Akagi Teiji
Adult Congenital Heart Disease Center, Okayama University Hospital, Okayama, Japan.
J Cardiol. 2015 Jan;65(1):17-25. doi: 10.1016/j.jjcc.2014.09.002. Epub 2014 Oct 11.
After the introduction of catheter intervention for atrial septal defect (ASD) in the pediatric population, therapeutic advantages of this less invasive procedure were focused on adult through geriatric populations. The most valuable clinical benefits of this procedure are the significant improvement of symptoms and daily activities, which result from the closure of left to right shunt without thoracotomy and cardiopulmonary bypass surgery. These benefits contribute to increase the number of adult patients of this condition who have hesitated over surgical closure. In terms of technical point of view for catheter closure of ASD, the difficulties still exist in some morphological features of defect, or hemodynamic features in the adult population. Morphological features of difficult ASD closure are (1) large (≥30 mm) ASD, (2) wide rim deficiency, and (3) multiple defects. Hemodynamic features of difficult ASD are (1) severe pulmonary hypertension, (2) ventricular dysfunction, and (3) restrictive left ventricular compliance (diastolic dysfunction) after ASD closure. To complete the catheter ASD closure under these difficult conditions, various procedural techniques have been introduced. These are new imaging modalities such as real-time three-dimensional imaging, new technical modifications, and new concepts for hemodynamic evaluation. Especially, real-time three-dimensional transesophageal echocardiography can provide the high quality imaging for anatomical evaluation including maximum defect size, surrounding rim morphology, and the relationship between device and septal rim. In adult patients, optimal management for their comorbidities is an important issue, which includes cardiac function, atrial arrhythmias, respiratory function, and renal function. Management of atrial arrhythmias is a key issue for the long-term outcome in adult patients. Because the interventional procedures are not complication-free techniques, the establishment of a surgical back-up system is essential for the safe achievement of the procedure. Finally, the establishment of a team approach including pediatric and adult cardiologists, cardiac surgeons, and anesthesiologists is the most important factor for a good therapeutic outcome.
在儿科人群中引入房间隔缺损（ASD）导管介入治疗后，这种侵入性较小的手术的治疗优势已从成人扩展至老年人群。该手术最有价值的临床益处是症状和日常活动的显著改善，这源于无需开胸和体外循环手术即可闭合左向右分流。这些益处促使更多曾对手术闭合犹豫不决的成年患者选择该治疗方法。从技术角度来看，ASD导管闭合在成人人群的某些缺损形态特征或血流动力学特征方面仍存在困难。难以进行ASD闭合的形态学特征包括：（1）大型（≥30mm）ASD，（2）边缘缺损宽，（3）多个缺损。难以进行ASD闭合的血流动力学特征包括：（1）严重肺动脉高压，（2）心室功能障碍，（3）ASD闭合后左心室顺应性受限（舒张功能障碍）。为在这些困难条件下完成导管ASD闭合，已引入了各种手术技术。这些技术包括实时三维成像等新的成像方式、新的技术改进以及血流动力学评估的新概念。特别是，实时三维经食管超声心动图可为解剖评估提供高质量成像，包括最大缺损尺寸、周边边缘形态以及封堵器与房间隔边缘的关系。在成年患者中，对其合并症的最佳管理是一个重要问题，这包括心脏功能、房性心律失常、呼吸功能和肾功能。房性心律失常的管理是成年患者长期预后的关键问题。由于介入手术并非无并发症的技术，建立手术备用系统对于安全完成手术至关重要。最后，建立一个包括儿科和成人心脏病专家、心脏外科医生和麻醉医生的团队协作模式是取得良好治疗效果的最重要因素。
