摘要︰
背景︰ 目前，為了適當治療因心房中膈缺損所引起的嚴重左到右分流，心房中膈閉合器已經成為一種很好的技術。在以往傳統的過程中，一般均於放射線下以測量氣球的腰身來確定缺陷的大小及選擇合適的閉合器。但是以經胸心臟超音波(TTE)的方法來測量缺陷大小及選用合適的閉合器的方式至今尚未研究過。
方法和材料︰ 在2002年12月至 2004年10月間，共有40位病患(15位男性，25位女性，平均年齡； 11.7 ± 7.8歲)患有第二型心房中膈缺損並於我們醫院接受心導管閉合手術。我們將其分成兩組，在第1 組中，30位病患分別以測量氣球腰身的方法和經胸心臟超音波的方法來測量缺陷大小。第2組，10位病患只以經胸心臟超音波的方法來測量缺陷大小，並依據在第1 組中Amplatzer 心房中膈閉合器(ASO)尺寸和經胸心臟超音波所測得破洞尺寸比率來選擇閉合器尺寸。所有的過程均在經食道心臟超音波的連續監視及全身麻醉下進行。
結果︰ 在第1 組中，經胸心臟超音波與伸展氣球的腰身所測量缺陷大小(SBD)的線性函數關係為y = 1.2645x-1.4465；R2 = 0.9861，而經胸心臟超音波所測得破洞尺寸與Amplatzer 心房中膈閉合器尺寸之間的線性函數關係為y = 1.3412x-1.2864；R2 = 0.9929。在第2組中，經胸心臟超音波所測得破洞尺寸與Amplatzer 心房中膈閉合器尺寸之間的線性函數關係為y = 1.3419x-0.1172； R2 = 0.9934。由第1 組和第2 組結果可見，經胸心臟超音波所測得破洞尺寸與Amplatzer 心房中膈閉合器尺寸之間有很好線性回歸關係(R2 =0.99)。在第2 組中，所有病患均成功的完成閉合器的植入手術，而且其閉合器的尺寸是依據在第1 組中Amplatzer 心房中膈閉合器尺寸和經胸心臟超音波所測得破洞尺寸比率所選取的。
結論 ： 以經胸心臟超音波來測量缺陷大小及選用合適的閉合器的方式是一種安全及理想的方法。而且依據我們的經驗，經胸心臟超音波來測量缺陷大小也比測量伸張的氣球腰身容易。

Abstract:
Background: At present, device closure of interatrial communication has become a well established technique in order to adequately treat severe left-to-right shunt associated with ASDs. During the traditional procedure, fluoroscopy with the waist of a compliant balloon is used to determine the appropriate size of the closure device and defect sizing. Choice of adequate closure device using transthoracic echocardiography (TTE) has been hitherto unreported.
Methods & Materials: Between December 2002 and October 2004, 40 patients (15 males, 25 females, mean age; 11.7 ± 7.8 years ) with secundum ASDs underwent transcatheter closure at our institution. In group 1, 30 patients had the procedure by balloon sizing and TTE sizing. In 10 patients (group 2), TTE sizing was used as the sole too l for selecting device size and the device size was chosen to be based on the Amplatzer septal occluder ( ASO ) size and TTE size ratio in group 1. The procedure was performed under continuous transoesophageal echocardiographic monitor with general anesthesia.
Results: The correlation was found between TTE and stretched balloon sizing diameter SBD ( y= 1.2645x-1.4465; R²=0.9861 ), and between TTE size and ASO size ( y = 1.3412x-1.2864; R²=0.9929 ) in group 1. In group 2, statistical correlation between TTE and ASO ( y=1.3419x-0.1172; R²=0.9934 ) was also found. Good linear regression between TTE size and ASO chosen size was noted in group 1 and group 2 (R²=0.99).In group 2, successful device implantation was accomplished in all patients whose device size was chosen to be based on the ASO and TTE ratio in group 1.
Conclusions: TTE sizing is a safe and ideal method to measure interatrial defect and choose the occluding device respectively. With our experience, the sizing based on the TTE is generally easier than measurement from the balloon sizing.

目 錄

頁次

中文摘要--------------------------------------------i
英文摘要--------------------------------------------ii
英文縮寫表------------------------------------------iii
論文內文:
序言（背景介紹）------------------------------------1
材料與方法------------------------------------------6
結果------------------------------------------------9
討論------------------------------------------------10
參考文獻--------------------------------------------19
表--------------------------------------------------26
圖--------- ----------------------------------------28
附錄------------------------------------------------44

1. Van Mierop LHS. Embryology of the atrioventricular canal region and pathogenesis of endocardial cushion defects. In: Feldt RH, McGoon DC, Ongley PA, et al., eds. Atrioventricular canal defects. Philadelphia: WB Saunders, 1976:1-12.
