双心房输注前列腺素E1和去氧肾上腺素对急性肺动脉高压犬血流动力学的影响

目的 观察双心房输注前列腺素E1和去氧肾上腺素对急性肺动脉高压犬血流动力学的影响.方法 15只杂种犬建立急性肺动脉高压模型后,随机均分为三组.A组通过Swan-Ganz导管至右心房给予前列腺素E1 20 ng·kg-1·min-1.通过左心导管至左心房给予去氧肾上腺素2μg·kg-1·min-1;B组经右心房给予和A组同样的两种药物和剂量;C组经右心房给予等容积的生理盐水.记录麻醉前(T0)、建模成功后10 min(T1)、20 min(T2)、给药后10 min(T3)、30 min(T4)、60min(T5)的HR、MAP、SpO2、CVP、平均肺动脉压(MPAP)、肺毛细血管楔压(PCWP)和心输出量(CO),计算心脏指数(CI)、肺循环阻力指数(PVRI)和体循环阻力指数(SVRI).结果 与C组比较,A、B组T3～T5时MPAP降低(P<0.05);与A组比较,B组T3～T5时CI、MAP和SVRI降低(P<0.05).结论 双心房分别输注前列腺素E1和去氧肾上腺素能降低急性肺动脉高压犬的MPAP,改善心功能.     

Evaluation of right atrial function using right atrial speckle tracking analysis in patients with pulmonary artery hypertension

Background

In patients with pulmonary artery hypertension (PAH), right ventricular pressure overload eventually causes right heart failure (RHF), leading to a poor prognosis. Right atrial (RA) overload and RA dysfunction occur in patients with PAH-complicated RHF.

Objectives

We evaluated RA function using right atrial longitudinal strain (RALS) by two-dimensional speckle tracking echocardiography (2D-STE) and investigated the association between RALS and the severity of RHF in patients with pulmonary artery hypertension (PAH) noninvasively.

Methods

We performed 2D-STE in 56 PAH patients and 20 normal control subjects. The peak global RALS and peak global RA longitudinal strain rate (RALSR) were analyzed by 2D-STE. Simultaneous right heart catheterization was performed to determine the right atrial pressure (RAP) and cardiac index (CI).

Results

Peak global RALS (34.6 ± 14.1 vs. 58.3 ± 9.9 %, p < 0.0001) and peak global RALSR (2.5 ± 1.3 vs. 3.1 ± 1.2 s^?1, p < 0.0001) were significantly lower in PAH patients compared with normal controls. There was a significant negative correlation between peak global RALS and RAP (r = ?0.8037, p < 0.0001). There was a significant positive correlation between peak global RALS and CI (r = 0.8179, p < 0.0001). Peak global RALSR was also correlated with RAP (r = ?0.7308, p < 0.0001) and CI (r = 0.7596, p < 0.0001).

Conclusions

RALS and RALSR by 2D-STE were useful for noninvasive evaluation of RA dysfunction and the severity of RHF in patients with PAH.

     

左心房追踪技术评价肺动脉高压患者右心房功能

目的应用左心房容积追踪(LAVT)技术评价肺动脉高压(PH)患者右心房功能。方法根据肺动脉收缩压(PASP)将60例PH患者(PH组)分为轻度PH亚组(Ⅰ组)、中度PH亚组(Ⅱ组)、重度PH亚组(Ⅲ组),以30名健康体检者为正常对照组;应用LAVT技术构建单平面右心房容积-时间曲线,获取右心房最大容积(RAVmax)、收缩期前容积(RAVpre)及最小容积(RAVmin),计算右心房被动排空容积(RAVp)、右心房被动排空分数(RAVIpEF)、右心房主动排空容积(RAVa)、右心房主动排空分数(RAVaEF)、右心房总排空容积(RAVt)和右心房总排空分数(RAVtEF)。用体表面积对各容积值进行标化,计算得出RAVmax、RAVmin、RAVpre、RAVt、RAVa及RAVp;采用双多普勒实时成像技术计算Tei指数。结果与正常对照组比较,PH组RAVmax、RAVmin、RAVpre、RAVt、RAVa、dv/dtS、dv/dtA增高、RAVp减低,差异均有统计学意义(P0.05);PHⅠ组、Ⅱ组、Ⅲ组中,RAVmax、RAVmin、RAVpre、RAVt、RAVa逐渐增大,RAVp逐渐减小(P0.05);Tei指数在PHⅠ组、Ⅱ组、Ⅲ组中依次增高(P0.05),Ⅲ组明显高于Ⅰ组、Ⅱ组(P0.05)。结论PH患者右心房助力泵功能、储存器功能增强、管道功能减低;LAVT可无创评价PH患者右心房功能。     

Pericardiotomy improves left ventricular compliance during sepsis-induced pulmonary artery hypertension.

