二尖瓣狭窄并中度反流的经皮二尖瓣球囊扩张术42例及随访观察

目的　探讨二尖瓣狭窄 (MS)并中度反流 (MR)患者经皮二尖瓣球囊扩张术 (PBMV)近远期疗效。方法　采用Inoue单球囊对 42例风心病二尖瓣狭窄并中度反流患者行PAMV治疗。结果　二尖瓣口面积由 (0 92± 0 2 2 )cm2 增至 (1 94± 0 2 5 )cm2 (P <0 0 1) ;二尖瓣跨瓣压差由 (2 7± 1 0 1)kPa降至 (1 0 2± 0 5 6 )kPa(P <0 0 1) ;心功能由 (2 6 1± 0 2 2 )级改善至 (1 42± 0 46 )级 (P <0 0 1) ;左室最大前后径无明显变化 (P >0 0 5 )。 2例患者二尖瓣反流较术前加重。随访 37例患者 (18± 4)个月 ,二尖瓣口面积、左室最大前后径及心功能与术后比较 ,均无明显变化 (P >0 0 5 )。结论　掌握好病例选择 ,严格把握球囊扩张尺度 ,风心病二尖瓣狭窄并中度反流患者PBMV近、远期疗效满意     

超声心动图评价左房减容对二尖瓣狭窄术后左心功能的影响

目的:以超声心动图技术评价左房减容术对二尖瓣狭窄患者瓣膜置换术后左心室收缩功能的影响。方法:82例患有二尖瓣狭窄者,实施心脏瓣膜置换术50例(A组),同时行左房减容术者32例(B组),所有患者分别于手术前和手术后3个月接受经胸超声心动图检查,分别测得LVEDD、LVESD、LAEDV、LAESV、FS、EF等参数。结果:B组在心室收缩功能与A组比较改善叫显(P<0.05)。两组左心室心肌重量指数有显著差异(P<0.05)。结论:恰当的左房减容术对二尖瓣狭窄患者术后的心功能恢复有一定帮助,并且操作简单。     

Subaortic stenosis produced by an accessory mitral valve: the role of echocardiography

Subaortic stenosis caused by an accessory mitral valve is an exceedingly rare finding. We report the case of an asymptomatic 14-year-old patient, in whom transthoracic echocardiography revealed an accessory mitral valve in the left ventricular outflow tract, producing mild subaortic stenosis. Except for an aneurysm of the interventricular septum, with no shunt, there were no other anomalies. Transesophageal echocardiography provided details about the morphology and location of the accessory valve. Being asymptomatic and having only a mild gradient, antibiotic prophylaxis for infective endocarditis and follow-up were recommended. After 2 years the patient is asymptomatic, with a similar echocardiographic gradient.     

Dynamic mild subaortic left ventricular obstruction caused by an accessory mitral valve attached to the anterior mitral valve in a young pregnant woman

Accessory mitral valve tissue is an extremely rare congenitalcardiac anomaly of embryologic development of the endocardialcushion. This anomaly is often associated with left ventricularoutflow tract obstruction (LVOTO). A 26-year-old pregnant femalewas referred to our Department of Cardiology with exertionalshortness of breath and tachycardia. Transthoracic and transesophagealechocardiography revealed a flexible circular (1.3 x 1.4 cm),mobile structure attached to the ventricular side of anteriormitral valve leaflet, with chordal attachments structure fromanterior papillary muscle. This picture is compatible with aparachute-like accessory mitral valve tissue. We performed anechocardiographic exercise test that shows a systolic flow turbulencestarting immediately proximal to this structure, resulting ina small increase in left ventricular outflow tract (LVOT) gradient(30 mmHg). Therefore we started low dose of beta-blocker therapyin order to decrease heart frequency and reduce the future riskof a worsening of an LVOT dynamic obstruction. Transthoracic and transesophageal echocardiography is criticalfor the differential diagnosis of LVOT and in the managementof accessory mitral valve tissue. In patients without rest andonly an exertional mild LVOTO and no other cardiac malformations,prophylactic removal of mitral accessory tissue excision isnot required; antibiotic prophylaxis for endocarditis can beindicated and a regular follow-up is recommended to identifyany progression in LVOTO entity.     

