. Method : Patients were enrolled from four participating European sites and followed up for 12 months post procedure. Outcomes were evaluated, including closure success and incidence of adverse events. Results : Seventy‐six patients received the ATRIASEPT device. Mean size of the defect was 15 ± 4 mm. Closure success was observed in 69 patients (89%) at the end of the procedure. Sixty‐four patients had a six‐month follow up with a complete closure by 58 patients (90%). Minor adverse events occurred in two patients. Significant functional improvement was reported by all symptomatic patients. Conclusion : Percutaneous closure of ASD ostium secundum type defects with the ATRIASEPT is safe and effective with high success rate and excellent mid‐term outcome. © 2010 Wiley‐Liss, Inc.     

婴幼儿继发孔型房间隔缺损介入治疗的可行性及长期疗效

目的总结经导管介入治疗婴幼儿先天性继发孔型房间隔缺损的可行性及长期疗效。方法研究海南省人民医院心内科2000年5月至2013年12月间经导管介入治疗的159例婴幼儿继发孔型房间隔缺损的临床资料。所有患儿术前均经临床体检、X线胸片、心电图、经胸超声心动图确诊为继发孔型房间隔缺损。经胸超声心动图测量房间隔缺损最大径、右心室舒张末期内径(RVDD)、右心房横径(RALD)及估测肺动脉收缩压,根据经胸超声心动图观察和测量房间隔缺损最大径结果选择适当的封堵器。结果入选159例患儿,其中中央型房间隔缺损143例,近上腔型房间隔缺损5例,近下腔型房间隔缺损11例。入选患儿中房间隔缺损合并其他畸形17例,房间隔缺损合并肺动脉高压15例。159例患儿中156例成功封堵(成功率98.1%),未成功的3例均为缺损下腔静脉缘残端不足(小于5 mm)。患儿房间隔缺损最大径(10.2±2.5)mm,封堵器直径(11.7±3.6)mm,输送鞘8.5(7~10)F。导管操作时间(15.6±2.2)min。随访时间为(7.4±2.1)年,时间范围为1个月~13年,随访期间患者无封堵器脱落或移位,也无栓塞及心内膜炎等并发症的发生。随访过程中,4例患儿术后即刻出现一过性窦性心动过缓,1例患儿在术后第2天出现二度1型房室传导阻滞,予地塞米松治疗7 d后恢复窦性心律;2例患儿分别在术后的第1年和第5年发现一度房室传导阻滞,在分别随访2年和4年中未发现进行性加重。术后第1天复查超声心动图发现3例新发的三尖瓣轻度反流和7例少量残余分流(宽约1~2 mm),发现三尖瓣轻度反流患儿在分别随访的1年,3.5年及10年中未发现反流加重及右心扩大,发现残余分流患儿有2例在1个月后恢复,4例在3个月后恢复,1例在1.5年后恢复。15例合并肺动脉高压患儿术后1个月肺动脉收缩压下降[(53±11.2)mm Hg vs.(32±4.8)mm Hg,P<0.01;1 mm Hg=0.133 k Pa],右心负荷降低(右心室舒张末期内径:(13.7±4.3)mm vs.(11.5±3.2)mm,P<0.01;右心房横径:(31.5±5.3)mm vs.(28.6±5.6)mm,P<0.01)。结论经导管介入治疗婴幼儿继发孔型房间隔缺损是一项安全、可行的技术,长期疗效良好。     

Secondary embolization of a Helex occluder implanted into a secundum atrial septal defect.

We report on a 2-year-old patient with atrial septal defect with a stretched diameter of 11 mm. The defect was closed uneventfully by use of a 25 mm Helex device. There was only trivial residual shunting (1 mm at the cranial margin of the device). After 36 hr, routine postinterventional echocardiography confirmed device embolization into the pulmonary artery. The child was asymptomatic. Transcatheter device retrieval with snares of different sizes, bioptomes, and retrieval forceps failed due to the mismatch of the diameter of the device and the small diameter of the pulmonary artery. Therefore, the device was retrieved surgically and the ASD closed by primary sutures. Secondary embolization of a Helex device complicated the closure of an uncomplicated atrial septal defect with a device-to-defect ratio according to the manufacturer's suggestion due to a mechanism not yet understood.