Surgical treatment of blunt cardiac trauma in children： report of 2 cases and review of literatures

Objective: Summarizing the clinical experience of surgical treatment in 2 cases of blunt cardiac trauma and reviewing the relevant literatures. Methods : A 6-year-old girl was diagnosed muscular ventricular septal defect and left ventricular aneurysm 2d after automobile accident and underwent ventricular septal defect repair 2 weeks after injury. Another 9-year-old boy was diagnosed severe mitral regurgitation resulted from rupture of posterior papillary muscle 9d after automobile accident and underwent mitral valvuloplasty 2 weeks after injury. Results: Heart function of the first patient was in New York Heart Association (NYHA) class Ⅰ , echocardiography showed no residual septal defect and the size of left ventricular aneurysm reduced. Heart function of the second patient is in NYHA class Ⅱ , echocardiography showed mild mitral regurgitation. Conclusion: Blunt traumatic heart disease occurs either because of heart compression between sternum and the spine and/or because of myocardial contusion ; A more aggressive strategy with surgical treatment earlier before deterioration of heart function is advocated; Earlier surgical correction of anatomic deformity will achieve a good result and a long time follow-up is necessary.     

Role of transesophageal echocardiography in pre- and post-percutaneous balloon mitral valvuloplasty.

Transesophageal echocardiogram (TEE) was performed in 33 consecutive patients with both rheumatic mitral stenosis and chronic atrial fibrillation to evaluate tfae usefulness of this technique for the detection of left atrial thrombi, mitral regurgitation before percutaneous balloon mitral valvuloplasty and iatrogenic atrial septal defect after the procedure. TEE correctly identified thrombi in 10 (30%) patients and significant mitral regurgitation in 5 patients who underwent surgical intervention. The remaining 18 patients underwent percutaneous balloon mitral valvuloplasty without evidence of systemic embolic event and obtained adequate outcome. Transesophageal color doppler echocardiography demostrated left-o-ight shunting flow through atrial septum in 5 of 7(71%) patients 3 days after the procedure and repeated TEE in 2 of these 5 patients showed no shunting after 6 months. In conclusion, TEE plays a definite role in the selection of patients for balloon mitral valvuloplasty and assessment of iatroge     

Risk factors for mortality after coronary artery bypass grafting in patients with low left ventricular ejection fraction

Background We managed to assess and confirm the risk factors for mortality after coronary artery bypass grafting （CABG） operations so as to map out the proper guidance of surgical strategy especially in patients with low left ventncular ejection fraction （LVEF） in domestic polyclinic like ours. Methods Five hundred and forty-eight consecutive patients underwent CABG from December 1999 through August 2005 were analyzed retrospectively. Eighty-nine cases had an LVEF of 40% or less. All together twenty-two candidate factors were evaluated for their association with perioperative death using univariate and multivariate stepwise Logistic analysis. Results When data from all the patients who had undergone CABG were taken into account, LVEF, left ventricular end diastolic diameter （LVEDD）, mitral regurgitation, aneurysm of the heart wall, mitral repair/replacement, resection of aneurysm, concomitant aortic valve replacement, and perioperative intra-aortic balloon counter-pulsation （IABP）, left ventricular assist device （LVAD） and cardiopulmonary bypass （CPB） all showed an association with perioperative death in univariate analysis, while an LVEF of 〉40%, on the other hand, appeared to be a protective factor. In multivariate analysis, moderate to severe mitral regurgitation, aneurysm of the heart wall, repair of septal perforation and aortic regurgitation were proved to be risk factors. When the analysis was restricted to patients with an LVEF of 40% or less, such variables as age, LVEDD, mitral regurgitation, mitral repair/replacement, IABP, and CPB were qualified as risk factors in a univariate analysis. Age, moderate mitral regurgitation, aneurysm of the heart wall, CPB, left main coronary artery disease and female were associated with pefioperative death in a multivariate logistic regression analysis. Conclusions Concerning the prognosis, patients who undergo CABG would have different risk factors when data from all the enrolled patients or data from patients with LVEF≤40% is compared. This is because low LVEF is itself an important risk factor. Regarding the low LVEF patients, the aggressive treatments including correction of mitral regurgitation and resection of aneurysm of the heart wall concomitant with CABG should be taken into account while planning the operative strategy to ensure the perioperative safety and prognosis.     

