实时三维经食管超声心动图在二尖瓣成形术中的应用研究

目的 探讨术中实时三维经食管超声心动图(RT-3D TEE)判断二尖瓣病变区域的准确性,以及评价二尖瓣成形术效果的价值.方法 19例因二尖瓣反流(MR)拟接受二尖瓣成形术患者,采集术前、术后RT-3D TEE图像,将术前所见与术中发现进行比较,并在术后即刻评价手术疗效.结果 RT-3DTEE诊断二尖瓣叶病变与术中发现完全相符16例,3例不符合,其中1例术前诊断前叶中间段、后叶中间段脱垂,术中仅发现瓣环扩大,瓣膜黏液退行性变;1例术前诊断后叶后内段脱垂,术中发现后叶中间段及后内段腱索断裂;1例术前提示瓣环扩大,术中发现后叶中间段脱垂.2D TEE诊断二尖瓣病变与术中发现完全相符仅10例,且对二尖瓣脱垂患者难以明确脱垂的确切瓣区和范围.术后即刻观察成形术效果,其中18例RT-3DTEE显示微量至少量二尖瓣反流,1例术后仍为中重度反流,改行二尖瓣置换术,二尖瓣成形术的成功率为94.7%.结论 RT-3D TEE明显提高了二尖瓣反流病因及病变部位定位的诊断准确性,在二尖瓣成形术手术方案制定及疗效的即刻评估方面发挥了非常重要的作用.     

实时三维经食管超声心动图对二尖瓣成形术的指导意义

目的探讨实时三维经食管超声心动图（TEE）在二尖瓣脱垂患者外科手术治疗中对二尖瓣结构精细化诊断、成形环选择的意义及术后即刻疗效评估的价值。 方法选择2016年11月至2017年3月浙江大学附属第一医院经胸超声心动图诊断为二尖瓣脱垂,并进行外科手术治疗的19例患者。19例患者均在麻醉后体外循环之前行实时三维TEE检查。并在手术完成心脏复跳后即刻再次进行检查,实时显示并记录存储图像。整个检查过程中与外科医师、麻醉医师同时观察图像,直接交流并与术中所见相对照,以术中所见为标准。应用实时三维超声重建对19例中度以上二尖瓣脱垂患者进行检查测量,观察二尖瓣瓣膜与腱索,测量二尖瓣的瓣环、瓣膜长度及纤维三角的直径。 结果术中TEE检查可从任意角度清晰显示二尖瓣瓣膜、瓣环、腱索、乳头肌的解剖结构、运动情况。实时观察二尖瓣厚度、活动度、有无钙化及赘生物,腱索有无断裂,并能补充诊断有无血栓及卵圆孔未闭。本组19例患者TEE判断二尖瓣脱垂区域与术中基本一致,以后叶P2区最多见。检出病因：二尖瓣腱索断裂导致脱垂共15例,其中12例探查到2处腱索断裂,与术中一致,准确率100%。本组19例患者TEE测量后提供的成形环尺寸14例一致,准确率73.7%（4/9）,4例术中选择测瓣器size比TEE测值小一号,1例术中选择测瓣器size比TEE测值大一号。 结论应用实时三维超声重建可客观地反映二尖瓣脱垂的病因及病变情况,提供直观的立体图像,对制定手术方案具有重要参考价值。并能为选择成形环的大小提供依据,节约了手术时间,具有实际的临床指导意义。术后即刻评价自体成形瓣膜的功能,并实时了解室壁运动及左心室收缩功能,也可以监测左心气体,有助于麻醉医师术中监护,同时提高了手术的成功率。     

