房间隔缺损封堵器选择失败患者术前心脏CT血管造影资料再分析

Reanalysis of pre-procedural cardiac CT angiography for unfitted occluders in patients undergone percutaneous atrial septal defects closure

目的对房间隔缺损封堵器选择失败患者的术前心脏CT血管造影资料进行再分析,寻找封堵器选择失败的可能因素。方法回顾性研究2013年1月至2014年12月在阜外医院行房间隔缺损封堵术中曾经更换封堵器且于术前行CT血管造影检查的40例成年患者,再次分析其术前CT血管造影资料。评估图像质量,将其分为4级：优（Ⅰ级）,良（Ⅱ级）,不良（Ⅲ级）,差（Ⅳ级）。重新测量缺损大小,利用标准测量方法确定缺损长径与短径及等效圆直径,并与术前CT报告上缺损测量结果及成功封堵后封堵器腰部直径（参考标准值）对比。结果共40例患者术中曾更换封堵器,其中38例术中更换封堵器后手术成功,2例转外科手术修补。CT血管造影图像质量Ⅰ级者1例,Ⅱ级者17例,Ⅲ级者13例,均为冠状动脉三阶段注射模式;Ⅳ级者9例,其中肺动脉扫描模式2例,主动脉扫描模式1例,冠状动脉扫描模式下多发缺损4例,2例心腔内CT值过低,缺损大小无法测量。对于CT血管造影图像质量为Ⅰ-Ⅲ级能满足基本缺损测量且成功行介入治疗的29例患者,标准化测量值与术前CT报告测量值对比,差值为（3.74±5.32）mm;将标准化测量值和术前CT报告测量值分别与参考标准值相比,前者与参考标准值的差值更小[（-3.51±2.68）mm],相关性更强（相关系数0.94,P〈0.05）。结论房间隔缺损患者术前CT血管造影检查的图像质量及测量方法不规范是影响房间隔缺损评估的一项因素,规范化的CT血管造影检查及测量能有效避免术中更换封堵器。

Objective To reanalyze the pre-procedural cardiac CT angiography for unfitted occluders in paitents undergone percutaneous atrial septal defect （ASD） closure. Methods The study included 443 consecutive patients who underwent both cardiac muhideteetor CT and transeatheter ASD closure between January 2013 to December 2014. The CT angiography data of patients, who had experienced an failure in selection of a proper oceluder during the procedure of percutaneous atrial septal defect closure, were retrospectively review. Image diagnostic acceptability was graded using a four-point scale as follows： Ⅰ , excellent; Ⅱ , good; Ⅲ, fair and Ⅳ, poor. The ASD was re-measured for the eases of Grade Ⅰ to Grade Ⅲ. The size was compared with the measurement on the CT report and post-operative oecluder-waist size （POS）, and their correlation were further evaluated. Results Forty patients [ 15 males and 25 females, aged from 18 to 72 years, mean age （49.23 ± 13.59） years] were enrolled in the study. Transeatheter ASD closure were successfully performed finally in 38 cases for trying another occluder, and 2cases were referred to surgery. In the the aspect of image quality, 1 case was catagori in Grade Ⅰ , 17 in Grade Ⅱ , 13 cases in Grade Ⅲ and triphasic contrast injection protocol for coronary artery was used in them; 9 cases in Grade IV, CT angiography was performed for aorta artery and pulmonary artery in 3 cases without ECG gated control. In the other 6 cases performed in coronary artery CTA mode, 4 cases with multiple ASDs, and 2 cases with obscure image for the extremely low contrast agent concentration. For ASD re-calculating, the differences was statistically significant compared with the result in the CT report, and both were statistically significant compared with the reference standard. The re-measurements show a better correlation with POS （r = 0.94, P 〈0. 05） than the latter. Conclusions Standard CT angiography imaging technology and ASD measurement method is indispensible in precise evaluation of ASD, which may avoid ASO selection failure.