西宁地区二尖瓣置换术后远期三尖瓣关闭不全的外科治疗

目的:探讨二尖瓣置换术后远期三尖瓣关闭不全的外科治疗。方法:15例二尖瓣置换术后三尖瓣关闭不全(中重度),经内科积极保守治疗11例,行外科手术治疗4例。结果:11例内科保守治疗者,术后1.6年~5.4年后因顽固性右心功能不全、心律失常死亡5例,病死率45%,4例外科手术治疗(2例成形,2例三尖瓣机械瓣替换)无手术死亡,随访0.6年~1.2年,均能从事一般体力活动,多次复查多普勒超声心动图三尖瓣返流(微量)2例。结论:二尖瓣置换术远期三尖瓣返流的产生与可逆的右心损害或严重的肺动脉高压有关。对于三尖瓣返流伴有临床症状,左心功能基本正常,经内科保守治疗后效果不佳者,行三尖瓣手术治疗可取得良好的治疗效果。     

三尖瓣成形在瓣膜替换中的应用

目的:本文总结三尖瓣成形经验.方法:从1987年1月～1998年12月,35例二尖瓣或二尖瓣加主动脉瓣替换患者同时行三尖瓣瓣膜成形.术前心功能Ⅲ、Ⅳ级27级.超声提示:三尖瓣呈中-重度关闭不全23例,轻度或无关闭不全但瓣环扩张大于35mm12例.全组行DeVega成形31例,Kay成形4例.结果:手术死亡3例(8.6%),近3年无手术死亡.对后29例作了随访,平均随访4.6个病人年,4年生存率为86%.结论:三尖瓣成形能改善左心瓣膜替换患者近远期手术结果.因此,对超声提示三尖瓣明显关闭不全或三尖瓣环直径大于35mm应行三尖瓣成形.通常将扩大的瓣环缩小至30mm,多可使返流减少或消失.     

loop或loop in loop技术腱索重建加二尖瓣成形环置入术治疗二尖瓣关闭不全

目的探讨loop或loop in loop技术腱索重建和二尖瓣成形环置入术治疗二尖瓣关闭不全的治疗效果。方法回顾性分析自2015年9月至2016年1月青岛大学附属医院心外科收治的8例二尖瓣关闭不全患者。其中,男性7例,女性1例;年龄(58.15±4.2)岁,SBE前叶腱索断裂导致关闭不全1例,心脏占位累及前叶腱索断裂导致关闭不全1例,单纯腱索断裂导致关闭不全4例,腱索延长导致关闭不全2例。术前超声心动图(TEE)显示:根据Carpentier标准,前叶脱垂5例,后叶脱垂1例,前叶合并后叶脱垂2例。二尖瓣重度关闭不全5例,中到重度关闭不全2例,中度关闭不全1例。术前射血分数(EF)平均(58.83%±2.9%),左心室舒张末直径(LVDD)平均(52.9±1.5)mm,左心房直径(LAD)平均(50.6±1.7)mm。所有患者均经胸正中切口,平均体外循环时间(123±11.7)min,平均主动脉阻断时间(106±9.5)min。4例患者置入Duran成形环,4例患者置入Edwards PhysioⅡ成形环,7例患者同时行三尖瓣成形术,1例患者同时行三尖瓣置换术。同时行冠状动脉搭桥术1例,主动脉瓣置换术1例。结果术后无患者死亡,无恶性心律失常及其他严重并发症。术后复查TEE显示,微量反流6例,未见反流2例。术后EF平均(58.13%±2.9%),未见明显改变。LVDD平均(46.7±1.5)mm,LAD平均(42.9±1.1)mm,均较术前明显改善。随访1~3个月,均为微量反流。结论 loop或loop in loop技术腱索重建和二尖瓣成形环置入术治疗二尖瓣脱垂近、中期效果确切。loop技术虽然可以比较容易锚定瓣叶的脱垂区域,但是一旦长度不合适,很难拆除,相比而言,loop in loop技术可以在术中非常容易地调整人工腱索的长度。因此,loop in loop技术比loop技术更加值得推广。     

