二尖瓣位机械瓣梗阻的彩色多普勒评价

目的评价彩色多普勒超声在诊断二尖瓣位机械瓣(单叶碟瓣)梗阻的价值。方法对比二尖瓣位机械瓣梗阻12例的彩色多普勒超声结果与手术所见。结果左心长轴切面和心尖四腔切面可较清晰地显示二尖瓣位机械瓣梗阻患者的瓣叶活动显著受限,瓣叶开放角度平均10°(0°-25°),彩色血流束呈单束或双束狭窄的边缘血流束,无瓣周漏及中度以上的瓣关闭不全,最大跨瓣血流速度及压差无显著改变:术中见12例瓣叶均被“卡”在近关闭状态位,开放角度小于300°,瓣周纤维肉芽组织增生伴血栓形成,瓣口狭小(0-0．5mm),其中4例瓣口及瓣周完全被血栓块“封堵”。结论彩色多普勒超声心动图显示机械瓣梗阻特征为瓣叶开放角度和幅度显著减小,瓣口呈边缘性狭窄血流束,与手术所见一致,但瓣口血流速度及压差指数等特异改变在彩色多普勒超声心动图不明显;虽然彩色多普勒超声心动图对异常增生组织和血栓的显示不清晰,但仍不失为诊断二尖瓣位机械瓣梗阻的简便有效的手段。     

经食管二维和三维超声心动图对二尖瓣人工机械瓣瓣周漏定位诊断价值

目的:探讨经食管实时二维和三维超声心动图诊断二尖瓣瓣人工机械瓣瓣周漏的临床价值。方法:回顾分析二尖瓣人工机械瓣瓣周漏26例的二维、三维经食管超声心动图表现特征,并与术中所见进行对比。结果:26例二尖瓣人工机械瓣瓣周漏患者,术中发现二尖瓣人工机械瓣瓣周漏36处,其中6例同时存在2处漏口,2例同时存在3处漏口。经食管实时三维超声心动图共发现瓣周漏30处,与术中发现符合率100%,二维经食管超声心动图共发现瓣周漏28处,与术中发现符合率77.8%。结论:经食管实时三维超声心动图能够清晰显示二尖瓣人工机械瓣瓣周漏的位置、形态和大小,有利于术前手术计划的选择和制定。     

主动脉瓣置换术后瓣周漏的临床及超声心动图分析

目的:探讨主动脉瓣人工瓣置换术后瓣周漏的临床特点及超声心动图应用价值。方法:回顾分析2002-03至2017-03在我院住院诊治的外科主动脉瓣置换术后瓣周漏患者123例,年龄12~74岁,平均(45±13)岁。首次换瓣手术包括我院手术及外院手术。所有患者入院行经胸或经食管超声心动图检查确诊瓣周漏。28例(22.8%)予内科保守治疗,95例(77.2%)再次手术治疗。结果:瓣周漏患者超声心动图彩色多普勒可见舒张期源于人工瓣瓣周的反流信号,部分二维超声可见人工瓣缝合环与周围组织之间的裂隙。根据超声心动图等影像学检查、术中所见及病理结果分析瓣周漏产生的原因,包括:感染性心内膜炎45例,白塞病23例,大动脉炎4例,疑诊免疫系统疾病5例,主动脉夹层2例,疑手术技术原因所致3例,余41例原因未能确定。全组患者死亡13例,放弃治疗病重出院5例,随访到的83例患者中,仍有瓣周漏中量以上反流者27例,心功能明显减低1例,55例好转或治愈。结论:有临床意义的瓣周漏是主动脉瓣置换术后的重要并发症,再手术比例高,复发率高,预后较差。主动脉瓣瓣周漏的原因以感染性心内膜炎最常见,其次为非特异性血管炎。     

