经皮二尖瓣球囊成形术(附22例报告)

本文报导22例经皮二尖瓣球囊成形术（PBMV），均获成功。左心房压从术前2．87±1．06降至术后1．20±0．49KPa（P＜0．001），二尖瓣辩跨瓣压差从2．8±0．71降至0．71±0．11KPa（P＜0．001）。二尖瓣瓣口面积自1．08±0．38增至2．11±0．40cm2（P＜0．001）。PBMV创伤小且安全，厅发局，故用于二尖瓣狭窄非手术治疗，深受患者欢迎。     

经皮二尖瓣球囊成形术在二尖瓣狭窄伴重度心力衰竭时的应用

介绍二尖瓣狭窄伴重度心力衰竭（心衰）患者实施经皮二尖瓣球囊成形术（PBMV）的结果和初步体会。9例患者中男6例，女3例，年龄24～52岁，全部患者心功能均为Ⅳ级（按NYHA分级），术前抗心衰药物治疗效果极不理想。经施行PBMV后，血流动力学明显得已改善：左房平均压由术前4．34±1．02kPa（1kPa=7．5mmHg）降至术后1．64±0．82kPa，二尖瓣跨瓣压差由术前3．26±0．84kPa降至术后0．72±0．56kPa；瓣口面积由术前0．78±0．30cm~2增至术后2．11±0．24cm~2，左房内径术后较术前缩小了约10mm（P值均＜0．001）；在短期内心功能迅速恢复至Ⅰ～Ⅱ级，运动耐量明显增加，心衰症状缓解率达100％。作者认为：二尖瓣狭窄伴重度心衰时，只要排除了加重心衰的其他原因，应尽早施行PBMV，PBMV是一种安全、可靠和行之有效的治疗方法。作者同时对PBMV时球囊方式选择及并发症的防治进行了讨论。     

甲状腺切除术中带状肌侧径路应用的初步报告

采用带状肌侧径路及带状肌正中径路完成36例甲状腺侧叶与腺叶加峡部切除术，两径路组各18例。带状肌侧径路组肿瘤大于正中径路组（4．4±1．92cm，4．2±1．67cm，P＜0．05），而切口长度（5．56±1．48cm，9．47±1．74cm，P＜0．001），甲状腺上极显露程度（P＜0．01），不横断带状肌例数（P＜0．05），手术时间（80．56±34．25min，140．56±5775min，P＜0．001），未中出血（70．57±62．07ml，164．44±98．53ml，P＜0．01）及水后负压引流量（22．78±18．65ml，41．67±24．55ml，P＜0．02）等指标均以带状肥料径路组为优．文中详细介绍了带状肌侧径路的手术操作，手术要点及其适应证。     

肝硬化患者胆囊运动功能的超声研究

应用实时超声技术，观察了30例肝硬化患者和20例正常人液体脂餐后的胆囊运动功能。结果如下：肝硬化组和对照组空腹胆囊容积分别为53．59±32．49ml和20．95±6．88ml（P＜0．01）；剩余容积分别为18．13±13．41ml和7．59±3．32ml（P＜0．001）；胆囊排空率分别为62．4±20％和63．48±11．62％（P＞0．05）；胆囊排空时间分别为98．5±30．15min和45．5±17．61min（P＜0．001）；餐后胆囊收缩频率分别为1．14±0．37次／10min和3．56±0．85次／10min（P＜0．001）；胆囊收缩幅度分别为0．12±0．06和0．13±0．04（P＞0．05）、结果发明．肝硬化患者存在胆囊张力低下和运动障碍。推测胆囊运动功能障碍在肝硬化患者胆囊结石的发病机制中可能起了一定作用。     