经胸与经食管超声心动图观察二尖瓣脱垂形态在诊断腱索断裂中的应用价值

目的 比较TTE与TEE诊断二尖瓣脱垂合并腱索断裂的准确率,评价超声观察二尖瓣脱垂形态在诊断腱索断裂中的价值。方法 选择经手术证实的二尖瓣脱垂患者25例,应用TTE与TEE观察二尖瓣脱垂部位并进行比较,分析二尖瓣脱垂形态及其与腱索断裂的关系。结果 25例二尖瓣脱垂患者中,前叶脱垂10例,后叶脱垂15例。TEE在二尖瓣脱垂部位的分区中比TTE准确。TTE诊断二尖瓣腱索断裂的准确率为53.84%,TEE的诊断准确率为84.62%,TEE明显优于TTE(P<0.05)。伴有腱索断裂的二尖瓣脱垂多表现为倾斜状脱垂(χ²=4.81,P<0.05)。结论 TEE能较TTE更准确地诊断二尖瓣脱垂。应用此两种技术,可根据二尖瓣脱垂形态间接判断是否存在腱索断裂。     

术中经食管超声评价儿童二尖瓣成形人工腱索植入的效果及临床价值北大核心CSCD

儿童二尖瓣脱垂多为先天性（腱索延长或断裂）,导致二尖瓣关闭不全,继发性左心增大、左心功能减低。我院行儿童二尖瓣成形人工腱索植入术治疗瓣叶脱垂,取得良好的效果。目前经食管超声（TEE）已成为二尖瓣成形术效果评价的常用方法,术后即刻观察二尖瓣反流量、人工腱索位置及活动情况,测量瓣叶对合高度及其他相关参数,因此,经TEE判断二尖瓣成形效果是较简捷和必要的手段。     

术中经食管超声评价儿童二尖瓣成形人工腱索植入的效果及临床价值

儿童二尖瓣脱垂多为先天性(腱索延长或断裂),导致二尖瓣关闭不全,继发性左心增大、左心功能减低。我院行儿童二尖瓣成形人工腱索植入术治疗瓣叶脱垂,取得良好的效果。目前经食管超声(TEE)已成为二尖瓣成形术效果评价的常用方法[1],术后即刻观察二尖瓣反流量、人工腱索位置及活动情况,测量瓣叶对合高度及其他相关参数,因此,经 TEE 判断二尖瓣成形效果是较简捷和必要的手段。     

体元模型动态三维重建超声显像在二尖瓣返流患者手术治疗中的应用

目的：本研究旨在采用体元（voxel)模型动态三维重建技术,以立体角度观察分析二尖瓣关闭不全患者二尖瓣的形态学特征,为手术方法的选择和术后疗效的评价提供依据。方法：研究对象为行二尖瓣成形术的病 列共15例。术中图像采集选用HPSonos2500多功能超声诊断仪和5MHz多平面食管探头,三维重建选用德国TOMTEC公司生产的ECHOSCAN计算机工作站,结果：上述患者术前前叶脱垂3例,后叶脱垂10例,前后叶均脱垂2例;其中合并腱索断裂9例,包括前叶腱索断裂2例,后叶腱索断裂7例。术后再次三维重建发现10例患者术后仅为二尖瓣轻微或轻度返流。5例患者术后出现轻中度返流,三维重建示3例轻度残余脱垂,2例对合不良,当即予以换瓣治疗。5例术后出现二尖瓣轻中度返流患者术前二尖瓣后叶脱垂合并广泛腱索断裂仅占1例,前叶脱垂合并腱索断裂占2例,前后叶均脱垂占2例其中1例合并腱索断裂,以二尖瓣前叶病变为主的二尖瓣重度返流的患者行二尖瓣成行术的疗铲远不如以二尖瓣后叶病变为主的二尖瓣关闭不全的患者（P<0.05)。结论：以二尖瓣前叶病变为主的重度二在瓣返流患者宜采用换瓣术。     