术中经食管超声心动图对心脏瓣膜置换术后即刻人工瓣膜功能异常的诊断价值

目的:探讨术中经食管超声心动图对心脏瓣膜置换术后即刻人工瓣膜功能异常的诊断价值。方法:回顾性分析2011年4月至2016年9月我院心脏瓣膜置换术后即刻急性人工瓣膜功能异常患者11例资料,总结术中经食管超声心动图结果,并与手术结果进行对照分析。结果:11例患者中,机械瓣置换术8例,生物瓣置换术3例。术中经食管超声心动图显示,瓣膜功能异常包括人工瓣膜梗阻(7例)及瓣膜关闭不全(4例)。术中经手术证实,人工瓣膜梗阻原因包括:残留血栓、残留腱索、保留二尖瓣后叶、主动脉瓣下隔膜、机械瓣离体瓣叶开放受限;人工瓣膜关闭不全原因包括:生物瓣瓣叶脱垂、缝线勒住生物瓣瓣脚及瓣膜内源性因素。11例患者再次接受手术,其中6例更换新的人工瓣膜,其余5例去除梗阻原因,所有患者均未再次出现人工瓣膜功能异常,住院期间无患者死亡。结论:经食管超声心动图可及时确认心脏瓣膜置换术后即刻人工瓣膜功能异常,协助判别内源性因素并指导外科补救。     

人工瓣膜心内膜炎25例临床分析

目的 总结人工瓣膜心内膜炎(PVE)的临床特点.方法 回顾性分析北京协和医院1992年1月至2008年12月收治的25例PVE患者的临床表现、基础心脏病、致病菌、超声心动图发现、治疗及转归特点.结果 全部病例为符合Duke标准的确诊病例.(1)多数患者的心脏基础病为风湿性心脏病及先天性心脏病,但10例(40%)PVE患者因合并感染性心内膜炎而接受前次换瓣手术,其中4例患者因PVE而接受2次换瓣手术.(2)11例(44%)PVE患者发生在前次心脏换瓣手术2个月内.发热(100%)、大血管栓塞(48%)、贫血(36%)是最常见的临床表现.14例(56%)培养出15株致病菌,为凝固酶阴性葡萄球菌5株(其中3株对甲氧西林耐药)、真菌4株、肠球菌2株、洋葱伯克霍尔德菌2株、嗜麦芽窄食单胞菌及链球菌各1株.(3)超声心动图检查的主要异常发现为人工瓣膜赘生物、瓣周漏、反流.13例经胸壁超声心动图检查(TFE)未发现PVE的病例经食道超声心动图检查(TEE)确诊.(4)18例(72%)PVE合并瓣周并发症(瓣周漏12例、瓣膜分离3例、瓣周脓肿2例、心内瘘1例),此外,大血管栓寒和充血性心力衰竭(16%)亦常见.尽管经过积极治疗,9例PVE在住院期间死亡.结论 PVE是心脏换瓣手术后的严重并发症,临床表现和自然瓣膜心内膜炎类似,但致病菌以匍萄球菌及真菌常见,容易并发严重并发症,病死率高.     

人工心脏瓣膜的选择与并发症

目前临床应用的人工瓣膜品种繁多,各有优缺点。总的看,机械瓣的优势在于其耐久性、瓣架低及双叶瓣对血流的梗阻小;缺点是栓塞率高、抗凝过度易发生出血以及溶血、瓣周漏等。生物瓣膜与之相反,栓塞、出血及瓣周漏发生率低,但耐久性差,用于年轻患者易发生钙化及退行性变,小型号瓣膜对血流阻力较大。     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

彩色多普勒超声对心脏粘液瘤的诊断价值

目的　探讨彩色多普勒超声对心脏粘液瘤的诊断价值。方法　应用 H P 10 0 0型多普勒超声心动诊断仪 ,对 18例心脏粘液瘤患者进行检查 ,采用 M型、二维超声观察粘液瘤对心脏各腔、瓣口的影响 ,运用彩色多普勒血流显像、脉冲多普勒 ( PW )、连续多普勒 ( CW )观察瓣口的血流频谱。结果　心脏粘液瘤主要表现为其所对的瓣膜的损伤引起的反流和瓣口堵塞所造成的有效瓣口面积的减少。结论　彩色多普勒超声心动图是诊断心脏粘液瘤的最佳方法 ,具有无创、安全、可重复及诊断正确率高的优点     