Regression of pulmonary valve stenosis due to a dysplastic valve presenting in the neonatal period

Severe pulmonary valve stenosis in the newborn period usuallyrequires either surgical relief or balloon valvoplasty. We describea neonate in whom the stenosis spontaneously regressed overnine years.     

Simplifying proximal isovelocity surface area as an assessment method of mitral valve area in patients with rheumatic mitral stenosis by fixing aliasing velocity and mitral valve angle

We aimed to test the ability of a simple equation using proximal isovelocity surface area method (PISA), created by fixing the angle to 100° and the aliasing velocity to 33 cm/s, to calculate mitral valve area (MVA) and assess severity in patients with rheumatic mitral stenosis (MS).Methods and resultsIn a series of 51 consecutive patients with rheumatic MS, MVA was assessed by four methods, conventional PISA equation (PISA_conventional), simple PISA equation (PISA_simple), pressure half time (PHT), and planimetry (PLN) which was taken as the reference method. All methods correlated significantly with PLN with the highest correlation found in case of PISA_conventional and PISA_simple (r = 0.97, 0.96, p < 0.001), while the correlation in case PHT was relatively weaker (r = 0.69, p < 0.001). Bland–Altman analysis revealed that the level of agreement with PLN was better in case of both PISA methods than PHT and, moreover, were close to each other. The number of cases that showed agreement of severity grade with planinetry was better in case of PISA_conventional (42 cases) and PISA_simple (44 cases) than that in case of PHT (34 cases, p = 0.037). Finally, the measure of agreement with Cohen’s Kappa test was better in case of PISA_conventional and PISA_simple than that in case of PHT.ConclusionProvided that aliasing velocity is fixed at 33 cm/s, PISA can effectively predict mitral valve area and severity of MS by a simple equation, with the advantage of easy and accurate calculation over other methods.     

Prolapse of the mitral valve in secundum atrial septal defect: A functional mechanism

Prolapse of the mitral valve in patients with secundum atrialseptal defect has been described angio-graphically and by two-dimensionalechocardiography. It has been suggested that prolapse of themitral valve in these patients is due to distortion of leftventricular shape and small left ventricular volume. To testthis hypothesis 10 patients with unrepaired secundum atrialseptal defect and 10 patients who had undergone repair of thedefect were studied by two-dimensional echocardiography. Theprevalence of mitral valve prolapse was 80% in the unrepairedgroup and 20% in the repaired group (P<0.01). Short axisof the left ventricle revealed septal bulging into the leftventricle, the end-diastolic ratio of minor to major axis being0.71 in the unrepaired group and 0.93 in the repaired group(P<0.001). Systolic and diastolic cross-sectional areas werelarger in the repaired group compared with the unrepaired group(P<0.05). Prolapse of the mitral valve in patients with secundumatrial septal defect may be related to the distorted left ventricularshape and small left ventricular volume.     

