Assessment Of Right Ventricular Function By Echocardiography In Adult Artrial Septal Defect Patients Before And After Percutaneous Closure

Background:Atrial Septal Defect(ASD),about one newborn in every1500live births can be found with Atrial Septal Defect.ASD accounted for about30%--40%in Congenital Heart Disease,the male to female ratio is about1:2.ASD is a kind of CHD that left-to-right shunt leads to increasing volume load of left ventricle.they can be no distinct symptoms in adolescence and people miss the optimum treatment time.most of the patients develop symptoms and go to see their doctor when they are confirmed to be ASD,while at the same time,they can be found with Pulmonary Arterial Hypertension(PAH),Right Ventricuar Insufficiency,Eisenmenger’s syndrome and lost the opportunity of surgical therapy.Recently studies in clinical domains suggested that the incidence rate of Right Ventricular Enlargement,Right Heart Insufficiency,Ventricular Arrhythmias and Sudden Cardiac Death was significantly increasing.In most heart center,to save the damaged right ventricular function of congenital atrial septal defect patients,experienced experts do interventional operation for their Tricuspid regurgitation and pulmonary regurgitation when they have the atrial septal defect intervention treatment. They found that the perioperative Mortality rate didn’t have obviously increase.but the long-term outcome of those patients was obviously better than those who didn’t have interventional therapy on their Tricuspid regurgitation and pulmonary regurgitation. So, the evaluation of right heart function for the congenital atrial septal defect patients’ condition judgment,Clinical intervention strategy formulation, interventional effect evaluation and the evaluation of prognosis of patients is of very important significance.In the past30years Transcatheter closure in patients with ASD has matured. existing contrastive research on Transcatheter closure and conventional thoracotomy repair of auricular septal defect all proved that interventional therapy in reducing intraoperative complications, blood transfusion volume and length of hospital stay hold all the trumps. ESC in2010for adult congenital heart disease management guidelines recommended that transcatheter closure on atrial septal defect can be used as the preferred treatment for those who have the pathogenesy involvement indications. Therefore, the accurate evaluation of right heart function of congenital ASDs after interventional treatment is of vital significance.It blocks the left to right shunt atrium level after treatment of atrial septal defects,makes the original abnormal hemodynamic reversed, the right heart system preload is reduced, the capacity load change leads to the right heart gradually retraction and cardiac remodeling.once some scholars had reseach on heart structure change of ASDs after treatment. They found that after interventional treatment for atrial septal defects,the right heart system was gradually rebounding in the process of follow-up. At the same time many clinical studies have shown that right heart retraction of atrial septum after interventional therapy cannot achieve normal adult reference range. But through changes in the structure of right heart to evaluate right heart function is not reliable.In2008, Giardini et al found that in pathogenesy follow-up of3years after the intervention treatment, the PeakOxygen uptake of patients with cardiopulmonary exercise testing and the VE/VCO2slope when motion have apparent improvement and this change is not affected by age,it indirectly confirmed that interatrial septum exercise tolerance and right heart function improved after interventional therapy. But the cardiopulmonary exercise testing is limited to figure, influenced by gender, the degree of stimulation and training,so it still can’t be as the quantitative assessment of right heart function index.Domestic and foreign scholars agree that heart MR can be as the gold standard for noninvasive assessment of right heart function. Teo, Schoen and others reported after interventional treatment for atrial septal defects,patients’right ventricular end-diastolic volume, Left Ventricular End-systolic Volume, right ventricular ejection fraction had apparent improvement. right ventricular ejection fraction reached normal adult reference range, at the same time, patients’ average pressure with pulmonary artery rebacked to normal levels, heart function got recovery, this confirmed that the right heart function after interventional treatment for atrial septal defects could be gradually restored to the level of healthy adults. However, cardiac magnetic resonance is limited by China’s national conditions, economic cost, patients’ heart rate and the influence of metal device.so it cannot be applied to be as the regular follow-up tool after interventional therapy of atrial septal defects.To sum up, although the different methods from variety of field to assess right heart function of congenital atrial septum defects has appeared, restricted to a particular of complexity right ventricular geometric structure, the unpredictability of physiology, pathology, so far, there is still no generally accepted and applicable right heart function evaluation methods. Echocardiography is currently used in clinical diagnosis and treatment of the most common, convenient, effective and good compliance clinical examination technology. Previous study results confirm RVFAC, TAPSE, S ’and cardiac magnetic resonance imaging (MRI), radioactive nuclide imaging technology of right heart function with good consistency. Issued by the ministry of the American ultrasonic echocardiographyassociation2010to assess adult right heart function guidelines recommended RV FAC, TAPSE, S ’index could be used as a regular assessment of right ventricular function. Ultrasonic two-dimensional Strain (Strain, S)is a kind of new technology based on TDI technologies, different from the application of TDI determination of myocardial movement speed which may overvalue or undervalue cardiac function due to myocardial transfer or involve movement,while the2DS can be less responsive to the position change of the heart or the surrounding tissue involved, it can better evaluate local cardiac function. Therefore, this study choose the RV FAC, TAPSE, S ’, two-dimensional ultrasonic longitudinal strain to evaluate the right heart function, considering the patient’s compliance, economic costs, which has obvious clinical applicability and effectiveness.Objective:Application of echocardiography technology to evaluate preoperative atrial septal defects adult patients’ right heart function and the moderate-term effect of right heart function after interventional treatmentObjects and methods:1)Research