人工心脏瓣膜置换术后瓣周漏的介入治疗研究进展

瓣周漏是人工瓣膜置换术后特有的严重并发症,常有肺动脉高压、心律失常、心力衰竭、溶血反应等临床表现。既往瓣周漏的治疗以外科手术为主,风险大,死亡率高。随着介入治疗技术的发展和器械的研发,介入治疗瓣周漏操作简单、安全有效,越来越多的应用于临床。本文就瓣周漏介入治疗的现状与展望做一综述。     

经食管二维和三维超声心动图对二尖瓣人工机械瓣瓣周漏定位诊断价值

目的:探讨经食管实时二维和三维超声心动图诊断二尖瓣瓣人工机械瓣瓣周漏的临床价值。方法:回顾分析二尖瓣人工机械瓣瓣周漏26例的二维、三维经食管超声心动图表现特征,并与术中所见进行对比。结果:26例二尖瓣人工机械瓣瓣周漏患者,术中发现二尖瓣人工机械瓣瓣周漏36处,其中6例同时存在2处漏口,2例同时存在3处漏口。经食管实时三维超声心动图共发现瓣周漏30处,与术中发现符合率100%,二维经食管超声心动图共发现瓣周漏28处,与术中发现符合率77.8%。结论:经食管实时三维超声心动图能够清晰显示二尖瓣人工机械瓣瓣周漏的位置、形态和大小,有利于术前手术计划的选择和制定。     

主动脉瓣置换术后瓣周漏的重新认识和应对

人工心脏瓣膜置换术后瓣周漏是瓣膜置换术后特有的并发症。早期对瓣周漏的认识局限于外科主动脉瓣换瓣术(SAVR)后瓣周漏的评估和治疗;近年来, 随着经导管主动脉瓣置换术(TAVR)的开展, TAVR术后瓣周漏逐渐引起学者的广泛关注, 其发生机制和治疗方案不同于SAVR术后。该文结合文献报道和作者的临床实践, 重新认识主动脉瓣瓣周漏, 并提出应对方案, 以期为临床提供指导。     

新型经导管主动脉瓣置换装置的临床应用研究进展

目前临床使用的经导管主动脉瓣膜置换装置均不可回收,难以在释放过程中精确掌控,容易造成定位释放的偏差;无预防减少瓣周漏的设计,瓣膜支架植入术后瓣周漏的发生率远高于外科换瓣手术。新型Lotus瓣膜支架在最终释放前可完全回收,重新定位;并且有预防瓣周漏的独特设计,可有效减少瓣周漏的发生。经PEPRISE系列研究证明:Lotus瓣膜装置可安全可靠地应用于临床,效果良好。     

主动脉瓣置换术后瓣周漏的临床及超声心动图分析

目的:探讨主动脉瓣人工瓣置换术后瓣周漏的临床特点及超声心动图应用价值。方法:回顾分析2002-03至2017-03在我院住院诊治的外科主动脉瓣置换术后瓣周漏患者123例,年龄12~74岁,平均(45±13)岁。首次换瓣手术包括我院手术及外院手术。所有患者入院行经胸或经食管超声心动图检查确诊瓣周漏。28例(22.8%)予内科保守治疗,95例(77.2%)再次手术治疗。结果:瓣周漏患者超声心动图彩色多普勒可见舒张期源于人工瓣瓣周的反流信号,部分二维超声可见人工瓣缝合环与周围组织之间的裂隙。根据超声心动图等影像学检查、术中所见及病理结果分析瓣周漏产生的原因,包括:感染性心内膜炎45例,白塞病23例,大动脉炎4例,疑诊免疫系统疾病5例,主动脉夹层2例,疑手术技术原因所致3例,余41例原因未能确定。全组患者死亡13例,放弃治疗病重出院5例,随访到的83例患者中,仍有瓣周漏中量以上反流者27例,心功能明显减低1例,55例好转或治愈。结论:有临床意义的瓣周漏是主动脉瓣置换术后的重要并发症,再手术比例高,复发率高,预后较差。主动脉瓣瓣周漏的原因以感染性心内膜炎最常见,其次为非特异性血管炎。     

