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什么是asd封堵房间隔缺损与左心耳封堵“一站式”手术的研究进展

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越来越多的循证医学证实,经皮左心耳封堵术预防心房颤动相关脑卒中安全有效。因此经皮左心耳封堵术正在国内外心血管病中心广泛开展并快速发展。目前,已经有很多术者把既往已经成熟的心血管病介入治疗和左心耳封堵术同期实施,比如心房颤动射频消融和左心耳封堵的“一站式”手术,冠状动脉支架植入和左心耳封堵的“一站式”手术等,初步的随访结果也证实了这些“一站式”手术的安全性和疗效。
对于成人房间隔缺损(ASD)患者而言,其自然病程中发生心房颤动的概率较高,既往单纯对其进行ASD介入治疗后,仍需口服抗凝药物进行心房颤动相关脑卒中的预防。为降低口服抗凝药物的出血风险,简化治疗策略,目前已有中心对成人ASD合并心房颤动的患者开始尝试同期实施ASD和左心耳封堵的“一站式”手术,近中期随访效果较好。为全面理解这类“一站式”手术的理论依据,探究手术策略和评估远期疗效,现综合目前的相关文献进行综述。






成人ASD患者并发
心房颤动的流行病学特征






多种先天性心脏病均可合并或继发心房颤动,如ASD、室间隔缺损、Ebstein畸形、法洛四联症、单心室、左心侧梗阻性病变、肺动脉高压等。其中ASD合并心房颤动较为常见。ASD是最常见的成人先天性心脏病,若不接受治疗(包括外科手术修补和介入治疗),有14%~22%的患者出现房性心律失常,包括心房扑动和心房颤动。研究显示,ASD患者并发房性心律失常的比例为8.9%。更值得注意的是,部分ASD患者在接受外科矫正手术或介入封堵治疗后,仍有8.0%~11.6%可能出现房性心律失常。
一项入选1390例ASD封堵术后患者的研究中,<40岁患者占32%,40~60岁占45%,>60岁占23%,平均随访10.6年,术后新发心房颤动的发生率为14.7%,随访结果提示缺损越大、年龄越大、肺动脉压越高以及并存甲状腺和二尖瓣疾病时,心房颤动发生的概率越高。通过随访研究发现,ASD介入封堵术中一过性心房扑动/心房颤动、ASD的后下边缘较短以及年龄>48岁都是ASD术后新发心房颤动的预测因素。有研究显示,直径>30mm的ASD是ASD介入封堵术后新发心房颤动的潜在危险因子。相关研究也提示ASD闭合时,大多数术前心房颤动患者不会恢复窦性节律。





ASD患者
并发心房颤动的机制探讨






目前认为,心房增大、心房纤维化和电重构均是发生心房颤动的病理机制。ASD伴有心房水平的左向右分流,致右心房长期容量超负荷进而引发右心房心肌电生理的重构,从而形成以右侧心房壁为解剖基础的折返径路而引起心房颤动等房性心律失常,因此有学者对心房颤动患者行右心房迷宫手术来进行治疗。也有研究显示,ASD患者的左心房也会因右心房增大进而受到慢性牵张,引发结构和电生理重构,此外,肺静脉和左心耳也存在诱发心房颤动的电生理作用因此ASD并发心房颤动的发病机制较为复杂。但这也提示,尽早矫正ASD,心房重构有可能逆转,进而减少后期心房颤动的发生。另外,还需指出的是,金属材质的ASD封堵器植入后,金属对心房肌的刺激也可能引发心房颤动。Nyboe等也发现患者闭合ASD后发生首次心房颤动的风险升高。最后,ASD封堵后的残余分流也是引发心房颤动的一个因素。






ASD合并心房颤动患者的

脑卒中风险及远期后







长期心房颤动患者由于心脏泵血功能减退,心房内易形成附壁血栓,从而增加脑卒中风险。研究发现,ASD合并心房颤动患者脑卒中事件增加,并且部分CHA2DS2-VASc评分较低的患者仍有较高的脑卒中风险。
在回顾了2万多例年轻先天性心脏病患者的随访资料,并与正常人群进行了比较,发现在42年的临床随访中,先天性心脏病患者更容易发生缺血性脑卒中,比正常人群高11倍,其中主动脉缩窄、ASD和卵圆孔未闭都是高危因素,而对先天性心脏病患者再进行独立的分析发现,先天性心脏病患者一旦合并心力衰竭或心房颤动,更容易诱发脑卒中,其发病风险是其他先天性心脏病患者的6倍。除了此项研究,著名的Euro Heart Survey也揭示,在5年随访中,4110例成人先天性心脏病患者约4%发生了包括短暂性脑缺血发作在内的脑血管事件。
研究发现,先天性心脏病患者的脑卒中风险是普通人的2.46倍。进一步单独对ASD患者进行分析发现,ASD或卵圆孔未闭的患者发生缺血性脑卒中的因素包括反常栓塞和并发心房颤动两个方面,单纯的封堵治疗只能预防反常栓塞。如果患者存在反常栓塞的可能性或已经发生反常栓塞,不论ASD的直径多大,均应进行封堵治疗。当ASD患者还存在心房颤动、深静脉血栓或者肺栓塞时,个体化的抗凝方案也应立即实施。






ASD合并心房颤动患者

脑卒中预防策略







研究显示,ASD合并心房颤动的患者采用抗心律失常药进行复律治疗,心房颤动复发率较高。对于ASD患者而言,闭合ASD后并不能纠正心房颤动,心房颤动引起脑卒中的风险持续存在,仍需终身服用抗凝药物治疗。因此,自从经导管左心耳封堵术问世以来,同期封堵ASD和左心耳的“一站式”手术便已在临床上出现。Zhang等研究也证明了同期封堵ASD和左心耳的“一站式”手术的安全性。
2019年8月,欧洲心律学会联合欧洲经皮心血管介入学会在EuroIntervention杂志上更新发布了经导管左心耳封堵专家共识,强调了超早期预防,即零级预防(有高风险发展为心房颤动、目前无心房颤动的ASD患者)。研究显示心房颤动射频消融后再行ASD封堵可通过双心房逆向重构,从而减少心房颤动复发。Sang等单中心研究也证明了先行ASD封堵后再行射频消融的有效性及安全性,手术入路为穿刺房间隔或ASD封堵器。


《2020欧洲心脏病学会/欧洲心胸外科协会心房颤动诊断和临床管理指南》中对ASD合并心房颤动的处理建议为:40岁以前行ASD闭合治疗,可以降低心房颤动发病率,但如果拟对术前有心房颤动病史的ASD患者行外科手术治疗,则可在外科手术同时行心房颤动消融。这提示,对ASD患者应尽早封堵或外科手术治疗,降低后期心房颤动的发生率。由于心房颤动可并发脑卒中、心力衰竭和猝死,因此,左心耳封堵+ASD封堵+心室率控制是合理的治疗选择。心房颤动消融(射频/冷冻)+ASD封堵和左心耳封堵的“一站式”治疗是可以选择的治疗方法,值得应用和研究。

END





文章来源:伍杨,白元,赵仙先.房间隔缺损与左心耳封堵“一站式”手术的研究进展.心血管病学进展,2022,43(06).

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●房间隔缺损合并三尖瓣反流

●心房颤动患者左心耳血栓形成的超声预测因素

●左心耳封堵术常见并发症及其防治

●先天性心脏病——房间隔缺损,到底是什么?

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