国产封堵器闭合房间隔缺损过程中的短暂ST段抬高2例_英文_.pdf

临床研究#Transient ST2seg m ent2elevation during transcatheter closure of atrial septaldefect(ASD)w ith ASD occluder m ade in China:A report of two casesWA NG Xian,HU Da2 yi,SU N Qi,TA N Chen(Department ofCardiology,BeijingM ilitaryGeneralHospita,l Beijing 100700,China)Abstract:AI M The safety and efficacy of atrial septal defect(AS D)occluder(ASDO)made in China for transcatheterclosure ofASD have investigated prospectively.W e report the pheno menon of transientST2seg ment2elevation(TSTE)duringtranscatheter closure ofASDwith ASDOmade in China in this single2centre study.M ETHODS A total of35 consecutivepatients in whom a septaldefect occluder(Huayishengjie Inc.,Beijing,China)was used to close a clinically significantASD were included in our study.All procedures perf or med under basic or local anaesthesia with transthoracic echocardio2graphic guidance.Interatrial communicationswere assessed by transthoracic echocardiography(TTE)with reference to size,position in the interatrial septum,proxi m ity to surrounding structures,and adequacy of septal ri m.Device selection wasbased on andmatched to the stretched dia meter of the co mmunication.Success defined as deploy ment of device in a stableposition to occlude the interatrial co mmunicationwithout inducing functional abnor mality or anatom icalobstruction.Occlu2sion status deter m ined byTTE during procedure and the follow up of the study at 3,6,and 12months.RESULTS In 2of the 35 patients from our centre,a transient ST2seg ment2elevation greater than 0.2mV was recorded and angina pectorisoccurred during the deploy ment of the device.The ECG changes and the sy mpto ms started abruptly and lasted for(412?212)m in.All the ECG changes occurred in lead II,III,and a VF.The association bet ween the heart rate,blood pressureand the ECG changeswas described.The bradycardia and hypotensionwere seen during S T2seg ment2elevation in these twopatients.The adm inistration of intravenous nitroglycerinwas perfor med,the symptoms and ECG changes didn.t recoveredi mmediately.W hen the deviceswere retrieved bywithdra wing it into the sheath by traction on the deliverywire,the symp2to mswere gradually eli m inated and EC G changes recuperated i mmediately.No haemodyna m ic derangement or transientECG changes occurred after the larger dia meter deviceswere exchanged.During the follo w2up of the study at 3,6,and 12months these two patients sho wed no further signs ofmyocardial ische m ia and were free of episodes of angina pectoris.CONCLUSION The pheno menon of ST2segment2 elevation during transcatheter closure ofASD may be caused by themechanical effects of the larger dia meter AS DO.K ey words:atrial septa defect;atrial septa defect occluder;transient S T2segment2elevation基金项目:国家卫生部/十年百项0推广项目基金资助(200713)通讯作者:王显,主任医师,主要从事介入心脏病学、预防心脏病学和中西医结合心脏病学研究 Emai:lWX0515 hotmai.l co m国产封堵器闭合房间隔缺损过程中的短暂 ST段抬高 2例王 显,胡大一,孙 琪,谭 琛(北京军区总医院心血管内科,北京 100700)摘要:目的 国产房间隔封堵器闭合房间隔缺损的安全性和有效性已得到证实。我们报告在使用国产封堵器闭合房间隔缺损过程中出现的短暂 ST段抬高现象 2例。方法 适合进行经皮封堵术的房间隔缺损患者 35例,使用北京华医圣杰公司生产的房间隔封堵器进行封堵。术前经胸超声充分评估缺损的大小、位置、与周围结构的距离以及房间隔的软硬边缘等,选择封堵器要与缺损的伸展直径相匹配。手术过程在局部麻醉或者基础麻醉下进行,术中使用经胸超声引导。封堵器释放后有效闭合缺损、位置稳定且不影响周边结构视为手术成功。术后 3,6,12月进行随访。结果 在 35例患者中有 2例在封堵器释放过程中,出现短暂性 S T段抬高超过 2 mV,伴有心绞痛发作。心电图改变和症状发作平均持续时间(4.2?2.2)m in,2例心电图改变均发生于 II,III和 aVF导联,此过程伴有心率减慢和血压降低。静脉注射硝酸甘油后心电图和症状没有得到即刻改善,但封堵器沿鞘管被收回后心电图立即#752#心 脏 杂 志(Chin Heart J)2008,20(6)改善、症状逐渐消失。换用较小型号的封堵器闭合房间隔缺损后,没有引起任何血流动力学异常和短暂性心电图改变。随访 3,6,12月没有发现心肌缺血和心绞痛发作。结论 经导管闭合房间隔缺损过程中出现的短暂 ST段抬高现象,可能与所选封堵器直径过大,刺激房间隔有关。