复杂先心病术中经食管超声心动图引导肌部室间隔缺损封堵三例

<正>临床资料患者1,女,9个月5天。经胸超声心动图(transthoracic echocardiography,TTE)示:法洛四联症;主动脉瓣下室间隔缺损,大小约9 mm;肺动脉瓣、瓣下及瓣上狭窄。体外循环(CPB)下行法洛四联症矫治术。主动脉开放心脏复跳后,经食管超声心动图(transesophageal echocardiography,TEE)示:室间隔肌部2处缺损(venrticular septal defect,VSD),直径分别为4 mm和1 mm(图1A)。TEE引     

微型经食管超声心动图指导心脏外科术后患者管理的研究进展

近年来,经食管超声心动图(transesophageal echocardiography,TEE)设备有微型化趋势,使其在心脏外科术后重症监护病房患者的管理中有重大临床意义和广泛的临床应用前景。本文介绍了微型经食管超声心动图(miniaturized transesophageal echocardiography,m TEE)技术和临床应用特点,并侧重其与标准TEE和经胸超声心动图(transthoracic echocardiography,TTE)的对比。     

经胸超声心动图检查在高危非心脏手术患者围术期管理中的应用

正经胸超声心动图(transthoracic echocardiography,TTE)能够直观的显示心脏结构及血流,是围术期评估心脏功能及血流动力学状态的重要手段。与经食管超声心动图(transesophageal echocardiography,TEE)比较,TTE具有侵入性小、操作简便等特点。Kratz等~([1])研究表明,麻醉科医师应用围术期TTE能够及时发现急诊及高危手术患者的新发心脏情况,并对引起血流动力学不稳定的因素进行判断,对此类患者的围术期管理产生积极作用。     

食管超声在经胸微创继发孔房间隔缺损封堵术中的应用

目的报告经食管超声心动图（TEE）用于58例经胸微创治疗继发孔房间隔缺损（ASD）封堵术的结果。方法术前经胸超声心动图（TTE）初步筛选58例继发孔型ASD患者,观察ASD大小及各残缘,并在术中指导封堵过程,术后评价封堵效果。结果封堵术后随访一个月后,54例完全闭合房间隔;2例残留少量房水平分流;2例封堵失败,行体外循环下修补术。手术并发症1例,无TEE相关并发症。结论TEE可在术前修正TTE诊断,并在选择封堵器、术中全程引导及术后疗效的即刻判断等方面起重要作用。     

本刊可以直接使用的英文缩略语（二）

经胸超声心动图（transthoracic echocardiography，TTE） 经食管超声心动图（transesophageal echocardiography，TEE）     

经食管超声心动图与经胸超声心动图引导下继发孔型房间隔缺损封堵疗效比较

目的比较经食管超声心动图(transesophageal echocardiography,TEE)与经胸超声心动图(transthoracic echocardiography,TTE)引导行经皮介入封堵术治疗继发孔型房间隔缺损(ostium secundum defect,OSD)的临床效果。方法选择84例继发孔型OSD患者,术前行TTE及TEE检查。根据术中影像学引导技术的不同分为TEE组(44例)和TTE组(40例),分别在TEE和TTE引导下行经皮介入封堵术。比较两组围术期指标、封堵成功率、一次封堵器选择成功率及术后并发症情况。结果两组患者封堵手术均成功。TEE及TTE测量OSD最大内径值存在统计学差异(P<0.05),而两者测量房顶缘残端、主动脉根部残端以及心房总长度等参数比较差异均无统计学意义(P>0.05)。TEE组手术时间、心内操作时间少于TTE组(P<0.05),一次封堵器选择成功率高于TTE组(P<0.05),而两组住院时间及封堵成功率比较均无统计学差异(P>0.05)。所有患者术后随访12个月,均无心包积液及血管损伤发生。TEE组发生残余分流及皮下气肿各1例,TTE组发生胸腔积液及皮下气肿各1例,两组比较差异无统计学意义(P>0.05)。结论TEE引导下行经皮封堵术治疗继发孔型OSD,测量参数准确,操作时间较短,封堵效果满意,安全性良好。     

