房间隔缺损合并肺动脉瓣狭窄患者同期行介入治疗的疗效评价
【关键词】 房间隔缺损
Concurrent percutaneous atrial septal defect closure and pulmonary valvuloplasty
【Abstract】 AIM: To evaluate the effectiveness and short term results of combined percutaneous ballon pulmonary valvuloplasty (PBPV) and atrial septal defect closure for pulmonary valvular stenosis （PS） associated with seccundum atrial septal defect （ASD） . METHODS: Eight patients, 3~37 （13±15）years old, were confirmed with ASD in association with PS by transthoracic echocardiography (TTE). Percutaneous balloon pulmonary valvuloplasty (PBPV) was done initially; ASD was closed later using Amplatzer occluder device under guidance of fluoroscopy and transesophageal echocardiography (TEE)or TTE, TTE were performed immediately and 24 h, 1 mo, 3 mo and 6 mo after occlusion to evaluate the efficiency. RESULTS: The procedure was successful in all 8 patients. Right ventricular systolic pressure significantly decreased from (11.57±4.09) kPa to ［5.49±2.09 kPa (P<0.001)］. The transpulmonary valve systolic gradient significantly decreased from (7.57±4.49) kPa to ［1.89±1.63 kPa (P<0.001)］ immediately after PBPV; No residual shunt of atrial septal was found in 8 patients immediately after the procedure and in the followup. CONCLUSION: Simultaneous PBPV and closure of the ASD appears to be an effective and safe modality for PS associated with ASD .It should be an alternative to surgery.
【Keywords】 heart septal defects, atrial; pulmonary valve stenosis; heart catheterization
【摘要】 目的： 初步评价房间隔缺损合并肺动脉瓣狭窄同期行介入的疗效. 方法： 8例患者，年龄3~37（13±15）岁，经临床及超声心动图确诊为房间隔缺损合并肺动脉瓣狭窄. 术前行彩色多普勒超声心动图检查，术中均行右室造影证实诊断. 首先在透视下经皮球囊肺动脉瓣成形术（PBPV）治疗肺动脉瓣狭窄（PS）, 术后即时右心导管观察右心室压力和跨肺动脉瓣压力压差变化；然后在食管超声心动图或经胸超声心动图监视下经导管置入Amplatzer伞封堵房间隔缺损，术后即时行超声心动图，术后24 h, 1 mo, 3 mo和6 mo分别行经胸超声心动图评价房间隔缺损治疗效果. 结果： 8例患者疗效均佳，PBPV术后即刻右室收缩压由(11.57±4.09) kPa降至(5.49±2.09) kPa (P<0.001)，肺动脉至右心室跨瓣压差由(7.57±4.49) kPa降至(1.89±1.63) kPa (P<0.001). 房间隔未见残余分流. 结论： 房间隔缺损合并肺动脉瓣狭窄同期行介入治疗疗效可靠，是外科治疗的一种有效替代治疗.
【关键词】 房间隔缺损；肺动脉瓣狭窄；心脏导管插入术
0引言
房间隔缺损（ASD）是常见的先天性心脏病，以往手术是其唯一的治疗方法. 随着介入医学的，已有若干器械应用于ASD的介入治疗,其中Amplatzer封堵器具有操作简便、成功率高、残余分流发生率低等优点，现在国内外广泛用于ASD的治疗［1-6］. 经皮球囊肺动脉瓣成形术（PBPV）是一种解除单纯肺动脉瓣狭窄（PS）的非手术疗法［7-9］. 但是对于ASD合并PS同期行介入治疗国内外报道较少. 我们从1998年4月开始应用Amplatzer伞封堵ASD，其中8例合并PS，成功地进行了同期行介入治疗，现报道如下.
1对象和方法
1.1对象199804/200212,8(男3, 女5)例均经临床体征、X线胸片、心电图及彩色多普勒超声心动图或经食管超声心动图（TEE）确诊为ASD合并PS ,同期采用PBPV介入治疗PS和Amplatzer伞封堵ASD. 均可于胸骨左缘2~3肋间闻及Ⅲ级以上收缩期喷射性杂音，7例闻及肺动脉瓣区收缩早期喷射音. 7例心电图显示右室肥厚. X光片见肺血减少，肺动脉段向上突出. 术前行彩色多普勒超声心动图检查，术中均行右心导管和右室造影证实诊断.