心脏瓣膜置换术后患者再次换瓣效果观察

目的观察心脏瓣膜置换术后再次换瓣的效果。方法本组59例患者,其中风湿性心脏病瓣膜替换术后58例,扩张性心肌病左室减容术同时行二、三尖瓣替换术后1例。因机械瓣膜急性功能障碍、人工瓣膜心内膜炎、人工瓣膜瓣周漏及生物瓣衰败出现瓣膜功能缺失者急症行再次换瓣手术,其中5例急症手术时行股动脉插管灌注。换瓣术后瓣周漏6例,4例行再次瓣膜置换术,2例限期直接采用带垫片褥式缝合修补术。生物瓣衰败43例中,23枚猪瓣及25枚牛心包瓣多为不同程度的瓣叶增厚、钙化,同时合并不同程度瓣叶撕裂、穿孔,择期行再次瓣膜替换术及附加手术。结果术后早期死亡2例,出现并发症4例,晚期死亡2例,失访5例。50例心功能恢复至Ⅰ~Ⅱ级。结论 心脏瓣膜置换术后出现严重瓣膜功能缺失者行再次换瓣效果较好。     

老年患者人工机械瓣膜置换术后再次换瓣手术160例

人工机械瓣膜置换术后再次换瓣手术常见病因为二尖瓣置换后再狭窄或主动脉瓣形成术后病变、生物瓣衰败和瓣周漏等,另外也可能发生人工机械瓣膜功能障碍或矫治后三尖瓣关闭不全〔1〕。部分患者还会发生复发性心脏瓣膜钙化、蜷缩或畸形等〔2〕。本文拟分析人工机械瓣膜置换术后再次换瓣手术患者临床手术及危险因素。     

Late complications of valve replacement: the benefits of non-invasive assessment

Non-invasive techniques were assessed for their capabilities of detecting prosthetic valve malfunctions in 70 consecutive patients with angiographically-documented or surgically-proven prosthetic valve dysfunction. Their 74 dysfunctioning valves were studied using phonocardiography, M-mode and two-dimensional echocardiography and Doppler methods, including pulsed and continuous wave (CW) Doppler echocardiography and two-dimensional Doppler color flow mapping (2DD). These results were compared among the examinations, and also compared between 43 patients with 44 dysfunctioning mechanical valves and 27 patients with 30 dysfunctioning bioprosthetic valves. Symptoms related to valve malfunction were recognized in all patients with prosthetic valve endocarditis and in all patients but one with stenotic condition. In patients with valvular regurgitation, however, symptoms were observed in only six of the 21 patients with mechanical prostheses and in 12 of the 25 patients with bioprosthetic valves (p less than 0.01). Among 43 patients with 44 mechanical valve dysfunctions, the sensitivities of phonocardiography, M-mode and two-dimensional echocardiography and Doppler techniques were 85, 65 and 86 percent, respectively, in 20 patients with stenosis; 100, 57 and 80 percent in seven patients with transvalvular regurgitation; and 100, 50 and 100 percent in 14 patients with paravalvular regurgitation. Similarly, among 27 patients with bioprosthetic valve dysfunctions, the sensitivities of phonocardiography, M-mode and two-dimensional echocardiography and Doppler methods were 67, 100 and 100 percent, respectively, in three patients with stenotic condition; 85, 65 and 100 percent in 20 patients with transvalvular regurgitation; and 60, 40 and 100 percent in five patients with paravalvular regurgitation. Furthermore, 26 of the 27 patients with malfunctioning mechanical valves and 20 of the 24 patients with malfunctioning bioprostheses had abnormal findings using more than two techniques. In addition, each patient had at least one abnormal finding. In conclusion, malfunctioning mechanical or bioprosthetic prostheses could be detected using non-invasive techniques. The combined use of phonocardiography, M-mode and two-dimensional echocardiography and Doppler techniques is most helpful in detecting malfunctioning prostheses.     

