经食管超声心动图在微创心脏外科直视手术中的应用

目的 探讨经食管超声心动图(TEE)在微创心脏外科直视手术(MIDCS)中的应用价值。方法 回顾性研究。纳入淮北矿工总医院2018年7月-2019年11月接受MIDCS的患者20例,其中男8例、女12例,年龄(57.5±10.2)岁。术前诊断:先天性心脏病6例,瓣膜病13例,左心房黏液瘤1例。20例患者术前均常规行经胸超声心动图(TTE)检查,术中均采用TEE监测。麻醉诱导后TEE检查修正诊断,指导建立体外循环,开放升主动脉前指导心腔排气;术中,于病变处理完成后即时TEE监测心内血流、瓣膜及心功能情况;于手术操作完成、心脏复跳后,应用TEE评价手术疗效,以无残余分流、瓣周漏、瓣膜关闭不全及左心室射血分数(LVEF)>50%为治愈。结果 经术中引导,20例患者均准确置于引流管、排空心脏。经TEE检查修正诊断5例:1例下腔型房间隔缺损术中发现另有一小的房间隔缺损,术中一并予以修补;1例房间隔缺损者房水平仅有微量分流,无需处理;2例三尖瓣关闭不全患者合并三尖瓣前叶裂,均行瓣叶修复后再予三尖瓣成形术;另1例则排除了左心房血栓。病变处理完成后,因术中TEE即时评估疗效不满意而更改手术方式2例:1例三尖瓣成形术后瓣膜关闭不满意者改行三尖瓣置换术,1例室间隔修补术后残余分流者改行胸骨正中切口继续修补。另有2例术毕即时通过TEE发现低心排血综合征,行主动脉内球囊反搏术。全组未见食管损伤和相关并发症,无手术死亡病例。术后均无残余分流、瓣周漏及少量以上反流,黏液瘤完全切除;术后患者症状明显缓解,LVEF为54%~69%(61.40%±3.65%),与术前[44%~67%(58.70%±5.19%)]比较差异有统计学意义(t=2.896, P<0.05)。本组患者治愈率100%。结论 术中TEE监测应用于MIDCS中,在补充修正诊断、引导体外循环建立、手术操作完成后监测心内排气、评价手术疗效等方面具有明显优势,为微创心脏外科直视手术的成功提供重要保障。     

卵圆窝形态的观测及临床解剖学意义

目的为临床房间隔手术治疗和经右心房导管介入治疗提供解剖学依据。方法对58例成人离体心脏卵圆窝的形态、横径、卵圆窝切迹进行观测。结果卵圆窝长轴长度为23.6±4.5mm,横轴长度为15.5±6.8mm;形态为卵圆形者占65.51%,圆形者占17.24%,长条形者占10.34%,不规则形占6.91%;卵圆窝上附有梳状肌者占20%,无梳状肌者占80%;无活瓣切迹占31.03%,有活瓣切迹者占68.97%,其切迹位于卵圆窝前上者占24.14%,后上占20.6%,前方占13.79%,上部占6.90%,后下占3.45%。结论卵圆窝形态差异甚大,68.97%卵圆窝在闭合时形成活瓣切迹,房间隔缺损封堵术时应引起注意。     

80例卵圆孔未闭超声心动图诊断分析

目的 本文对我院应用超声心动图(TTE)诊断的80例小儿卵圆孔未闭(PFO)进行探讨,分析卵圆孔未闭的血流动力学变化,诊断方法及卵圆孔未闭的临床意义,评估超声心动图技术诊断儿童卵圆孔未闭患者应用价值.方法 采用美国通用公司生产的GEVivid S-6彩色多普勒超声诊断仪,对80例卵圆孔未闭患者的声像特点、发生情况及分流方向进行比较分析.结果 合并室间隔缺损21名,占检查者26.2%(其中男性 12名,女性 9名,年龄8d~9岁 );动脉导管未闭者4名,占检查者5%,(男性 1名,女性3 名,年龄15d~5岁);三尖瓣闭锁1名,占检查者1.25%(女性,3月).其中71例卵圆孔分流束小于4 mm,9例分流束大于4 mm.结论 超声心动图是诊断卵圆孔未闭的一种可靠方法.     

