房间隔缺损等效圆转换在封堵器选择中的初步应用

目的比较房间隔缺损长径CT血管造影术（CTA）测量值及等效圆直径（ECD）理论值与房间隔缺损参考标准之间的差异及相关性,探讨以等效圆转换解决房间隔缺损形状影响封堵器选择问题的可行性。方法前瞻性研究96例成功施行房间隔缺损封堵术患者,患者均于术前行冠状动脉CTA检查以除外冠心病,将患者冠状动脉CTA资料进行三维容积重建,采用CT横断序列辅助测量技术（CTAS）测量房间隔缺损的长径a（ASDa,a）与短径b（ASDb,b）,运用Zanchetta转换公式ECDz=（b4/a2+a2-b2）^1/2,计算ECD理论值,参考回归方程Y（ASO）=1.03X（ECDz）-0.45±1（mm）指导封堵器的选择。于术后第2日拍摄正、侧位胸片,在侧位胸片上测量封堵术后封堵器的腰部直径（POS）,以此作为房间隔缺损直径的参考标准。再分别运用等面积转换公式ECDs=（ab）^1/2、等周长转换公式ECDc=b+2（a-b）/π、以及等周长转换公式的简化公式ECDcs=b+2（a-b）/3计算各自的等效圆直径理论值。首先将各等效圆直径及ASDa分别与ASO型号相比较,筛查差值≥0 mm的病例数,并进行χ2检验;其次比较房间隔缺损三种等效圆直径理论值及ASDa与参考标准值间的差异,进一步分析各值与参考标准值及与术中选择使用的封堵器型号之间的相关性。结果 ASDa与ASO之差>0 mm者共8例,ECDz与ASO之差>0 mm者1例,Fisher’ Exact Test示P=0.017,差异有统计学意义;ECDs、ECDc及其简化形式ECDcs之差均>0 mm。各等效圆直径及ASDa与POS相比,ECDz标准差最大,为2.29 mm;ECDc标准差最小,为2.05 mm;ECDz与POS相关性良好（Y=1.10X+2.42;R2=0.89,P<0.05）,ASDa与POS的相关性与之相近（Y=0.98X+2.54;R2=0.89,P<0.05）,ECDc与POS的相关性最强（Y=1.06X+2.38;R2=0.91,P<0.05）。结论房间隔缺损等效圆转换能克服参考最大径选择封堵器的局限性,且等周长转换与金标准有更好的相关性,是指导封堵器选择的理想工具。     

房间隔缺损介入治疗封堵器选择的影响因素

目的 探讨房间隔缺损(ASD)介入治疗封堵器选择的影响因素.方法 1114例ASD患者,男388例,女726例,年龄2～75(26.3±17.0)岁.按14岁作为儿童与成人的划分点,成人组779例,平均年龄(34.4±13.5)岁;儿童组335例,平均年龄(7.3±3.9)岁.经胸超声心动图测量不同切面缺损大小及边缘长短,根据ASD最大直径选择封堵器,分析不同年龄、缺损形态和边缘大小时,选择封堵器的差别.结果 1114例ASD患者,成功封堵1085例,技术成功率为97.4%.1085例患者中,ASD最大直径为(19.7±7.8)mm,所选择的封堵器直径为(25.8±8.9)mm,封堵器与ASD最大直径差值为(6.1±3.4)mm,封堵器/最大直径为1.3∶1.成人和儿童组ASD大小相近,但成人组封堵器直径、封堵器加大值明显大于儿童组(P<0.05);封堵器/ASD最大直径成人组为1.2～1.8∶1,儿童组为1.1～1.6∶1.随着缺损直径的增大,成人组选择封堵器的加大值亦增加,但非成比例增加.儿童组随着缺损直径的增大,选择封堵器的加大值有增大的趋势,但差异无统计学意义.ASD的最大直径与封堵器的大小显著相关,成人和儿章组其相关系数分别为0.911和0.944(均P<0.01).以ASD最小直径/ASD最大直径的比例来描述缺损的形态,发现随着最小直径与最大直径比值的增大,各组间ASD最大直径或封堵器直径虽无差异,但封堵器加大值明显增大.主动脉侧无缘组选择的封堵器、封堵器加大值明显大于有缘组(均P<0.01).结论 介入治疗ASD,封堵器选择应以测量的ASD最大直径为主体,尚需参考年龄、缺损的形态及其边缘的状况适当增减.     