Acute left ventricular failure after transcatheter closure of a secundum atrial septal defect in a patient with hypertrophic cardiomyopathy

We report a case of acute left ventricular failure at one hour after transcatheter closure of a secundum atrial septal defect (ASD) in a 28-year-old man with hypertrophic cardiomyopathy. Afforded noninvasive mechanical ventilation and the administration of intravenous morphine and high doses of furosemide, the patient exhibited improvement of his clinical condition, reduction of pulmonary congestion at chest X-ray, and satisfactory blood gas analyses in twelve hours. Twenty- four hours later, the patient received oral administration of furosemide and metoprolol. After 7 days the patient was discharged in good clinical condition. At follow-up at 12 months, the patient had remained symptomatically improved from NYHA Class III symptoms before the procedure to Class II symptoms. There was no latent arrhythmia at the follow-up examination. Follow-up transthoracic echocardiography estimated an improvement of the left ventricular function. So, transcatheter closure of a secundum ASD in a patient with hypertrophic cardiomyopathy is feasible, and a thorough understanding of the hemodynamic condition of ASD and hypertrophic cardiomyopathy will reduce the complication of ASD closure.

     

Real-time Three-dimensional Echocardiography in Assessment of Congenital Double Orifice Mitral Valve

The application of real-time three-dimensional echocardiography (RT 3DE) in the diagnosis of double orifice mitral valve (DOMV) was explored. Five cases of DOMV were examined by using 2-dimensional echocardiography (2DE) and RT 3DE. The spatial morphology of malformed mitral valve and its change in hemodynamics were observed. DOMV associated with partial atrio-ventricular septal defect was found in 3 cases (in which 2 cases had cleft mitral valve) and isolated DOMV in 2 cases; and moderate to severe mitral regurgitation was detected in 3 cases, and mild mitral regurgitation in 1, and no regurgitation in 1 case; 1 case had complicated rhumatic heart disease. Three cases were preoperatively discovered by 2DE, while 2 missed (1 case was discovered post-operatively). Four cases were diagnosed by RT 3DE preoperatively, and 1 case was diagnosed post-operatively (not examined by RT 3DE preoperatively). It was suggested that RT 3DE is a reliable technique in the diagnosis of DOMV; it permitted comprehensive and noninvasive assessment of mitral valve and may supplement 2D TTE in the assessment of DOMV.     

The role of echocardiography in mini-invasive surgical device closure of ventricular septal defect

<正>Objective To assess the application of echocardiography in mini-invasive surgical device closure of ventricular septal defect (VSD) . Methods 73 VSD patients including 35 with aneurysm formation and among them 21 with multi-defects in the aneurysm were treated by mini-invasive device closure. A closure device was positioned to the defect through parasternal mini-incision in all patients. TEE was used to monitor the whole procedure,to     

Congenital left ventricular diverticulum diagnosed by echocardiography

To the editor:Left ventricular diverticulum is a rare congenital anomaly,and poorly understood.The first patient was described by O'Bryan in 1838) Here we report a case of a 19-year-old young man with isolated huge left ventricular divertivulum He was admitted to our hospital for heart assessment.He had no connective tissue disorders or other systemic anomalies,and there was no signification family history of disease.Transthoracic echocardiography and magnetic resonance imaging (MRI) showed a large outpouching lesion that contained full-thickness myocardium at the anterolateral wall of the left ventricle without any other cardiac defects (Figure 1).Computed tomography angiography showed no significant coronary artery stenosis.This established the diagnosis of isolated left ventricular diverticulum.The man's cardiac function was within normal limits,and a surgical procedure was not indicated.     