1.2经皮球囊肺动脉瓣成形术操作见［10］.
1．3ASD的介入治疗 ① Amplatzer封堵器： 美国AGA公司制造，由具有自膨胀性的双盘及连接双盘的“腰部”三部分组成. 双盘及“腰部”均系镍钛记忆合金编制的密集网状结构，双盘内充高分子聚合材料；“腰部”的直径决定可封堵的ASD的大小，根据腰部的直径分为4～38 mm等27种型号. 输送器由内芯和外鞘组成，鞘管外径为8 F 12F. ② 封堵术过程： 在经食道超声心动图（TEE）或经胸超声心动图（TTE）指导下完成ASD的封堵治疗［11］.
统计学处理：数据以x±s表示，组间比较采用配对t检验.
2结果
术中均行右心导管检查，右室收缩压为(11.57±4.09) kPa，肺动脉至右心室跨瓣压差为(7.57±4.49) kPa. PBPV术后即刻右室收缩压降至(5.49±2.09) kPa (P<0.001与术前相比)，肺动脉至右心室跨瓣压差降至(1.89±1.63) kPa (P<0.001与术前相比). PBPV后1例发生右室流出道痉挛，口服普萘洛尔3~6 mo，超声随访6 mo右室一肺动脉收缩压差明显下降.
8例ASD直径TTE为5~16（9.2±7.4） mm，选择的封堵器直径为8~20（13.0±9.2） mm，4例在TEE指导下完成ASD封堵器置入，另4例TTE指导下完成ASD封堵器置入. 8例封堵器置入均成功，技术成功率100%. 术中未发生任何并发症，无急诊手术病例. 术后即刻TEE或TTE显示8例（100%）的ASD封堵完全，封堵器位置良好，未对毗邻解剖结构产生影响. 随访6 mo，均未见封堵器移位及ASD再通，右房、室内径基本恢复正常. 未见其他并发症的发生.
3讨论
对单纯PS来说，PBPV是解除右室流出道梗阻的有效方法［7-9］. 事实上，已有报道PBPV用于瓣膜下狭窄导致的左右心室流出道梗阻的解除. 大部分ASD患者可采用各种介入治疗措施（ASDO）代替外科治疗［1-6］. 但是，对于ASD合并PS患者一次同期行介入治疗国内外报道较少. 对本研究8例ASD合并PS患者我们进行了一次同期行介入治疗，取得了良好效果，右室流出道梗阻得到有效缓解，房水平左向右分流完全消失，随访结果令人满意. 虽然PBPV和ASDO作为单纯的治疗方法已分别用于PS和ASD的治疗，我们的经验表明对ASD合并PS同期行介入治疗是有效而且安全.
ASD合并PS时行介入的适应证是符合PBPV的条件同时合并的继发孔型ASD适合介入治疗. 具备PBPV和ASDO经验者均具有一次同期行介入治疗复合畸形的技术条件，必须首先行PBPV，以免先行ASDO后PBPV失败需行外科治疗，给患者造成不必要的痛苦和负担. 当行PBPV时应避免球囊挤入右室流出道而出现激惹现象，致右室压力不降甚而升高，影响疗效判定. 若果出现上述情况导致右室流出道痉挛，应给予(受体阻滞剂治疗并暂缓ASDO，观察一段时间后行ASDO. ASDO的经典方法是在经食道超声心动图指导下完成操作，随着经验的积累准确的经胸超声心动图可满足术中需要［12-14］.
ASD合并PS较单纯PS引起的心肌损伤重，右心室顺应性下降是引起患者心功能储备减低和运动负荷能力下降的重要原因. 如果采用外科的方法在体外循环下行ASD修补的同时作肺动脉瓣切开与肥厚的漏斗部肌肉切开，甚至采用人造补片扩大流出道，必然进一步心室顺应性下降，对患者术后康复远不如介入治疗.
总之，对ASD合并PS患者一次同期行介入治疗是有效而安全的，只要适应证选择正确，可代替外科手术.
