Berger F, Ewert P, Dähnert I, Stiller B, Nürnberg J H, Vogel M, von der Beek J, Kretschmar O, Lange P E
Deutsches Herzzentrum Berlin Abteilung für Angeborene Herzfehler/Kinderkardiologie Augustenburger Platz 1 13353 Berlin.
Z Kardiol. 2000 Dec;89(12):1119-25. doi: 10.1007/s003920070139.
Over the last few years, various devices for the interventional closure of atrial septal defects (ASD) up to a diameter of 20 mm have been developed. We report our clinical experience in closing ASD with a diameter larger than 20 mm diameter with the Amplatzer Septal Occluder (ASO).
The stretched diameter of the ASD was measured by inflating a sizing balloon within the defect until an indentation in the circumference in the balloon could be observed. An ASO with a stent diameter 2-4 mm larger than the indentation in the circumference of the balloon was chosen and implanted via 9-12 French sheaths. In contrast to the closure of smaller defects, pullback of the device onto the atrial septum was only performed when the connecting stent of the ASO was completely deployed in order to achieve maximal centering characteristics and optimal support of the retention skirt of the left atrial disc on the edges of the defect. Only then was the right atrial disc deployed and actively configured by advancing the sheath and the delivery cable against the atrial septum. Implantation was only attempted if the atrial septal rims (except the anterior rim around the aorta) measured more than 7 mm by echocardiography to avoid injury or disturbance of sensitive intracardiac structures. After placement, the fixation of the device and the mechanical stability was proven by an extensive "Minnesota wiggle". The ASO was released only when TEE showed no or a trivial residual color flow through the connecting stent; otherwise repositioning was performed.
Out of 352 patients (P) with successful closure of interatrial defects, 70 P (age: 1.1-77.3 years) had stretched defects larger than 20 mm diameter (median 22 mm diameter (20-36), 25/75% quartiles = 20/26 mm). Mean shunt size was Qp:Qs 2.1:1 (0.7-3.9:1), mean fluoroscopy time 10.9 min (0-63). Complete closure could be achieved in 85.7/93.1/100% after 3 months, 1 and 2 years, respectively. Besides 3 P with persistent atrial fibrillation, only 5 P showed transient atrial tachyarrhythmias, 2 only periprocedural and 3 within the first 3 months after implantation were treated with beta-blocker. In one patient, an acute embolization of the device occurred because a diminished posterior rim was not visualized by a monoplane TEE probe necessitating surgical explantation and defect occlusion. Despite oversizing the device, no "mushrooming" misconfiguration were observed.
Transcatheter closure of large atrial septal defects with the Amplatzer Septal Occluder is feasible, safe and effective. Risk of complications do not seem to occur more frequently than after closure of smaller defects if one adheres to certain sizing and implantation measures. The incidence of transient atrial tachyarrhythmias seems to be low.
在过去几年中，已开发出各种用于介入性闭合直径达20毫米的房间隔缺损（ASD）的装置。我们报告了使用Amplatzer房间隔封堵器（ASO）闭合直径大于20毫米的ASD的临床经验。
通过在缺损内充盈测量球囊直至观察到球囊圆周出现压痕来测量ASD的伸展直径。选择支架直径比球囊圆周压痕大2 - 4毫米的ASO，并通过9 - 12法式鞘管植入。与闭合较小缺损不同，仅在ASO的连接支架完全展开后才将装置回撤至房间隔，以实现最大的居中特性和左心房盘的固定裙边在缺损边缘的最佳支撑。只有在那时才展开右心房盘，并通过将鞘管和输送电缆向房间隔推进来主动塑形。仅当超声心动图测量房间隔边缘（除主动脉周围的前边缘外）超过7毫米时才尝试植入，以避免损伤或干扰敏感的心内结构。放置后，通过广泛的“明尼苏达摆动”证明装置的固定和机械稳定性。仅当经食管超声心动图（TEE）显示连接支架无或仅有少量残余血流时才释放ASO；否则进行重新定位。
在352例成功闭合房间隔缺损的患者中，70例（年龄：1.1 - 77.3岁）伸展缺损直径大于20毫米（中位数直径22毫米（20 - 36），四分位数间距25/75% = 20/26毫米）。平均分流大小为Qp:Qs 2.1:1（0.7 - 3.9:1），平均透视时间10.9分钟（0 - 63）。分别在3个月、1年和2年后，完全闭合率可达85.7%/93.1%/100%。除3例持续性心房颤动患者外，仅5例出现短暂性房性快速心律失常，其中2例仅在围手术期出现，3例在植入后前3个月内出现，用β受体阻滞剂治疗。1例患者发生装置急性栓塞，原因是单平面TEE探头未显示后缘减小，需要手术取出装置并封堵缺损。尽管装置尺寸过大，但未观察到“蘑菇状”畸形。
使用Amplatzer房间隔封堵器经导管闭合大型房间隔缺损是可行、安全且有效的。如果遵循某些尺寸测量和植入措施，并发症风险似乎不会比闭合较小缺损后更频繁地发生。短暂性房性快速心律失常的发生率似乎较低。