用Amplatzer房间隔缺损封堵器堵闭边缘不足的房间隔缺损

目的边缘＜5mm通常是房间隔缺损经导管堵闭的禁忌证,本研究探讨用Amplatzer房间隔缺损封堵器经导管堵闭部分边缘缺乏或边缘＜5mm的房间隔缺损的可行性.方法对23例边缘＜5mm的房间隔缺损患儿用Amplatzer封堵器进行堵闭,其中男10例,女13例,平均年龄10.7岁.20例经食道超声心动图或心内超声心动图测量的房间隔缺损前缘0～4mm,2例下缘为2mm,1例后缘为2mm.同期,48例边缘＞5mm的患儿做对照.结果全部23例边缘＜5mm的房间隔缺损患儿和48例对照儿均成功安装了封堵器.两组间年龄、缺损大小和所用封堵器大小无显著差异.23例边缘＜5mm的患儿中17例(73.9%)即刻完全堵闭,对照组44例(91.7%)即刻完全堵闭(P＜0.05);24h复查边缘＜5mm患儿及对照组的完全堵闭率分别是91.3%和93.8%(P＞0.05);6个月复查两组完全堵闭率分别是95.7%和95.8%(P＞0.05).与对照组比较,边缘＜5mm的患儿手术时间[分别为(72.5±26.5)和61.4±21.9min]和X线曝光时间[分别为(12.6±7.0)和(9.8±4.2)min]长.两组患儿术中和术后均未出现并发症.结论前、后或下缘＜5mm的房间隔缺损仍可以用Amplatzer房间隔缺损封堵器经导管堵闭,但长期手术效果尚待查明.     

房间隔缺损介入治疗封堵器的选择对心脏重构的影响

目的 探讨经导管介入封堵术治疗继发孔型房间隔缺损(ASD)的封堵器选择对其疗效及心脏形态学重构的影响.方法 入选146例ASD患者,年龄13.5～70.0(33.5±12.4)岁.其中73例(A组)根据椭圆周长数学公式计算缺损直径选择封堵器型号,另外73例(B组)根据超声心动图测量长径选择封堵器型号.应用经胸超声心动图分别测量ASD患者经导管封堵治疗术前、术后3 d、3个月和6个月的左心房收缩末期横径(LALD)、右心房横径(RALD)、RALD/LALD比值、右心室舒张末期内径(RVDD)、左心室舒张末期内径(LVDD)、RVDD/LVDD比值及肺动脉内径.结果 A组缺损内径为(20.16±4.98)mm,B组为(21.36±5.69)mm,差异无统计学意义.封堵器直径A组小于B组[(21.95±6.78)mm比(25.85±6.75)mm,P<0.05].142例封堵术成功,两组成功率差异无统计学意义,无主要手术相关并发症发生.随访6个月无残余分流发生.两组患者随访期间RALD、RVDD、RALD/LALD和RVDD/LVDD比值明显下降,肺动脉内径逐渐缩小,LALD、LVDD逐渐增大.A组改善心房重构程度明显大于B组(P<0.05).结论 椭圆形周长公式在非圆形ASD封堵器选择中具有重要应用价值;封堵器大小对心脏重构有明显影响.     

