继发孔型房间隔缺损合并心房颤动经导管封堵的疗效观察

Effectiveness of Transcatheter Closure in Secundum-Type Atrial Septal Defect with Atrial Fibrillation

目的:探讨对继发孔型房间隔缺损(atrial septal defect,ASD)合并心房颤动(atrial fibrillation,AF)患者进行介入封堵治疗的围手术期并发症及疗效。方法:对36例合并AF的继发孔型ASD患者进行介入封堵治疗。术前发现有左心房或者左心耳血栓者予华法林治疗,当国际标准化比率(international normalized ratio,INR)维持在0.89～2.63(1.21±0.38),且经TEE证实无左心房及左心耳血栓时,在X线及体表超声心动图(transthoracic echocardiography,TTE)的引导下使用国产房间隔缺损封堵器(atrialseptal defect occluder,ASDO)进行封堵治疗。术后24h及1、3、6个月随访心电图、胸X线片和TTE。结果:2例患者术前TEE未见左心房血栓,但术前出现大脑前动脉和中动脉栓塞而未行介入封堵。其余34例患者均完成了介入封堵术,其中1例术后2h因心包填塞转至心外科手术,证实为左心房顶穿孔;1例使用2个封堵器,3例术中更换封堵器。手术后即刻成功率为97.1%,一次成功率88.2%。本研究中选用ASDO的直径为12～42(28.9±7.9)mm。在33例成功封堵的患者中,封堵术后半年内自行转复为窦性节律者8例,占22.2%;1例行心脏电复律治疗后也转复并维持窦性节律。随访中术后有残余分流者有3例,2例在术后6月、1例在术后1年随访TTE见残余分流消失。结论:合并AF的继发孔型ASD患者,在经TEE筛选并在术前进行充分抗凝治疗后对其进行介入治疗是有效和相对安全的。

Objective：To investigate the efficacy and perioperative complications of transcatheter closure for secundum type atrial septal defect（ASD） with atrial fibrillation（AF）.Methods： A total of 36 patients with ASD and AF underment transcatheter closure using atrial septal defect occluder（ASDO） which was made in China.Patients with thrombus in left atrium or left atrial appendage took warfarin,and the preoperative international normalized ratio（INR） of them were 0.89 to 2.63（1.21±0.38）.After confirmation of no thrombus in left atrium or left atrial appendage by transesophageal echocardiography（TEE） transcatheter closure was performed under the guide of X—rays and transthoracic echocardiography（TTE）.At the 24th hours,1st month,3rd months and 6th months after operation,electrocardiogram（ECG）,chest Xrays and TTE were done.Results： Two patients abandoned interventional closure because of thrombosis of anterior cerebral artery and middle cerebral artery before operation,although no thrombus was detected in left atrium or left atrial appendage in TEE.Among the 34 remaining patients who completed the interventional therapy,one case underwent surgery due to cardiac tamponade owing to perforation of the top of left atrium 2 hours after occlusion;two occluders were implanted in a double ASD case.Occluders were replaced in three cases.The immediate success rate was 97.1% and the total success rate was 88.2%.The diameters of ASDO ranged from 12 to 42（28.9±7.9） mm.Sinus rhythm recovery without any intervention was noted in eight patients within 6 months after the closure,one patient underwent electro-cardioversion therapy and convered to sinus rhythm.Residual shunt was detected in 3 cases 24 hours after occlusion,but no residual shunt was noted in TTE within 12 months after occlusion.Conclusions： Transcatheter closure is an effective and safe method for treating secundum type ASD with AF after a adequate preoperative anticoagulant therapy.TEE must be done before transcatheter closure to select appropriate patients.