全机器人心脏外科手术中经食管超声心动图的应用

目的 探讨术中经食管超声心动图(transesophageal echocardiography,TEE)在全机器人心脏外科手术中的作用.方法 2007年1月至2011年3月,对接受全机器人心脏外科手术的193例患者行术中TEE检查,其中房间隔缺损111例,黏液样退行性变(瓣叶脱垂或连枷样瓣叶)所致二尖瓣反流51例,心房黏液瘤31例.TEE应用于:(1)体外循环(CPB)转机前,进一步明确病变性质及其发生部位;(2)建立外周CPB时,引导下、上腔静脉内插管及升主动脉内灌注针的置放;(3)心脏复跳后,即刻评价手术效果及有无手术相关并发症.结果 以术中所见为标准,TEE诊断病变性质及其发生部位总的准确性分别为100%和98.8%.下、上腔静脉内插管及升主动脉内灌注针均置于适当位置,TEE引导置管成功率为100%.心脏复跳后,TEE显示所有患者手术均获成功,无手术相关并发症.结论 术中TEE在全机器人心脏外科手术中不可缺少.

Abstract：

Objective To delineate the utility and results of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing robot-assisted cardiac surgery. Methods Intraoperative TEE was performed in 193 patients undergoing robot-assisted procedures in cardiac surgery over a period of 4 years. (1) Before CPB, a comprehensive TEE was performed to document the lesions and their precise localization. ( 2 ) During establishment of peripheral CPB, a arterial cannula was placed percutaneously into the right internal jugular vein and passed into the superior vena cava; a venous cannula was inserted into the right common femoral vein and passing it into the inferior vena cava with its tip just inferior to the inferior vena cava-right atrium junction; a arterial perfusion cannula was passed into the ascending aorta with its tip approximately 3 cm from the aortic valve under TEE guidance. (3) After weaning from CPB, TEE was performed to evaluate the efficiency of the procedure. Results (1) The concordance with surgical findings concerning the lesions and precise localization was 100% and 98. 8% among all the patients, respectively. (2) All cannulae were located in the correct position. (3) TEE confirmed successful procedures with no concomitant complication in all the patients. Conclusion Intraoperative TEE is a valuable adjunct in the assessment of robot-assisted cardiac surgery.     

经食管超声心动图在心脏介入治疗中的应用

<正>经食管超声心动图(transesophageal echocardiography,TEE)在近些年正发展成为一项重要的快速床旁心血管系统影像评估检查技术。TEE检查的经胃-食道路径所得图像能减少信号衰减,提高超声频率,继而提高图像空间分辨率,使所获得的超声图像更加清晰。此外,与术前其他影像检查或者经胸超声心动图(transthoracic echocardiography,TTE)相比,TEE能够提供实时信息并可实现动态监测,而且不影响手术进行。本文拟综述TEE在常见心脏介入治疗中的应用及其优势。     

本刊可以直接使用的英文缩略语（二）

经胸超声心动图（transthoracic echocardiography，TTE） 经食管超声心动图（transesophageal echocardi。graphy，TEE）     

本刊可以直接使用的英文缩略语

经胸超声心动图（transthoracic echocardiography, TTE）经食管超声心动图（transesophageal echocardiography,TEE）彩色多普勒血流显像（eolor Doppler flow imaging, CDFI）彩色多普勒能量图（color Doppler energy, CDE）     

Successful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle

Cardiac metastatic liposarcoma is a rare tumor. We report a case of successful resection of a cardiac metastatic liposarcoma extending into the superior vena cava (SVC), right atrium, and right ventricle. Using cardiopulmonary bypass (CPB) by venous cannulation of the upper portion of the SVC and inferior vena cava (IVC), the intracardiac tumor was completely resected. Surgical resection with the addition of radiotherapy prolonged the patient's life.     

Survival after intraoperative pulmonary embolism of a patient with left adrenal tumor

We report a case of severe shock associated with intraoperative pulmonary embolism (PE). A 15-year-old girl was scheduled to undergo left adrenalectomy and removal of vena cava tumor thrombi. She had suffered from preoperative PE and a temporary IVC filter had been inserted. After left adrenalectomy and removal of vena cava tumor thrombi, IVC was declamped. Forty-five minutes after IVC declamping, circulatory collapse developed with severe hypoxia. Transesophageal echocardiography (TEE) revealed right ventricular dysfunction. We diagnosed PE and immediately started cardiopulmonary resuscitation. Ten minutes later, a stable cardio-respiratory condition was reestablished. TEE findings showed the restoration of right ventricular function. She recovered without any neurological complications. TEE may be useful for diagnosis of acute PE by secondary signs of pulmonary artery obstruction. When intraoperative PE is suspected, TEE should be used for early diagnoss of PE and monitoring cardiac function. This case also suggests that cardiopulmonary resuscitation maneuvers may ameliorate PE itself.     