人工心脏瓣膜置换术后出现瓣周漏1例的护理

目的探讨人工心脏瓣膜置换术后发生瓣周漏的临床特点和护理要点。方法对患者进行针对性的治疗和护理,以达到治愈的目的。结果经过精心的治疗和护理,患者治愈出院。结论结合患者的病情和心理特点,落实术前准备及术后全面细致的病情观察,加强针对预防瓣周漏的护理措施,以减少瓣周漏的发生。     

人工机械瓣功能障碍的超声诊断

目的　评价人工机械瓣功能障碍彩色多普勒超声心动图的诊断价值。方法　使用 Sequoia2 5 6、HP5 5 0 0、ATL超 9彩色多普勒超声诊断仪检查 42例 (4 4个人工瓣 )术后重复出现临床症状的病人 ,并与手术结果进行比较。结果超声诊断瓣膜梗阻 12个 ,瓣周漏 16个 ,瓣内漏 16个 ,与手术相符率为 :人工瓣膜梗阻为 10 0 %,瓣周漏为 81%,瓣内漏为 87%。引起功能障碍原因有血栓、赘生物、缝线撕脱、碟片磨损。结论　超声诊断人工机械瓣功能障碍准确性高 ,是临床上评价人工机械瓣功能障碍的最重要检查方法。     

球囊再扩张治疗经导管主动脉瓣置入术后瓣周漏效果

<正>背景:经导管主动脉瓣置入术(TAVI)术后严重的主动脉瓣瓣周漏与患者死亡直接相关,术后即刻使用球囊再扩张瓣膜成形术可使主动脉瓣膜支架充分扩张治疗瓣周漏。在导管室通过升主动脉造影和超声心动图测量血流动力学指标:主动脉瓣反流指数(AR-Index),可快速、准确、客观地反映TAVI术后即刻瓣周漏的严重程度。目的:测量ARIndex,是否可以判断主动脉瓣球囊再扩张术治疗TAVI术后     

人工心脏瓣膜的选择与并发症

目前临床应用的人工瓣膜品种繁多,各有优缺点。总的看,机械瓣的优势在于其耐久性、瓣架低及双叶瓣对血流的梗阻小;缺点是栓塞率高、抗凝过度易发生出血以及溶血、瓣周漏等。生物瓣膜与之相反,栓塞、出血及瓣周漏发生率低,但耐久性差,用于年轻患者易发生钙化及退行性变,小型号瓣膜对血流阻力较大。     

保留原生物瓣缝环的二尖瓣、主动脉瓣再次换瓣

生物瓣结构退化是生物瓣置换术后再次换瓣的最常见原因,再次换瓣时取出退化的原生物瓣既费时又有风险,如取出二尖瓣易引起心脏破裂、冠状动脉回旋支损伤和瓣周漏,取出主动脉瓣易损伤瓣环导致瓣周漏等。该研究采用一种“瓣上瓣”植入技术,即保留原生物瓣缝环或支架,在原缝环上放置新双叶机械瓣。 方法 自1991年5月至1999年12月,连续50例病人因生物瓣退化施行再次换瓣手术。男     

Primary pancreatic lymphoma. Report of five cases

Primary pancreatic lymphoma (PPL) is a very rare disease. We report five cases of PPL (4 men and 1 woman, mean age 65 years) diagnosed and treated at our Institution from 1987 to 1997. None of these patients had evidence of extrapancreatic disease and they were categorized as PPL involving pancreas only (stage IE, 3 patients) or pancreas and peripancreatic lymph nodes (stage IIE, 2 patients). The most common presenting symptoms were abdominal pain and weight loss. Imaging techniques showed a mass of the pancreatic head in all cases. The histological diagnosis (3 diffuse-large cell non-Hodgkin's lymphoma and 2 lymphoplasmacytic lymphoma/immunocytoma) was made by ultrasound-guided fine needle aspiration biopsy and tissue core fine-needle biopsy in three patients and by surgery in the remaining two patients. The three patients diagnosed by percutaneous biopsy were treated with chemotherapy as front-line therapy and two of them received also local radiotherapy; one of these patients is still alive in complete remission at 69 months, one died of an unrelated disease at 67 months and one died of lymphoma relapse at 88 months. Two patients underwent pancreaticoduodenectomy plus adjuvant chemotherapy; one of them died of recurrent cholangitis 8 months after surgery while the other one is still alive in complete remission after 160 months. This study shows that: 1) imaging techniques can suggest the suspicion of PPL but are unable to distinguish PPL from pancreatic adenocarcinoma; 2) histological diagnosis can be easily obtained by percutaneous US-guided tissue core biopsy; 3) surgery can be avoided both for diagnosis and therapy but the treatment of choice of PPL may only be evaluated on a larger series of patients.     