经食管超声心动图术中评价PV-4人工腱索植入二尖瓣成形术

目的应用经食管超声心动图（TEE）,评价二尖瓣腱索断裂,行PV-4人工腱索植入二尖瓣成形术效果和应用前景。 方法随机对30例二尖瓣腱索断裂患者行二尖瓣成形术,术前及术后即刻进行TEE彩色血流显像检查,其中Ⅰ组15例患者行人工腱索植入22根（前叶18根,后叶4根）。Ⅱ组15例患者未行人工腱索植入。 结果术前Ⅰ组中度二尖瓣反流为7例（占46.7%）,重度二尖瓣反流为8例（占53.3%）,Ⅱ组中度二尖瓣反流为5例（占33.3%）,重度二尖瓣反流为10例（占66.7%）,术后Ⅰ组无二尖瓣反流为5例（占33.3%）,轻微二尖瓣反流为10例（占66.7%）,Ⅱ组轻微二尖瓣反流为5例（占33.3%）,轻度二尖瓣反流为9例（占60.0%）,中度二尖瓣反流为1例（占6.7%）。 结论TEE彩色血流显像显示植入人工腱索的患者,无二尖瓣反流者占33.3%,轻微反流者占66.7%,而未植入人工腱索的患者均有二尖瓣反流,轻微反流者占33.3%,轻度反流者占60.0%,中度反流者占6.7%,成形效果较人工腱索植入者为差。     

经食管超声心动图在二尖瓣成形术治疗中应用价值

目的:探讨经食管超声心动图在二尖瓣成形术治疗中的临床价值。方法:选取2015年1月~2016年8月我院心外科收治的30例风湿性二尖瓣关闭不全患者为研究对象,所有患者均行二尖瓣成形术,术前术后应用经食管三维超声心动图对瓣膜形态、腱索、瓣环等进行观察,并计算瓣环面积、瓣环周长和前后叶面积等二尖瓣三维结构参数,同时对手术成功情况进行评估。结果:患者的瓣环面积、瓣环周长、瓣叶面积、前叶面积、后叶面积、脱垂高度、脱垂容积和瓣叶非平面夹角等参数均较术前明显减小,前叶角度、后叶角度均较术前明显增大,差异均有统计学意义,P<0.05;30例患者中一次性二尖瓣手术成功者28例,成功率为93.3%,其余2例确定为术中3级反流后,改变手术方式采用二尖瓣人工瓣膜置换术进行了治疗。结论 :经食管超声心动图在二尖瓣成形术治疗中的临床价值极高,是评估二尖瓣成形术成功与否的重要依据。     

双孔二尖瓣成形术

二尖瓣成形术治疗二尖瓣关闭不全是一种技术要求高、难度大的工艺性手术。由于二尖瓣病变病理改变复杂，很难要求统一固定的术式。二尖瓣成形术的方法较多。困难亦较大。合并腱索的病变及瓣叶脱垂所致的瓣叶对位问题，亦大大增加了二尖瓣成形术的复杂因素。自1968年Carpentier发明二尖瓣成形环以来，各种成形技术不断涌现，但对有些病变，特别是前叶脱垂，在外科技术上仍具有挑战性，较早采用的瓣膜三角形切除、对缘缝合或腱索折叠、缩短术式效果不理想；临床上已应用的腱索转移、腱索缩短、腱索置换以及瓣体转移等多项外科修复技术手术操作相对复杂，费时较长、技术难度相对大。二尖瓣前叶在二尖瓣闭合功能中占有重要地位，完整的功能活动对前叶面积和瓣体的活动度有着严格的要求。     

经胸超声心动图详细定位二尖瓣脱垂部位在二尖瓣成形术中的应用价值

目的尝试运用经胸二维超声心动图对二尖瓣脱垂的具体部位及病因进行详细区分和准确判断。方法39例二尖瓣脱垂患者，于二尖瓣成形或置换术前进行经胸超声心动图检查，初步判断脱垂瓣叶的准确部位及病因，外科术中直视下诊断。结果根据外科二尖瓣结构修正命名，术前二尖瓣水平短轴观及其衍生的非标准切面诊断出脱垂的局部瓣体44处，共涉及65个分区，15例患者发现断裂的腱索；术中证实分别为51处瓣体、78个分区，20例检出断裂腱索，符合率86％、83％和75％；5例患者脱垂瓣叶及腱索上发现赘生物并均在术中证实。结论经胸二维超声心动图能对大多数二尖瓣脱垂的具体部位及病因作出准确判断。二尖瓣水平短轴观及其衍生的非标准切面具有重要价值。     

Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability for repair.

