房间隔缺损合并肺动脉瓣狭窄介入治疗的临床评价

Combinedinterventional treatment in patients with pulmonary valve stenosis and atrial septal defect

目的：探讨房间隔缺损（ASD）合并肺动脉瓣狭窄（PS）行介入治疗的临床安全性及其疗效。方法：31例患者,年龄2.5~67（中位年龄31）岁;24例经胸超声心动图（TTE）诊断为ASD合并PS,房间隔缺损最大直径为7~27（16.0±4.8）mm,7例超声心动图术前漏诊ASD,肺动脉瓣狭窄压差35~120（89.8±22.9）mm Hg（1mm Hg=0.133k Pa）,所有患者术前行右心室造影检查。先行经皮球囊肺动脉瓣成形术（PBPV）,而后置入房间隔缺损封堵器闭合缺损,选择的封堵器直径为12.0~38.0（22.6±5.9）mm。结果：本组28例行PBPV术及ASD介入封堵治疗28均获得成功;其中3例封堵器脱落入主动脉,介入方法取出后,再置入较大封堵器封堵成功,PBPV术后即刻右室收缩压由术前（89.8±22.9）mmHg下降至（39.8±11.3）mm Hg,肺动脉右心室跨瓣压差由术前mm Hg降至（14.8±8.9）mm Hg（P〈0.001）。右心室舒张末压由术前（9.9±0.28）mm Hg降至（5.07±0.57）mm Hg（P〈0.005）,PBPV术后即刻跨瓣压差下降达优良为100%。术后超声心动图随访于术后即刻、1、3及6个月,疗效满意,房间隔未见残余分流。结论：同期介入治疗肺动脉瓣狭窄合并房间隔缺损安全可行,效果良好,但由于合并PS患者,超声心动图术前常常低估或漏诊ASD,因此,需先行肺动脉瓣球囊扩张术后,超声心动图重新复核ASD大小,再行ASD封堵术,必要时分期手术。

Objective：To investigate the methodology and follow -up results for combined interventional treatment in patients with congenital pulmonary valve stenosis and atrial septal defect. Methods：Thirty-one patients of age ranged from 2.5 -67 （midian age 31 ）years with puhuonary valve stenosis and atrial septal defect, twenty-four patients diagnosed by transthoracic eehocardiography,seven patients missed-diagnosed by transthoracic echoeardiography , pulmonary transvalvular pressure gradient 1 35 - 120 （64.9 ±21.5 ） mmHg, 1mmHg =0. 133kPal , all patients preformed right ventricular angiograghy. The atrial septal defect echo diame- ter was 7 - 27 （ 16.0 ±4.8 ）mm. All patients underwent percutaneous balloon pulmonary valvuloplasty initially. Atrial septal defect was closed later using atrial septal oceluder. The occlusion device diameter was 12.0 - 38.0（22.6 ± 5.9） mm. Results：28 patients were treated successfully, occluder dislodged in 3 patients, all were retrieved using a transcatheter approach and larger occlude were implanted successly. After the procedure, right ventricular systolic pressure decreased from （ 89.8 ± 22.9） mmHg to （ 39.8 ±11.3 ） mmHg, transvalvular pressure gradient decreased from （64.9 ±21.5） mmHg to （ 14.8 ±8.9） mmHg（P 〈 0.001 ）. Right ventricular end-diastolic pressure decreased from （ 9.9 ±0.28 ） mmHg 降至 （ 5.07 ±0.57 ） mmHg （ P 〈 0. 005 ） , The transvalvular gradient decreased continuously during the follow-up. Transthoracic echocardiography was performed immediately after the procedure and also on the first, third and sixth month later to follow up the outcome. No residual shunt of atrial septal was found in all patients. Conclusion ： Combined percutaneous treatment in patients with pulmonary valve stenosis and atrial septal defect is effective and safe. Atrial septal defects are often underestimated or missed by echocardiography in those patients suffering from atrial septal defect with pulmonary valve stenosis. So, after percutaneous balloon pulmonary valvuloplasty, the size of atrial septal defect should be further estimated before percutaneous atrial septal defect occlusion. Percutaneous atrial septal defect occlusion should be executed at another scheduled time if it is not appropriate to be executed at the same time with percutaneous ballon pulmonary valvuloplasty.