关键词:房间隔缺损;房间隔缺损封堵器;短暂性 ST段抬高中图分类号:R542.5 文献标识码:A 文章编号:100927236(2008)062752206INTRODUCTIONPreviously various devices for transcatheter closure ofatrial septa defect(ASD)were introduced1-3,espe2cially,a new device of a self expanding circular doubledisc with a conjoint waist made up of nitinol windings(Amplatzer septal occluder,AGA Medical Corpora2tion,Golden Valley,Minnesota,USA)has been intro2duced for the purpose ofnon2surgical transcatheter clo2sure ofASD and other interatrial co mmunications.Ini2tial ani mal studies and early human experience havebeen pro mising 4.Several ASD occluders(ASDO)made in China have currently being evaluated and theirsafety and efficacy were de monstrated.W e report ourinitial experience and short ter m outco me with theASDdevice made in China(Huayishengjie Inc.,Beijing,China)for non2surgical transcatheter closure ofASD.Co mplications of transcatheter closure of ASD havebeen described and investigated.We recorded the phe2no menon of transient ST2segment2elevation in the inferi2or leads and the sy mpto ms of angina pectoris.MATERIALS AND METHODSPatient selectionApproval fro m respective local ethics co mmittee wasobtained.All patients had a clinically significant fossaovalis ASD,and cardiac surgery was indicated.Theywere invited to participate in the tria.lInitial selectionwas based on transthoracic echocardiographic assess2men.t ASD with a transthoracic echocardiographic di2ameter of30mm or lesswith a suitable septal ri m ofatleast 5 mm fro m the right pul monary veins,coronarysinus,superior caval vein,inferior caval vein,andmi2tral valvewere considered suitable.Patients with patent foramen ovale and a history ofstroke or transient ischaemic attack with a positive con2trast echocardiographic study and patients with fenes2trated Fontan procedurewere included in the tria.lIn2f or med consent was obtained fro m all patients or theirparents or legal guardian.DeviceThe ASDO used in the trial is a circular double discframe with a conjointwaistmade ofwindingsofnitino,la nickel2titaniu m alloy.N itinol has the properties of su2per2 memory and super2elasticitywhich make it suitablefor the design of the device.The principle of the deviceis based on the conjointwaist/stenting0 theASD,pro2viding both fixation and occlusion.Polyester inserts areplaced within the device to facilitate thro mbosis and oc2clusion.The quoted size of the device is the dia meterof the conjointwais.tTechniqueA ll the procedureswere performed under basic or localanaesthesia.Detailed assessment of the size and mor2phology of theASD was perfor med by transthoracic ech2ocardiography(TTE)with either a biplane or a multi2plane probe.Themaxi mum dia meter of the defec,ttheseptal length,and the distance of the edge of the defectfro m the right pul monary veins,the orifice of the coro2nary sinus,and the mitral valve were measured usingthe transverse plane.The distances fro m the superiorand inferior caval vein were measured fro m the sagittalor vertical plane.I mages of the anterior ri m adjacent tothe posterior border of the aorta were obtained usingboth the horizontal and vertical plane.The selectedASDO was attached to the deliverywire bythe scre w mechanism and was loaded by withdrawinginto the loader by traction on the occluder delivery sys2tem(ODS).The collapsed ASDO was then advancedthrough the long sheath that had previously been posi2tioned in the left atrium.Under fluoroscopic control theleft atrial disc was extruded by advancing the deliverywire.The sheath and the deliverywire were withdrawnin unison until resistance was met when the extrudedleft atrial disc was apposed to the atrial septum.TheASDO was thenf ully deployed by withdrawing thesheath over the deliverywire to extrude the right atrial#753#心 脏 杂 志(ChinHeart J)2008,20(6)disc.Once the devicewas fully deployed across theASD,itsposition and stability were assessed by fluoroscopy andTTE.Its position was deemed opti mal if the devicewasTTE stable and did not