房间隔缺损介入治疗封堵器的选择对心脏重构的影响

Objective To evaluate the effects on cardiac remodeling post transcatheter closure by Amplatzer septal occluder selected by oval circumference formula in patients with atrial septal defect (ASD). Methods A total of 146 patients with ASD (68 males,mean 33.5 years) treated by transcatheter closure with the Amplatzer oceluder were enrolled in this study. The diameter of defects was corrected with the oval circumference formula (group A, 73 cases) or by echocardiography (group B, 73 cases). Cardiac remodeling was assessed by transthoracie echocardiography (TIE) before the procedure, 3 days, 3 months and 6 months after ASD closure. Results The mean ASD diameter was similar between the two groups [(20.16±4.98) mm vs. (21.36±5.69) mm, P > 0.05] and the mean diameter of the selected occluder of group A was significantly smaller than that in group B [(21.95±6.78)mm vs. (25.85±6.75)mm, P< 0.05]. Procedural success rate was identical between the two groups (97.3%) and the defects were completely occluded and there was no residual shunt during the 6 months follow up period, there were also no complications during and after the procedure. The lateral diameter of right atrial (RALD), the diastolic diameter of right ventricle (RVDD), RALD/LALD, RVDD/LVDD and pulmonary diameter (PD) were significantly decreased while the lateral diameter of left atrial (LALD) and left ventricle (LVDD) were significantly increased post ASD closure in both groups. At 6 months follow up, BALD decreased by (18.63±10.59) % in group A versus (10.14±6.59) % in group B, LALD increased by (13.42± 8.38) % in group A versus (9.28±4.95) % in group B and RALD/LALD ratio decreased by (26.35± 11.24)% in group A versus (13.98±8.96) % ingroupsB (all P<0.05).Conclusion ASD occluder selection based on the oval circumference formula is superior to that made by echocardiography in terms of more favorable cardiac remodeling post ASD closure.     

Amplatzer封堵器在经导管封堵房间隔缺损中的临床应用

评价应用Amplatzer封堵器经导管封堵房间隔缺损(ASD)的疗效。研究证明该方法是一种有效的非手术方法,具有操作简便、安全、技术成功率高及封堵效果好等优点,适合于各年龄组继发孔型ASD的介入治疗。其临床应用的远期疗效尚需继续观察。     

高海拔地区老年患者房间隔缺损的介入治疗

目的探讨高原地区经导管介入封堵治疗老年患者房间隔缺损(ASD)的有效性和安全性。方法回顾性分析经导管封堵治疗的51例老年ASD患者的临床和介入治疗资料。结果全组治疗成功率90.2%,经胸超声心动图(TTE)测量ASD平均大小为(24.3±5.8)mm,封堵器平均大小为(28.2±8.6)mm,均采用国产封堵器。术后3个月平均肺动脉收缩压较术前下降明显(P<0.05),右心房、右心室内径较术前减小。微少量残余分流3例,3个月后复查分流消失。并发症发生率11.8%,无死亡。随访6⁴2个月,封堵器无移位,心功能改善。结论高原地区老年ASD患者有缺损大,肺动脉高压程度严重,并发症多的特点。严格掌握适应证,规范操作,积极治疗并发症,是成功封堵的关键。     

左盘外包膜房间隔封堵器治疗卵圆孔未闭的实验研究

目的 评价国产左盘外包膜房间隔封堵器治疗卵圆孔未闭的疗效和安全性.方法 广西巴马小型猪共12只,穿刺其卵圆窝建立卵圆孔未闭动物模型.在X线透视下以国产左盘外包膜房间隔封堵器进行卵圆孔未闭的封堵.术后1、2、3和6个月行超声心动图检查后处死实验动物,对标本进行病理检查.结果 所有封堵器均未观察到血栓和赘生物,封堵器边缘金属丝无断裂、变色、腐蚀.术后6个月的超声心动图检查未显示心房水平分流.封堵器和周边的房间隔组织紧密连接,封堵器表面的胶原组织和内皮层逐渐增厚,炎症逐渐消退.结论 左盘外包膜房间隔封堵器具有良好的生物相容性,内皮化迅速且完全,可以有效地封堵卵圆孔未闭.     