国产封堵器介入治疗房间隔缺损的疗效及安全性

目的 评价应用国产房间隔封堵器治疗房间隔缺损的疗效及安全性。方法 12例房间隔缺损患者，男性4例，女性8例，年龄18-45岁。对患者均使用经体表超声心动图（TTE）监测。封堵器选用国产房间隔封堵器（北京华圣杰科技有限公司研制）。房间隔缺损封堵术后48h进行TTE复查，术后1、3、6个月随访得查心电图、TTE、X线，并观察疗效及安全性。结果 11例封堵手术成功，即刻手术成功率91.67%，术中及术后48hTTE星移斗转测均无残余分流。术后1、3、6个月随访，原有临床不适症状缓解，TTE显示封堵器位置稳定，房间隔水平无分流。结论 国产房间隔封堵器对房间隔缺损进行介入治疗，临床使用有效、安全。     

经皮穿刺闭合房间隔缺损的应用解剖

目的为经皮穿刺闭合房间隔缺损提供相关的应用解剖资料。方法解剖测量50例(男29,女21)正常成年人心脏标本。结果卵圆窝长(20.9±5.4)mm,宽(14.3±3.7)mm。卵圆窝中点距冠状窦口中点(19.7±4.1)mm;距膜性房间隔(22.6±3.8)mm;距三尖瓣隔侧瓣中点(25.1±4.2)mm和距主动脉隆凸底部的中点(24.7±4.2)mm。卵圆窝中点距二尖瓣前瓣中点距离为(19.9±4.4)mm。卵圆窝缘的厚度在12、3、6和9点钟处分别是(4.1±0.7)、(3.2±0.7)、(2.3±0.5)和(3.3±0.7)mm。右上、下肺静脉汇入左心房的入口处水平距房间隔的距离分别为(8.2±2.2)mm和(12.4±3.8)mm。结论依据本文测量结果,经皮穿刺闭合房间隔缺损封堵器的厚度在5mm左右,且其弹性变化应适应房间隔厚度的变化为宜。     

经食道心脏超声对应用Amplatzer封堵器治疗房间隔缺损的观察

目的 :观察应用Amplatzer封堵器经导管治疗二孔型ASD的疗效 ,并评价经食道超声 (TEE)在介入治疗ASD中的价值。方法 :全组共 1 8例 ,均为二孔型ASD ,年龄 1 4～ 4 1岁 ,平均 2 1 .6岁。TEE测ASD最大直径 3 3mm ,平均 2 1 .4mm ,缺损周边有足够的房间隔空间。在透视及TEE监视下经导管置入Amplatrzer封堵器封堵ASD ,术后即刻、2 4h、3个月分别行TEE检查 ,评价治疗效果。结果 :全组技术成功率为 1 0 0 % ,术后 2 4hTEE检查显示 1 4例ASD完全闭合 ,4例存在微量残余分流 ,术后 3个月均无残余分流 ,无任何并发症。结论 :应用Amplatzer封堵器经导管治疗二孔型ASD操作简便 ,成功率高 ,是目前导管介入治疗ASD的首选治疗器材。TEE在对病例的筛选、引导封堵器的置入及术后疗效评价等方面有极重要的作用。     

