Hammerstingl Christoph, Lickfett Lars, Jeong Kyung-Mi, Troatz Clemens, Wedekind Jan-Arne, Tiemann Klaus, Lüderitz Berndt, Lewalter Thorsten
Department of Medicine-Cardiology, University of Bonn, Bonn, Germany.
Am Heart J. 2006 Aug;152(2):362.e1-5. doi: 10.1016/j.ahj.2006.04.034.
According to present knowledge, pulmonary vein isolation (PVI) bears a low interventional risk and has a high feasibility. For completion of PVI, left atrial access is achieved via single or double transseptal puncture. We sought to determine the incidence and echocardiographic characteristics of persistent iatrogenic atrial septal defect (iASD) after PVI. Further objectives were to define clinical and periprocedural risk factors for the development of iASD.
Every patient admitted for PVI at our hospital was screened for eligibility for study participation. Exclusion criteria were inability for undergoing transesophageal echocardiography, preexisting atrial septal defect, open-heart surgery or another transseptal procedure during the follow-up period. Transesophageal echocardiography was performed before PVI and after 9 months. Interatrial shunt was characterized by echocardiographic parameters; right-to-left-shunting (RLS) was quantified by contrast echocardiography.
Forty-two patients were included, 27 patients underwent PVI with single transseptal puncture and additional advancement of a second electrophysiologic catheter (group A) 15 patients underwent PVI with double transseptal puncture (group B). In 8 patients of group A, iASD persisted after the follow-up period, including 6 patients with distinct RLS. We saw no iASD in group B (P = .011, CI -0.79 to -0.11). Preprocedural pulmonary artery pressure was significantly higher in patients with iASD and accompanying RLS, compared with patients with iASD and no evidence of RLS (23.75 +/- 0.50 vs 17.59 +/- 5.82, P = .048, CI 0.048-12.27).
This is the first study that demonstrates a high incidence of long-term persistent iatrogenic atrial septal defect with RLS after PVI. All interatrial shunts occurred after single transseptal puncture with passage of 2 electrophysiologic catheters into the left atrium. Increased preprocedural pulmonary artery pressure seems to promote the occurrence of RLS across iASD.
根据目前的认识，肺静脉隔离术（PVI）的介入风险较低且可行性较高。为完成PVI，通过单次或双次经房间隔穿刺进入左心房。我们试图确定PVI术后持续性医源性房间隔缺损（iASD）的发生率及超声心动图特征。进一步的目标是明确iASD发生的临床及围手术期危险因素。
筛选我院因PVI入院的每例患者是否符合研究参与条件。排除标准为无法接受经食管超声心动图检查、既往存在房间隔缺损、在随访期间接受过心脏直视手术或其他经房间隔操作。在PVI术前及术后9个月进行经食管超声心动图检查。通过超声心动图参数对房间隔分流进行特征描述；通过对比超声心动图对右向左分流（RLS）进行定量分析。
纳入42例患者，27例患者通过单次经房间隔穿刺及额外推进第二根电生理导管进行PVI（A组），15例患者通过双次经房间隔穿刺进行PVI（B组）。A组有8例患者在随访期后iASD持续存在，其中6例有明显的RLS。B组未发现iASD（P = 0.011，可信区间-0.79至-0.11）。与有iASD但无RLS证据的患者相比，有iASD且伴有RLS的患者术前肺动脉压显著更高（23.75±0.50 vs 17.59±5.82，P = 0.048，可信区间0.048 - 12.27）。
这是第一项证明PVI术后长期持续性医源性房间隔缺损伴RLS发生率较高的研究。所有房间隔分流均发生在单次经房间隔穿刺并将两根电生理导管送入左心房之后。术前肺动脉压升高似乎会促进iASD处RLS的发生。
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