Edge-to-edge chordal transfer repair for anterior leaflet prolapse of mitral valve in 21 patients

Background Repair of anterior mitral leaflet （AML） prolapse is still a technical challenge for cardiac surgeons. It is an important issue to find a way to repair the AML prolapse with a reliable and reproducible technique.Methods Between January 2002 and June 2009, the operation of chordal transfer based on the ＂edge-to-edge＂technique was performed in 21 patients with serious mitral valve regurgitation because of prolapse of the anterior leaflet.After the operation, echocardiography was performed in each patient before discharge and at the time of follow-up.Results All patients survived the operation. One patient required mitral valve replacement because of anterior leaflet perforation 3 days after the operation. The other patients were free from reoperation. At the time of follow-up, all these patients were in New York Heart Association （NYHA） functional class I. In all these patients, pre-discharge and follow-up echocardiography showed neither stenosis nor significant regurgitation of the mitral valve： the cross-sectional area of the mitral valve was 3.3-4.8 cm2 （mean （3.78：±0.52） cm2）, the mean regurgitation area was （0.45：±0.22） cm2. At the same time, both dimension of left atrium and left ventricle reduced significantly （left atrium diameter： pre-operation （48.26±11.12） mm, post-operation （37.57±9.56） mm, P 〈0.05; the end-diastolic diameter of the left ventricle：pre-operation （61.43±8.24） mm, post-operation （42.35±10.79） mm, P〈0.01）.Conclusion ＂Edge-to-edge＂ chordal transfer technique is a simple, reliable, and reproducible technique that can provide good results for repair of anterior leaflet prolapse of mitral valve.     

Long-term outcome of correction of tetralogy of Fallot in 56 adult patients

Background Although most patients with tetralogy of Fallot undergo radical repair during infancy and childhood,patients that remain undiagnosed and untreated until adulthood can still be treated.This study aimed to evaluate longterm outcomes of adult patients with tetralogy of Fallot who were treated surgically,and to determine the predictors of postoperative pulmonary regurgitation.Methods Fifty-six adult patients underwent complete surgical repair.Forty-three patients （76.8%） required a transannular patch.Systolic,diastolic,and mean pressure in the main pulmonary artery were measured after repair.Results The early mortality rate was 3.6%.The 16-year survival rate was （84.4±11.5）%.Late echocardiography revealed 41 patients with transannular patch who had pulmonary regurgitation,consisting of mild pulmonary regurgitation in 28 patients,moderate in eight,and severe regurgitation in five patients.In addition,there was right ventricular outflow tract stenosis in nine patients,moderate/severe tricuspid valve regurgitation in seven,and residual ventricular septal defect in five.Logistic regression analysis demonstrated that the mean pulmonary pressure measured just after repair predicted late pulmonary regurgitation.Conclusions The long-term survival of surgically treated adult patients with tetralogy of Fallot is acceptable.The mean pressure 〉20 mmHg in the main pulmonary artery measured right after surgical repair may be a feasible reference to time the reconstruction of the pulmonary valve.     

Utility of echocardiographic tissue synchronization imaging to redirect left ventricular epicardial lead placement for cardiac resynchronization therapy

Background Cardiac resynchronization therapy （CRT） with biventricular pacing has demonstrated cardiac function improvement for treating congestive heart failure （HF）. It has been documented that the placement of the left ventricular lead at the longest contraction delay segment has the optimal CRT benefit, This study described follow-up to surgical techniques for CRT as a viable alternative for patients with heart failure. Methods Between April 2007 and June 2012, a total of 14 consecutive heart failure patients with New York Heart Association （NYHA） Class Ill-IV underwent left ventricular epicardial lead placements via surgical approach. There were eight males and six females, aged 36 to 79 years （（59.6±9.2） years）. The mean left ventricular ejection fraction （LVEF） was （33.6±7.4）%. All patients were treated with left ventricular systolic dyssynchrony and underwent left ventricular epicardial lead placements via a surgical approach. Tissue Doppler imaging （TDI） and intraoperative transesophageal echocardiography were used to assess changes in left heart function and dyssynchronic parameters. Also, echo was used to select the best site for left ventricular epicardial lead placement. Results Left ventricular epicardial leads were successfully implanted in the posterior or lateral epicardial wall without serious complications in all patients. All patients had reduction in NYHA score from Ⅲ-Ⅳ preoperatively to Ⅱ-Ⅲ postoperatively. The left ventricular end-diastolic diameter （LVEDD） decreased from （67.9±12.7） mm to （61.2±7.1） mm （P〈0.05）, and LVEF increased from （33.6±7.4）% to （42.2±8.8）% （P〈0.05）. Left ventricular intraventricular dyssynchrony index decreased from （148.4±31.6） ms to （57.3±23.8） ms （P〈0.05）. Conclusions Minimally invasive surgical placement of the left ventricular epicardial lead is feasible, safe, and efficient. TDI can guide the epicardial lead placement to the ideal tar qet location.     