Echocardiographic evaluation of porcine bioprosthetic valves: Experience with 309 normal and 59 dysfunctioning valves

To determine the clinical value of echocardiographic evaluation of porcine bioprosthetic valves, the findings in all patients who had porcine bioprosthetic valve replacement and adequate quality echocardiographic studies from 1978 to 1982 were analyzed. The study includes 309 normal and 59 dysfunctioning valves. Valve dysfunction resulted from spontaneous cusp degeneration in 39 (34 valve regurgitations, 5 stenoses), infective endocarditis in 12, paravalvular regurgitation in 5, regurgitation of redundant cusps, mitral valve thrombi, and aortic stent stenosis in 3 others. Echocardiographic findings were correlated with gross surgical pathologic or autopsy findings in 45 of the 59 dysfunctioning valves. Echocardiographic abnormalities were demonstrated in 41 of 59 (69%) dysfunctioning valves. A systolic mitral or diastolic aortic valve flutter was diagnostic of a regurgitant valve caused by a torn or unsupported cusp margin and was observed in 28 of 34 (82%) regurgitant valves with no false-positive studies. Echocardiographic cusp thickness of ≥ 3 mm correctly identified all regurgitant and stenotic valves with gross anatomic evidence of localized or generalized cusp thickening or calcific deposits. Echocardiographic valve abnormalities were observed in only 4 of 12 patients with infective endocarditis and in 1 of 5 with paravalvular regurgitation.Thus, echocardiography provides important information regarding the function of porcine bioprosthetic valves and is of value in the decision to replace these valves, especially when dysfunction is due to spontaneous cuspal degeneration. Echocardiography is neither sensitive nor specific in patients with infective endocarditis and paravalvular regurgitation.     

Color Doppler flow mapping in cardiomyopathies and prosthetic valves

Summary The clinical significance of color Doppler flow mapping was assessed in patients with cardiomyopathies and prosthetic valves. Left and right ventricular obstruction and mitral regurgitation can be detected in patients with hypertrophic cardiomyopathy. Specific flow patterns in the left ventricle are clearly demonstrated in dilated cardiomyopathy. Concomitant regurgitation is easily detected in patients with dilated cardiomyopathy. The major role of this technique in patients with prosthetic valves exists in the detection of prosthetic valve regurgitation. In bioprosthetic valves, differentiation between transvalvular and paravalvular regurgitation is possible. The specific complications following the mechanical valve implantation, such as an aorto-right ventricular and aorto-left ventricular communication, can be detected using this technique. Although some problems remain, this technique is useful in the management of patients with cardiomyopathies and prosthetic valves.     

经食管超声心动图评价人工心脏瓣膜的功能

本文利用经胸及经食管超声技术观察了51例人工瓣膜置换术后的瓣膜功能及反流程度,并比较了两种技术在评价人工瓣膜中的优缺点。结果表明:(1)经食管超声心动图(TEE)在观察左房及左心耳血栓,判定二尖瓣位人工机械瓣反流程度及鉴别反流与瓣周漏方面均优于经胸超声心动图(TTE)技术,(2)TEE在检出人工二尖瓣反流方面明显优于TTE,且TEE及TTE对人工二尖瓣反流的检出率分别为87.76%和14.29%,(3)TEE在检出主动瓣反流方面与TTE比较,无显著性差异(P>0.05),但可低估瓣膜反流程度。经食管超声技术是判定二尖瓣位人工瓣功能异常的敏感、可靠方法。     

Doppler echocardiography assessment of prosthetic heart valves

Transthoracic Doppler echocardiography is an accurate noninvasive method for the evaluation of prosthetic valve function. The flow characteristics and pressure gradients of normally functioning mechanical and bioprosthetic valves have been, in general established. Normal functioning mitral valve prostheses have a valve area > 1.8 cm² with the St. Jude valve having the largest effective valve area and normally functioning aortic prosthetic valves have a peak instantaneous gradient of < 45 mmHg, with the Starr-Edwards valves (Starr-Edwards, Irvine CA) showing the highest gradients. The incidence of minimal or mild regurgitation is approximately 15% to 30% in the mitral position and 25% to 50% in the aortic position, with the higher incidence of regurgitation seen with mechanical compared to bioprosthetic valves. Transthoracic Doppler echocardiography can accurately detect patients with prosthetic valvular stenosis. The presence of prosthetic aortic regurgitation can also generally be accurately assessed, except in the presence of both prosthetic aortic and mitral valves. Assessment of prosthetic mitral regurgitation remains limited due to significant attenuation of the ultrasound beam by the prosthesis and the frequent underestimation of severity of regurgitation. Other limitations of transthoracic studies include assessment of leaflet morphology, detection of vegetations and valve abscesses, and differentiation between valvular and paravalvular regurgitation.     