Ligation versus propranolol for the primary prophylaxis of variceal bleeding in cirrhosis

In this randomized controlled multicenter trial, we compared endoscopic variceal banding ligation (VBL) with propranolol (PPL) for primary prophylaxis of variceal bleeding. One hundred fifty-two cirrhotic patients with 2 or more esophageal varices (diameter >5 mm) without prior bleeding were randomized to VBL (n = 75) or PPL (n = 77). The groups were well matched with respect to baseline characteristics (age 56 +/- 10 years, alcoholic etiology 51%, Child-Pugh score 7.2 +/- 1.8). The mean follow-up was 34 +/- 19 months. Data were analyzed on an intention-to-treat basis. Neither bleeding incidence nor mortality differed significantly between the 2 groups. Variceal bleeding occurred in 25% of the VBL group and in 29% of the PPL group. The actuarial risks of bleeding after 2 years were 20% (VBL) and 18% (PPL). Fatal bleeding was observed in 12% (VBL) and 10% (PPL). It was associated with the ligation procedure in 2 patients (2.6%). Overall mortality was 45% (VBL) and 43% (PPL) with the 2-year actuarial risks being 28% (VBL) and 22% (PPL). 25% of patients withdrew from PPL treatment, 16% due to side effects. In conclusion, VBL and PPL were similarly effective for primary prophylaxis of variceal bleeding. VBL should be offered to patients who are not candidates for long-term PPL treatment.     

Technologies for targeting the peripheral pulmonary nodule including robotics

Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground‐glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes.     

Bilateral pulmonary nodules as a manifestation of primary pulmonary T-cell lymphoma

Primary pulmonary lymphoma (PPL) is an uncommon pathology and is usually of the B-cell type, originating in lymphoid tissue associated with the bronchial mucosa (MALT/BALT lymphoma). Very few cases of T-cell PPL, the majority diagnosed by open lung biopsy, have been described in medical literature. We report a case of an immunocompetent patient with fever and bilateral pulmonary nodules, diagnosed with T-cell PPL by transbronchial biopsy. The patient’s condition deteriorated and she responded poorly to chemotherapy. PPL should be included in the differential diagnosis of patients with fever and bilateral pulmonary nodules.     

Factors influencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesions

Background and objective:   Endobronchial ultrasound (EBUS) has increased the diagnostic yield of bronchoscopic biopsy of peripheral pulmonary lesions (PPL). However, certain lesions cannot be localized by EBUS, and the factors associated with the visibility of PPL by EBUS have not been investigated. This study evaluated the factors predicting the visualization of EBUS in PPL and the diagnostic yield of EBUS-guided transbronchial biopsy (TBB).
Methods:   n 2007, 83 patients with PPL underwent EBUS-guided TBB, and their medical records were reviewed and analysed retrospectively.
Results:   Of the 83 patients examined, EBUS images could not be obtained in 23 patients (28%). Lesion size was a determining factor for the visibility of PPL, with the visualization yield of EBUS in lesions <20 mm being significantly lower than that in lesions ≥20 mm ( P  < 0.001). A definitive diagnosis of PPL localized by EBUS was established using EBUS-guided TBB in 73% of patients. There were no significant differences in diagnostic yield related to underlying disease, lobar distribution, CT scan appearance or presence of complications. Multivariate analysis revealed that the location of PPL on CT scans and position of the probe were independent predictors of the diagnostic yield by EBUS-guided TBB ( P  < 0.001 and P  = 0.001, respectively).
Conclusions:   Lesion size is a significant factor predicting visualization of EBUS for PPL. The location of PPL on CT scans and position of the probe are significantly related to a higher diagnostic yield with EBUS-guided TBB.     

Transjugular approach for transcatheter closure of mitral paraprosthetic leak

Transcatheter closure of mitral paraprosthetic leak (PPL) using femoral antegrade transseptal or retrograde approach is often unsuccessful when the involved part of the mitral annulus is difficult to access or when the left atrium is large. We report the successful use of jugular venous approach to perform transseptal antegrade PPL closure in a 49‐year‐old male with mitral PPL located in the anteromedial part of the annulus. This technique could serve as a useful alternative in patients in whom transcatheter closure of mitral PPL is technically difficult. © 2009 Wiley‐Liss, Inc.     