Perioperative management of pregnant patients with heart disease for caesarian section under anaesthesia

One hundred pregnant patients, of age group 22 to 35 years, with different types of cardiac ailments (mitral stenosis, mitral regurgitation, mitral valve prolapse, aortic regurgitation, atrial septal defect, ventricular septal defect, coarctation of the aorta, Eisenmenger syndrome, hypertrophic obstructive cardiomyopathy and operated tetralogy of fallot), put up for elective caesarian section underanaesthesia, were managed in the department of anaesthesiology at IPGME&R/SSKM Hospital, Kolkata from January 1996 to December 2002. The aim of the study was to observe the maternal and foetal outcome in different heart diseases. Death occurred in 2 patients (67%) with Eisenmenger syndrome, in one patient (20%) with hypertrophic obstructive cardiomyopathy and in one patient (5%) with critical mitral stenosis (mitral orifice area = 0.6 cm2) with pulmonary arterial hypertension (PAH). Neonatal mortality was observed in 4 patients [Eisenmenger syndrome--3 (100%); coarctation of the aorta--1 (33%)]. Another 8 patients developed severe heart failure (HF) [severe mitral stenosis (mitral orifice area = 1-1.2 cm2)--2 (10%); hypertrophic obstructive cardiomyopathy--4 (80%); coarctation of the aorta--2 (66%)]. Foetal dysmaturity was observed in 20 neonates (54%) belonging to mothers of New York Heart Association (NYHA) classes III and IV. Congenital heart disease (ventricular septal defect) was detected in 3 offsprings (20%) of mothers with ventricular septal defect. The study concludes that most pregnant cardiac patients can have a satisfactory outcome with careful perioperative management.     

主动脉瓣置换术127例临床分析

目的总结主动脉瓣人工机械瓣替换术的临床经验。方法对主动脉瓣机械瓣替换手术127例进行临床分析,年龄13—76岁,平均54．5岁,60岁以上38例。风湿性心脏病64例,先天性瓣叶畸形28例,退行性病变14例,感染性心内膜炎（IE）18例,其中人工瓣膜感染性心内膜炎3例。单一主动脉瓣狭窄5例,主动脉瓣关闭不全76例,狭窄伴关闭不全46例。其中有主动脉窦瘤破裂3例,合并二尖瓣病变68例和（或）三尖瓣病变43例、合并升主动脉瘤样扩张或主动脉夹层8例、冠心痛2例、陈旧性脑血管意外6例,室间隔缺损3例、房间隔缺损3例。心功能Ⅲ级82例,Ⅳ级45例。术前术后心脏超声指标进行对比（LVED、LVEDV、跨瓣压差、LVEF、LVEFS）。结果心超提示：LVED、LVEDV、跨瓣压差较术前明显减少,LVEF、LVEFS明显升高,差异有统计学意义,提示主动脉瓣机械瓣替换术后心功能近期明显改善,中期效果更好。平均随访36个月。结论主动脉瓣机械瓣替换术后心功能较术前明显改善,生活质量明显提高,随着手术技术、心肌保护技术、围术期处理的提高、心肌缺血再血管化手术及对伴发心脏其它疾病的正确处理,手术并发症和病死率明显下降。     

Outcome of surgery for sinus of Valsalva aneurysm with discrete membranous subaortic stenosis

Background  Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly, and SVA with discrete membranous subaortic stenosis is even rarer. The aim of the study was to make sure the incidence of SVA with discrete membraneous subaortic stenosis in SVA and their surgical results. We retrospectively analyzed 234 patients receiving surgical repair of SVA and reported the incidence of ventricular septal defect, aortic regurgitation, and discrete membranous subaortic stenosis. We also reported seven cases of SVA combined with discrete membranous subaortic stenosis and their surgical results.