2. Sylvius J. Excerpt from Isagoge Anatomica, Venice. In: Rashkind WJ. ed. Congenital heart disease. Philadelphia: Hutchinson Ross,1982;8.
3. de Vinci L. Excerpt from Quardernia Anatomica II. In; Rashkind WJ. ed. Congenital heart disease. Philadelphia: Hutchinson Ross,1982;102.
4. von Rokitansky C. Die Defect der Scheidewande des Herzens. Vienna: Braumuller, 1875.
5. Roesler H. Interatrial septal defect. Arch Intern Med 1934;54:339.
6. Bedford DE, Papp C, Parkinson J. Atrial septal defect. Br Heart J 1941;3:37-68.
7. Ha JW, Shin MS, Kang S, Pyun WB, Jang KJ, Byun KH, Rim SJ, Huh J, Lee BI, Chung N. Enhanced detection of right-to-left shunt through patent foramen ovale by transthoracic contrast echocardiography using harmonic imaging. Am J Cardiol. 2001 Mar 1;87(5):669-71, A11.
8. Barratt-Boyes BG. The results of repair of atrial septal defect using the atrial well method. Ann R Coll Surg Engl 1963;33:209.
9. Gibbon JH. Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med 1954;37:171-185.
10. Gessner IH. Atrial septal defect. In: Moller JH, ed. Perspective in pediatric cardiology. Vol.6. Surgery of congenital heart disease. Pediatric Cardiac Care Consortium 1984-1995. Ar monk, NY: Futura,1998:31-44.
11. Sastry S, McCollum C. Patent foramen ovale and stroke. Circulation. 2001 Feb 27;103(8):E46-7.
12. Overell JR, Lees KR, Bone I. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism. Circulation. 2001 Mar 13;103(10):E56.
13. Webb G. Do patients over 40 years of age benefit from closure of an atrial septal defect? Heart. 2001 Mar;85(3):249-50.
14. Mattioli AV, Aquilina M, Oldani A, Longhini C, Mattioli G. Frequency of atrial septal aneurysm in patients with recent stroke: preliminary results from a multicenter study. Clin Cardiol. 2001 Apr;24(4):297-300.
15. Hufnagel C, Gillespie J. Closure of intra-auricular septal defects. Bull Georgetown Univ Med Center 1959; 4:137-9.
16. King T, Mills N. Nonoperative closure of atrial septal defects. Surgery 1974; 75:383-88.
17. King T, Thompson S, Steiner C, Mills N. Secundum atrial septal defect: nonoperative closure during cardiac catheterization. JAMA 1976; 235:2506-9.
18. Mills N, King T. Nonoperative closure of left-to-right shunts. J Thorac Cardiovasc Surg 1976; 72(3):371-8.
19. Rashkind W. Transcatheter treatment of congenital heart disease. Circulation 1983; 67:711-6.
20. Rashkind W. Interventional cardiac catheterization in congenital heart disease. Int J Cardiol 1985; 7:1-10.
21. Beekman R, Rocchini A, Snider A, Rosenthal A. Transcatheter atrial septal defect closure: preliminary experience with the Rashkind occluder device. J intervent Cardiol 1989; 2:35-41.
22. Alp N, Clarke N, Banning AP. How should patients with patent foramen ovale be managed? Heart. 2001 Mar;85(3):242-4.
23. Faella HJ, Sciegata AM, Alonso JL, Jmelnitsky L. ASD closure with the Amplatzer device. J Interv Cardiol. 2003 Oct;16(5):393-7
24. Schrader R. Indication and techniques of transcatheter closure of patent foramen ovale. J Interv Cardiol. 2003 Dec;16(6):543-51. Review.
25. Kaulitz R, Peuster M, Jux C, Paul T, Hausdorf G. Transcatheter closure of various types of defects within the oval fossa using the double umbrella device (CardioSEAL)--feasibility and echocardiographic follow-up. Cardiol Young. 2001 Mar;11(2):214-22.
26. J. Masura, P. Gavora, A. Formanek and Z.M. Hijazi. Transcatheter closure of secundum atrial septal defects using the new self-centering Amplatzer Septal Occluder: initial human experience. Cathet Cardiovasc Diagn 1997; 42: 388-393.