Diagnosis of prosthetic mitral valve malfunction with combined echo-phonocardiography.

Fifty-three patients were studied with combined echo-phonocardiography or phonocardiography alone following prosthetic valve replacement. In sixteen of these patients, clinical deterioration developed, and all subsequently underwent cardiac catheterization and/or surgery. Two patients came to autopsy. Included in this group of sixteen patients were five with obstructed prosthesis, six with paravalvular regurgitation, and five with left ventricular dysfunction. Measurements were made of the time interval from the aortic valve closure sound to the peak opening of the mitral prosthesis determined echocardiographically or to the mitral prosthetic opening click (A2-MVO). Echocardiographic studies of left ventricular wall motion were also performed. The A2-MVO interval was significantly shortened (P less than 0.01) with prosthetic valve obstruction (.05 +/- .02 sec) and paravalvular regurgitation (.05 +/- .01 sec) compared with normally functioning prostheses (Starr-Edwards ball valves .10 +/- .02 sec, Lillehei-Kaster tilting disc prostheses .09 +/- .01 sec). Shortening of this interval was not specific for these conditions because it was sometimes shortened with left ventricular dysfunction. Echocardiographic studies of left ventricular wall motion were helpful in distinguishing among prosthetic valve obstruction, paravalvular regurgitation and left ventricular dysfunction. The combined echo-phonocardiographic technique was especially helpful in detecting malfunction of tilting disc prostheses, because the technique enables measurement of the A2-MVO interval in the absence of an audible opening click.     

Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves

Clinical and necropsy findings are described in 54 patients, aged 25 to 83 years (mean 53), who died within 60 days of simultaneous replacements of both mitral and aortic valves. The patients were separated into 4 groups on the basis of the presence of stenosis (with or without associated regurgitation) or pure regurgitation of each valve: 30 patients (56%) had combined mitral and aortic valve stenosis; 12 patients (22%) had mitral stenosis and pure aortic regurgitation; 8 patients (15%) had pure regurgitation of both valves; and 4 patients (7%) had pure aortic regurgitation and mitral stenosis. Necropsy examination in the 54 patients disclosed a high frequency (48%) of anatomic evidence of interference to poppet or disc movement in either the mitral or aortic valve position or both. Anatomic evidence of interference to movement of a poppet or disc in the aortic valve position was twice as common as anatomic evidence of interference to poppet or disc movement in the mitral position. Interference to poppet movement is attributable to the prosthesis's being too large for the ascending aorta or left ventricular cavity in which it resided. The ascending aorta is infrequently enlarged in patients with combined mitral and aortic valve dysfunction irrespective of whether the aortic valve is stenotic or purely regurgitant. Likewise, the left ventricular cavity is usually not dilated in patients with combined mitral and aortic valve stenosis, the most common indication for replacement of both left-sided cardiac valves. Of the 54 patients, 12 (22%) had 1 mechanical and 1 bioprosthesis inserted. It is recommended that both substitute valves should be mechanical prostheses or both should be bioprostheses.     