【】
［1］ Zhang YS, Jia GL, He Z, Luan RH, Zhang J, Wang XY. Transcatheter closure of secundum atrial septal defects using Amplatzer occluder device ［J］. Xinzang Zazhi (Chin Heart J), 2000;12(5):379-381.
［2］ Hijazi ZM, Cao Q, Patel HT, Rhodes J, Hanlon KM. Transesophaphageal echocardiographic results of catheter closure of atrial septal defect in children and adults using Amplatzer device ［J］. Am J Cardiol, 2000;85(11):1387-1390.
［3］ Thanopoulos BD, Laskari CV, Tsaousis GS, Zarayelyan A, Vekiou A, Papadopoulos GS. Closure of atrial septal defect with the Amplatzer occlusion device: Preliminary results ［J］. J Am Coll Cardiol, 1998;321(5):1110-1116.
［4］ Zhang YS, Dai ZX, Liu JP, Zhang J, Li H, Jia GL. Transcatheter closure of secundum atrial septal defects using Amplatzer occluder device with transthoracic echocardiography ［J］. Xinzang Zazhi I (Chin Heart J), 2001;13（5）：373-395.
［5］ Dai ZX, Zhang YS, Li H, Jia GL, L JP, Zhang J, Wang XY. Transcatheter closure of complex atrial septal defects ［J］. Xinzang Zazhi (Chin Heart J), 2002;4(2):152-156.
［6］ Rao PS, Berger F, Rey C, Haddad J, Meier B, Walsh KP, Chandar JS, Lloyd TR, de Lezo JS, Zamora R. Sideris EB. Results of transvenous occlusion of secundum atrial septal defects with the fourth generation buttoned device: comparison with first, second and third generation devices. International Buttoned Device Trial Group ［J］. J Am Coll Cardiol, 2000; 36(2):583-592.
［7］ Hofbeck M, Singer H, Buheittel G, Ries M. Balloon valvuloplasty of critical pulmonary valve stenosis in a premature neonate ［J］. Pediatr Cardiol, 1999;20(2):147-149.
［8］ Tulzer G, Arzt W, Franklin RC, Loughna PV, Mair R, Gardiner HM. Fetal pulmonary valvuloplasty for critical pulmonary stenosis or atresia with intact septum ［J］. Lancet, 2002;360(9345):1567-1568.
［9］ Trani C, Rigattieri S, Mazzari MA, Lombardo A, Pennestri F, Violini R, Pucci E, Crea F, Schiavoni G. Combined percutaneous pulmonary valvuloplasty and patent foramen ovale closure in an adult with recurrent transient ischemic attacks ［J］. Ital Heart J, 2002; 3(7):424-426.
［10］ Fawzy ME, Awad M, Galal O, Shoukri M, Hegazy H, Dunn B, Mimish L, Al Halees Z. Longterm results of pulmonary balloon valvulotomy in adult patients ［J］. J Heart Valve Dis, 2001;10(6):812-818.
［11］ Zhang YS, Jia GL, Liu JP, Dai ZX, Li H, Zhang J, Wang XY, Ma XT. Evaluation of treatment efficiency of transcatheter closure of secundum atrial septal defects using Amplatzer occluder device ［J］. Xinzang Zazhi (Chin Heart J), 2001;13(6):476-478.
［12］ Zhang YS, Dai ZX, Jia GL, Zhang J, Li H, Wang XY. Feasibility of transcatheter closure of atrial septal defect with Amplatzer septal occluder selected directly guidedby transesophageal echocardiography measured diameter ［J］. Disi Junyi Daxue Xuebao (J Fourth Mil Med Univ), 2001;22(21):1921-1923.
［13］ Zhang YS, Li H, Zhang J, Jia GL, Dai ZX, Wang XY.Transthoracic echocardiographic guidance for closure of secundum atrial septal defects with the Amplatzer septal occluder device in adults ［J］. Disi Junyi Daxue Xuebao (J Fourth Mil Med Univ), 2002;23(1):28-30.
［14］ Zhang YS, Zhang J, Li H, Jia GL, Dai ZX, Wang XY. Feasibility of transcatheter closure of atrial septal defect with Amplatzer septal occluder guided directly by transthoracic echocardiography measured diameter ［J］. Disi Junyi Daxue Xuebao (J Fourth Mil Med Univ), 2002;23(2):181-183.