27. K.C. Chan, M.J. Godman, K. Walsh et al., Transcatheter closure of atrial septal defect and interatrial communications with a new self expanding nitinol double dis device ( Amplatzer septal occluder): multicenter UK experience. Heart. 1999; 82:300-306.
28. Matitiau A, Birk E, Kachko L, Blieden LC, Bruckheimer E. Transcatheter closure of secundum atrial septal defects with the amplatzer septal occluder: early experience. Isr Med Assoc J. 2001 Jan;3(1):32-5.
29. Waight DJ, Koenig PR, Cao QL, et al. Transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: clinical experience and technical considerations. Curr Intervent Cardiol Rep 2002; 2:70-7.
30. Iacovino J. Mortality outcome of surgically treated atrial septal defects. J Insur Med. 2001;33(1):37-41.
31. Z.D. Du, Z.M. Hijazi, C.S. Kleinman, N.H. Silverman, K. Larntz and Amplatzer Investigators, Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial, J Am Coll Cardiol 2002; 39:1836-1844.
32. U.Mazic, P. Gavora and J. Masura, The role of transesophageal echocardiography in transcatheter closure of secundum atrial septal defects by the Amplatzer Septal Occluder. Am Heart J 2001; 142:482-488.
33. Latiff HA, Samion H, Kandhavel G, Aziz BA, Alwi M. The value of transesophageal echocardiography in transcatheter closure of atrial septal defects in the oval fossa using the Amplatzer septal occluder. Cardiol Young. 2001 Mar;11(2):201-4.
34. Z.M. Hijazi, Z. Wang, Q.L. Cao, P. Koenig, D. Waight and R. Lang, Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv 2001; 52: 194-199.
35. M.J. Mullen, B.F. Dias, F. Walker, S.C. Siu, L.N. Benson and P.R. McLaughin, Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol 2003; 41:285-292.
36. T. Bartel, T. Konorza and J. Arjumand et al., Intracardiac echocardiography is superior to conventional monitoring for guiding closure of interatrial communications, Circulation 2003; 107:795-797.
37. Koenig PR, Abdulla RI, Cao QL, Hijazi ZM. Use of intracardiac echocardiography to guide catheter closure of atrial communications. Echocardiography. 2003 Nov;20(8):781-7.
38. Boccalandro F, Baptista E, Muench A, Carter C, Smalling RW. Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect. Am J Cardiol. 2004 Feb 15;93(4):437-40
39. Holmvang G. A magnetic resonance imaging method for evaluating atrial septal defects. J Cardiovasc Magn Reson. 1999;1(1):59-64.
40. Grebe O, Giesler M, Kestler HA, Hombach V, Hoher M. Magnetic resonance imaging after percutaneous closure of a patent foramen ovale. Circulation. 2001 Nov 27;104(22):E117-8.
41. Buecker A, Spuentrup E, Grabitz R, et al. Magnetic resonance-guided placement of atrial septal closure device in animal model of patent foramen ovale. Circulation. 2002; 106:511-518.
42. Beerbaum P, Korperich H, Esdorn H, et al. Atrial septal defects in pediatric patients: noninvasive sizing with cardiovascular MR imaging. Radiology. 2003; 228:361-369.
43. Carcagni A, Presbitero P. New echocardiographic diameter for Amplatzer sizing in adult patients with secundum atrial septal defect: preliminary results. Catheter Cardiovasc Interv. 2004 Jul;62(3):409-14.
44. Zahid Amin. et al. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv. 2004; 63:496-502.
45. Demkow M, Ruzyllo W, Konka M, Kepka C, Kowalski M, Wilczynski J, Rydlewska-Sadowska W. Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder. Catheter Cardiovasc Interv. 2001 Feb;52(2):188-93.
46. Zanchetta M, Onorato E, Rigatelli G, Dimopoulos K, Pedon L, Zennaro M, Maiolino P. Use of Amplatzer septal occluder in a case of residual atrial septal defect causing bidirectional shunting after percutaneous Inoue mitral balloon valvuloplasty. J Invasive Cardiol. 2001 Mar;13(3):223-6.
47. Wahab HA, Bairam AR, Cao QL, Hijazi ZM. Novel technique to prevent prolapse of the Amplatzer septal occluder through large atrial septal defect. Catheter Cardiovasc Interv. 2003 Dec;60(4):543-5.
48. Schwerzmann M, Windecker S, Wahl A, Mehta H, Nedeltchev K, Mattle H, Seiler C, Meier B. Percutaneous closure of patent foramen ovale: impact of device design on safety and efficacy. Heart. 2004 Feb;90(2):186-90.