Doppler hemodynamic characteristics of four widely used aortic valve prostheses

Fifty-one patients with normofunctioning aortic prosthetic heart valves were evaluated by Doppler-Echocardiography to determine type-related flow characteristics. The four mechanical valves tested were: Starr-Edwards (1200-1260 aortic), Bjork-Shiley (60 degrees-60 degrees cc aortic), Medtronic-Hall (aortic) and St. Jude Medical (aortic). The most significant dynamic indexes were calculated: Peak (PG) and Mean (MG) Gradient across the valve, Cardiac Index (CI) or Cardiac Output (CO), Regurgitant Jets, Effective Orifice Area (EOA), Spectral Diagram Systolic Trend (SDST) and PVRT (time required to reach peak velocity during systole)/LVET (left ventricular ejection time) Ratio. Patients with Doppler assessed prosthetic dysfunction were dropped out of the study group. As expected, significant reverse correlation (-0.70) was found when transvalvular pressure gradients were compared with valve size. Significant direct correlation (0.82) was found when EOA was compared with valve size, thus suggesting the high reliability of the continuity equation in the assessment of the real orifice area. The Starr-Edwards valve, when compared with the other prostheses of the same size, showed the highest calculated transvalvular gradient; the St. Jude Medical showed the lowest. On the other hand, the Starr-Edwards valve was not commonly associated with regurgitation, while the St. Jude valve was usually moderately incompetent. Those hemodynamic differences should guide the selection of the ideal prosthetic valve for elective surgical indications. Doppler measurements provided noninvasive information similar to that given by cardiac catheterisation, which was reproducible and specific for valve function. According to this high sensitivity and specificity and to the absolute innocuity of the procedure, Doppler-Echocardiography should be considered the elective technique for long-term follow-up in patients with aortic prosthetic heart valves.     

Presence of a congenitally bicuspid aortic valve among patients having combined mitral and aortic valve replacement

Although bicuspid aortic valve occurs in an estimated 1% of adults and mitral valve prolapse in an estimated 5% of adults, occurrence of the 2 in the same patient is infrequent. During examination of operatively excised aortic and mitral valves because of dysfunction (stenosis and/or regurgitation), we encountered 16 patients who had congenitally bicuspid aortic valves associated with various types of dysfunctioning mitral valves. Eleven of the 16 patients had aortic stenosis (AS): 5 of them also had mitral stenosis, of rheumatic origin in 4 and secondary to mitral annular calcium in 1; the other 6 with aortic stenosis had pure mitral regurgitation (MR) secondary to mitral valve prolapse in 3, to ischemia in 2, and to unclear origin in 1. Of the 5 patients with pure aortic regurgitation, each also had pure mitral regurgitation: in 1 secondary to mitral valve prolapse and in 4 secondary to infective endocarditis. In conclusion, various types of mitral dysfunction severe enough to warrant mitral valve replacement occur in patients with bicuspid aortic valves. A proper search for mitral valve dysfunction in patients with bicuspid aortic valves appears warranted.     

Comparison of transthoracic and transesophageal assessment of prosthetic valve dysfunction

Transesophageal echocardiography has added another dimension to the assessment of prosthetic valve dysfunction with high-resolution images that allow for more detailed structural evaluation of tissue and mechanical valves. This study is a retrospective analysis of 140 prosthetic valves (90 tissue, 50 mechanical) in the mitral (89), aortic (45), and tricuspid (6) position in 116 patients studied by transthoracic and transesophageal echocardiography techniques. Transesophageal echocardiography was consistently better than the transthoracic technique in the evaluation of structural abnormalities of tissue valves in the mitral and aortic positions with respect to leaflet thickening, prolapse, flail, and vegetations. With transesophageal echocardiography, five tissue mitral valves had flail leaflets that were not identified by the transthoracic technique. Transesophageal echocardiography was better than transthoracic in the detection, quantification, and localization of prosthetic mitral regurgitation. Physiological mitral regurgitation was detected in 31 valves by transesophageal echocardiography compared to seven by transthoracic technique. By transesophageal echocardiography, mitral regurgitation was paravalvular in 24% compared with 4% by transthoracic technique. Left atrial spontaneous contrast was seen in 42% of the patients with a mitral prosthesis detected only by transesophageal echocardiography. Six patients had left atrial or left atrial appendage thrombus and in five patients they were detected only by transesophageal echocardiography. We conclude that transesophageal echocardiography should be a complimentary test to transthoracic studies in patients with suspected prosthetic valve dysfunction or for the follow-up of older tissue valves.