心肌内谷氨酸浓度变化在 CPR 后心功能障碍中的意义北大核心CSCD

目的：通过微渗透技术观察心肺复苏（ CPR）后心肌内谷氨酸浓度的变化和心功能障碍的关系。方法在6只成年新西兰兔大脑皮层和心肌内置入微量渗析管,然后建立室颤心脏骤停模型。室颤6 min,ROSC后采集渗析液检测谷氨酸浓度,超声评价左心室收缩功能,电镜观察大脑皮层和心肌细胞损伤情况。结果诱发室颤前大脑皮质内的谷氨酸浓度为（76．07±8．50）μmmol／L,ROSC后30 min迅速升高至（107．70±7．17）μmmol／L,2 h达到顶峰（139．62±15．64）μmmol／L,随后下降,3 h下降至（68．86±3．78）μmmol／L。 ROSC后30 min心肌内谷氨酸浓度为（87．26±14．14）μmmol／L,较室颤前（40．33±5．39）μmmol／L明显升高（P＜0．001）,持续1 h左右逐渐下降,ROSC后90 min左右降至（47．82±6．72）μmmol／L。 ROSC后60 min FS值为（39．00±1．79）％、EF为（47．00±3．90）％,低于基础值（44．83±3．25）％和（53．17±4．58）％（ P＝0．001和0．008）。 ROSC后4 h兔大脑皮层细胞线粒体明显肿胀,线粒体脊模糊甚至消失,部分空白化,核周围有凋亡小体形成,心肌细胞内未见凋亡小体形成。结论兔室颤6 min,ROSC后心肌内高浓度的谷氨酸可能和心功能障碍有关。     

缺血再灌流对心肌的损伤及参麦注射液的保护作用的研究

本实验通过结扎复制心肌缺血再灌流损伤模型，观察参麦注射液血浆丙二醛含量、溶酶体组织蛋白酶活性的影响。结果发现，心肌缺血30min和再灌流60min时，血浆丙二醛含量分别由缺血前1．53±0．36nmol／ml上升到3．86±0．47和4．82±0．53nmol／ml（P值均＜0．01），血浆组织蛋白酶D活性由缺血前的0．025±0．005U／mg蛋白质分别上升到缺血后30min时的0．049±0．003和再灌流60min时的0．087±0．008U／mg蛋白质（P值均＜0．01）。注射参麦注射液后再灌流60分钟，血浆丙二醛含量为3．83±0．36nmol／ml（与对照组相比P＜0．01）；组织蛋白酶D活性为0．055±0．007U／mg蛋白质（与对照组相比P＜0．01）。提示参表注射液在体内通过对抗心肌缺后再灌流中的氧自由基损伤和稳定溶酶体膜作用，保护心肌的缺血再灌流损伤。     

急诊床旁漂浮导管技术在严重急性心力衰竭患者中的应用

目的探讨急诊床旁漂浮导管技术在严重急性心力衰竭（HF）患者临床应用中的意义。方法以23例经常规处理效果不佳的急性严重心力衰竭患者为研究对象，尽早留置漂浮导管。留置漂浮导管后30min和48h，记录心率（HR）、中心静脉压（CVP）、肺毛细血管楔压（PCWP）、心排血量（CO），并计算心脏指数（CI），然后根据情况选用各种药物治疗。HF患者根据出院时预后分为病情好转组和病情恶化组，对两组患者留置漂浮导管后30min和48hHR、CVP、PCWP、CO、CI变化进行比较。结果病情好转组患者留置漂浮导管治疗后HR86±8．2次／min，较前（102．2±11．4次／min）明显下降（P〈0．01），CVP8．7±1．2mmHg，较前（11．9±1．6mmHg）明显下降（P〈0．01），PCWP（13．4±1．2mmHg），较前（19．1±1．4mmHg）明显下降（P〈0．01），CO4．50±0．67L／min，较前（3．23±0．42L／min）明显升高（P〈0．05），CI3．47±0．23L／min·m^-2，较前（2．32±0．87L／min·m^-2）明显升高（P〈0．05）。病情恶化组患者留置漂浮导管治疗后HR103±10．6次／min，较前（98±9．4次／min）无显著差异（P〉0．05），CVP13．2±1．2mmHg，与前（11．1±1．4mmHg）无显著差异（P〉0．05），PCWP25．8±4．2mmHg与前（21．5±4．5mmHg）无显著差异（P〉0．05），CO3．01±0．58L／min较前（3．35±0．38L／min）无显著差异（P〉0．05），CI2．18±0．82L／min·in^-2，与较前（2．58±0．42L／min·m^-2）无显著差异（P〉0．05）。结论漂浮导管在血流动力学不稳定的急性严重心力衰竭患者的评估病情，指导临床治疗和预后评估中有不可代替的重要性。     

