背景︰ 以心房中膈閉合器治療因心房中膈缺損所引起的嚴重左到右分流疾病已廣為醫界所接受，但對於兒童之大型心房中膈缺損是否適合以心房中膈閉合器治療，至今所發表的文獻仍少。我們收集近年來於高雄榮民總醫院兒童醫學部接受心房中膈閉合器治療心房中膈缺損的病人的臨床資料加以研究分析。
方法和材料︰ 在2002年六月至 2005年十二月間，共有52位病患(平均年齡； 13.5 ± 8.7歲) 接受心導管手術治療大型第二型心房中膈缺損 (大於25 mm) 。我們將其分成兩組，在第1組中，共39位病患其心房中膈缺損位於主動脈瓣後之組織缺乏或少於5 mm，第2組，13位病患其心房中膈缺損位於主動脈瓣後之組織大於5 mm。所有的步驟均在經食道心臟超音波的連續監視及全身麻醉下進行，除了10位病患只以經胸前心臟超音波的方法及局部麻醉下進行。我們評估病患的心房中膈閉合器置放的成功率，及選擇的閉合器的大小，置放的方法及可能的併發症。
結果︰ 全體病患的心房中膈閉合器置放的成功率為( 96.1%)，其成功率在兩組病患中之比較，並無統計學上的差異 (95% vs 100%, P > 0.05) 。其中2位病患各因栓塞及置放失敗而必須接受外科治療。所選擇的心房中膈閉合器的大小在第1組病患大於第2組的病患(29.7 ± 3.9 vs 26.7 ± 3.0mm, P = 0.04)，另外第1組病患利用使用右上肺靜脈置放心房中膈閉合器的方式多於第2組的病患，並具有統計學上的意義。在兩組病患之比較下，其併發症及心房中膈缺損的關閉率並無統計學上的差異。
結論 ： 以心導管方式利用心房中隔閉合器治療兒童之大型心房中膈缺損為一安全且有效的治療方法，主動脈瓣後之組織缺乏並不影響心房中膈閉合器治療心房中膈缺損的成功率，經由慎選合適的病人，病人的心房中隔缺損可以不需手術而安全的加以閉合。

Background: We reviewed our experience using the Amplatzer septal occluder (AGA Medical, Golden Valley, MN) to close large, secundum-type atrial septal defects (ASDs) in children.
Methods: Between June 2002 and December 2005, 52 patients (mean age 13.5 ± 8.7 years) underwent transcatheter closure of large (&#8805;25 mm), secundum ASDs by using the Amplatzer septal occluder (ASO). Groups 1 and 2 included patients with a retroaortic rim of <5 mm (n = 39) or &#8805;5 mm(n = 13), respectively. All procedures were performed with general anesthesia and transesophageal echocardiographic guidance except for 10 patients, which involved local anesthesia and 3-dimensional transthoracic echocardiography. Successful device implantations, device sizes, approaches, complications, and closure rates were assessed.
Results: Device implantation was successful in 50 patients (96.1%), with no difference between groups (95% vs 100%, P > 0.05). In 2 patients, implantation failed because of embolism or deployment failure. Devices were larger in group 1 than in group 2 (29.7 ± 3.9 vs 26.7 ± 3.0 mm, P =0.04). The right upper pulmonary-vein approach was more common in group
1 than in group 2 (P = .0001). Complications and closure rates did not differ between the groups (P > .05).
Conclusions: Transcatheter closure of large, secundum ASD by using the ASO device was feasible, and complication rates were low. A deficient retroaortic rim did not preclude successful device implantation; however, a large device may be needed to close large ASD. Close long-term follow-up is necessary to determine the safety of transcatheter closure of large ASDs in children.

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1. Sideris EB, Leung M, Yoon JH, Chen CR, Lochan R, Worms AM, Rey C, Meier B (1996) Occlusion of large atrial septal defects with a centering button device: early clinical experience. Am Heart J; 131:356-9.
2. Momenah TS, McElhinney DB, Brook MM, Moore P, Silverman NH (2000) Transesophageal echocardiographic predictors for successful
transcatheter closure of defects within the oval fossa using the CardioSEAL septal occlusion device. Cardiol Young ; 10:510-8.