Sepsis-induced pulmonary artery hypertension (SIPAH) causes an increase in right ventricular (RV) afterload, dilatation of the RV, leftward shift of the interventricular septum (IVS), and therefore decreases left ventricular compliance (LVC). This study was designed to evaluate the role of pericardiotomy during SIPAH as an alternative to vasodilators (which cause a detrimental increase in shunt fraction) to improve LVC. Systemic and pulmonary hemodynamics, pulmonary function, RV, and LVC were acquired at baseline (BL), during SIPAH with closed pericardium (PAHCP) and after opening the pericardium (PAHOP). Systemic hemodynamics and pulmonary function did not change significantly during the experiment. The infusion of live bacteria induced a significant rise in mean pulmonary artery pressure from 16 +/- 5.3 at BL to 36.8 +/- 3.3 and 35.0 +/- 6.4 mm Hg during PAHCP and PAHOP, respectively, (P less than 0.05). Pulmonary vascular resistance index and right ventricular stroke work index (RVSWI) displayed a similar rise in response to SIPAH (P less than 0.05 vs BL). Pericardiotomy did not affect pulmonary hemodynamics or RVSWI. Right ventricular contractility did not increase following pulmonary hypertension while the pericardium was closed (440 +/- 78 vs 410 +/- 125, P less than 0.05); however, it rose, although not significantly, to 615 +/- 326 after pericardiotomy. RV time tension index displayed a rise during SIPAH with the pericardium intact and returned to baseline values after pericardiotomy; however, these changes were not significant. RVC did not change significantly throughout the experiment. In contrast, LVC decreased significantly after SIPAH and significantly improved after pericardiotomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multifocal right atrial myxoma and pulmonary embolism

Multifocal cardiac myxoma with greater than two foci is rarely reported in the literature. We report a case of a 22-year-old woman who presented with profound right heart failure, and was found to have seven right atrial myxomas with bilateral pulmonary embolism, including near-complete occlusion of right pulmonary arterial flow. Multifocal atrial myxoma occurs most often in the familial setting, and often is associated with recurrence. Her disease was nonfamilial. She was successfully treated with surgical resection, and has had complete recovery with no evidence of recurrence over a 4-year period.     

前列腺素E1肺动脉途径给药对肺动脉高压患者的降压效果

目的 探讨前列腺素E1肺动脉途径给药对肺动脉高压患者的降压效果.方法 择期行非体外循环冠状动脉搭桥术合并肺动脉高压患者30例,性别不限,年龄65 ～ 82岁,体重60 ～ 88 kg,ASA分级Ⅱ或Ⅲ级,肺动脉收缩压＞40 mm Hg.采用随机数字表法,将其随机分为2组(n=15):中心静脉给药组(C组)和肺动脉给药组(P组).麻醉诱导后行右颈内静脉穿刺置入Swan-Ganz导管用于监测血流动力学指标.切皮后,C组和P组分别通过中心静脉导管和肺动脉导管输注前列腺素E120 ～ 50 ng·kg-1 ·min-1,使肺动脉收缩压降至25～ 30 mm Hg.分别于给药前5 min(To)及给药后5 min(T1)记录心率、平均动脉压、中心静脉压、肺动脉收缩压、肺毛细血管楔压和心脏指数,计算肺血管阻力和周围血管阻力.记录前列腺素E1的用量.结果 与C组相比,P组前列腺素E1用量减少,T1时肺动脉收缩压和肺血管阻力降低,平均动脉压和周围血管阻力升高(P＜0.05).结论 经肺动脉途径给药可提高前列腺素E1降低肺动脉高压的效价,且不影响体循环血流动力学.     

Results of right atrial to right ventricular and right atrial to pulmonary artery conduits for complex congenital heart disease.