二尖瓣形态对经皮球囊二尖瓣成形术近远期疗效的影响

目的 观察不同瓣膜形态的二尖瓣狭窄患者行经皮球囊二尖瓣成形术的近远期疗效.方法 根据Wilkins超声二尖瓣形态学积分,将385例二尖瓣狭窄患者分为＞8分组(125例)和≤8分组(260例).均采用改良Inoue法对患者行经皮球囊二尖瓣成形术.术后进行随访,并比较两组患者的临床疗效.结果 经皮球囊二尖瓣成形术成功370例,＞8分组经皮球囊二尖瓣成形术的成功率低于≤8分组(92.8％比97.7％,P＜0.05).术后6个月,两组患者各项超声心动图检查指标均较术前显著改善(均P＜0.05);与≤8分组(254例)比较,＞8分组(116例)经皮球囊二尖瓣成形术后左心房平均压、肺动脉收缩压、跨瓣压差及二尖瓣瓣口面积的改变值均较小[分别为(14.22±5.02)mm Hg(1 mm Hg=0.133 kPa)比(15.44±5.19) mm Hg、(26.13±9.27) mm Hg比(31.93±9.98)mm Hg、(9.21±4.11)mm Hg比(10.16 ±4.21)mm Hg和(1.02±0.15)cm2比(1.20±0.22)cm2,均P＜0.05].经皮球囊二尖瓣成形术成功且完成远期随访[(78±20)个月]的患者共353例,两组患者各项超声心动图检查指标均较术前显著改善(均P＜0.05);与≤8分组(245例)比较,＞8分组(108例)左心房平均压、肺动脉收缩压、跨瓣压差及二尖瓣瓣口面积的改变值均较小[分别为(13.28±5.06) mm Hg比(14.77±5.17)mm Hg、(21.19±9.17) mm Hg比(28.92±9.91) mm Hg、(7.30±4.40)mm Hg比(9.16±4.28)mm Hg和(0.92±0.17)cm2比(1.07±0.20)cm2,均P＜0.05],且再狭窄发生率较高(20.4％比8.2％,P＜0.05).结论 二尖瓣瓣膜形态是决定经皮球囊二尖瓣成形术疗效的关键因素之一.对于超声二尖瓣形态学积分低的患者,经皮球囊二尖瓣成形术成功率较高,术后近期及远期随访疗效较好,再狭窄发生率较低,治疗方案可优先选择经皮球囊二尖瓣成形术.     

Critical assessment of two-dimensional echocardiographic estimation of the mitral valve area in rheumatic mitral valve disease: calcific deposits in the valve as a major determinant of the accuracy of the method

The accuracy of two-dimensional echocardiographic estimationof the mitral valve area (MVA) and the effects which the morphologicalfeatures of the valve (degree of stenosis, coexistent regurgitation,extent of calcific deposits) exert on the approximation of sucha measurement have been evaluated. In 29 patients, who underwent surgical replacement of a rheumaticmitral valve, correlation was assessed between the echocardiographicvalues of MVA and the anatomical ones measured on excised valvesby means of a sizer set to detect area differences up to 0.1cm² Though the correlation obtained was statistically significant(P <0.001) the percentage deviation (%) between the two seriesof measurements was appreciable (29.38 ± 20.14%, mean± 1 s.d.). The degree of stenosis and the presence or absence of regurgitationdid not affect %. Only the amount of calcific deposits, evaluatedfrom the radiographs of the excised valves, influenced the discrepancybetween the two methods, % being significantly higher (P <0.05) in the calcified valves than in the not or minimally calcifiedones. Though the two-dimensional echocardiographic estimates ofM VAin rheumatic mitral valve disease are correlated with the anatomicalarea, their predictive value in the estimation of the true orificesize is poor in the individual patient, in view of the largediscrepancy between the echocardiographic and anatomical measurementsfound in our study.     

Interpretative reproducibility of two-dimensional echocardiographic images. Analysis of intraobserver, interobserver and beat to beat reproducibility of the mitral value orifice

The intraobserver, interobserver and beat to beat interpretativereproducibility of two-dimensional echocardiographic imagesof the mitral valve area has been studied retrospectively ina group of 37 patients affected by rheumatic mitral valve disease.Reproducibility has been expressed either in terms of mean absoluteor percent error of duplicate measurements. A group of 11 normalsubjects was used for comparison. In our normal group the intraobserver, interobserver and beatto beat reproducibility averaged 1.8±2.1%, 3.1±1.4%,2.7±2.0% or 0.12± 0.14 cm², 0.21±0.10cm²,0.17±0.13 cm², respectively. In our patient populationthe intraobserver, interobserver and beat to beat reproducibilityaveraged 2.7±2.7%, 4.1±4.9%, 4.6± 3.6%or 0.05±0.05 cm², 0.08± 0.10cm², 0.08±0.06cm².In both groups there was no statistical difference among intraobserver,interobserver and beat to beat reproducibility either in termsof percent or absolute value. The mean percent error did not significantly differ betweennormal or stenotic valves or, in this latter group, among valvesof different sizes (1.4cm²; 1.5–2.4 cm²; 2.5 cm²). Themean absolute error, on the contrary, statistically differedbetween the two groups or among valves of different sizes, beinglarger in normals or in valves 1.5 cm². Thus, the interpretativereproducibility for two-dimensional echocardiographic imagesof the mitral valve area is small and acceptable for most clinicalpurposes. The use of mean percent error of duplicate measurementsmakes the quantification of reproducibility easily comprehensiblein clinical practice and insensitive to the actual cross sectionalarea of the structure examined thus allowing the data to beextended to cardiac structures of different sizes.     