实时三维经胸超声心动图诊断三尖瓣瓣根撕裂1例

<正>1病例简介男，41岁，主诉：胸闷气短、呼吸困难1年，加重1个月。10年前有车祸外伤史，2019年12月出现间歇性胸闷气短，当地医院诊断为先天性心脏病、三尖瓣前瓣裂并关闭不全。查体：听诊胸骨左缘第四肋间闻及收缩期吹风样杂音；胸部平片提示心胸比0.7，右心比例大，双侧胸膜反应。术前经胸超声心动图二维图像见图1，超声提示：三尖瓣前瓣裂，三尖瓣关闭不全，右心房、右心室扩大。实时三维经胸超声心动图检查（图1C、D）修正诊断为：三尖瓣前瓣瓣根相邻两处裂孔，三尖瓣关闭不全，右心房、右心室扩大。     

主动脉瓣及二尖瓣双瓣置换术48例临床观察

目的：探讨主动脉瓣及二尖瓣双瓣置换术的手术方法和效果。方法：全组病例在全麻、低温、体外循环下实施手术。中度血液稀释，主动脉根部灌注冷停跳液，心包腔内放置冰屑，经右心房、房间隔置换二尖瓣，主动脉根部横切口置换主动脉瓣。18例合并三尖瓣关闭不全者同期行De Vega环缩术，9例合并左心房血栓者同期行血栓取出术，1例合并动脉导管未闭者同期行动脉导管缝闭术。结果：术后低心排6例，二次开胸止血5例，放置起搏器2例，死亡2例，死亡率为4．16％。结论：对风湿性心脏病主动脉瓣及二尖瓣双瓣置换患者，加强围术期处理，提高手术技巧，术中良好的心肌保护以及平稳灌注，重视三尖瓣病变的处理和保留二尖瓣下结构是手术成功的关键。     

三尖瓣返流的造影诊断

三尖瓣返流的病因复杂,在二尖瓣换瓣术的处理中必须认真考虑。本文以右心室造影为重点,对各种检查方法综合探讨。一、三尖瓣返流的病因及病理三尖瓣返流最常见于慢性风湿性心脏病病人,其次是先天性心脏病,其他病因如外伤、心内膜炎、类癌综合症、心肌病、冠心病等非常罕见。发生于慢性风心病的三尖瓣返流可以是功能性的,也可以是器质性的。后者瓣膜有增厚、僵硬、皱缩和瓣环扩大等改变。然而,造成三尖瓣返流最常见的因素并不是瓣膜损     

彩超诊断二尖瓣关闭不全的临床价值

心脏瓣膜病——二尖瓣关闭不全是各种心肌病变及心脏肿瘤所致二尖瓣装置(瓣叶、瓣环、腱索．乳头肌)和左心室的结构和功能的异常使二尖瓣前、后叶在心脏收缩时不能完全闭合，左心室的血液部分倒流至左心房而致的一系列血流动力学改变?彩色多普勒超声诊断二尖瓣关闭阳性率高．目前，已成为诊断二尖瓣关闭不全的首选方法．为临床提供     

风湿性心脏病三尖瓣功能性返流的多因素分析

目的:探讨风湿性二尖瓣和主动脉瓣病变继发三尖瓣功能性返流的影响因素及影像诊断特点。方法:77例风湿性二尖瓣、主动脉瓣病变,均作二维超声心动图、超声多普勒和远达X线胸片检查,根据超声诊断有否三尖瓣功能性返流分为两组,对相关指标进行单因素和多因素分析。结果:单因素分析:三尖瓣返流组与无返流组之间,二尖瓣病变类型、左房内径(LAD)、心胸比率、肺动脉段凸度、左心耳凸度、右房高/心高比率、右下肺动脉干宽径及双重影、肺水肿的比率有显著性差异,P值均小于0.05;而病程、心房纤颤、瓣膜病变部位、左室收缩末径(LVDS)、左室舒张末径(LVDD),返流组和无返流组间无显著性差异。多因素分析:二尖瓣病变类型、心胸比率、肺动脉段凸度与三尖瓣功能性返流密切相关。结论:二尖瓣狭窄、心脏增大程度和肺动脉高压是风湿性二尖瓣病变继发三尖瓣功能性返流的主要相关因素和预测因子。     

实时三维超声心动图观测二尖瓣人工瓣1例

患者男,56岁。典型二尖瓣面容,平时感胸闷气短、活动受限。查体心界向左下扩大,二尖瓣听诊区可闻及舒张期隆隆样杂音及收缩期吹风样杂音,外院诊断为风湿性心脏病:二尖瓣中重度狭窄并中度关闭不全。近来症状持续加重,夜间睡觉不能平卧,双下肢出现水肿。为行二尖瓣置换术收治入院。术前超声检查:左房左室扩大,左房尤著;二尖瓣前后叶均可见钙化,舒张期二尖瓣口最大开放面积1.0cm2,最大血流速度2.3m/s;收缩期二尖瓣前后叶闭合不全,反流容积55ml,最大反流速度4.2m/s。二尖瓣环内径4.4cm。患者行二尖瓣置换术(二叶金属瓣)后二维超声复查,怀疑有瓣…     