The Fontan procedure was initially proposed for tricuspid atresia (TA). We describe our experience with modifications of this operation and its application to previously uncorrectable congenital lesions. From 1975 to 1979, 26 patients have undergone a Fontan-like procedure, at a mean age of 14 years (range: 3 months to 23 years). Nineteen patients had TA, one patient had mitral atresia, four patients had a univentricular heart, one patient had a "criss-cross" heart, and one patient had pulmonary atresia. Previous procedures included eight Glenn shunts, 18 systemic to pulmonary artery (PA) shunts, two PA bands, and two atrial septectomies. Thirteen patients underwent right atrial (RA) to PA connections, with a valved conduit in nine patients and without in four. Two patients had simultaneous Glenn shunts. Thirteen had RA to right ventricular (RV) conduits, with a valve in 12 patients and without in one. There were five early deaths (<30 days, 19%) and no significant difference between the RA to PA connection (four deaths of 13) versus the RA to RV connection (one death of 13). The mortality rate was higher in patients undergoing RA to PA connection without valved conduit (one death of nine with a valve, three deaths of four without, p < 0.05), while the Glenn shunt did not affect mortality (one death of seven with, three of six without, p < 0.1). There were no late deaths (mean follow-up: 24 months). Seven patients underwent recatheterization with a mean RA pressure of 14 mmHg (range: 9--25 mmHg). Thus, the "Fontan" procedure can be done with an acceptably low mortality with good functional results, both for TA and other complex lesions.     

Giant left atrial myxoma causing severe pulmonary hypertension

This report describes a case of giant left atrial myxoma in a 43-year-old woman. She presented with general malaise and dyspnea. Electrocardiogram showed severe right-axis deviation. Transthoracic echocardiography demonstrated a giant mobile mass with size of 6.5 × 4.5 cm in the left atrium. This mass protruded into the left ventricle in diastole and disturbed transmitral left ventricular filling flow. Bilateral atrium and right ventricle were dilated. Severe tricuspid regurgitation was demonstrated with peak pressure gradient of 91 mmHg. This mass was surgically excised and was diagnosed as benign atrial myxoma by histological analysis. Pulmonary hypertension was improved after surgery.     

Inhibition of urea tubular reabsorption by PGE1 infusion in man.

We have shown that the inhibition of prostaglandin (PG) synthesis in man decreases the fractional clearance of urea (FCurea). To understand the mechanism(s) by which PG affect the renal handling of urea, 6 normal volunteers were randomly studied in maximal antidiuresis (by water deprivation and by administering 1-desamino-8-D-arginine vasopressin) before and during PGE1 infusion, in two separate occasions: (A) after 7 days of normal protein (1 g/kg b.w./day) and water intake (10 ml/kg b.w./day), and (B) after 7 days of low protein intake (0.5 g/kg b.w./day) and high water intake (80 ml/kg b.w./day) to lower the corticomedullary osmotic gradient. During infusion of PGE1 at rates of 0.01, 0.05 and 0.1 micrograms/min/kg, randomly administered, the urinary fluid losses were replaced by infusing equal volumes of hypotonic NaCl (80 mmol/l). To evaluate the time effects of this protocol, control studies were performed in an other 8 subjects receiving vehicle infusion without PGE1. In study A, FCurea rose by 23% (p less than 0.01) at the lowest PGE1 infusion rate (0.01 micrograms/min/kg), in the absence of any simultaneous change in water and salt output, Uosm, PAH and inulin clearance. Higher PGE1 infusion rates (0.05 and 0.1 micrograms/min/kg) were associated with a progressive increase of FCurea (50%, p less than 0.001 and 91%, p less than 0.001, respectively), fractional clearance of water and salt output, inulin and PAH clearance and reduced Uosm from 1,005 (22 SEM; basal value) to 772 (38 SEM; minimum value) mosm/kg (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Isoflurane in pulmonary hypertension and failure of the right ventricle

We evaluated the effects of the use of 1.2% isoflurane (group A) in a group of patients (n = 13) referred for mitral valve surgery, with pulmonary hypertension and right ventricular failure. We evaluated the hemodynamic status in baseline conditions, after isoflurane ++ administration and in relative hyper- and hypovolemia. We compared the results with those in 17 patients (group B) in identical clinical state who did not receive isoflurane during anesthesia. The evaluated parameters were: mixed venous Hb saturation (SvO2), heart rate (HR), pulmonary capillary pressure (PCP), central venous pressure (CVP), mean blood pressure (mBP), mean pulmonary arterial pressure (mPAP), cardiac index (CI), arteriolar pulmonary resistances (APR), peripheral vascular resistances (SVR), stroke index (SI), left ventricular work (LVW), right ventricular work (RVW), and O2 consumption (VO2). In group A, after isoflurane ++ administration, CI was 107.05% and 80% of baseline values in relative hypervolemia and hypovolemia, respectively. In group B (control), CI was 121.48% and 88.28% of basal values in relative hypervolemia and hypovolemia, respectively. In group A, SVR were 73.59% and 76.72% in hypervolemia and hypovolemia, respectively, while in group B they were 86.21% and 106.80%. In group A, APR were 90.85% and 89.96% in hypervolemia and hypovolemia, while they were 80.72% and 102.34% in group B. We found that isoflurane results in a greater peripheral than pulmonary vasodilation with a greater impairment in right ventricular function.     

