Rao P S, Ende D J, Wilson A D, Smith P A, Chopra P S
Department of Pediatrics, University of Wisconsin Medical School, Madison, USA.
Can J Cardiol. 1995 Sep;11(8):695-701.
Feasibility, effectiveness and safety of transcatheter occlusion of secundum atrial septal defect (ASD) with buttoned device have been demonstrated.
To evaluate the follow-up results of the ASD with buttoned device method to assess its long term efficacy and safety.
Patient age at device implantation ranged from seven months to 51 years and weight ranged from 3.6 to 105 kg. Successful implantation of the device was accomplished in 20 of 22 consecutive patients (91%) seen during a 33-month period ending August 1992. Patients were divided into three groups based on the type of shunt across the ASD: group I (n = 14)--left-to-right shunt; group II (n = 5)--presumed paradoxical embolism; and group III (n = 1)--right-to-left shunt. These 20 patients were followed for 29 +/- 11 months, range 16 to 52 months. Follow-up included clinical evaluation, chest x-ray and echo-Doppler studies, and was performed two weeks, and three, six and 12 months after occlusion and yearly thereafter. Most patients received 5 to 10 mg/kg/day acetylsalicylic acid for 12 weeks following the device implantation.
In 14 left-to-right shunt ASD closures, the right ventricular size diminished from 2.3 +/- 0.6 to 1.7 +/- 0.3 cm immediately after closure (P < 0.01) and remained decreased (1.6 +/- 0.46 cm) at last follow-up. Paradoxical/flat septal motion was present in 11 of 14 patients (79%) before closure while such an abnormal septal motion was not present in any at follow-up. Small to trivial left-to-right shunts across the implanted device were seen in six of 14 patients (43%) immediately after closure while trivial shunts were present in three of 14 (21%) at follow-up. Small shunts became trivial and trivial shunts disappeared. None of the patients had any clinical signs of ASD and none required surgical intervention during the follow-up period. None of the five patients with cerebrovascular accident (CVA)/paradoxical embolism had recurrence of CVA. Repeat transesophageal contrast echocardiographic study with Valsalva revealed minimal right-to-left shunt in two of five patients (40%) initially, which disappeared at follow-up. The single patient with CVA secondary to atrial right-to-left shunt following previous tetralogy repair had a transient ischemic episode four months after closure and underwent surgery at the discretion of the primary cardiologist. There were no wire fractures on follow-up x-rays. None developed endocarditis.
These data indicate that effective ASD occlusion can be accomplished in left-to-right shunt and paradoxical embolism patients. Modification of the device to position the square-shaped patch on the right atrial side may be necessary to prevent CVA in patients with right-to-left shunts.
纽扣式封堵器经导管封堵继发孔房间隔缺损（ASD）的可行性、有效性和安全性已得到证实。
评估采用纽扣式封堵器封堵ASD的随访结果，以评价其长期疗效和安全性。
植入封堵器时患者年龄为7个月至51岁，体重为3.6至105千克。在截至1992年8月的33个月期间，连续就诊的22例患者中有20例（91%）成功植入封堵器。根据ASD分流类型将患者分为三组：I组（n = 14）——左向右分流；II组（n = 5）——推测为反常栓塞；III组（n = 1）——右向左分流。这20例患者随访了29±11个月，范围为16至52个月。随访包括临床评估、胸部X线和超声多普勒检查，在封堵后2周、3个月、6个月和12个月以及此后每年进行。大多数患者在植入封堵器后12周接受5至10毫克/千克/天的阿司匹林治疗。
在14例左向右分流的ASD封堵术中，封堵后即刻右心室大小从2.3±0.6厘米减小至1.7±0.3厘米（P < 0.01），在末次随访时仍减小（1.6±0.46厘米）。封堵前14例患者中有11例（79%）存在反常/扁平中隔运动，而随访时无1例出现这种异常中隔运动。封堵后即刻14例患者中有6例（43%）在植入封堵器处出现小至微量的左向右分流，随访时14例中有3例（21%）存在微量分流。小分流变为微量分流，微量分流消失。随访期间无1例患者出现ASD的任何临床体征，也无1例需要手术干预。5例脑血管意外（CVA）/反常栓塞患者均无CVA复发。重复经食管对比超声心动图检查瓦尔萨尔瓦动作显示，最初5例患者中有2例（40%）存在微量右向左分流，随访时消失。1例既往法洛四联症修复术后因心房右向左分流继发CVA的患者在封堵后四个月出现短暂性缺血发作，并由主诊心脏病专家决定接受手术。随访X线检查未见导线断裂。无一例发生心内膜炎。
这些数据表明，左向右分流和反常栓塞患者可实现有效的ASD封堵。对于右向左分流患者，可能需要对封堵器进行改良，将方形补片置于右心房侧以预防CVA。