Predicting Postprandial Lipemia in Healthy Adults and in At-Risk Individuals With Components of the Cardiometabolic Syndrome

To determine whether a single-point triglyceride (TG) concentration could estimate the 8-hour postprandial lipemic (PPL) response, men and women performed baseline PPL ( n =188) and postexercise PPL ( n =92) trials. Correlations were generated between TG concentrations at baseline and at various time points after a high-fat meal vs 8-hour area under the TG curve (TG-AUC) and peak TG level. Stepwise multiple regression and bootstrap simulations using TG level and additional predictor variables of sex, age, percentage of body fat, training status, and maximal oxygen consumption indicated that the 4-hour TG concentrations accounted for >90% of the variance in TG-AUC and peak TG responses during the PPL trials. Equations were confirmed by cross-validation in healthy as well as at-risk individuals with components of the cardiometabolic syndrome. Our data suggest that the 4-hour TG value is highly related to the total 8-hour PPL response and can be used for accurate estimation of PPL in a clinical or research setting.     

原发性胰腺淋巴瘤研究进展

原发性胰腺淋巴瘤是一种无特异性临床表现的罕见胰腺疾病,目前其病因、发病机制均尚不清楚,有报道术前误诊率达100%,采用化疗、放疗为主的综合治疗预后好于胰腺癌。为提高对原发性胰腺淋巴瘤的诊断水平,减少不必要的手术及提高治疗成功率,此文对原发性胰腺淋巴瘤的诊治进展作一综述。     

原发性胰腺淋巴瘤诊疗体会

目的 探讨原发性胰腺淋巴瘤（PPL）的临床特点以及诊疗体会。方法回顾性分析5例原发性胰腺淋巴瘤的临床资料。结果本组5例患者中病灶位于胰头部3例,胰体尾2例。临床表现包括上腹痛、黄疸、发热、盗汗,体重减轻等。其中一例CAl9—9增高,其余肿瘤指标均处于正常范围。影像学检查均示胰腺癌可疑,2例行剖腹探查术、组织活检,2例行胰十二指肠切除术。1例行外周浅表淋巴结活检,均诊断为胰腺非霍奇金淋巴瘤。术后5例患者均予以CHOP（环磷酰胺、阿霉素、长春新碱、泼尼松）方案化疗。结论原发性胰腺淋巴瘤临床症状不典型,极易与胰腺癌混淆,影像学对诊断有提示作用,最终的诊断需要依靠病理学检查。治疗手段为手术切除术后加以化疗,无法切除的患者仅行化疗。胰腺原发淋巴瘤的预后明显优于胰腺癌。     

Postprandial lipemia in postmenopausal women with high fasting high-density lipoprotein cholesterol

BACKGROUND: Several groups of patients at high risk for cardiovascular disease have been found to show an exaggerated postprandial hypertriglyceridemia. Postprandial lipemia (PPL) therefore has been implicated as a potential additional risk factor that has been evading us. The purpose of this study was to test the effect of high fasting high-density lipoprotein cholesterol (HDL-C) levels on PPL in postmenopausal females. METHODS: Oral fat tolerance test, as quantified by the areas under the curve (AUC) of triglyceride (TG) levels, was given to 3 groups: normal postmenopausal females (control), postmenopausal females with exceptionally high HDL-C and a familial history of longevity (longevity syndrome), and postmenopausal females that were heterozygotes of familial hypercholesterolemia (hFH) with exceptionally high HDL-C. RESULTS: The PPL was not different between the control and longevity syndrome groups but was significantly higher in the hFH group; AUC (SD), in mg/dl/h; 749 (195), 882 (278) and 1244 (497) respectively, p=0.002. In linear regression analysis only fasting TG levels were a significant predictor of the AUC (Coefficient B = 11.779, p < 0.001). CONCLUSIONS: In subjects with longevity syndrome the PPL is similar to controls, which means that high fasting HDL-C has not any beneficial influence on PPL. The fasting TG concentration is the main determinant of PPL. Furthermore, postmenopausal females with hFH have higher TG response postprandially, even in the case of high fasting HDL-C. Whether there is a threshold below or above, where HDL-C becomes a significant independent determinant of PPL is a question to be answered by future research.