Surgical treatment of a right atrial myxoma with pulmonary embolism

We report on an 18-year-old man with a right atrial myxoma complicated by widespread pulmonary infarction. Under cardiopulmonary bypass, a typical gelatin-like myxoma of 65 g in weight and the segments of pulmonary infarction were simultaneously removed. From the excised lung specimens, pulmonary tissue infarction caused by myxoma acting as a blocker was recognized. This was a very rare case of myxoma complicated by pulmonary infarction, and we report here the successful removal of the right myxoma and partial pneumonectomy.     

Intravenous infusion of prostaglandin E1 (PGE1) in management of limb ischemia

Twenty-three patients who had advanced arteriosclerotic disease of the lower extremities as manifested by rest pain, nonhealing ischemic ulcers, or impending gangrene and who were not candidates for direct arterial revascularization procedure underwent intravenous infusion of prostaglandin E1 (PGE1). Thirty-nine per cent of the patients showed subjective and/or objective improvement in the blood supply, and in 22 per cent (5 patients) amputation was avoided. Complications were minor and disappeared once the infusion was discontinued. PGE1 in prescribed dosages can be safely infused intravenously. Even though the results are not as encouraging as when PGE1 is given by the intra-arterial route, IV therapy improves the ischemic symptoms and avoids the necessity of amputation in some patients.     

Ethanol-induced acute pulmonary hypertension and right ventricular dysfunction in pigs

Editor—Absolute ethyl alcohol (ETOH) is used with increasedfrequency in the treatment of conditions such as percutaneousablation of unresectable hepatic tumours, sclerotherapy of oesophagealvarices, ventricular septal ablation, and i.v. embolizationof arteriovenous malformations.^1–3 Although the incidenceof complications with the use of ETOH is relatively low, episodesof cardiopulmonary collapse have been described.⁴ The postulatedmechanism is severe pulmonary vasoconstriction from the suddenpassage of ETOH into the pulmonary circulation,⁵ causing pulmonaryhypertension (PHTN) and right ventricular (RV) strain.⁶ However,there is limited information on the effects of i.v. ETOH onheart function, pulmonary and systemic haemodynamics,⁷ and inclinical conditions similar to those encountered during therapeuticprocedures. We have studied the causal relationship between     

A giant right atrial villous myxoma with simultaneous pulmonary embolism

INTRODUCTION

Primary cardiac tumors are rare and approximately three quarters of them are benign and up to half of the benign tumors are myxomas. Right atrial villous myxoma with pulmonary embolism is an unusual apparition.

PRESENTATION OF CASE

A 29 year-old male was admitted to our outpatient clinic with progressive exertional dyspnea, chest pain and intermittent feeling faint. A giant right atrial villous mobile mass was detected by means of transthoracic echocardiography. To exclude possible pulmonary embolism, chest computed tomography scan was performed and showed filling defects in the branch of the pulmonary artery. The mass was totally resected.

DISCUSSION

RA villous myxoma is a rare subtype in an unusual location with high potential of pulmonary embolism. Early surgery for villous myxoma has a great importance in order to reduce the risk of pulmonary embolism.

CONCLUSION

3D TEE should be a sufficient technique for diagnosis and evoluation of shape, size and origin of the cardiac mass an adequate guide to surgical treatment.     

A comparison between right atrial and pulmonary arterial oxygen tensions

Oxygen tensions of 50 simultaneously withdrawn blood samples from the right atrial orifice of a triple-lumen pulmonary artery catheter and from the pulmonary artery lumen were compared. Mixed venous oxygen tensions ranged from 21 mmHg to 44.9 mmHg. The correlation coefficient was 0.96 (t = 2.09; P = 0.01). The benefits and drawbacks of intermittent right atrial oxygen tension monitoring are discussed.     

Postoperative right atrial and pulmonary embolism after prolonged spinal surgery

Perioperative pulmonary thromboembolism can proceed rapidly with grave prognosis, in which immediate or accurate diagnosis and management is not easy. According to the literatures, patients receiving spinal surgery are at relatively lower risk of developing thromboembolism. We would like to present a case of postoperative pulmonary thromboembolism which developed after a prolonged lumbar spinal surgery. Tachycardia and unstable hemodynamics were noted postoperatively. Pulmonary and right atrial thrombi were disclosed by transesophageal echocardiography. Although cardiotomy and thrombectomy were immediately performed, the patient finally died 3 days after the operation. The pathogenesis of venous thromboembolism (VTE) in the surgical patients, the risk factors which predispose a patient to VTE, diagnosis, and treatment as well as the prophylactic measures of VTE are herein reviewed and discussed.