经食道超声诊断主动脉瓣单瓣畸形1例

患者男，48岁．间断胸痛伴阵发性呼吸困难5年．加重1个月。经胸超声心动图检查：左室内径明显增大．左房轻度增大，右房轻度增大．右室内径正常；室间隔及左室壁厚度增厚．室间隔运动减低，余室壁运动幅度尚可；主动脉瓣明显增厚、回声增强．瓣叶结构显示不清。CDFI显示舒张期主动脉瓣轻至中度反流信号．连续多普勒超声显示收缩期主动脉瓣上流速明显增快．压差增大。     

Endocarditis marántica

Marantic endocarditis is characterized by the presence of sterile vegetations in the heart valves, and is associated with hypercoagulability states (cancer, autoimmune diseases, HIV). Its main complications are stroke, pulmonary thromboembolism, acute intestinal ischemia and splenic, renal and hepatic infarcts. We present the case of a 57-year-old patient with a history of uterine neoplasia. She went to the emergency department due to sudden loss of strength in the left side of the body. A computed tomography (CT) scan showed right ischemic stroke, and she underwent endovascular reperfusion and thrombectomy. Four days later, she suffered acute respiratory failure, with angio-CT showing pulmonary thromboembolism. Later, paroxysmal atrial fibrillation and distal ischemia in the second toe of the left foot appeared. She was diagnosed with marantic endocarditis by means of transesophageal echocardiography, and died 72 h later due to multiorgan failure. Early diagnosis and treatment with anticoagulation can reduce the mortality of this disease, since it is underdiagnosed, and often only comes to light during postmortem examination.     

食管超声引导下经胸微创封堵先天性心脏病的临床应用分析

目的总结食管超声引导下非体外循环经胸微创封堵先天性心脏病的临床应用经验。方法选择2011年11月~2013年5月食管超声引导下经胸微创封堵房间隔缺损（ASD）、室间隔缺损（VSD）患者65例,其中ASD 18例,VSD 47例。对术前、术中及术后情况进行回顾性分析。结果无手术死亡。中转体外5例。封堵成功患儿均于术后4 h内撤离呼吸机,监护室滞留1 d,术后3~5 d出院。复查心脏超声仅1例膜周VSD有轻微残余分流,随诊观察6个月后自行闭合。余患儿均无残余分流。1例术后心包积液,行心包穿刺后痊愈。1例患儿术中发生Ⅲ度房室传导阻滞,术后3 d恢复。全部病例均无溶血发生。结论食管超声引导下经胸微创封堵治疗先天性心脏病无需体外循环及输血,操作简单,安全可靠,值得推广。食管超声对缺损结构的准确反映和正确引导是手术成功的关键。     

Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients.

AIMS: The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt. METHODS AND RESULTS: One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests. CONCLUSION: This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.     

经食管超声心动图引导下经胸小切口行漏斗部室间隔缺损封堵术的疗效分析

目的评价经食管超声心动图引导下经胸小切口行先天性心脏病漏斗部室间隔缺损封堵术的临床疗效和安全性。方法回顾性分析2013年1~6月河北省儿童医院21例漏斗部室间隔缺损患儿经食管超声心动图引导下经胸小切口行漏斗部室间隔缺损封堵术的临床资料,其中男10例、女11例,年龄8~24（16±8）个月,体重（9±3）kg,室间隔缺损大小（4.5±2.5）mm。经食管超声心动图引导下完成21例经胸小切口漏斗部室间隔缺损封堵术。用经食管超声心动图评估封堵器的位置、对房室瓣和主动脉瓣的影响以及有无残余分流。结果无围术期死亡和并发症发生。21例室间隔缺损患儿中20例成功封堵,成功率95.2%。其中1例因缺损太大,转为体外循环下直视室间隔缺损修补术。安置封堵器时间（32±16）min,封堵器大小（5±3）mm;住院时间6~8 d。所有患者术后随访3~6个月,随访期间超声心动图提示：封堵器回声清晰,位置正常,无轻度以上残余分流和瓣膜反流。结论经食管超声心动图引导下经胸小切口行漏斗部室间隔缺损封堵术易于操作、疗效确切、安全可靠。     

Dynamic right ventricular outflow obstruction: A rare cause of hypotension during anestesia induction

IntroductionDynamic obstruction of right ventricle outflow tract (RVOTO) is a rare condition that may acutely cause severe heart failure. It has been reported in some hypertrophic cardiomyopathies, after lung transplantation, and in some cases of hemodynamic instability after cardiopulmonary bypass.Presentation of caseWe report the case of a 71-year-old man who developed severe hypotension during the induction of general anesthesia for surgical coronary revascularization. Hypotension did not respond to the initial treatment with vasoconstrictors and fluids. RVOTO was suspected during pulmonary artery catheterization because of the difficulty of the catheter tip to move from the right ventricle to the pulmonary artery and, successively, because of the finding of a large gradient between the systolic pressure in the right ventricle and in the pulmonary artery. The diagnosis was confirmed by transesophageal echocardiogram (TEE). Hemodynamics recovered after the infusion of cristalloids, 1 L, and the suspension of vasoconstrictors and inotropes.DiscussionThis is the first case in which RVOTO was observed during the induction of general anesthesia. Although this is a rare condition, the diagnostic suspect is of outmost importance because treatment is mainly based on fluid administration, and drugs with positive inotropic properties (like most vasoconstrictors) are contraindicated.ConclusionsRVOTO is an unusual, but possible cause of severe arterial hypotension during general anesthesia induction. TEE is useful for the evaluation of severely hypotensive patients who do not respond to routine treatment with fluids and vasoconstrictors.     

Coronary Sinus Obstruction after Atrioventricular Canal Defect Repair

The coronary sinus can become obstructed with any instrumentation at or near the ostium such as in atrioventricular canal defect repairs. This complication may lead to a wide range of consequences including dyspnea, angina, myocardial infarction, and sudden death. The following report illustrates the importance of careful perioperative echocardiographic evaluation of the coronary sinus in procedures that may affect the sinus and its ostium.