隐形切口心脏不停跳心内手术312例

总结我们从 1998.0 1-2 0 0 2 .0 4间对 3 12例不同类型的心脏病采用腋下微型直切口心脏不停跳下行心内直视手术的结果 ,旨在探讨该方法的适应证及优缺点。1　临床资料1.1　一般资料本组 3 12例 ,男 178例 ,女 13 4例 ,年龄 0 .5 -4 9岁 ,平均 13 .4± 7.9岁 ,其中先天性房间隔缺损 (ASD) 167例 ,室间隔缺损 (VSD) 13 6例 ,ASD合并部分肺静脉异位引流 11例 ,三房心 1例 ,主动脉窦瘤破入右房 4例 ,Ebstein畸形 1例 ,部分心内膜垫缺损 2例 ,心电图不完全性右束支传导阻滞 3 9例 ,不完全左束支传导阻滞 17例 ,,完全性右束支传导阻滞 8例 ,…     

阑尾神经瘤合并恶性肿瘤临床病理分析

目的探讨阑尾神经瘤的临床病理特点并分析其与恶性肿瘤之间的关系。方法收集2011年1月～2017年9月吉林省延边大学附属医院行恶性肿瘤根治术合并切除阑尾患者383例及行单纯阑尾切除术患者2 515例,镜下观察,并行免疫组化染色进行分析、比较。结果恶性肿瘤合并阑尾神经瘤67例,占17.5%,其中女性患者44例,占11.5%,男性患者23例,占6.0%。行单纯阑尾切除术患者2 515例,其中阑尾神经瘤51例,占2.02%,其中女性患者42例,占1.67%,男性患者9例,占0.36%。结论阑尾神经瘤合并恶性肿瘤时其发病率远大于单纯阑尾切除术中阑尾神经瘤。     

小儿房间隔缺损的治疗策略

房间隔缺损（ASD）是指在胚胎发育过程中房间隔的发生、吸收和融合发生异常,导致左右心房残留未闭的缺损。是先天性心脏病中常见疾病之一,其发病率占总先天性心脏病的第2位,约10%～30%。根据ASD胚胎发育机制和解剖学特点分为继发孔型和原发孔型。     

先天性心脏病合并感染性心内膜炎的临床及预后分析

目的总结分流型先天性心脏病合并感染性心内膜炎(IE)患者的临床特点、治疗及影响预后的因素。方法分析我院2001年1月-2010年12月收治的51例分流型先天性心脏病合并IE患者的临床资料。结果合并于分流型先天性心脏病的IE占全部IE患者的20.6%,其中室间隔缺损和动脉导管未闭是最常见的先天性心脏病。链球菌属(47.1%)是最常见的致病菌。52.9%的患者出现并发症,主要为瓣膜受损和系统性栓塞。38例患者(58.8%)行手术治疗,其中21例于IE活动期行早期手术。先心病合并IE的死亡率为19.6%。回归分析显示,严重心力衰竭(P<0.05)和神经系统并发症(P<0.05)是死亡率的预测因子,而手术治疗是死亡率降低的独立预测因子(P<0.05)。结论先天性心脏病合并IE者死亡率较高。出现严重心力衰竭和中枢神经系统并发症提示预后不良,手术治疗可显著降低死亡率。     

Communication of the coronary sinus with both atria

The coronary sinus of a healthy 18-year-old man who died of a skull fracture was found to communicate with both the right and left atria. The anomaly can function as an atrial septal defect; thus, it needs recognition in the treatment of a patient with an interatrial shunt with an apparently normal right atrium.     

