置入房间隔缺损封堵伞的形态对术后头痛的影响

Association between the morphology of the implanted atrial septal defect occluding umbrella and postoperative headache

目的探讨房间隔缺损(ASD)大小、封堵伞型号及封堵伞释放后形态变化等因素是否影响ASD患者在封堵术后出现头痛症状。方法纳入自2014年1月至2017年12月在北部战区总医院成功行ASD封堵术患者567例。根据患者封堵术后有无头痛症状分为有症状组和无症状组。采用X线下导管校准法测量释放后封堵伞展开直径(d)、厚度(L)、封堵伞左侧伞面的最大直径(D2),并计算i值(计算公式为i=D2/L)。分析两组在年龄、性别等生理因素,缺损大小、i值等相关因素之间的差异,对有组间差异的因素进一步行多因素logistic回归分析,探讨ASD封堵术后出现头痛症状的影响因素。在无症状组中采用线性回归分析封堵伞型号与ASD直径的关系。结果共纳入567例成功置入单封堵伞的继发孔型ASD患者,其中男性148例(26.1%),年龄(34.4±19.4)岁。随访时间为(12.7±2.8)个月。有症状组51例,无症状组516例。有症状组患者通过强化抗血小板治疗,有29例术后头痛症状消失或有不同程度减轻。有症状组和无症状组的ASD最大直径(TTE测量)和封堵伞型号差异无统计学意义(P均>0.05)。有症状组的d值[(19.80±6.67)mm比(17.40±7.28)mm,P=0.041]、D2[(43.29±7.41)mm比(39.20±9.59)mm,P=0.013]、L值[(13.06±3.72)mm比(10.19±2.90)mm,P=0.025]均大于无症状组,i值小于无症状组[(3.54±0.88)比(3.99±0.93),P=0.010]。多因素logistic回归分析结果显示,L值(OR=1.286,95%CI 1.176~1.406,P=0.002)和i值(OR=0.916,95%CI 0.867~0.968,P<0.001)为ASD封堵术后患者出现头痛症状的独立影响因素,而d值和D2值不是其独立影响因素(P均>0.05)。在非症状组患者中得到线性方程:封堵伞型号=1.121×ASD最大直径(TTE测得)+6.414。结论ASD封堵术后的头痛症状与封堵伞释放后展开直径及左侧封堵伞面的最大直径无关,而与封堵伞的厚度与i值有关,提示选择过大的封堵伞增加伞的厚度是引起术后头痛的主要原因。为降低头痛的发生,应尽量选择合适的封堵伞,术者不宜因担心封堵伞脱落移位而加大封堵伞型号;对封堵伞偏大者术后应加强抗血小板治疗以减少或改善患者的头痛症状。封堵伞型号=1.121×TTE测量ASD最大直径+6.414,可以作为临床选择ASD封堵伞型号的参考值。

Objective To explore whether the atrial septal defect(ASD)size,the type of occlusion umbrella selected,and the morphological changes after release of occlusion umbrella affect the headache symptoms of ASD patients after operation.Methods A total of 567 ASD ptients,who underwent successful implantion with a single occlude from January 2014 to December 2017 in General Hospital of Northern Theater Command were enrolled.The patients were divided into symptomatic group and asymptomatic group according to the presence or absence of headache symptoms after occlusion.X-ray catheter calibration method was used to measure the diameter(d),thickness(L),maximum diameter of the left umbrella surface after release(D2)and the value of i(i=D2/L).Risk factors related to headache were analyzed by multivariate logistic regression analysis.linear regression analysis was used to detect the relationship between the type of occluder umbrella and ASD diameter in asymptomatic group.Results A total of 567 patients with one occluder umbrella were included,and 148(26.1%)cases were male.The age was(34.4±19.4)years old.The follow-up time was(12.7±2.8)months.There were 51 cases in the symptomatic group and 516 cases in the asymptomatic group.In 29 patients who were treated by extending the course or increasing the dose of aspirin,the symptoms disappeared or improved.There was no significant difference in the maximum ASD diameter(TTE measured)and the size of occluder between the symptomatic group and asymptomatic group(both P>0.05).The value of d((19.80±6.67)mm vs.(17.40±7.28)mm,P=0.041)D2((43.29±7.41)mm vs.(39.20±9.59)mm,P=0.013)and L((13.06±3.72)mm vs.(10.19±2.90)mm,P=0.025)of the symptomatic group were all higher than that of the asymptomatic group,while the i value was smaller((3.54±0.88)vs.(3.99±0.93),P=0.010).The results of multivariate logistic regression analysis showed that the value of L(OR=1.286,95%CI 1.176-1.406,P=0.002)and the value of i(OR=0.916,95%CI 0.867-0.968,P<0.001)were independent factors of headache symptoms in patients after ASD occlusion,while the value of d and the value of D2 were not independent factors(both P>0.05).Linear equations obtained from asymptomatic patients showed the size of occluder=1.121×the maximum ASD diameter of TTE measured+6.414.Conclusions There is no correlation between the symptoms with the expanded diameter and the maximum diameter of left umbrella’s surface after released.The Postoperative discomfort symptoms is significantly correlated to the thickness of the occluder and the value of i.It is suggested that headache could be induced by the oversized occlude,thus choosing the appropriate size of the occluder is essential to reduce the occurrence of postoperative headache symptoms.Increasing the size of occluder because of worrying about the abscission and removal of the occlude is unreasonable.The antiplatelet therapy should also be strengthened to reduce the occurrence of symptoms and improve the symptoms of the patients if the occluder’s size is too large.This regression equation(The size of occluder=1.121×the maximum ASD diameter of TTE measured+6.414)could be used as a reference for the suitable selection of ASD occluder.