血清铜及铜/锌值对肝癌鉴别作用的研究

本文测定了15例肝硬化、15例原发性肝癌病人的血清铜及铜／锌比值，并与17例正常人血清铜及铜／锌比值相比较，结果发现：①肝硬化和肝癌组病人血清锌水平低于正常对照组（分别为15．94±0．06和15．44±9．92μmol／L），但两组患者之间无显著性差异（P＞0．05）；②肝硬化组和肝癌组病人的血清铜水平均高于对照组，肝癌组病人的血清铜水平又显著高于肝硬化组（分别为31．92±0．07μmol／L和20．25±0．06μmol／L，P＜0．001），而肝硬化组与正常组血清铜水平差异不显著（20．25±0．06μmol／L和17．35±2．75μmol／L，P＞0．05）；③肝硬化组和肝癌组病人的血清铜及铜／锌显著高于对照组（分别P＜0．05和P＜0．001）．两组病人之间的血清铜／锌值有显著性差异（P＜0．001）。提示血清铜及铜／锌的测定有助于肝硬化和肝癌的鉴别诊断。     

经纤维支气管镜引导气管插管在机械通气病人中的临床应用

目的探讨采用经纤支镜引导气管插管的方法、安全性、临床效果、并发症。方法对60例具有气管插管机械通气指征的患者采用经纤支镜引导气管插管，其中经鼻插管者45例，经口插管者15例，经口插管改换为经鼻插管者10例；分别测定术前、术后4h动脉血气分析及动态监测术前、术中、术后4h SaO2、HR；记录正式插管或换管操作时间。结果该操作技术简单易行；插管术后4 hPaO2（85±2．78）mmHg及SaO2（95±1．61）％与术前PAO2（56±2．65）mmHg及SaO2（87±2．59）％比较有上升、有显著性差异（P〈0．001）；插管术中SaO2（83±2．61）％与术前SaO2（87±2．59）％比较有下降，有显著性差异（P〈0．001），但平均插管操作时间（1．65±0．42）min短，病人能耐受；插管术中HR（123±5．23）次／min与术前HR（118±5．43）次／分比较有上升，有显著性差异（P〈0．001）；插管术后4hHR（90±4．70）次／min与术前HR（118±5．43次／分）比较有下降，有显著性差异（P〈0．001）；换管术中SaO2（95．7±0．95）％与术前SaO2（96．5±1．58％）比较有下降，但无显著性差异（P〉0．05），但平均换管操作时间（1．58±0．29）min短，病人能耐受；换管术中HR（93．7±5．76）次／min与术前HR（9013±5．42）次／min比较有上升，但无显著性差异（P〉0．05）；气管插管或换管操作术中均无心律失常发生，成功率100％（60／60）。结论采用经纤支镜引导气管插管或换管的方法具有操作技术易掌握、简单易行、行之有效、操作时间短、病人痛苦小能耐受、安全性好、插管准确、成功率高、并发症少等优点，值得临床推广应用。     

肝静脉阻塞型布-加综合征介入治疗研究

目的探讨经皮肝穿刺肝静脉再通和成形术在肝静脉阻塞型布-加综合征中应用价值。方法18例肝静脉阻塞型布-加综合征患者采用经皮肝穿刺肝静脉再通和成形术治疗,随访2a,观察治疗后近、中期疗效。结果治疗成功15例,成功率83．33％;术后6个月患者平均肝静脉压（11．26±3．74）cmH2O明显低于术前（54．11±15．40）cmH2O（P〈0．05）,门静脉血流量（868±168）mL／min和血容量（14．23±3．26）cm／s明显高于术前（792±189）mL／min和（10．18±3．23）cm／s（P〈0．05）;术后6个月、1a和2a受干预血管的初始再通分别为14,12和11例。结论经皮肝穿刺肝静脉再通和成形术治疗布一加综合征安全可行,疗效满意。     