obstruct the right pul monaryveins,coronary sinus,caval veins,or themitral valve.Any residual shunt was documented using color flo wDoppler on TTE.TheASDO was then released by anti2clockwise rotation of the delivery wire.Before this re2lease,the device could easily be retrieved bywithdra2wing it into the sheath by traction on the deliverywire.A final assessment of the position of the devicewas per2f or med by TTE follo wing its release.The patientswere discharged the next day on an anti2platelet dose of aspirin.A repeat transthoracic echocar2diography,electrocardiography,and chest X ray wereperfor med the next day before discharge.Follo w upwasarranged for 3,6,and 12months after the i mplan.tData collection and analysisA ll datawere collected on a set data shee,tcollated bya single coordinator,and entered into a common data2base for analysis.Descriptive statistical data are pres2ented asmean(SD).RESULTSBasic dataI mplants were perfor med on 35 patients with a fossaovalisASD during the study period fro m October 2006to October 2007.They ranged in age fro m 2 to 65(2416?217)years and in weight fro m 1210 to 7210(4615?314)kg.Procedural ti me ranged fro m 2510 to18010(9114?2910)m in with screening ti me fro m610 to 4910(1611?810)min.There were 32 suc2cessful i mplants and three failures.Total successf ulocclusion ratewas 9114%.The position of two larger devices(40mm and 42mm)was considered unsuitable or unstable after i mplanta2tion.The deviceswere withdrawn before release.Therewas one patient referred for emergency surgery o wing tomalposition of the device.The device escaped to leftatrium after released.The device was retrieved at sur2gery and theASD closed at the same ti me the follo wingdaywithout any further co mplication.The most worrying co mplication occurred in an infantwith a 8 mm VSD occluder and a 12mm ASDO.Therewas cerebral embolismwhen shewas admitted for crani2al CT 4 hours after the procedure.This resolved follo w2ing treatmentwith heparin and anticoagulation.Transient ST2segment2elevation during transcathe2ter closure ofASDIn 2 of the 35 patients fro m our centre,transient ST2seg ment2elevation greater than 012 mV was recordedand angina pectoris occurred during deploy ment of thedevice(Table 1).The ECG changes and the sy mpto msstarted abruptly and lasted for(412?212)min.Allthe ECG changes occurred in lead II,III,and aVF(F igure 1).Pericardial effusion could be excluded in2stantaneously by TTE in these two cases.Regrettably,coronary angiogram was not performed in these patientswho presented with the longest episodes.The associa2tion between the heart rate,blood pressure and theECGchangeswas described co mpletely in these t wo patients(Table 2).The intravenous nitroglycerin was per2for med in these t wo patients,but the sy mpto ms andECG changes didn.t recovered i mmediately.When thedeviceswere retrieved bywithdrawing it into the sheathby traction on the delivery wire,the sy mpto ms weregradually eli minated and ECGchanges recuperatedi mmediately.There was no associated haemodynamicderangement or transient ECG changes after the largerdevices were exchanged.During the follo w2up of thestudy at 3,6,and 12months these two patients sho wedno further signs ofmyocardial ischae mia and were freeof episodes of angina pectoris.Table 1 Two patientswith the occurrence of ST2seg ment2elevation greater than 012mV and angina pectorisPatientNo.SexAge(yr)T i me afterTSM(m in)Duration ofST2elevation(m in)Localization ofST2elevationin ECGASDdiameter(mm)ASDOdiameter(mm)DiameterofODS(F ranch)1F17105II,III,AvF2632/38/3214F2F1264II,III,aVF1218/1612FTSM:Trans2septalmanipulation.