60岁以上老年继发孔型房间隔缺损的治疗策略(附139例临床分析)

Strategy of treatment for secundum atrial septal defect in patients older than 60 years of age

目的:介绍老年继发孔型房间隔缺损(ASD)的几种治疗方法,并分析其治疗效果。方法:自2002年1月至2009年6月,我院收治的139例60岁以上的老年继发孔型ASD病例。其中43例行经导管房缺封堵术;21例行微创经胸房缺封堵术;55例行体外循环下房缺修补术;20例因各种原因未行手术,给予药物保守治疗。结果:导管封堵组、经胸封堵组、和手术修补组患者均无死亡。术后远期随访导管封堵组,1例术后第4年死于脑出血。其余2组术后远期随访无死亡。房缺闭合术后心功能较术前明显改善,术后早期复查超声心动图均无残余分流,右心房、右心室明显缩小,肺动脉压力明显降低。保守治疗组,随访病例共有8例死亡。其中4例死于心力衰竭(心衰),1例死于心衰合并尿毒症,1例死于脑出血,1例死于呼吸衰竭,1例死因不详。结论:高龄本身并非老年房间隔缺损手术禁忌,老年患者通过封堵器或手术闭合房缺仍可以重构右心房、右心室,降低肺动脉压,显著改善心功能。3种闭合方法各有优缺点,应根据具体情况选择手术方式。

Objective：To review and analyze the results of several ways for treatment for atrial septal defect in the elderly in a single institution.Methods：139 patients aged from 60 to 89 years old（mean 66.32 ± 5.33）from January 2002 through June 2009,form the cohort of this study.Among them,43 cases underwent transcatheter closure of their ASDs with occluder device;21 cases underwent minimally invasive per-thoracic closure of their ASDs with occluder device;55 cases underwent ASD repair operation with cardiopulmonary bypass;20 cases did not undergo any operation except medical treatment for kinds of reasons.Results：Results：There were no operative death in all those patients who underwent transcatheter closure,trans-thoracic closure,and surgical repair of ASD.At the time of follow-up,all these patients were still alive except 1 died from cerebral haemorrhage 4 years after the transcatheter closure of ASD.The heart function was much better than preoperation in those patients.（In NYHA Class,pre-closure 3.08 ± 0.23 vs.post-closure 2.14 ± 0.19,n = 117,P 0.01）Post-operative ultrasound showed no residual shunt in those cases,both the right atrial and the right ventricular reduced significantly 〔the diameter of the right atrium：pre-closure（47.23 ± 10.12） mm vs.postclosure（38.25 ± 8.73） mm,n = 119 P 0.01〕,the diameter of the right ventricular：pre-closure（50.21 ± 9.37） mm vs.post-closure（40.29 ± 11.08） mm,n = 119,P 0.01）,the pulmonary pressure also decreased significantly 〔pre-closure（52.79 ± 24.94） mm Hg（1 mm Hg = 0.133 kPa） vs.post-closure（39.70 ± 16.03） mm Hg,n = 119,P 0.01〕.Among those who underwent no operation,8 cases had died before the time of follow-up：4 died from heart failure,1 from heart and renal failure,1 from cerebral hemorrhage,1 from respiratory failure,and 1from unclear reason.Conclusion：Age itself is not contraindication for the closure of ASD in the elderly.Closure of the ASD can still remodel the right atrium and ventricular,decrease the pulmonary artery pressure,and improve the cardiac function in the elderly patients.Appropriate selection of the way to close ASD and proper peri-operative therapy are keys for success of the operation.