49. Ferreira SMAG, Ho SY, Anderson RH. Morphological study of defects of the atrial septum within the oval fossa: implications for transcatheter closure of left-to-right shunt. Br Heart J 1992;67:316-320.
50. Rosenzweig BP, Nayar AC, Varkey MP, Kronzon I. Echo contrast-enhanced diagnosis of atrial septal defect. J Am Soc Echocardiogr. 2001 Feb;14(2):155-7
51. Frazin L, Talano JV, Stephanides L, Loeb HS, Kopel L, Gunnar RM. Esophageal echocardiography. Circulation 1976; 54:102-8.
52. Souquet J, Hanrath P, Zitelli L, et al. Transesophageal phased array for imaging the heart. IEEE Trans Biomed Engineer 1982; 29:707.
53. Hanrath P, Kremer P, Langestein BA, Matsumoto M, Bleifeld W. Transesophageal eckokardiographie: Einneues Verfahren zur dynamischen Ventrikel-funktionsanalyse. Dtsch Med Wochenschr 1981; 106:525-32.
54. Hanrath P, Schluter M, Langenstein BA, et al. Detection of ostium secundum atrial septal defects by transoesophageal cross-sectional echocardiography. Br Heart J 1983; 49:350-8.
55. Omoto R, Kyos S, Matsumura M, Adachi H, Maruyama M, Matsunaka T. New direction of biplane transesophageal echocardiography with special emphasis on real-time biplane imaging and matrix phased-array biplane transducer. Echocardiography 1990; 7:691-8.
56. Stumper O, Elzenga NJ, Hess J, Sutherland GR. Transoesophageal echocardiography in children with congenital heart disease – an initial experience J Am Coll Cardiol 1990; 16:433-41.
57. Peter Ewert, Felix Berger, Ingo Daehnert. et al. Transcatheter closure of atrial septal defects without fluoroscopy: feasibility of a new method. Circulation. 2000; 101:847-853
58. Creszynski T: Intracardiac method for the investigation of structure of the heart with the aid of ultrasonics. Arch Immun Ter Dow. 1960; 8:551.
59. Z.M. Hijazi, Z. Wang, Q.L. Cao et al., Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv. 2001; 52:194–199.
60. Holmvang G, Palacios IF, Vlahakes GJ, et al. Imaging and sizing of atrial septal defects by magnetic resonance. Circulation 1995; 92:3473-3480.
61. Theissen P, Sechtem U, Mennicken U, Hilger HH, Schicha H. Non-invasive diagnosis of atrial septal defects and anomalous pulmonary venous return using magnetic resonance tomography. Nuklearmedizin 1989; 28:172-180.
62. Collins CM, Chandran KB, Skorton DJ: Three-dimensional cardiac imaging. Echocardiography 1988;5:311.
63. Raqueno R et al: Four-dimensional reconstruction of tw-dimensional echocardiographic image. Echocardiography 1989;6:323.
64. Levine RA et al: Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation 1989;80:589.
65. Pandian NG et al: Three-dimensional and four-dimensional transesophageal echocardiographic imaging of the heart and aorta in human beings using a computed tomographic imaging probe. Echocardiography 1992;9:677.
66. Schwartz S et al: Simulation of intraoperative visualization of cardiac structures and study of dynamic surgical anatomy with real time three-dimensional echocardiography. Am J Cardiol 1994;73:501.
67. Greenleaf JF et al: Multidimensional visualization in echocardiography: an introduction. Mayo Clin Proc 1993;68:213.
68. Belohlavek M et al: Three- and four-dimensional cardiovascular ultrasound imaging: a new era for echocardiography. Mayo Clin Proc 1993;68:221.
69. Pandian NG et al: Dynamic three-dimensional echocardiography: methods and clinical potential. Echocardiography 1994;11:237
70. Marx GR et al: Delineation of site, relative size and dynamic geometry of atrial septal defects by real-time three-dimensional echocardiography. J Am Coll Cardiol 1995;25:482.
71. Lu JH, Hsu TL, Hwang B, Weng ZC. Visualization of Secundum Atrial Septal Defect Using Transthoracic Three-Dimensional Echocardiography in Children: Implications for Transcatheter Closure. Echocardiography. 1998 Oct;15(7):651-660.
72. Yu TH, Fu M, Chua S. Three-dimensional echocardiographic image of atrial septal aneurysm: report of two cases. Chang Gung Med J. 2000 Nov;23(11):701-5.