老年房间隔缺损患者介入治疗的临床分析

目的 探讨老年房间隔缺损患者的临床特征及行经导管封堵治疗的安全性和有效性.方法 入选2000年5月至2010年6月行经导管封堵治疗的(64.5±3.8)岁房间隔缺损患者82例.经导管封堵术中行右心导管检查.术后1d、1个月、3个月和6个月进行随访.分析老年房间隔缺损患者的临床特征,观察房间隔缺损封堵前后肺动脉压及心功能的改变情况.结果 82例房间隔缺损患者中,合并肺动脉高压37例,发生率为45.1％.封堵前的右心导管检查显示,患者肺动脉收缩压为(44.1±12.4)mm Hg(1 mm Hg=0.133 kPa),肺动脉平均压为(25.2 +6.8)mm Hg.1例重度肺动脉高压患者不适宜经导管封堵治疗,其余81例均成功行介入治疗,无手术相关并发症.36例封堵成功的肺动脉高压患者肺动脉收缩压由术前的(52.7±10.3)mm Hg下降至术后的(31.8 +6.3)mm Hg(P＜0.05),肺动脉平均压由术前的(30.9±4.7) mm Hg下降至术后的(21.8±3.4) mm Hg(P＜0.05).与术前比较,术后1d、1个月、3个月和6个月NYHA心功能分级改善.术后新发心房颤动6例.结论 老年房间隔缺损患者通常合并肺动脉高压.只要严格掌握适应证和规范操作,经导管封堵治疗老年房间隔缺损仍是一种安全有效的方法.     

永久性心脏起搏器植入术中发生心房纤颤时心房电极导线定位经验

目的:研究永久性心脏起搏器植入术中心房纤颤(房颤)发作时以右心房波振幅最大处为右心房电极导线固定位置的可行性。方法:22例房颤发作时植入右心房电极导线的患者术中,测试右心房波振幅,术后随访恢复窦性心律(窦律)时测试右心房波振幅、起搏阈值,2者进行对比分析。结果:房颤心律时,所测得的右心房振幅与转为窦律后所测得的右心房波振幅有较好相关性,2者差异无统计学意义[(2.4±1.0)mv比(2.7±1.2)mv,P>0.05]。房颤时术中右心房波振幅平均(2.4±1.0)mv(1.6～3.7mv)者,在房颤转为窦律后所测定的心房感知和起搏功能良好。结论:在房颤发作时,右心房波振幅作为永久心脏起搏器合适的感知及起搏参数,有一定的临床实用价值。     

Standard right atrial ablation is effective for atrioventricular nodal reentry with earliest activation in the coronary sinus

INTRODUCTION: Reports suggest that coronary sinus (CS) or left atrial ablations may be necessary for treatment of AV nodal reentrant tachycardia (AVNRT) with earliest retrograde atrial activation in the CS. We assessed the efficacy of standard right atrial catheter ablation approaches in these tachycardias and determined the incidence of earliest activation in the CS in AVNRT. METHODS AND RESULTS: We retrospectively evaluated intracardiac recordings from 225 consecutive patients who underwent electrophysiologic studies and radiofrequency (RF) ablation for AVNRT in two institutions. Atrial activation during AVNRT was evaluated using multiple catheters according to standard protocol used in our laboratories. RF ablations in the triangle of Koch were performed in all patients. Eighteen of 225 patients (8%) had earliest activation in one of the CS poles. The demographics and AVNRT characteristics of these 18 patients were similar to those of the other 207 patients who did not have CS as earliest activation site and included both typical and atypical AVNRT. Following RF ablation, none of the 18 patients had inducible AVNRT. CONCLUSION: Successful RF ablation can be performed at standard sites in the triangle of Koch regardless of earliest site of atrial activation. The incidence of CS as earliest retrograde atrial activation site in AVNRT is 8%.     

Right atrial blood cyst with total occlusion of the right coronary artery

Cardiac blood cysts are rarely seen in adult patients and in the right atrium. The origin of cardiac blood cysts is not understood, and several hypotheses have been proposed. We present a rare case of right atrial blood cyst with total occlusion of the right coronary artery (RCA). Inflammatory processes may have played an important role in the development of the cyst, because infiltration of inflammatory cells was observed in the cystic wall. Additionally, total obstruction of the proximal RCA indicated that ischemia and/or infarction in the right atrium might be related to formation of the cyst.     