Adrenomedullary epinephrine excretion and myocardial norepinephrine release during cardiopulmonary bypass

It has long been known that shock or surgical stress promotes an epinephrine (E) excretion from the adrenomedullary glands. In fourteen adult cardiac patients, plasma E values in both superior vena cava (SVC) cannula and inferior vena cava (IVC) cannula during total cardiopulmonary bypass (CPB) are studied at three stages, before aortic cross clamp (pre AXC), after release of aortic cross clamp (post AXC) and at 34 degrees C rectal temperature in rewarming (34 degrees C RT). Although E values in both SVC and IVC are slightly higher values than normal in pre AXC, they increase sharply to peaked values at post AXC and decline uniformly close to normal at 34 degrees C RT. IVC-E is constantly significantly higher (statistically) than SVC-E at each of all three stages. It is strongly suggested that E response to CPB is mainly originated from the adrenomedullary glands, and cardiac reflex which has sympathetic efferent limbs triggered by myocardial ischemia can indicate the increase in E during AXC. Myocardial norepinephrine (NE) release in heart ischemia such as acute myocardial infarction has been generally accepted. To examine whether myocardial NE release occurs during AXC, if there is the association of NE release with any clinical parameters, the second investigation is done in twenty-six adult cardiac patients. Plasma NE values in both the radial artery (A) and the coronary sinus (CS) are measured at six stages, pre AXC (stage 1), post AXC (stage 2), post CPB (stage 3), three hours after off CPB (stage 4), six hours off CPB (stage 5) and twelve hours off CPB (stage 6).(ABSTRACT TRUNCATED AT 250 WORDS)     

超声导引下介入治疗房间隔缺损合并肺动脉瓣狭窄的临床体会

目的本文报告我院1998年10月-2006年11月应用彩色超声（CDE）导引介入治疗房间隔缺损（AsD）合并肺动脉瓣狭窄（Ps）14例的临床体会。方法14例患者，男5例，女9例。年龄3-53岁，平均（20．9士9．8）岁。ASD均为单一中央型。PS轻度6例，中度8例。其中合并卵圆孔未闭和左上腔静脉各l例。使用仪器日本东芝6000型和美国惠普1500型彩色多普勒血流显象仪（CDE）和食道超声（TEE）探头频率分别为2．5MHZ和5MHZ。术前用CDE诊断，术中用CDE及TEE配合术后第2天及随诊均应用CDE。结果应用CDE选择14例ASD合并PS，在CDE和TEE导引及监测下成功进行肺动脉瓣球囊扩张（PBPV）和ASD闭合术，技术成功率100%4，用CDE随诊1～96个月，无任何并发症。结论ASD合并PS介入治疗必须要在CDE和TEE导引及监测下完成CDE主要观察心尖、剑下四腔心、两房心及大动脉短轴切面，TEE主要观察房间隔及上、下腔静脉长轴切面，大动脉短轴及四腔心切面。     

The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus

Transesophageal echocardiography (TEE) is sometimes used in renal cell carcinoma excision for evaluating the extension of tumor in the inferior vena cava (IVC), characterizing the tumor anatomy, monitoring the tumor during surgical mobilization, and assessing cardiac function. Although the risk for embolization is small, when embolization does occur, its consequences can be catastrophic. In this case report, we describe the crucial role of TEE in diagnosing an intraoperative migratory embolus from the IVC to the pulmonary artery and also provide both single-frame photographs and Internet-accessible videos of the event. Our case illustrates the key role that TEE played in the intraoperative management of a patient with renal cell carcinoma undergoing surgical excision of tumor. TEE aided in accurately defining the cephalad extent of the thrombus, provided continuous monitoring of the thrombus during surgical manipulation, and allowed immediate identification of its embolization and proper notification of the surgeons. This case illustrates the crucial role TEE played in the management of a migratory tumor embolus and argues for its routine use during excision of renal cell carcinomas invading the IVC.     