Mitral valve (MV) repair is the procedure of choice for MV prolapse or flail. However, valve repair is more technically demanding and requires a precise definition of MV morphology to determine the timing, complexity, and feasibility of repair. We prospectively examined 170 consecutive patients with MV prolapse or flail referred for MV repair. The MV valve was systematically assessed by intraoperative transesophageal echocardiography. MV anatomy was independently assessed at the time of operation. Accuracy of transesophageal echocardiography in identifying MV segments ranged from 90% to 97%, and was best for the middle segment/scallop of either anterior or posterior leaflet. MV repair was successful in 91% of patients. Success rate was the lowest (78%) in the presence of extensive bileaflet disease involving at least 2 segments of each leaflet. Independent predictors of unsuccessful repair were central jet of mitral regurgitation, calcification or severe dilatation of the mitral annulus, and extensive leaflet disease with involvement of at least 3 segments.     

Identifying patients with degenerative mitral regurgitation for mitral valve repair and replacement: a transesophageal echocardiographic study.

OBJECTIVE: We sought to preoperatively identify the suitability of patients with degenerative mitral valve (MV) regurgitation for MV repair (MVR) and MV replacement. BACKGROUND: MVR is the preferred method of treatment over MV replacement, if surgically feasible. MVR preserves left ventricular function and decreases risk of hemolysis, thromboembolism, and-in the absence of anticoagulation-hemorrhage. However, the ability to identify patients suitable for MVR preoperatively is somewhat limited. METHODS: In all, 76 patients underwent MV operation for severe symptomatic mitral regurgitation. The decision to operate was at the discretion of the referring physician in consultation with respective cardiothoracic surgeons at two separate, nonrelated institutions. All patients underwent preoperative and/or intraoperative transesophageal echocardiographic studies. RESULTS: In all, 35 patients (46%) underwent MVR and 41 (54%) underwent MV replacement. There was no difference in the percentage of MVRs between the two institutions: 17 cases (41%) at Hahnemann University Hospital, Philadelphia, Pa, versus 18 cases (53%) at Northwestern University Memorial Hospital, Chicago, Ill (P = not significant). Age was found to be a significant univariate predictor with older age favoring MV replacement. On average, patients who underwent MVR were 11 years younger then those who underwent MV replacement. Heart failure was also found to be a significant univariate predictor: as New York Heart Association functional class worsened, MV replacement was more likely. Echocardiographic variables favoring MVR included chordal length (>29 mm, P <.001), length of posterior mitral leaflet (>17 mm, P <.008), and length of anterior leaflet (>25 mm, P <.01). The only echocardiographic parameter favoring replacement was the presence of anterior mitral annular calcification. Using multivariate analysis, older age (>63 years) was again a significant predictor favoring MV replacement (P <.002; odds ratio [OR] 20). Longer chordal length (>29 mm) was the strongest predictor favoring MVR (P <.001; OR 11.2). Longer length of the posterior leaflet (>17 mm; OR 5.07) and mitral annulus size > 35 mm (OR 7.75) were also significant multivariate predictors favoring MVR. The presence of anterior mitral annular calcification favored MV replacement using multivariate analysis (OR 25). CONCLUSIONS: Patients suitable for MVR can be identified preoperatively using a combination of clinical and echocardiographic parameters.     

Advances in 3D echocardiography for mitral valve

The advent of real-time (RT) 3D transesophageal echocardiography (TEE) in 2007 has enhanced our understanding of the location and extent of the pathology of the native, as well as prosthetic, mitral valve (MV), particularly for MV prolapse and the anatomy of perivalvular dehiscence with prosthetic MV. MV quantification programs provide precise assessment of many quantitative MV parameters allowing 3D echocardiography to determine and quantify the geometry of mitral apparatus, including mitral annulus and periannular region, leaflet volume and anatomy, tethering distances, and tenting volumes. The detailed, accurate and optimal RT spatial visualization of the MV with 3D TEE gives greater confidence to the echocardiographer, interventionalist and the surgeon alike, facilitating medical and surgical treatment decisions. This article highlights recent advances in RT 3D TEE and transthoracic echocardiography echocardiographic imaging of the MV.     