Methods  Between January 1999 and December 2009, seven patients of SVA with discrete membranous subaortic stenosis underwent surgical repair of SVA and resection of subaortic discrete membrane. There were six male and one female patients. The mean age was (33.71±13.25) years (range 16–52 years). Associated cardiovascular lesions were aortic regurgitation (n=7), ventricular septal defect (n=5), coarctation of aorta (n=1), bicuspid aortic valve (n=1), patent ductus arteriosus (n=1), and aortic valve stenosis (n=1). The aortic valve was replaced in four patients and valvuloplasty was done in three. The other co-existing anomalies were corrected at the same time. All the seven patients were followed up from 18 to 125 months (mean (63.14±39.54) months). Among 234 SVA patients who underwent surgical repair, the number of cases with coexisting ventricular septal defect, aortic regurgitation, and discrete membranous subaortic stenosis was 129, 108, and 7, respectively.

Results  There was neither early death after operation nor late death during the follow-up period. All the seven patients were in the New York Heart Association (NYHA) functional classes I and II. There was no recurrence of discrete subaortic membrane during the follow-up period. The incidence of ventricular septal defect, aortic valve incompetence, and discrete membranous subaortic stenosis among 234 SVA patients was 55.13%, 46.15%, and 2.99%, respectively.

Conclusions  Surgical repair of SVA with discrete membranous subaortic stenosis showed good mid-term results. Resection of discrete subaortic membrane should be done actively while repairing SVAs. Long-term results need to be followed up.

     

Early repair of mechanical complications after acute myocardial infarction

Acute mitral regurgitation and ventricular septal defect after myocardial infarction are devastating complications with high mortality. Surgical intervention is warranted for these entities, but the timing of operation remains controversial. In a previous retrospective study of patients with acute mitral regurgitation, we concluded that early emergency operation be undertaken. We describe nine patients subsequently seen at the Mayo Clinic (seven with acute mitral regurgitation and two with acute ventricular septal defect) who underwent emergency operation within four days of evaluation. Four patients were operated on within four hours after the onset of their complications. All patients survived the perioperative period. Eight of nine are alive and well over a mean follow-up period of 9.7 months. We recommend early surgical repair of mechanical complications after acute myocardial infarction.     

缺血性二尖瓣关闭不全的外科治疗

目的总结缺血性二尖瓣关闭不全的外科治疗经验。方法28例缺血性二尖瓣关闭不全的患者接受手术治疗,其中轻度返流10例,中度返流6例,重度返流12例。11例有心肌梗死史;术前左室舒张末径62.8±6.7mm,左房内径50.1±6.4mm,左室射血分数>0.511例,0.3~0.517例。3例接受单纯冠状动脉旁路移植术(CABG),4例接受CABG加二尖瓣成形术(MVP),2l例接受CABG加二尖瓣置换术(MVR)。结果术后早期死亡4例,其余均痊愈出院。出院时患者心功能NYHA分级均为1~2级,术后早期超声心动图显示左室舒张末径和左房内径均较术前缩小(P<0.05)。结论中度以上的缺血性二尖瓣返流应手术处理,CABG+MVR是一种可靠的方法。     

CABG联合MVR治疗老年冠心病合并中重度功能性二尖瓣反流效果分析

目的 比较分析老年冠状动脉粥样硬化性心脏病（以下简称冠心病）合并中重度功能性二尖瓣反流患者行单纯冠状动脉旁路移植术（CABG）和CABG联合二尖瓣置换术（MVR）的临床疗效。方法 选取2009年6月—2018年4月徐州医科大学附属淮安医院诊治的老年冠心病合并中重度功能性二尖瓣反流患者106例作为研究对象。根据手术方式将其分为CABG组和CABG+MVR组,分别于术前及术后1年检查患者左室射血分数、左心室舒张末期内径和二尖瓣反流面积,评估纽约心脏病协会（NYHA）心功能分级改善情况,并记录患者住院时间、ICU时间、体外循环时间等手术指标。结果 CABG+MVR组术中体外循环时间、升主动脉阻断时间及术后ICU时间与CABG组比较,差异有统计学意义（P?<0.05）,CABG+MVR组时间较长;IABP使用比例、住院时间和围手术期病死率比较,差异无统计学意义（P?>0.05）;两组患者术后1年较术前：左室舒张末期内径和二尖瓣反流面积减小,左室射血分数增加,NYHA心功能分级明显改善（P?<0.05）。结论 老年冠心病合并中重度功能性二尖瓣反流患者行CABG+MVR手术可改善患者心功能,提高生活质量,具有临床疗效佳、安全性好等优点。     