慢性缺血性二尖瓣关闭不全的外科治疗

目的：探讨慢性缺血性二尖瓣关闭不全（IMR）的手术治疗方法和效果。方法：2004-04~2008-09,冠脉搭桥同期外科治疗IMR 21例,其中中度反流17例,重度反流4例。二尖瓣成形术6例,其中使用人工瓣环4例。瓣膜置换术15例,其中双叶机械瓣8例、生物瓣7例。结果：全组手术死亡1例。17例术后平均随访24个月,远期死亡1例,生存者远期心功能l~Ⅱ级者16例,Ⅲ级者1例。术后超声复查左心室内径较术前明显缩小,瓣膜功能良好。结论：中度和中度以上缺血性二尖瓣关闭不全在作冠脉搭桥术时应同时手术处理病变的瓣膜,术后效果满意。而手术矫治的方法应根据瓣膜的病理改变和手术者的经验决定。     

先天性二尖瓣及三尖瓣发育畸形1例

患者男性．20岁。因憋喘及心前区杂音来诊。听诊：心尖区可闻及舒张期滚筒样杂音．并伴有震颤．肺动脉瓣区第二心音亢进。超声心动图显示：双房、右室扩大．左室腔内径偏小．右室壁增厚（约11mm）．室间隔及左室游离壁厚度及动度正常。     

Geometric differences of the mitral valve apparatus in atrial and ventricular functional mitral regurgitation

BackgroundFunctional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies.MethodsPatients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT.ResultsOf 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p ?< ?0.01) and left atrial volume (rho 0.909, p ?< ?0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p ?< ?0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p ?< ?0.01) and LVESV (rho 0.824, p ?< ?0.01), but not left atrial size (rho 0.16, p ?= ?0.45).Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry.ConclusionFMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities.     

Tricuspid valve anatomy of massive to torrential tricuspid regurgitation: Computed tomography analysis

BackgroundWe aimed to comprehensively assess tricuspid valve anatomy and to determine factors associated with the more advanced stages beyond severe TR (i.e., massive to torrential).MethodsWe retrospectively analyzed the pre-procedural cardiac CT images in patients with ≥severe TR using 3mensio software. The tricuspid valve annulus size, right-atrial and right-ventricular dimensions, tenting height, and leaflet angles were measured.ResultsA total of 103 patients were analyzed. The mean effective regurgitant orifice area was 61.7 ​± ​31.5 ​mm², vena contracta was 13.1 ​± ​4.6 ​mm, and massive/torrential TR was observed in 62 patients. Compared to patients with severe TR, patients with massive/torrential TR had a larger tricuspid annulus area (18.6 ​± ​3.4 ​cm² vs. 20.6 ​± ​5.3 ​cm², p ​= ​0.037), right atrial short-axis diameter (66.1 ​± ​9.1 ​mm vs. 70.6 ​± ​9.9 ​mm, p ​= ​0.022), increased tenting height (8.8 ​± ​3.6 ​mm vs. 10.7 ​± ​3.7 ​mm, p ​= ​0.014), and greater leaflet angles (anterior leaflet: 22 ​± ​9° vs. 32 ​± ​13°, p ​< ​0.001; posterior leaflet: 22 ​± ​11° vs. 30 ​± ​11°, p ​= ​0.003). In the multivariable logistic regression model, the angle of anterior leaflet (OR 1.08, 95%CI 1.03–1.14, p ​= ​0.004) and posterior leaflet (OR 1.07, 95%CI 1.02–1.13, p ​= ​0.007) were associated with massive/torrential TR. Additionally, patients with massive/torrential TR more often had TR jets from non-central/non-anteroseptal commissure (34% vs. 76%, p ​< ​0.001). In the multivariable model, a greater angle of the leaflets and a more elliptical annulus were associated with non-central/non-anteroseptal TR jets.ConclusionsAnterior and posterior leaflet angles are significant factors associated with massive/torrential TR. Furthermore, leaflet angles and ellipticity of the tricuspid valve are associated with the location of TR jets.     