Diagnosis of interatrial shunts using contrast echocardiography

M-mode contrast echocardiography with peripheral venous injections was performed in 73 patients with interatrial communications: 48 (group 1) had a hemodynamically significant atrial septal defect (ASD), 19 (group 2) had a patent foramen ovale (PFO) without clinical or oxymetric evidence of a shunt. The remaining 6 (group 3) had an interatrial communication in combination with severe additional congenital malformations predisposing to a right to left (R-L) shunt. Contrast studies were considered positive for a shunt lesion when at least five clearly recognizable contrast echoes appeared in the left heart following one injection. During quiet respiration positive contrast studies were obtained in 85% of all ASD patients (including all 10 with Eisenmenger's reaction and 31/38 [82%] uncomplicated cases); in 37% of the PFO cases (including 3/13 with normal right heart pressures), and in 53/73 (73%) of all patients with interatrial communications. The intensity of contrast shunting was variable in all groups. Opacification of the mitral funnel (which is typical for an atrial level shunt) was observed in 45 patients. In 8 patients with positive studies the few contrast echoes, that appeared in the left heart were first seen after they had left the mitral valve. Contrast injections into the pulmonary artery were performed in a control group of 29 patients. No contrast appeared in the left heart as expected. In 57 patients (39 ASD, 17 PFO, 1 group 3) contrast studies were also performed during the Valsalva maneuver. Valsalva provocation resulted in increased contrast shunting in 19, led to new mitral funnel opacification in 9 and improved the sensitivity of contrast echocardiography by 9 and 26% in ASD and PFO cases respectively. The intensity of contrast shunting was largely independent of the hemodynamic findings and was often variable upon subsequent injections in the same patient. Therefore contrast echocardiography is not helpful in predicting the L-R shunt or the pulmonary artery pressure and does not seem suited for follow-up studies. The differentiation between true contrast echoes in the left heart and artifacts, noise echoes, "overload", or incomplete mitral structures and the differentiation between interatrial and interventricular contrast shunting is usually easy. However the distinction between a hemodynamically significant ASD and pulmonary arteriovenous fistulas, certain venous anomalies or a patent foramen ovale may be difficult or even impossible by contrast echocardiographic criteria alone. Resting two-dimensional contrast echocardiograms were recorded in 57 patients including 34 with ASD, 18 with PFO and 5 from group 3.(ABSTRACT TRUNCATED AT 400 WORDS)     

Outcome of Transcatheter Closure of Oval Shaped Atrial Septal Defect with Amplatzer Septal Occluder

Purpose

For the successful completion of transcatheter closure of atrial septal defects with the Amplatzer septal occluder, shape of the defects should be considered prior to selecting the device. The purpose of this study is to evaluate the results of a transcatheter closure of oval shaped atrial septal defect.

Materials and Methods

From November 2009 until November 2011, cardiac computed tomography was performed on 69 patients who needed a transcatheter closure of atrial septal defect. We defined an oval shaped atrial septal defect as the ratio of the shortest diameter to the longest diameter ≤0.75 measured using computed tomography. A trans-thoracic echocardiogram was performed one day after and six months after.

Results

The transcatheter closure of atrial septal defect was performed successfully in 24 patients in the ovoid group and 45 patients in the circular group. There were no serious complications in both groups and the complete closure rate at 6 months later was 92.3% in the ovoid group and 93.1% in the circular group (p>0.05). The differences between the device size to the longest diameter of the defect and the ratios of the device size to the longest diameter were significantly smaller in the ovoid group (1.8±2.8 vs. 3.7±2.6 and 1.1±0.1 vs. 1.2±0.2).

Conclusion

Transcatheter closure of an oval shaped atrial septal defect was found to be safe with the smaller Amplatzer septal occluder device when compared with circular atrial septal defects.     

The nature of the superior sinus venosus defect

The location, and morphology, of the superior sinus venosus interatrial communication remains contentious. As part of a clinical study, we examined anatomic specimens and echocardiograms so as to clarify the arrangement of the normal atrial septal structures, and compared them with the arrangement found in the superior sinus venosus defect. The pathognomonic diagnostic criterion in the abnormal hearts was overriding of the intact muscular rim of the oval fossa by the mouth of the superior caval vein. This muscular rim is, in reality, a tube of myocardium which encloses a core of extracardiac adipose tissue. Understanding of this anatomic conundrum clarifies the understanding of the structures of both the normal atrial septum and sinus venosus defects. Clin. Anat. 11:349–352, 1998. © 1998 Wiley-Liss, Inc.     