Effect of coronary sinus electrode on the optimal atrial defibrillation pathway for an atrioventricular defibrillator

INTRODUCTION: Previous studies have demonstrated significant failure in converting atrial fibrillation (AF) using a conventional ventricular pathway. The aim of this study was to assess the benefit of incorporating a coronary sinus (CS) lead into the atrial defibrillation pathway in atrial defibrillation threshold (ADFT) reduction in patients with persistent AF. METHODS AND RESULTS: This study was a prospective, randomized assessment of shock configuration on ADFT in 18 patients undergoing elective internal cardioversion for persistent AF (mean AF duration: 8 +/- 9 months). The lead system included a dual-coil defibrillation lead (Endotak DSP, Guidant) with a distal right ventricular (RV) electrode and a proximal superior vena cava (SVC) electrode, a CS lead (Perimeter, Guidant), and a left pectoral cutaneous electrode (Can). In each patient, dual step-up ADFTs were determined for each of three vectors: (1) RV --> SVC+Can; (2) CS --> SVC+Can; and (3) RV --> CS+SVC+Can (group 1, n = 8) or RV+CS --> SVC+Can (group 2, n = 10), using R wave-synchronized biphasic shocks. Successful defibrillation was achieved in all patients without any ventricular proarrhythmia. ADFT of CS --> SVC+Can (11.8 +/- 5.6 J) was significantly lower than ADFT of RV --> SVC+Can (16.5 +/- 7.8 J, P = 0.021). ADFT of CS --> SVC+Can was similar to RV --> CS+SVC+Can (group 1: 12.0 +/- 6.5 J vs 17.4 +/- 4.8 J, P = 0.16), but it was significantly higher than RV+CS --> SVC+Can (group 2: 9.0 +/- 3.9 J vs 11.6 +/- 5.0 J, P = 0.049). CONCLUSION: Patients with persistent AF of substantial duration can be reliably cardioverted using a conventional implantable cardioverter defibrillator (ICD) lead set; however, the incorporation of a CS lead to the conventional ICD lead configuration significantly lowered ADFT. The optimal shock vector that incorporates a CS lead for atrial defibrillation requires future studies.     

Early human experience with use of a deflectable fiberoptic endocardial visualization catheter to facilitate coronary sinus cannulation

BACKGROUND: Despite improvements in cardiac resynchronization therapy (CRT) implantation techniques, a significant minority of CRT attempts are unsuccessful. Inability to cannulate the coronary sinus (CS) because of difficult anatomy is a major reason for unsuccessful CRT implantation. Direct visualization of intracardiac structures during the implant may facilitate access into the CS. The present study describes CRT implantation with the aid of an endocardial visualization catheter (EVC). METHODS: Fifty-eight consecutive patients (mean age 72 +/- 12 years; ejection fraction 26.2% +/- 7.0%; New York Heart Association [NYHA] class 2.9) underwent CRT implantation using a steerable fiberoptic EVC (Acumen Medical, Inc., Sunnyvale, CA). RESULTS: The EVC was able to visualize the CS ostium in all cases. The CS was successfully cannulated in 57 (98.3%) of 58 patients. The time from vascular access to CS visualization was 6 +/- 5 minutes, and the total time to CS access was 8 +/- 6 minutes. Successful left ventricle (LV) lead implantation was accomplished in 55 (94.8%) of 58 patients. Three patients who had a previous history of failed LV lead implantation were successfully implanted using the EVC. CONCLUSION: Fiberoptic imaging of intracardiac structures during CRT implantation may be performed rapidly in a wide range of patients with an EVC. The ability to visualize right atrial anatomy may aid CS access and LV lead implantation.     