二尖瓣病变定位经食道超声检查与术中发现的对照研究

目的:应用经食道超声心动图序列二尖瓣病变定位切面与术中发现进行对照研究,寻找对应二尖瓣不同小叶分区的相应切面及标准化操作规程,以供临床决策及提高手术成功率。方法:二尖瓣脱垂并伴有中度以上的二尖瓣反流拟行外科手术患者53例。术前行食道超声检测瓣膜病变类型与小叶分区定位,与术中发现进行对照。二尖瓣的解剖定位采用Carpentier命名法,将前叶分为A1、A2及A3,后叶分为P1、P2及P3。术前1周及术中食道超声应用中食道四腔心切面、中食道5腔心切面、显示冠状静脉窦的短四腔心切面、两腔心切面、二尖瓣交界区两腔心切面、中食道左心室长轴切面及胃底左心室短轴切面进行二尖瓣病变的小叶分区定位。外科医生术中记录二尖瓣瓣膜脱垂、腱索断裂等病理类型及A1、A2及A3;P1、P2及P3病变部位。结果:46例资料完整的患者276个小叶被分析。在7个可以显示二尖瓣小叶分区定位的切面中,中食道五腔心切面、中食道四腔心切面、显示冠状静脉窦的短四腔切面、三腔心切面及结合彩色血流的胃底左心室短轴切面与术中发现的吻合率较高。结论:通过食道超声选择序列合理的切面可以在二尖瓣手术前进行较为准确的病变小叶分区定位,为外科手术,尤其是二尖瓣成形术提供必要的术前资料。     

二尖瓣狭窄左心房血栓前状态局部凝血功能异常的研究

目的　研究风湿性心脏 (风心 )病二尖瓣狭窄左心房局部血小板、凝血和纤溶功能的改变。方法　测定左心房、右心房、股静脉和股动脉的血浆血小板颗粒膜蛋白 (GMP 140 )、抗凝血酶Ⅲ(ATⅢ )、蛋白C(PC)、纤溶酶原激活物抑制物 1(PAI 1)、纤维蛋白降解产物 (FDP)、组织纤溶酶原激活物 (t PA)、D 二聚体 (DD)和vonWillbrand因子 (vWF)。结果　对照组和风心病组均表现左心房局部的高血小板活化、高凝血和高纤溶状态 ,而右心房则相反。风心病组左心房GMP 140含量显著高于对照组 (P <0 0 5 ) ,ATⅢ含量显著低于对照组 (P <0 0 0 1) ,纤溶功能和对照组比较差异无显著性。风心病无或轻度左心房云雾影患者和重度云雾影患者比较 ,血浆GMP 140含量显著低于重度组(P <0 0 5 ) ,血浆ATⅢ含量显著高于重度组 (P <0 0 5 ) ,PC含量显著低于重度组 (P <0 0 5 )。风心病左心房ATⅢ含量和云雾影呈直线相关 (r=- 0 72 ,P <0 0 1)。结论　风心病二尖瓣狭窄患者左心房血小板和凝血功能显著亢进 ,左心房云雾影能够反映左房高凝状态。     

Isolated supravalvular aortic stenosis with left ventricular diverticulum and cleft mitral valve: Surgical repair in adulthood

Supravalvular aortic stenosis is an uncommon but well characterized congenital narrowing of the ascending aorta above the level of the coronary arteries. It can be a familial disorder, can occur sporadically, or can be associated with Williams syndrome. We are reporting a very rare presentation of supravalvular aortic stenosis with associated left ventricular diverticulum and cleft mitral valve. Repair consisted of resection of the ascending aorta, patch augmentation of the aortic root, and mitral valve repair. Follow-up echocardiography demonstrated normal mitral and aortic valve function and a postoperative three-dimensional computed tomographic scan showed a normal shape of the reconstructed ascending aorta.     