object:Treatment group:Diagnosed adult ASDs and54cases undergoing interventional treatment from guangdong general hospital between December2012and August2013,3cases of atrial fibrillation after treatment.1case of permanent pacemaker implantation in3months postoperative because of sick sinus syndrome,1case of postoperative residual shunt,2cases were lost to follow-up, a total of47patients (male16cases, female21) finished6months follow-up.According to ESC2010adult congenital heart disease interventional treatment guidelines and the actual situation of the guangdong people’s hospital,patient standard is as follows:1.older than18;2.chest cardiac echocardiography before treatment:secundum atrail septal defect;8-32mm diameter of atrial septal defects;distance from the edge of atrial septal defects to the mitral valve roots is over7mm, and to the superior vena cava, coronary sinus, inferior vena menva, pulmonary vein>5mm;3, the interatrial septum stretched diameter is greater than the diameter of the closure device;4, intraoperative cardiac catheterization:pulmonary blood flow/systemic blood flow (Qp/Qs) is equal or greater than1.5.;Pulmonary artery systolic pressure/aortic systolic blood pressure (Pp/Ps) is equal or lesser than0.8;The total pulmonary resistance is equal or lesser than8.Exclusion criteria is as follows:Postoperative residual shunt;Merging other cardiac malformation;Merge secondary pulmonary hypertension syndrome or Eisenmenger’s syndrome,(Eisenmenger’s syndrome,total pulmonary resistance)8wood unit);Coronary heart disease, valvular heart disease, persistent atrial fibrillation or atrial flutter.Lost to follow-up.Control group:At the same time choose20healthy adult volunteers,7patients were male,13female cases.Healthy adult volunteers had no cardiovascular disease history and family history;the echocardiography,electrocardiogram and other report showed all normal from their history health exmination.2) Research methods:All the patients in treatment group in the preoperative and postoperative1day, six months after using echocardiography diagnosis inspection, under the condition of two-dimensional image imaging. From the apical four chamber view to get tricuspid free wall M type, tissue doppler, right ventricular systolic final and right ventricular end-diastolic image, and measure the tricuspid valve systolic displacement (TAPSE), tricuspid annulus systolic peak velocity (TAPSa,S’), at the end of the right ventricular systolic area (AreaES) and right ventricular end-diastolic area (AreaED);The right ventricle two-dimensional longitudinal strain. Measured under the same conditions, the control group of healthy adults appeals data. Right ventricle Fractionalarea change,(RVFAC) by the following formula:RVFAC=(AreaED-AreaES)/AreaED*100%.3) Statistical Methods:Congenital atrial septal defect treatment group and the control group of normal healthy adults:using SPSS13.0software, measurement data (±s) that the groups were compared using univariate analysis of variance completely random, with P<0.05was considered statistically significant. Congenital atrial septal defect follow-up time point for each treatment group comparison:using SPSS13.0software, measurement data (±s) that the follow-up data from different time periods using analysis of variance, pairwise comparisons using LSD-t test, p<0.05as statistically significant. Area under the ROC curve analysis was used to compare the accuracy of different indicators.Results:1) The basis of two observations comparison shows:two selected cases by sex, age was not statistically significant; groups at baseline AreaED, AreaES, TAPSE, TASa a significant difference in the treatment group is greater than the control group of healthy adults (P<0.001, P<0.001, P=0.045, P=0.004); groups, there were significant differences in baseline RVFAC, but the treatment group were lower than in healthy adults in the control group (P=0.007), the two groups at baseline Basal FW RV-S, MidFW RV-S has a statistically significant difference, atrial septal defect treatment group were higher than in healthy adults in the control group (P=0.013,P=0.007), Apical FW RV-S, Basal Sep RV-S, Mid Sep RV-S, Apical Sep RV-S at baseline control group of healthy adults with no significant difference (P=0.751, P=0.782, P=0.866, P=0.572).2) The right heart function index preoperative area under ROC curve:RVFAC, TASa index area under the curve is greater than0.7, TAPSE, BasalFW RV-S, Mid FW area under the RV-S curve is less than0.7, the area under the curve of0.750TASa, indicators in the area of the right ventricular function max.3) Comparison of atrial septal defect treatment follow-up observation indicators: atrial septal defect treatment group AreaED, AreaES after one day, were statistically different before and after6months after surgery one day, after six less than the previous month preoperative (P<0.01, P<0.01), after6months and1day after surgery is also a significant difference, after less than six months after1day (P <0.01); TAPSE, TASa surgery there after one day statistically significant difference compared with the preoperative, postoperative one day less than before surgery (P <0.01, P<0.01), but no significant difference one day before and6months after surgery; former RVFAC with preoperative phase than one day after the changes were not statistically significant, but before and after6months of operation, there were significant differences (P<0.01, P<0.01) after1day; atrial septal defect treatment group BasalFW RV-S, Mid FW RV-S, after one day with a statistically significant preoperative, postoperative one day less than before surgery (P<0.01, P<0.01), but after6months and1day after surgery ApicalFW RV-S, Basal Sep RV-S, MidSep RV-S, contrast Apical Sep RV-S before and after surgery, and no statistically significant difference; comparison not statistically significant. 4) After one day of each right heart function parameters under the ROC curve comparison:TAPSE, BasalFW RV-S, the area under the curve Mid FW RV-S is less than0.7, the area under the curve of0.833TASa in the right ventricular function indicators The area under the largest area after6months RVFAC indicators ROC curve was0.658.Conclusion:The right heart of adult ASDs fter interventional therapy compared with preoperative atrial septal defects had obvious retraction, but did not return to normal adult level, right heart retraction was not that good; right heart function indexes of the echocardiogram, evaluating the right heart function change by TASa of adult atrial septal defects before interventional therapy and after treatment gets the highest accuracy;RVFAC can assess right heart function change after ventricular remodeling of adult atrial septal defects with interventional treatment, but the evaluation accuracy is not high.