Cardinal vein isomerism: an embryological hypothesis to explain a persistent left superior vena cava draining into the roof of the left atrium in the absence of coronary sinus and atrial septal defect.

BACKGROUND: A persistent left superior vena cava (PLSVC) is a relatively frequent systemic venous anomaly associated with congenital heart defects. This anomaly has been explained with the persistence of the left superior cardinal vein. PLSVC usually drains into the right atrium, via coronary sinus, but it joins the left atrium in approximately 8% of the cases either directly in the setting of atrial isomerism, or via an unroofed coronary sinus, or through a coronary sinus type atrial septal defect. CASE REPORT: We describe a case of an adult patient with atria in the situs solitus, PLSVC draining into the left atrium, atresia of coronary sinus without atrial septal defect, and with additional cardiac anomalies (ventricular septal defect and discrete subaortic stenosis). CONCLUSION: A possible embryological explanation to this case rises from a right partial isomerism of the superior cardinal veins, which gives reason for both the coexistence of the PLSVC draining into the left atrium and the absence of coronary sinus, atrial septal defect, or coronary sinus ostium.     

Aneurysm of fossa ovalis in adults: a pathologic study.

BACKGROUND: Aneurysm of the fossa ovalis is an out pouching, space-occupying, interatrial septal structure. The anatomic morphology and characteristics of this aneurysm are of interest for pathologists and cardiologists alike. METHODS: We identified 33 specimens of adult hearts with a large size aneurysm of the fossa ovalis (length equal to or more than 10 mm from the plane of the atrial septum) in a registry of cardiovascular disease. Anatomic-morphologic features of these aneurysms were examined by macroscopic and histopathologic studies. RESULTS: Nineteen aneurysms were from females (57%) and 14 were from males (43%). Most aneurysms had a dome shape with maximal length of the aneurysmal excursion into an atrium varying from 10 to 35 mm (mean 16+/-5 mm) and width varying from 16 to 40 mm (mean 24+/-6 mm). Twenty-four aneurysms (73%) protruded into the right atrium while only nine (27%) penetrated into the left atrium. In 24 patients the interatrial ostium II was patent, and in 22 (91%) of them, abnormal increased intracardiac pressure was deemed responsible for the formation of the aneurysm. Among nine patients in whom the foramen ovale was closed, eight (89%) had an aneurysm protruding into the right atrium, and only one aneurysm penetrated into the left atrium. In six patients, the aneurysm further stretched an already patent foramen ovale resulting in creation of an atrial septal defect so that bidirectional shunting could occur, and in three cases, the aneurysm narrowed the inferior vena caval orifice. In three hearts, the aneurysm wall had endocardial fibrosis, and in three other specimens, a focal mural thrombus was present on the aneurysmal surface. Most common associated cardiac conditions in this series included atherosclerotic coronary artery disease (51%), aortic valvular disease (21%) and mitral valve disease (24%). CONCLUSIONS: Aneurysm of the fossa ovalis is a space-occupying, redundant structure, most commonly with a dome shape. In a majority of cases, the formation of this aneurysm relates to the effect of extrinsic mechanisms, which create abnormally elevated intracardiac pressures. The aneurysm protruded into the right atrium in 73% of cases. Endocardial fibrosis and a focal mural thrombus were present in several cases on the aneurysmal wall. Bidirectional shunt via stretched patent foramen ovale and distal embolization can contribute to complications related to the aneurysm.     

Cardiac tamponade due to perforation by an Amplatzer atrial septal occluder in a patient with Marfan syndrome

Device closure of atrial septum defect was performed using an Amplatzer septal occluder in a 48-year-old patient with Marfan syndrome. Acute tamponade due to perforation was observed 2 months after catheter intervention. Careful consideration of the indication for device closure for atrium septal defect is necessary in patients with Marfan syndrome.     