心脏跳动中巨大心脏二尖瓣置换术远期疗效

目的 :评价在浅低温体外循环心脏跳动中巨大心脏病人二尖瓣置换术的远期疗效。方法 :对 131例巨大心脏患者在心脏跳动中施行二尖瓣置换术 ,早期死亡 5例。术后随访到 111例 ,失访 15例 ,随访率 88.1% ,随访时间 0 .5～ 9.0年。随访方法是对病人采用信访、电话随访和门诊复查相结合进行长期随访。结果 :远期死亡 9例 ,死亡原因为心衰 5例、心律失常 2例、瓣周漏 1例、原因不明 1例。 3、6、9年累积生存率为 92 .3%、84 .1%、79.5 %。随访结果与术前及术后早期结果进行统计学处理 ,左室收缩末直径、左室舒张末直径及心功能等指标差异均有统计学意义 (P <0 .0 5 )。左房型及右室型远期疗效较好 ,全心型及左室型效果较差。结论 :在心脏跳动中行巨大心脏的二尖瓣置换手术切实可行 ,安全有效 ,心肌保护效果良好 ,远期效果满意。随访期间加强心功能支持和室性心律失常防治 ,有助于提高巨大心脏二尖瓣置换术的远期疗效     

“双片法”矫治完全型房室间隔缺损45例

目的总结"双片法"矫治完全型房室间隔缺损的临床经验和疗效。方法 2007年3月~2013年7月,广东省高州市人民医院对45例完全型房室间隔缺损患者施行了"双片法"矫治,男31例,女14例。年龄8个月~11岁,平均3.5岁。体重6~33 kg,平均13 kg。其中A型27例,B型11例,C型7例。主动脉阻断时间87~166 min,平均(118±32.6)min;体外循环时间:106~204 min,平均(144±37.8)min。结果全组手术均成功,术后1例在监护病房发现存在室水平残余分流,经再次手术处理后治愈,1例出现Ⅲ度房室传导阻滞,心率42~56 bpm,需要安装永久起搏器。术后B超检查示6例有轻中度二、三尖瓣关闭不全,其余病例二、三尖瓣关闭佳,房及室水平分流消失。1例随访至6年出现二尖瓣重度关闭不全,行二尖瓣机械瓣置换后治愈。术后随访患者心功能Ⅰ~Ⅱ级。结论 "双片法"矫治完全型房室间隔缺损简便实用,效果确切,手术关键是房室瓣的有效成形和防止房室传导阻滞。     

危重心脏瓣膜病瓣膜替换有关问题探讨

目的探讨危重心脏瓣膜病的外科诊断标准,总结其治疗经验。方法对1980年1月~2004年2月施行的危重心脏瓣膜病瓣膜置换术254例进行回顾性总结分析,其中男性120例,女性134例;年龄12~73岁;术前心功能III级82例,IV级172例;二尖瓣置换158例(57例为再次手术),主动脉瓣置换14例,二尖瓣 主动脉瓣置换82例。全部病人置入瓣膜均为机械瓣。同时施行三尖瓣成形82例,左房血栓清除30例,左房成形20例,冠状动脉搭桥3例,经主肺动脉内关闭未闭动脉导管6例,室间隔缺损修补4例,主动脉窦瘤破裂合并室间隔缺损修补及异常传导束切割各2例。结果早期死亡13例(5.1%),低心排出量综合征、呼吸衰竭及心室纤颤为最常见的死亡原因。结论注重术前准备,选择适当手术时机,合理纠正病变,避免手术不当并发症及加强术后并发症处理可进一步提高外科疗效。