国产封堵器治疗房间隔缺损疗效评价

目的　通过与Amplatzer封堵器临床疗效比较 ,评价国产封堵器治疗房间隔缺损 (ASD)的效果。方法　选择 6 0例ASD患者 ,男 2 2例 ,女 38例 ,年龄 3～ 5 6岁。采用配对方式分两组 ,介入治疗与随访由同一组医师负责 ,比较两组患者临床疗效、手术操作难易程度及并发症发生情况。结果　两组患者介入封堵术技术成功率 10 0 % ,术后即刻肺动脉压力较术前显著下降 ,两组间即刻残余分流、封堵器回收再放置、X线透视时间差异无显著性。结论　国产封堵器与Amplatzer封堵器技术要求相似 ,均具有操作简便、效果可靠、成功率高、安全等优点 ,但两种封堵器价格差异显著 ,从经济角度考虑 ,条件合适时应选择国产封堵器。     

Coil reduction of the right ventricular cavity in a boy with pulmonary atresia, intact ventricular septum, and an aneurysmal coronary sinusoid.

Coronary sinusoids are often found in patients with pulmonary atresia and intact ventricular septum. We report on a 4-year-old boy with such pathology in whom, after completion of the Fontan-circulation, the pulsatile flow through a major sinusoid significantly increased the size of a coronary artery up to aneurysmal dimensions. Because percutaneous closure of the sinusoid was unsuccessful, the right ventricular cavity was partially obliterated with coils. This resulted in a significant decrease of right ventricular stroke volume, regression of the pulsatility and of the coronary size, with good clinical result at 1.5 years of follow-up.     

合并慢性左心衰竭的老年冠心病患者经桡动脉介入治疗的临床评估

目的 探讨经桡动脉介入治疗老年冠心病合并慢性左心衰竭患者的临床疗效和安全性. 方法 120例老年冠心病合并慢性左心衰患者,根据介入治疗术式的不同分为经桡动脉治疗组64例,经股动脉治疗组56例;回顾性分析X线曝光时间,术后卧床时间及并发症发生率等. 结果 桡动脉组穿刺并介入治疗成功者60例,共成功扩张病变75处,其中前降支38处,回旋支19处,右冠状动脉18处,行支架置入73枚.股动脉组手术穿刺并介入治疗成功者54例,共成功扩张病变63处,其中前降支36处,回旋支12处,右冠状动脉15处,共行支架置人61枚.两组介入治疗情况及病变程度差异无统计学意义.桡动脉组较股动脉组穿刺至置管时间延长,平均卧床时间缩短,卧床期间急性左心衰发生率减少(均P＜0.01);桡动脉组穿刺并发症、下肢深静脉血栓发生率、体循环和肺栓塞发生率均较股动脉组减少(均P＜0.05).股动脉组腰背疼痛、排尿困难、腹胀发生率明显高于桡动脉组(P＜0.05). 结论 经桡动脉介入治疗老年冠心病合并慢性左心衰竭安全性高,相比经股动脉径路占有诸多优势.     

Arteriographic demonstration of both kinking at the origin and compression between the great vessels of an anomalous right coronary artery arising in common with a left coronary artery from above the left sinus of valsalva

Angled angiographic views demonstrated two areas of significant systolic narrowing in an anomalous right coronary artery arising in common with a left coronary artery from above the left sinus of Valsalva: (1) an ostial stenosis due to kinking as the anomalous artery turned sharply to the right after its origin from the aorta; (2) compression of the proximal segment as it coursed between the aorta and pulmonary artery. Appropriate angiographic studies to evaluate the presence of these changes may help to elucidate their significance.     

Single coronary artery from the right aortic sinus of Valsalva with anomalous prepulmonic course of the left coronary artery

Cardiac computed tomography allows for improved, noninvasive and accurate visualization of coronary artery anomalies. The case of a single coronary artery with origin from a single ostium in the right sinus of Valsalva with an anomalous course of the left coronary artery anterior to the pulmonary trunk is presented. The unusual distal reconstitution of a normal anatomical course at the junction of the mid and distal left anterior descending artery with occlusion of the proximal circumflex artery has not, to the authors’ knowledge, been previously described.