Stent implantation and balloon angioplasty for treatment of branch pulmonary artery stenosis in children

OBJECTIVES: Comparison of the results of branch pulmonary artery stenosis treated with balloon angioplasty (BA) or stent implantation (SI) in children. BACKGROUND: Branch pulmonary artery stenosis may be treated with BA or SI. METHODS: We compared the results of 147 interventions of branch pulmonary artery stenosis in 87 children (median age 3.6 years). Patients were treated during 1989-2000 with BA and during 2001-2004 with SI. Primary endpoints were acute complications and reintervention during follow up. Secondary variables were age, vessel diameter increase, acute success rate, balloon/vessel diameter ratio, pulmonary artery hypoplasia indices, and procedure related factors. RESULTS: The acute vessel diameter increase with BA (4.31 +/- 1.98 vs. 7.15 +/- 2.31 mm) and SI (3.71 +/- 1.58 vs. 6.97 +/- 2.68 mm) was significant within both groups (P < 0.001), but not between both groups. The reintervention rate was comparable between both groups, but median time to reintervention was shorter after SI in infants compared to BA. The balloon/vessel diameter ratio was on average higher in BA than the stent/vessel diameter ratio in SI (3.49 +/- 2.16 vs. 2.42 +/- 0.56; P < 0.05) and was a significant risk factor (P < 0.01) for the higher complication rate after BA (BA: 14.1% vs. SI: 4.8%). No mortality occurred in both groups. CONCLUSION: BA and SI are safe interventional catheter therapies of branch pulmonary artery stenosis. The immediate results of BA and SI are comparable. The higher complication rate after BA, especially in infants, was associated with a higher balloon/vessel diameter ratio. SI seems to be a safe permanent alternative with foreign material, but requires more reinterventions in infants due to its therapeutic strategy.     

Effect of unilateral diaphragm paralysis on branch pulmonary artery flow

Background: Respiration is known to be a significant contributor to pulmonary flow in patients who have had Glenn or Fontan procedures. Objective: The purpose of this study was to evaluate the effect of respiration on branch pulmonary artery flow in normal participants, in those with uncomplicated Glenn or Fontan procedures, and in those with uncomplicated biventricular (2V) repairs, and to compare them with similar groups of postoperative patients who had unilateral diaphragm paralysis. Methods: Twenty-one normal infants and children were studied, along with 10 who had undergone uncomplicated bidirectional Glenn or Fontan palliation. Also studied were 10 patients with uncomplicated 2V repairs and 17 patients having ultrasound demonstration of diaphragm paralysis. Nine had undergone Glenn or Fontan procedures and 8 had undergone 2V repair. With the use of conventional pulsed Doppler, branch right and left pulmonary artery waveforms were recorded during spontaneous respiration. The velocity time integral (VTI); heart rate (HR); and systolic, diastolic, and mean velocities were measured at end-expiration and during inspiration. The pulsatility index (PI) (PI = systolic velocity − diastolic velocity/mean velocity) was calculated for each condition. Results: In normal participants PI was 1.69 with a 4.7% increase with inspiration; VTI × HR was 1859. In patients who had undergone uncomplicated Glenn/Fontan procedures PI was 1.06 with a 27.5% increase with inspiration; VTI × HR was 1303, all P = .001 versus normal participants. In patients with 2V repairs PI was 1.7 with a 5.6% increase with inspiration; VTI × HR was 1850, all P = ns versus normal participants. Patients with Glenn/Fontan connections and diaphragm paralysis had lower PI (0.81), inspiratory increase (7.9%), and VTI × HR (610) on the affected side, all P = .001 versus the normal side, and versus patients who had undergone uncomplicated Glenn/Fontan procedures. Patients with 2V repair with a pulsatile source of pulmonary flow had a smaller significant difference in the measured indices. Three patients underwent diaphragm plication with improvement in PI, inspiratory increase in PI, and VTI × HR postplication. Conclusion: In normal participants and patients with uncomplicated 2V repair, inspiration has little effect on PI in branch pulmonary arteries. In patients who have undergone uncomplicated Glenn/Fontan procedures, PI is less than that of normal participants and the effect of inspiration is approximately 5-fold greater. This significant effect of inspiration on pulmonary flow is lost on the affected side in patients with Glenn/Fontan connections and diaphragm paralysis, and is blunted on the affected side in patients with 2V repair and diaphragm paralysis. Loss of diaphragm function is associated with redistribution of pulmonary flow away from the affected side. (J Am Soc Echocardiogr 2002;15:1132-9.)     