Two-dimensional echocardiographic evaluation of the severity of mitral stenosis with reference to the prediction for mitral valve commissurotomy or replacement

Thirty patients with mitral stenosis were classified into three grades of severity reflected by anterior mitral leaflet and subvalvular apparatus using two-dimensional echocardiography in order to study the possibility of predicting the type of surgery indicated, and were evaluated pre- and postoperatively for systolic and diastolic volumes; left heart function using left ventricular posterior wall movement (LVPWVSmax, LVPWVdmax) and posterior wall excursion (PWE) and newly devised left atrial empty volume ratio (LAEVR). The LVPWVSmax was increased from 57 +/- 7 to 74 +/- 7 mm/s (p less than 0.001) in grade I, from 48 +/- 13 to 63 +/- 9 mm/s (p less than 0.02) in grade II, and from 44 +/- 6 to 64 +/- 7 mm/s (p less than 0.001) in grade III. The LVPWVdmax showed an increase from 68 +/- 15 to 91 +/- 15 mm/s (p less than 0.001) in grade I, from 57 +/- 17 to 86 +/- 18 mm/s (p less than 0.01) in grade II, and from 55 +/- 11 to 83 +/- 6 mm/s (p less than 0.01) in grade III. In the PWE, there was an improvement from 12.4 +/- 1.6 to 15.5 +/- 2.1 mm (p less than 0.01) in grade I; from 10.5 +/- 2.0 to 12.5 +/- 1.5 mm (p less than 0.02) in grade II; and from 9.4 +/- 1.5 to 14.4 +/- 1.5 mm (p less than 0.001) in grade III. In the LAEVR, there was also an improvement from 65 +/- 12 to 39 +/- 21% (p less than 0.01) in grade I.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of heart rate on transmitral flow velocity profile and Doppler measurements of mitral valve area in patients with mitral stenosis.

To study the effect of heart rate changes on Doppler measurements of mitral valve area atrial pacing was performed in 14 patients with mitral stenosis and sinus rhythm. Continuous wave Doppler and haemodynamic measurements were performed simultaneously at rest and during pacing-induced tachycardia. (1) Mitral valve area was determined using the conventional pressure half time method. (2) Additionally, mitral valve area was calculated with a combined Doppler and thermodilution technique according to the continuity equation. (3) Simultaneous invasive measurements were used for calculation of the mitral valve area according to the Gorlin formula. With increasing heart rate (69 +/- 13-97 +/- 15-114 +/- 13 beats min-1) mitral valve area either determined by the continuity equation (1.0 +/- 0.2-1.0 +/- 0.3-1.1 +/- 0.4 cm2) or the Gorlin formula (1.2 +/- 0.3-1.2 +/- 0.4-1.3 +/- 0.4 cm2) remained constant. Both methods correlated closely not only at rest (r = 0.88, SEE = 0.11 cm2, P less than 0.001), but also during atrial pacing (first level: r = 0.95, SEE = 0.10 cm2, P less than 0.001, second level: r = 0.95, SEE = 0.13 cm2, P less than 0.001). In contrast, mitral valve area calculated according to the pressure half time method increased significantly during atrial pacing (1.0 +/- 0.3-1.8 +/- 0.5-2.0 +/- 0.5 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated pulmonic valve endocarditis in an adult patient with ventricular septal defect and infundibular pulmonary stenosis

Ventricular septal defect associated with infundibular pulmonary stenosis is a relatively uncommon congenital cardiac defect. We report the first case of a patient with perimembranous small ventricular septal defect and infundibular stenosis suffered from pulmonary valve endocarditis and septic pulmonary embolism.