Intraoperative TEE for the management of pulmonary tumour embolism during chondroblastic osteosarcoma resection

PURPOSE: Chondroblastic osteosarcoma requiring surgical intervention is associated with a high risk of pulmonary tumour embolism. Rapid intraoperative diagnosis with transesophageal echocardiography (TEE) allowed changing the management plan and treatment of a life-threatening pathology. CLINICAL FEATURES: A 32-yr-old female with right pelvic chondrosarcoma presented for right hemipelvectomy. Two hours into the operation during ligation of the iliac blood vessels the patient's hemodynamic condition deteriorated and was followed by cardiac arrest. TEE was performed immediately and revealed massive tumour embolism in the right and left pulmonary arteries. Large tumour emboli were removed from the right and left pulmonary arteries after median sternotomy under cardiopulmonary bypass and moderate hypothermia. The hemipelvectomy was completed on the next day after fluid and inotropic agent resuscitation. An inferior vena cava filter was placed below the renal veins. The patient was discharged from hospital ten days after the surgery. CONCLUSION: This case report illustrates the important role TEE can play in the early diagnosis and subsequent surgical treatment of noncardiac emergencies. Intraoperative TEE can have a significant impact on the decision making process in life threatening emergencies.     

TEE bei intracavaler Ausdehnung von Nierenzellkarzinomen Intraoperatives Management mit transösophagealer Echokardiographie

OBJECTIVE: To evaluate the role of intraoperative real-time transesophageal echocardiography (TEE) for the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension. METHODS: Retrospective analysis of the intraoperative application of TEE in a series of 4 patients. RESULTS: Real-time TEE with a multiplane probe allowed visualization of inferior vena cava tumor extensions, accurate assessment of the distal extent of vena cava invasion into hepatic veins and right atrium, monitoring of embolism and evaluation of cardiac preload and function in all patients. CONCLUSION: Intraoperative TEE is a useful adjunct to the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension.     

Detection of iatrogenic cardiac tamponade by transesophageal echocardiography during vena cava filter procedure

PURPOSE: To present a patient who developed cardiac tamponade during insertion of an inferior vena cava (IVC) filter. Intraoperative transesophageal echocardiography (TEE) was used as a means to diagnose the cardiac tamponade and to facilitate guiding of pericardiocentesis. CLINICAL FEATURES: A 45-yr-old man with protein S deficiency complicated by repeated attacks of deep vein thrombosis and pulmonary thromboembolism was scheduled for insertion of an IVC filter. He had history of chronic renal insufficiency, heart failure, and cerebral infarction with mild left hemiparesis. Current medication included diltiazem (30 mg, I tab tid ), prednisolone (5 mg, 2 tabs qd ), and warfarin (2.5 mg daily). Preoperative transthoracic echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of left ventricle. Nuclear medicine examination by (99)Tc showed ejection fractions of left ventricle and right ventricle as 20% and 22%, respectively. Under the impression of protein S deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, he was arranged for the procedure of vena caval filter insertion. Unfortunately, iatrogenic cardiac tamponade occurred during the course of the procedure with rapid hemodynamic deterioration. Because of the expedient of routine monitoring of cardiac condition with TEE, a prompt diagnosis was made. We successfully improved the patient's hemodynamic status after transthoracic echo-guided pericardiocentesis. CONCLUSION: Intraoperative TEE is recommended to be used routinely in patients undergoing vena cava filter procedures. The availability of echocardiographic monitoring in the operation room allows the confirmation of the diagnosis and facilitation pericardiocentesis.     

Case report: Inferior vena-cava right atrial anastomotic stenosis after bicaval orthotopic heart transplantation

PURPOSE: This case report describes the occurrence of acute postoperative liver and renal failure after bicaval orthotopic heart transplantation (OHT) due to stenosis of the inferior vena cava (IVC)-right atrial (RA) anastomosis. We also discuss the role of measuring femoral venous pressure and transesophageal echocardiography (TEE) in establishing the diagnosis. CLINICAL FEATURES: A 42-yr-old female patient with idiopathic dilated cardiomyopathy underwent an OHT, using the bicaval anastomotic technique. During the first 12 hr postoperatively she developed unexplained kidney and liver failure. Her left and right ventricular functions were excellent and the right and left sided filling pressures were normal. The femoral pressure was elevated while the RA pressure was normal. An emergent TEE showed colour-flow and Doppler characteristics consistent with IVC-RA anastomotic stenosis. Emergent surgical re-exploration was undertaken; a hemostatic suture was found at the RA cannulation site that had caused the constriction of the IVC-RA anastomosis. CONCLUSIONS: Acute liver and renal failure after OHT can have multiple causes including ischemia due to a low flow state. This case demonstrates the importance of doing a detailed intraoperative TEE after OHT, and the importance of repeating the intraoperative examination after any hemostatic sutures are placed. Femoral venous pressure monitoring can be a useful diagnostic tool in detecting IVC-RA stenosis.