Segmentary fetal branch pulmonary artery blood flow velocimetry: in utero Doppler study.

OBJECTIVE: To evaluate changes in human, fetal segmentary, pulmonary artery blood flow velocimetry throughout pregnancy. DESIGN: Ninety-nine women with a singleton, low-risk gestation between 14 and 37 weeks of pregnancy were selected to participate in a prospective, cross-sectional study. All fetuses were evaluated using power and color Doppler ultrasound. Flow velocity waveforms at three sites of the right pulmonary artery were obtained. The pulsatility index (PI) was calculated in the proximal, mid and distal segment of the pulmonary artery. Mean values and 95% confidence interval (CI) for each segment were determined in correlation with gestational age. RESULTS: A full study that included Doppler measurements of all three segments of the pulmonary artery was completed on 99 fetuses. The highest mean PI of 2.36 was obtained in the proximal segment of the right pulmonary artery (CI = 2.29-2.42), whereas in the mid and distal segments the mean PI decreased significantly to 1.57 (CI = 1.53-1.61) and 1.02 (CI = 1.0-1.0) (P < 0.001), respectively. Throughout gestation, the mean PI measurements in the proximal, middle and distal segments of the branch pulmonary artery increased slightly, but without statistical significance (r = 0.274, 0.248, 0.047), respectively; (P > 0.5). CONCLUSIONS: The data obtained suggests that pulmonary circulation maintains stable vascular resistance during gestation in the human fetus. However, the PI obtained from the separate segments of the branch pulmonary artery is unique and each differs from the other, reflecting the proximity to the heart and the peripheral impedance at each location.     

Alterations in segmentary branch pulmonary artery blood flow velocimetry in fetuses of diabetic mothers.

OBJECTIVE: To evaluate pulmonary blood flow in fetuses of diabetic mothers by measuring changes in fetal segmentary pulmonary artery blood flow velocimetry throughout pregnancy. METHODS: Thirty-eight women with pregestational diabetes between weeks 18 and 38 were compared with 99 women with singleton low-risk gestations as controls. Flow velocity waveforms at the proximal middle and distal segments of the right pulmonary artery were obtained with power and color Doppler sonography in all fetuses. The pulsatility index of each segment was compared between the 2 groups. The mean value and 95% confidence interval for each segment were determined in correlation with gestational age for both groups. RESULTS: The highest mean pulsatility indices were obtained in the proximal segment of the pulmonary artery and were 2.25 in the diabetes group and 2.36 in controls. The mean pulsatility indices were significantly decreased in the middle and distal segments to 1.59 and 1.10 in the diabetes group and to 1.57 and 1.02 in controls (P < .05). There were no significant differences in pulsatility indices measured at the proximal and middle segments between the study and control groups. However, the mean pulsatility index +/- SD measured at the distal segment in the diabetic group was 9% higher than in controls (1.10 +/- 0.13 versus 1.02 +/- 0.12; P = .01). The mean pulsatility index (in the study and control groups) in each arterial segment did not change significantly throughout gestation (P > .1). CONCLUSIONS:. In human fetuses throughout gestation, the pulmonary circulation maintains stable vascular resistance in both diabetic and normal pregnancies. However, in all gestations, the pulsatility index in each segment of the pulmonary artery is unique and reflects the proximity to the heart and the impedance at each location. The significantly higher pulsatility index in the diabetes group might be related to alterations in the microcirculation of diabetic patients.     

