Oki T, Iuchi A, Fukuda N, Tabata T, Hayashi M, Tanimoto M, Manabe K, Kageji Y, Sasaki M, Hama M
Second Department of Internal Medicine, Faculty of Medicine, Tokushima University, Japan.
J Am Soc Echocardiogr. 1994 Sep-Oct;7(5):506-15. doi: 10.1016/s0894-7317(14)80008-4.
To investigate the clinical significance and problems of right-to-left (R-L) shunt flow dynamics in atrial septal defects, we performed transesophageal color and pulsed Doppler echocardiography in 30 patients with atrial septal defects of the ostium secundum type. The 30 patients consisted of 20 with a pulmonary artery systolic pressure of less than 40 mm Hg, four with a pressure of 40 to 60 mm Hg, three with a pressure of 90 mm Hg or more, two patients with pulmonic stenosis, and one patient with Ebstein's anomaly. R-L shunting was determined by the presence of a shunt flow signal across the defect during each cardiac cycle. The time of R-L shunt flow was compared with the various parameters obtained by echocardiography and cardiac catheterization. R-L shunt flow signals were detected at the following times: (1) at the onset of ventricular contraction or the closing phase of the tricuspid valve in five patients with isolated atrial septal defect. These patients showed an increase of mean right atrial pressure but had no severe pulmonary hypertension; (2) during ventricular systole in five of 26 patients with tricuspid regurgitation and one patient with Ebstein's anomaly. The tricuspid regurgitant signal was directed toward the ostium of the defect in three patients and was massive in the other patients; (3) during middiastole in three patients without pulmonary hypertension. These patients showed massive left-to-right shunt flow from end systole to early diastole; and (4) during atrial systole in three patients with severe pulmonary hypertension and two patients with pulmonic stenosis. The former, in particular, showed the aliasing signal as a high-speed shunt flow. In two of the three patients with severe pulmonary hypertension, R-L shunting continued from atrial systole to early ventricular systole and was also observed in early diastole. R-L shunt flow was detected in patients with atrial septal defects not only with pulmonary hypertension but also without pulmonary hypertension and was influenced by the right atrial pressure in the phase of tricuspid valve closing, the volume or direction of tricuspid regurgitation, rebound flow caused by massive left-to-right shunt flow, the grade of right ventricular distensibility or the complication of pulmonary hypertension, and complications with other cardiac anomalies. Thus R-L shunt flow in patients with atrial septal defects was detected easily by transesophageal color and pulsed Doppler echocardiography because of the high efficiency of this method for its detection.
为了研究房间隔缺损中右向左（R-L）分流血流动力学的临床意义及问题，我们对30例继发孔型房间隔缺损患者进行了经食管彩色及脉冲多普勒超声心动图检查。这30例患者中，20例肺动脉收缩压低于40mmHg，4例压力为40至60mmHg，3例压力为90mmHg或更高，2例患有肺动脉狭窄，1例患有埃布斯坦畸形。通过每个心动周期中缺损处分流血流信号的存在来确定R-L分流。将R-L分流血流时间与通过超声心动图和心导管检查获得的各种参数进行比较。R-L分流血流信号在以下时间被检测到：（1）在5例孤立性房间隔缺损患者的心室收缩开始或三尖瓣关闭期。这些患者平均右心房压力升高，但无严重肺动脉高压；（2）在26例三尖瓣反流患者中的5例以及1例埃布斯坦畸形患者的心室收缩期。3例患者的三尖瓣反流信号指向缺损口，其他患者反流信号较强；（3）在3例无肺动脉高压患者的舒张中期。这些患者显示从收缩末期到舒张早期有大量左向右分流血流；（4）在3例严重肺动脉高压患者和2例肺动脉狭窄患者的心房收缩期。前者尤其显示出高速分流血流的混叠信号。在3例严重肺动脉高压患者中的2例，R-L分流从心房收缩期持续到心室收缩早期，在舒张早期也可观察到。房间隔缺损患者中不仅在有肺动脉高压时可检测到R-L分流血流，在无肺动脉高压时也可检测到，并且受三尖瓣关闭期右心房压力、三尖瓣反流的量或方向、大量左向右分流血流引起的反流、右心室扩张程度或肺动脉高压并发症以及其他心脏异常并发症的影响。因此，由于经食管彩色及脉冲多普勒超声心动图检测R-L分流血流的效率高，房间隔缺损患者中的R-L分流血流很容易被检测到。