二尖瓣狭窄球囊成形术对瓣口面积和左心房、左心室压力及内径的影响

目的 :观察经皮球囊二尖瓣成形术 (PBMV)前后二尖瓣口面积 (MVA)和左心房左心室压力及内径的关系。方法 :2 8例手术成功二尖瓣狭窄患者分成中度狭窄组 (15例 ,A)和重度狭窄组 (13例 ,B) ,对其术前术后指标进行检验和直线回归统计分析。结果 :1周内A组左心房内径和B组左心室内径变化不明显 (P >0 0 5 ) ,A组的左心房内径缩小值 ,左心房压力下降值 ,MVA扩大值、扩大率均 B组 (P <0 0 1) ,其余指标无差异 (P >0 0 5 ) ;术前MVA与术后MVA扩大率 ,左心房内径变化有显著相关性 (P <0 0 1)影响术后左心房大小的因素主要是术前MVA ,术前左心房内径和术后MVA扩大率。据术前MVA的大小可估计术后MVA、左心房、左心室压力和内径的变化。结论 :PBMV可显著的改善患者的血流动力学指标 ,在重度二尖瓣狭窄患者更明显 ,有适应征者应积极进行此项手术治疗。     

Cardiac CT Prior to Left Atrial Appendage Closure Device Implantation and Percutaneous Mitral Valve Interventions

Recent advances in percutaneous techniques have allowed them to emerge as an attractive alternative to surgery in select patients. Left atrial appendage closure has emerged as a novel therapeutic option in patients an nonvalvular atrial fibrillation who cannot take anticoagulation therapy. Furthermore, percutaneous mitral valve procedures have shown promising results in high risk patients. These percutaneous procedures require multimodality imaging for preprocedural planning and during the procedure. Computed tomography has emerged as an attractive imaging modality prior to percutaneous procedures given its ability to perform comprehensive assessment of cardiac and extracardiac structures. This review assesses the role of computed tomography as it pertains to left atrial appendage occlusion and mitral valve transcatheter procedures.     

Transesophageal echocardiography during percutaneous balloon mitral valvuloplasty

To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 +/- 0.3 to 1.9 +/- 0.4 cm2). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of transesophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support.     

Real-time three-dimensional transesophageal echocardiography in transcutaneous, catheter-based procedures for repair of structural heart diseases

We review the use of real-time three-dimensional transesophageal echocardiography (RT3D-TEE) in guiding percutaneous catheter-based procedures to repair structural heart defects. The utility of this novel imaging technique in percutaneous mitral valve repair and valvuloplasty, aortic valve insertion, device closure of atrial and ventricular septal defects, obliteration of the left atrial appendage, and pulmonary vein ablation is described. The main advantages of RT3D-TEE lie in its ability to visualize the entire length of intracardiac devices, including their tips, and to demonstrate their relationship to cardiac structures, to provide en face views of cardiac structures (such as the interatrial septum and the mitral valve) that are unobtainable in real time by any other imaging technique, and to allow for continuous monitoring during the procedure. It is likely that RT3D-TEE will become the standard of care for guidance of percutaneous, catheter-based procedures.     

超声心动图对急症诊断经皮二尖瓣球囊扩张术瓣叶穿孔的价值

本文分析5例风湿性心脏病重度二尖瓣狭窄患者，经皮二尖瓣球囊扩张术（PBMV）后，瓣叶穿孔的超声心动图（UCG）特异性表现为：原狭窄的二尖瓣口无改变，而瓣叶（多见前叶）回声连续中断，彩色多普勒显示（CDFI）收缩期大量蓝色为主返流束经撕裂穿孔瓣叶入左房，此表现为急症诊断PBMV穿孔提供了明确可靠的依据。     