#754#心 脏 杂 志(Chin Heart J)2008,20(6)Figure 1 ECG changes in lead II,III,and aVFTable 2 The association bet ween the heart rate,blood pressure and the ECG changesPatientNo.HR before STelevationb.p.mHR during STelevationb.p.mHR afterSTelevationb.p.mHypotensionY/NBradycardiaY/N17852-5882YY28055-6185NYST:ST2seg ment;Y:Yes;N:No.DISCUSSIONThe current study demonstrates that transient ST2seg2ment2elevation may be an occurrence in patients under2going transcatheter closure ofASD.In our centre tria,lthese effects were not user dependen.t Manipulation ofthe deliverywire and ODS after successful trans2septalaswell as the antenna tip of theODS withASDO in theleft atrium or the large diameter of occluder effect onthe interatrial/special struct0 were possibly related tothis effec.tThe occurrence of ST2seg ment2elevation during tran2scatheter closure ofASD and interatrial co mmunicationswith a new self expanding nitinol double disc device(Amplatzer septal occluder)has been first described bychan et al5.The authors attributed this effect to coro2nary spasm triggered by air e mbolism.Another descrip2tion of ischaemic events during interventional cardiacprocedures has included the closure of atrial septal de2fectswith the Amplatzer septal occluder 4,6.The phe2no menon of potentially life2threatening ST2seg ment2ele2vation during the other interventional cardiac procedureslike left atrial ablation procedures has been reported.There have been two reports of ischaemic co mplicationsduring catheter ablation,both concerning ablation ofaccessory pathways located at the left free2 wall7,8.The observation of ST2seg ment2elevation during pul mo2nary vein isolation has been first described using athrough2the2 balloon circu mferential ultrasound ablationsystem in a catheter feasibility trial9.The authorsattributed this effect to coronary spasm triggered by airembolism.Three cases ofmyocardial ischaemia duringablation of left atrial tachycardia and pul monary veinsfor atrial fibrillation have been reported 10.The authorsattributed this to the occurrence of spasm,which couldbe reversed with intracoronary nitrates.One aspect that interventional cardiac procedures likeclosure of atrial septal defects and left atrial ablationprocedures have in co mmon is the puncture andmanip2ulation of the septum aswell as the insertion of one ortwo sheaths across the septum to reach the left atriu m.During the course of the intervention,multiplemanipu2lations of the catheters as well as the sheath itself arerequired,possibly involving the atrial septum and adja2cent structures.In t wo cases in our study,the administration of intrave2nous nitroglycerin during the procedures didn.t lead toan i mmediate reversal of ischaemic sy mpto ms,and alsothe ECG changes didn.t resolve i mmediately.W hen thedeviceswere retrieved bywithdrawing it into the sheathby traction on the delivery wire,the sy mpto ms weregradually eli minated and ECGchanges recuperatedi mmediately.There was no associated haemodynamicderangement or transient ECG changes after the largerdiameter devices were exchanged.During the follo w2up#755#心 脏 杂 志(ChinHeart J)2008,20(6)of the study at 3,6,and 12months these t wo patientssho wed no further signs of myocardial ischaemia andwere free of episodes of angina pectoris.In spite of cor2onary angiogram was not performed in these patientswho presented with the longest episodes.We could notdetect direct or indirect evidence of air embolism suchas slo w flo w within the coronary arteries.In our view,this supports the fact that the aetiology of ischaemiawasnot caused by air e mbolism.W e,therefore,concludethat a differentmechanism may account f or this.The same transient ischae mic effects after catheter abla2tion of a left free2 wall accessory pathway in an infantwas reported11,using a trans2septal approach.Coro2nary angiography sho wed nor mal coronary arteries;ina