Scintigraphic diagnosis of tricuspid regurgitation

The authors describe a simple technique for diagnosis of tricuspid regurgitation. Red blood cells were labeled in vivo with 99mTc and 22 patients were studied with ECG-gated blood-pool imaging of the liver. A single region of interest was manually drawn around the liver and a time-activity curve obtained. The per cent change in liver counts during the cardiac cycle was found to be significantly higher in the 12 patients with tricuspid regurgitation (Group I) (mean, 4.04 +/- 1.6%; range, 1.3-21.4%) compared with the 10 controls (Group II) (mean, 0.35 +/- 0.16%; range, 0.013-1.3%) (p less than 0.05). Using a 1% change in liver counts as the criterion of a positive study, all 12 cases in Group I were diagnosed correctly, but there was one false positive in Group II; thus the sensitivity was 100% and the specificity 90%.     

Assessment of mitral valve regurgitation at electron-beam CT: comparison with Doppler echocardiography

PURPOSE: To prospectively compare mitral valve regurgitation fractions calculated at electron-beam computed tomography (CT) (Doppler echocardiography as reference standard) and to evaluate accuracy of electron-beam CT volume and flow measurements compared with magnetic resonance (MR) imaging results. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Volume and flow measurements were performed at electron-beam CT in 219 patients (197 men, 22 women; mean age, 61.5 years +/- 10.4 [standard deviation]), of whom 157 had known isolated mitral valve regurgitation. Regurgitation volume was calculated as the difference between left ventricular total and forward stroke volumes. Regurgitation fractions were compared with corresponding echocardiographic grades (grades 0-IV) by using Spearman rank correlation and a weighted kappa test. In 22 patients, CT volume and flow measurements were compared with MR results by using intraclass correlation. RESULTS: Regurgitation fractions at CT correlated well with echocardiographic grading (rank correlation coefficient, r(S) = 0.82; P < .05). Mean regurgitation fractions for echocardiographic grades 0, I, II, III, and IV were 3.1% +/- 6.2, 12.7% +/- 9.9, 25.3% +/- 12.3, 40.4% +/- 11.5, and 55.9% +/- 13.7, respectively. The most suitable thresholds for differentiating echocardiographic grades were calculated regurgitation fractions of 6%, 20%, 30%, and 44%; with these thresholds, individual echocardiographic grades were differentiated (grades 0 vs I-IV, 0-I vs II-IV, 0-II vs III-IV, and 0-III vs IV, respectively) with sensitivities of 89%, 87%, 86%, and 93% and specificities of 81%, 87%, 92%, and 91%, respectively. There was perfect agreement in classification of mitral valve insufficiency between electron-beam CT and echocardiography in 134 (61%) patients and a mismatch by one grade in 72 (33%) and by two grades in 13 (6%) (kappa = 0.84). Intraclass correlation coefficients between CT and MR imaging for total and forward stroke volumes and regurgitation volume and fraction were 0.88, 0.79, 0.93, and 0.89, respectively. CONCLUSION: Electron-beam CT provides quantitative information on severity of mitral valve regurgitation, but semiquantitative classification of regurgitation showed mismatch between electron-beam CT and Doppler echocardiography by at least one grade in more than one-third of all patients.     

外伤性二尖瓣关闭不全的外科治疗

目的 探讨外伤性二尖瓣关闭不全的临床特点、外科治疗方法及其手术效果.方法 回顾分析2000年12月-2007年11月收治的16例外伤性二尖瓣关闭不全外科手术治疗的临床病例.16例中术前心胸比例0.55±0.07,左心室射血分数为(51.2±23.2)%,按纽约心脏病学会(NYHA)心功能分级:Ⅰ～Ⅱ级者10例(63%).手术方法包括二尖瓣成形14例,二尖瓣置换术2例,并同期矫治合并病变.随访14例,随访时间(35.2±25.7)个月.结果 外伤至出现二尖瓣关闭不全症状的时间为(23.3±50.9)个月.随访时,13例二尖瓣成形者,二尖瓣血流正常4例,微量反流7例,少量反流2例.14例左心室射血分数为(66.8±9.0)%,较术前明显升高(P＜0.05).心功能NYHA Ⅰ～Ⅱ级者13例(93%),与术前比较,心功能NYHA Ⅰ～Ⅱ级者所占百数比明显增高(P＜0.01).结论 外伤性二尖瓣关闭不全可在外伤后即刻出现,亦可在外伤后数年逐渐出现.选择适当的手术时机,应用综合性二尖瓣成形术或者二尖瓣置换术,多能获得满意的中远期效果.