Advances in 3D echocardiography for mitral valve

The advent of real-time (RT) 3D transesophageal echocardiography (TEE) in 2007 has enhanced our understanding of the location and extent of the pathology of the native, as well as prosthetic, mitral valve (MV), particularly for MV prolapse and the anatomy of perivalvular dehiscence with prosthetic MV. MV quantification programs provide precise assessment of many quantitative MV parameters allowing 3D echocardiography to determine and quantify the geometry of mitral apparatus, including mitral annulus and periannular region, leaflet volume and anatomy, tethering distances, and tenting volumes. The detailed, accurate and optimal RT spatial visualization of the MV with 3D TEE gives greater confidence to the echocardiographer, interventionalist and the surgeon alike, facilitating medical and surgical treatment decisions. This article highlights recent advances in RT 3D TEE and transthoracic echocardiography echocardiographic imaging of the MV.     

Robotic mitral valve repair for all categories of leaflet prolapse: improving patient appeal and advancing standard of care

OBJECTIVE: To characterize the early outcomes of robotic mitral valve (MV) repair using standard open techniques.PATIENTS AND METHODS: We prospectively studied 100 patients with severe mitral regurgitation due to leaflet prolapse who underwent robot-assisted MV repair using conventional open-repair techniques between January 1, 2008, and December 31, 2009, at Mayo Clinic, Rochester, MN.RESULTS: The mean age of the patients was 53.9 years; 77 patients (77%) were male. Fifty-nine patients (59%) had posterior leaflet prolapse, 38 (38%) had bileaflet disease, and 3 (3%) had isolated anterior leaflet prolapse. Median cross-clamp and bypass times decreased significantly during the course of the study (P<.001). Median postoperative ventilation time was 0 hours for the last 25 patients, with most patients extubated in the operating room. No deaths occurred. Reexploration for postoperative bleeding occurred in 1 patient (1%); 3 patients (3%) required percutaneous coronary intervention. Median hospital stay was 3 days. One patient (1%) underwent mitral reoperation for annuloplasty band dehiscence. Residual regurgitation was mild or less in all patients at dismissal and 1 month postoperatively. Significant reverse remodeling occurred by 1 month, including decreased left ventricular end-diastolic diameter (–7.2 mm; P<.001) and left ventricular end-diastolic volume (–61.0 mL;P<.001).CONCLUSION: Robot-assisted MV repair using proven, conventional open-repair techniques is reproducible and safe and hastens recovery for all categories of leaflet prolapse. One month after surgery, significant regression in left ventricular size and volume is evident.CT = computed tomography; LV = left ventricular; LVEDD = LV end-diastolic diameter; LVEF = LV ejection fraction; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiographyThe standard of care to correct severe mitral regurgitation (MR) due to degenerative mitral valve (MV) disease is MV repair. In studies comparing MV repair with MV replacement with a prosthetic valve, repair achieved better survival and equivalent, if not better, durability. The availability of a reproducible MV repair technique as a safe and reliable alternative to prosthetic replacement has influenced the indications for surgical intervention in patients with MR due to leaflet prolapse. After successful MV repair, patients who maintain sinus rhythm resume full activities and do not need long-term anticoagulant therapy. Compliance with international guidelines¹ recommending early MV repair has been heterogeneous for 3 main reasons: (1) hesitancy of some otherwise active and asymptomatic individuals to accept the need for an invasive cardiac surgical procedure; (2) reluctance of cardiologists to refer such patients for an operation requiring sternotomy; and (3) concern that MV replacement instead of repair might be performed at the time of surgery.The growing interest in catheter-based interventions for less invasive approaches has led to the clinical introduction of mechanistically incomplete procedures, such as the percutaneous mitral clip.² Rather than expecting that the intricate judgment-based maneuvers of MV repair might be reproduced using a catheter, we considered the use of proven surgical techniques via minimally invasive incisions to present an opportunity to maintain known outcomes while improving patient acceptance and clinical compliance with guidelines recommending early MV repair. The purpose of our study was to determine whether a robot-assisted, minimally invasive MV repair might be safely performed using all conventional open-repair techniques.     

