Schubert S, Peters B, Abdul-Khaliq H, Nagdyman N, Lange P E, Ewert P
Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum Berlin, Berlin, Germany.
Catheter Cardiovasc Interv. 2005 Mar;64(3):333-7. doi: 10.1002/ccd.20292.
Transcatheter closure of atrial septal defects (ASDs) is a safe and effective treatment. Over the past years, an increasing number of elderly patients (age > 60 years) have been admitted for transcatheter closure to prevent ongoing congestive heart failure from volume overload. However, recent data point to the risk of serious acute left ventricular dysfunction leading to pulmonary edema immediately after surgical or transcatheter ASD closure in some patients. In this study, we used a technique described before to recognize in advance patients at risk of left heart failure after ASD closure. Those patients at risk were then treated with preventive conditioning medication for 48-72 hr before definitive transcatheter ASD closure was performed. Fifty-nine patients aged over 60 years (range, 60-81.8 years; median, 68 years) were admitted to our institution for transcatheter closure of an atrial septal defect. All patients received evaluation of atrial pressures before and during temporary balloon occlusion of the ASD. Patients with left ventricular restriction due to increased mean atrial pressures (> 10 mm Hg) during ASD occlusion received anticongestive conditioning medication with i.v. dopamine, milrinone, and furosemide for 48-72 hr before definitive ASD closure with an Amplatzer septal occluder was performed. In 44 patients without any signs of left ventricular restriction, ASD closure was performed within the first session. Fifteen (25%) out of 59 patients showed left ventricular restriction. In the majority of patients with LV restriction, the mean left atrial pressures with occluded ASD were significantly decreased after 48-72 hr of conditioning medication. Definitive ASD closure was then performed in a second session. Only two patients received a fenestrated 32 mm Amplatzer occluder due to persistent increased atrial pressures > 10 mm Hg even after conditioning medication. There were no significant differences in shunt, device size, or defect size between the two groups. Balloon occlusion of atrial septal defects identifies patients with left ventricular restrictive physiology before ASD closure. Intravenous anticongestive conditioning medication seems to be highly effective in preventing congestive heart failure after interventional closure of an ASD in the elderly patient with a restrictive left ventricle.
经导管封堵房间隔缺损（ASD）是一种安全有效的治疗方法。在过去几年中，越来越多的老年患者（年龄>60岁）因经导管封堵术入院，以预防容量超负荷导致的进行性充血性心力衰竭。然而，最近的数据表明，在一些患者中，手术或经导管ASD封堵术后会立即出现严重急性左心室功能障碍并导致肺水肿的风险。在本研究中，我们使用之前描述的一种技术来提前识别ASD封堵术后有左心衰竭风险的患者。然后，在进行确定性经导管ASD封堵术前，对这些有风险的患者使用预防性调节药物治疗48 - 72小时。59名年龄超过60岁（范围60 - 81.8岁；中位数68岁）的患者因房间隔缺损经导管封堵术入住我院。所有患者在ASD临时球囊封堵前后均接受了心房压力评估。在ASD封堵期间因平均心房压力升高（>10 mmHg）导致左心室受限的患者，在使用Amplatzer房间隔封堵器进行确定性ASD封堵术前，接受静脉注射多巴胺、米力农和呋塞米的抗充血调节药物治疗48 - 72小时。在44名无任何左心室受限迹象的患者中，在第一次手术中进行了ASD封堵。59名患者中有15名（25%）出现左心室受限。在大多数左心室受限的患者中，经过48 - 72小时的调节药物治疗后，ASD封堵时的平均左心房压力显著降低。然后在第二次手术中进行确定性ASD封堵。即使经过调节药物治疗，仍有两名患者因心房压力持续升高>10 mmHg而接受了带孔的32 mm Amplatzer封堵器。两组之间在分流、器械大小或缺损大小方面无显著差异。房间隔缺损的球囊封堵术可在ASD封堵术前识别出具有左心室限制性生理特征的患者。静脉注射抗充血调节药物似乎在预防老年左心室受限患者ASD介入封堵术后的充血性心力衰竭方面非常有效。