综合性超声心动图引导及评价肥厚型梗阻性心肌病经皮导管肥厚室间隔化学消融术的方法学研究

目的：探讨超声心动图技术引导肥厚型梗阻性心肌病（HOCM）患者经皮导管肥厚室间隔化学消融术（PTSMA）的可行性及有效性。方法：应用综合超声心动图技术术前筛选HOCM患者5例。介入治疗术中以二维、多普勒和彩色多普勒监测及引导PTSMA。结果：除一例患者因冠状动脉间隔支太细无法消融而终止PTSMA外,余4例均取得良好效果。左室流出道流速及压差均有一不同程度的下降;二尖瓣及其腱索收缩期前向运动现象均有不同程度缓解;二尖瓣近流明显减轻。结论：综合性超声心动图技术可在术前筛选HOCM患者,术中指导及监测PTSMA,术后评价疗效及随访观察。     

超声心动图评价经皮球囊导管二尖瓣分离术的疗效观察——附40例随访报告

本文用二维超声心动图对40例风湿性二尖瓣狭窄(MS)经皮球囊导管二尖瓣分离术(PBMC)的疗效进行随访观察并对比研究。随访时间:24～43个月,平均28.8个月。疗效观察的主要超声参数是二尖瓣前后径、左右径。二尖瓣口面积、左房内径、左室内径、CE 幅度。对所得参数分别与术前比较。结果表明:PBMC 的2～3.5年内的疗效满意、安全可靠。     

Novel Aspects of 3D Echocardiography in Percutaneous Mitral Valve Interventions: Update 2013

The rapidly increasing importance of percutaneous treatment options for mitral valve diseases promotes the demand for reliable periprocedural guidance by transesophageal echocardiographic imaging. For several interventional mitral leaflet repair techniques real-time 3-dimensional transesophageal echocardiographic (RT3D TEE) guidance has been described to be indispensible. RT3DE TEE provides excellent insight into the mitral valve pathology, which improves procedure planning, safe guidance of device navigation and direct assessment of procedural success. For balloon mitral valvuloplasty 3D echocardiography has shown to effectively accelerate the procedure. The complexity of transcatheter mitral valve repair as well as transcatheter closure of paravalvular leakages of mitral valve prosthesis demands accurate evaluation of the target lesion and guidance of the navigation of the device catheter. All these features have recently found to be uniquely provided by three-dimensional echocardiography. The benefits of RT3D TEE led to its recommendation for percutaneous mitral valve repair procedures in current guidelines. This review of recent literature reports current applications and requirements for refinements in using 3D imaging modalities.     

高龄二尖瓣狭窄患者经皮二尖瓣球囊扩张术治疗的疗效分析

目的：分析60岁以上二尖瓣狭窄的患者行经皮二尖瓣球囊扩张术（percutaneousballoonmitralvalvuloplasty,PBMV）治疗的安全性和临床效果。方法：29例60岁以上二尖瓣狭窄的患者,食道超声示未见左房血栓后,采用Ross法穿刺房间隔,用Inoue球囊进行扩张,所有患者术前、术后应用体表超声心动图监测其二尖瓣瓣口面积、跨瓣压差、左心房直径、左心房平均压。肺动脉压力以及二尖瓣反流与否。手术后24h、1个月、6个月应用体表超声心动图随访。结果：29例患者均成功实施球囊扩张术,术后及随访6个月时左心房平均压、左心房直径、肺动脉压力较术前均降低,差异有统计学意义（P〈0．05）。1例术前二尖瓣轻微反流,术后为轻度到中度反流。29例患者术后心功能均得到明显改善,舒张期杂音完全消失或减弱。结论：对于瓣膜无明显钙化、瓣下结构超声心动评分≤6分、心功能Ⅲ级以上、合并其他瓣膜病变较轻的老年患者,PBMV同样可以取得较好的疗效。     

Recent developments in percutaneous mitral valve treatment

In recent years, various percutaneous techniques have been introduced for the treatment of mitral regurgitation (MR), including direct leaflet repair, annuloplasty and left ventricular remodeling. Percutaneous mitral repair targets both primary degenerative and secondary mitral valve regurgitation and may be considered in selected high-surgical-risk patients. The assessment of mitral functional anatomy by echocardiography and computed tomography is crucial when selecting the appropriate repair strategy, according to the regurgitant valve lesion and the surrounding anatomy. The ongoing clinical use of new devices in annuloplasty and percutaneous mitral valve replacement is a promising new scenario in the treatment of MR that goes beyond the conventional surgical approach.