主动脉瓣置换术后二尖瓣穿孔超声表现1例

患者因“反复心累、气促1+年,加重3+月”入院。术前TTE诊断为：主动脉瓣重度返流,二尖瓣轻度返流,感染性心内膜炎可能性。患者拟行主动脉瓣置换术。麻醉后TEE再次明确术前超声诊断,外科医师遂即体外循环下行主动脉瓣置换术。体外循环脱机后TEE监测发现二尖瓣前叶瓣体出现新增反流束,缩流颈为2mm,考虑以下原因：1. 术前超声及术中TEE漏诊的可能性;2.可疑医源性二尖瓣损伤;3.因术中未对二尖瓣进行探查,不排除血流动力学不稳定加重瓣体损伤。外科医师遂即行二尖瓣瓣叶修复术,术后TEE显示二尖瓣前叶瓣体反流消失,主动脉瓣未见瓣周漏。患者于术后12天顺利出院。     

经胸和经食管超声心动图在全机器人二尖瓣修复术中的应用

目的探讨经胸(TTE)和经食管(TEE)超声心动图在全机器人二尖瓣修复术中的作用。方法对22例于我科因重度二尖瓣反流行全机器人二尖瓣修复术患者的超声影像资料进行回顾性分析。在术前,应用TTE评价二尖瓣反流功能解剖(病因、反流发生机制及脱垂瓣叶部位)及反流严重程度。在术中,应用TEE于体外循环(CPB)转机前,进一步明确二尖瓣反流发生机制及脱垂瓣叶部位;建立外周CPB时,引导下、上腔静脉插管及升主动脉内心脏停搏液灌注针的放置;心脏复跳后,即刻评价有无残余二尖瓣反流。在患者出院前,应用TTE再次评价有无残余二尖瓣反流。结果在术前,TTE评价二尖瓣反流病因的准确度为100%;TTE诊断二尖瓣脱垂及其发生部位的准确度分别为100%和97.0%。在术中,TEE诊断二尖瓣脱垂及其发生部位的准确度与术前TTE相同;TEE可准确引导上、下腔静脉插管及升主动脉内心脏停搏液灌注针放置,其成功率为100%;心脏复跳后,TEE显示所有患者手术均成功,无残余二尖瓣反流和手术相关并发症。患者出院前TTE证实所有患者均无残余二尖瓣反流。结论术前TTE可准确评价二尖瓣反流功能解剖,为判断二尖瓣修复可行性及选择手术适应证提供有价值的信息。术中TEE可进一步明确二尖瓣反流功能解剖;准确引导上、下腔静脉内插管及升主动脉内灌注针的放置;即刻评价手术效果。因此,TTE和TEE在全机器人二尖瓣修复术中是不可缺少的检查手段。     

老年人主动脉瓣周钙化的影像诊断和临床意义

目的　评价经胸和食道超声心动图诊断老年人主动脉瓣周钙化的价值及其临床意义。方法　完成全部检查者共 5 0例 ,其中男性 2 4例 ,女性 2 6例 ,自身前后对照 ,每位入选对象先后接受经胸超声心动图 (TTE)、经食道超声心动图 (TEE)检查和螺旋CT检查各一次。结果　螺旋CT示瓣周钙化阳性 19例 ,阴性 31例。以螺旋CT为对照 ,TTE的敏感性为 6 3% ,特异性为 71% ,准确性为 6 8% ;TEE的敏感性为 79% ,特异性为 6 5 % ,准确性为 70 % ;联合检查的敏感性为 84 % ,特异性为 5 8% ,准确性为 6 8%。螺旋CT阳性组高血压发病率显著高于阴性组 (P <0 0 5 )。结论　三种检查方法比较 ,差异均有显著性意义(P <0 0 1)。以螺旋CT为对照 ,TEE诊断早期老年性主动脉瓣周钙化的敏感性显著高于TTE ,特异性和准确性接近