3. Chan KC, Godman MJ, Walsh K, Wilson N, Redington A, Gibbs JL (1999) Transcatheter closure of atrial septal defect and interatrial communications with a new self expanding nitinol double disc device(Amplatzer septal occluder): multicentre UK experience. Heart; 82:300-6.
4. Hausdorf G, Kaulitz R, Paul T, Carminati M, Lock J ( 1999) Transcatheter closure of atrial septal defect with a new flexible, self-centering device (the STARFlex occluder). Am J Cardiol ;84:1113-6.
5. Rigby ML (1999) The era of transcatheter closure of atrial septal defects. Heart; 81:227-8.
6. Masura J, Gavora P, Formanek A, Hijazi ZM (1997) Transcatheter closure of secundum atrial septal defects using the new self-centering Amplatzer septal occluder: initial human experience. Catheter cardiovasc Diagn; 42:388-93.
7. Thanopoulos BD, Laskari CV, Tsaousis GS, Zarayelyan A, Vekiou A, Papadopoulos GS (1998)Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results. J Am Coll Cardiol; 31:1110-6.
8. Hijazi ZM, Cao Q, Patel HT, Rhodes J, Hanlon KM(2000) Transesophageal echocardiographic results of catheter closure of atrial septal defect in children and adults using the Amplatzer device. Am J Cardiol; 85:1387-90.
9. Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K (2002) 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; 39:1836-44.
10. Kannan BR, Francis E, Sivakumar K, Anil SR, Kumar RK (2003) Transcatheter closure of very large (> or = 25 mm) atrial septal defects using the Amplatzer septal occluder. Catheter Cardiovasc Intervent; 59:522-7.
11. Demkow M, Ruzyllo W, Konka M, Kepka C, Kowalski M, Wilczynski J, Rydlewska-Sadowska W (2001) Transvenous closure of moderate and larges secundum atrial septal defects in adults using the Amplatzer septal occluder. Catheter Cardiovasc Interv; 52:188-93.
12. Varma C, Benson LN, Silversides C, Yip J, Warr MR, Webb G, Siu SC, McLaughlin PR (2004) Outcomes and alternative techniques for device closure of the large secundum atrial septal defect. Catheter Cardiovasc Interv; 61:131-9.
13. Murphy JG, Gersh BJ, McGoon MD, Mair DD, Porter CJ, Ilstrup DM, McGoon DC, Puga FJ, Kirklin JW, Danielson GK (1990) Long term outcome after surgical repair of isolated atrial septal defect: follow up at 27 to 32 years. N Engl J Med; 323:1645-50.
14. Horvath KA, Burke RP, Collins JJ Jr, Cohn LH(1992) Surgical treatment of adult atrial septal defect: early and long-term results. J Am Coll Cardiol; 20:1156-9.
15. Hughes ML, Maskell G, Goh TH, Wilkinson JL(2002) Prospective comparison of costs and short term health outcomes of surgical versus device closure of atrial septal defect in children. Heart; 88:67-70.
16. Thomson JD, Aburawi EH, Watterson KG, Van Doorn C, Gibbs JL (2002) Surgical and transcatheter (Amplatzer) closure of atrial septal defects: a prospective comparison of results and cost. Heart; 87:466-9.
17. Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L, Giamberti A, Pome G, Bossone E, Frigiola A (2002) Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol; 39:1061-5.
18. Levi DS, Moore JW (2004) Embolization and retrieval of the Amplatzer septal occluder. Catheter Cardiovasc Interv; 61:543-7.
19. Cooke JC, Gelman JS, Harper RW (1999) Chiari network entanglement and herniation into the left atrium by an atrial septal defect occluder device. J Am Soc Echocardiogr; 12:601-3.
20. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS (2004) 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; 63(4):496-502.
21. Chun DS, Turrentine MW, Moustapha A, Hoyer MH (2003) Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder. Catheter Cardiovasc Interv; 58(2):246-51.
22. Chien KJ, Lee CL, Huang TC, Lin CC, Weng KP, Huang SH, Hsieh KS. A noninvasive sizing method to choose fitted Amplatzer septal occluder by transthoracic echocardiography in patients with secundum ASD. Heart and Vessels; (in print)