Clinical anatomy of the atrial septum with reference to its developmental components

Knowledge of development is of crucial importance and can help clarify mechanisms of maldevelopment, but it must be properly validated. Concepts of development must be consistent with the anatomy seen in postnatal life. Such consistency is not always achieved. We have reviewed new and old accounts of cardiac embryology with regard to the definitive structure of the atrial septum. The key to understanding is to distinguish between folds of the atrial wall and true interatrial partitions. The flap valve of the oval foramen, and its inferior rim, are true septal structures, whereas the other rims, particularly the antero‐superior rim, are infoldings enclosing extracardiac fat. During embryonic life, the systemic venous tributaries must achieve entrance only to the right side of the primary atrium. Development of the pulmonary venous component is a late event, with the canalizing vein using the dorsal mesocardium to gain access to the left side of the atrium. Once the systemic venous tributaries have achieved their rightward shift, the primary septum, together with the mesenchymal cap, grows between the systemic and pulmonary venous orifices. Closure of the primary foramen is achieved by fusion of the mesenchymal cap of the primary septum with the atrioventricular endocardial cushions and the vestibular spine (an additional mesenchymal structure carried on the right side of the pulmonary venous orifice). The superior margin of the newly formed secondary foramen is produced by an infolding of the atrial walls. Historically these mechanisms received appropriate recognition, but not all receive their proper due in current writings. Clin. Anat. 12:362–374, 1999. © 1999 Wiley‐Liss, Inc.     

Development of the venous pole of the heart in the frog Xenopus laevis: A morphological study with special focus on the development of the venoatrial connections

The heart of lung‐breathing vertebrates normally shows an asymmetric arrangement of its venoatrial connections along the left‐right (L‐R) body axis. The systemic venous tributaries empty into the right atrium while the pulmonary venous tributaries empty into the left atrium. The ways by which this asymmetry evolves from the originally symmetrically arranged embryonic venous heart pole are poorly defined. Here we document the development of the venous heart pole in Xenopus laevis (stages 40–46). We show that, prior to the appearance of the mouth of the common pulmonary vein (MCPV), the systemic venous tributaries empty into a bilaterally symmetric chamber (sinus venosus) that is demarcated from the developing atriums by a circular ridge of tissue (sinu‐atrial ridge). A solitary MCPV appears during stage 41. From the time point of its first appearance onwards, the MCPV lies cranial to the sinu‐atrial ridge and to the left of the developing interatrial septum and body midline. L‐R lineage analysis shows that the interatrial septum and MCPV both derive from the left body half. The CPV, therefore, opens from the beginning into the future left atrium. The definitive venoatrial connections are established by the formation of a septal complex that divides the lumen of the venous heart pole into systemic and pulmonary venous flow pathways. This complex arises from the anlage of the interatrial septum and the left half of the sinu‐atrial ridge. Developmental Dynamics 240:1518–1527, 2011. © 2011 Wiley‐Liss, Inc.     

Alternative explanations to the differences of femoral and brachial saline contrast injections for echocardiographic detection of patent foramen ovale

Patent foramen ovale (PFO) of the interatrial septum is a cardiac foetal remnant, which frequent persistence in adulthood has important implications in a variety of clinical conditions. Echographic diagnosis of PFO is based on detection of interatrial shunt by means of contrast microbubbles identification after venous injection of a first-generation echographic contrast agent. Current recommendations propose venous femoral injection of contrast for enhanced echographic detection of PFO instead of venous brachial administration, as femoral injection has been shown to have higher sensitivity for PFO detection. Inferior vena cava inflow directed toward interatrial septum has been considered the explanation for increased sensitivity of femoral delivery of contrast. In the present paper, it is hypothesised that the main determinants of these differences between injection sites are technical factors related to right atrial contrast opacification and proper transient right atrial pressure rise, rather than intraatrial flow streaming. Effects of inferior vena cava inflow stream, although significant during foetal life, would be negligible after birth. Rationale and evidence, basis for further research, and practical implications leading to a simpler and safer routine technique for echographic detection of PFO are presented and discussed.