儿童超声心动图冠状动脉正常参考值及临床意义

目的探讨建立儿童超声心动图冠状动脉正常参考值及其临床意义.方法对400例出生1个月至12岁的健康儿童进行超声心动图检查,其中男232例、女168例.检测冠状动脉(LCA、LAD、pRCA、mRCA、dRCA)内径和左冠状动脉前降支舒张期峰值流速(LAD-Vmax),分析其与体表面积(BSA)、左心室心肌质量(LV mass)和主动脉瓣环内径(ARD)的相关性.结果男性儿童的BSA、LV mass、LAD-Vmax、LCA、LAD、pRCA、mRCA、dRCA分别为(0.60±0.25) m 2、(28.85±14.16) g、(26.04±4.24)m/s、(2.27±0.36) mm、(1.85±0.32) mm、(1.87±0.34) mm、(1.77±0.31) mm、(1.69±0.32)mm,大于女性儿童的(0.58±0.26) m 2、(27.55±14.06) g、(25.46±4.13) m/s、(2.19±0.34)mm、(1.80±0.32)mm、(1.83±0.35)mm、(1.76±0.33)mm、(1.68±0.31)mm,但差异均无统计学意义(t=0.577、0.799、1.043、1.913、1.850、0.853、0.236、0.166,P均>0.05). LCA、LAD、pRCA、mRCA、dRCA内径随年龄增长而增大(F=147.93、101.56、124.39、190.74、149.68,P均<0.05). LCA、LAD、pRCA、mRCA、dRCA 内径随 BSA 增大而增大,呈异方差性正相关(r =0.896、0.852、0.877、0.914、0.917,P均<0.05). LCA、LAD、pRCA、mRCA、dRCA内径均与LV mass呈正相关(r=0.821、0.779、0.798、0.857、0.855,P均<0.05). LCA、LAD、pRCA、mRCA、dRCA 内径均与ARD呈正相关(r=0.814、0.768、0.782、0.814、0.817,P均<0.05).冠脉比值LCA/ARD、LAD/ARD、pRCA/ARD、mRCA/ARD、dRCA/ARD均随BSA增大而明显减小. LAD-Vmax随BSA有增加趋势,但无相关性(r=0.023,P>0.05).结论健康儿童冠状动脉内径与年龄、BSA之间有一定相关性.应用BSA、LV mass及冠状动脉比值等回归方程,计算标准化的Z值,有助于客观定量冠状动脉扩张,诊断儿童冠状动脉病变,值得在临床推广应用.     

肺动脉吊带畸形合并呼吸道感染患儿的护理

目的探讨肺动脉吊带畸形(PAS)合并呼吸道感染患儿的护理要点及注意事项。方法分析3例PAS合并呼吸道感染患儿的临床资料,加强病情观察,及时清理呼吸道,保持呼吸道通畅,做好喂养指导和心理护理。结果 3例患儿均合并支气管狭窄和呼吸道感染,有明显的呼吸道梗阻症状,经过精心护理,均好转出院,未发生护理并发症。结论加强对PAS合并呼吸道感染患儿的病情观察,加强呼吸道管理和喂养指导,保持呼吸道通畅等,可促进患儿的康复,使患儿顺利过渡到手术期。     

经胸超声心动图诊断小儿左冠状动脉起源于肺动脉

部分小儿病例存在婴儿型与成人型的交叉重叠,难以截然分型.     

Normal fluctuations in pulmonary artery pressures and cardiac output in patients with severe left ventricular dysfunction.

BACKGROUND: One barrier to accurate interpretation of changes in hemodynamic pressures and cardiac output is lack of data about what constitutes a normal fluctuation. Few investigators have examined normal fluctuations in these parameters and none have done so in patients with left ventricular dysfunction. AIMS: To describe normal fluctuations in pulmonary artery pressures and cardiac output in patients with left ventricular dysfunction. METHODS: Hemodynamically stable advanced heart failure patients (N=39; 55+/-6 years old; 62% male) with left ventricular dysfunction (mean ejection fraction 22+/-5%) were studied. Cardiac output and pulmonary artery pressures were measured every 15 min for 2 h. RESULTS: Mean+/-standard deviation fluctuations were as follows: pulmonary artery systolic pressure=7+/-4 mmHg; pulmonary artery diastolic pressure=6+/-3 mmHg; pulmonary capillary wedge pressure=5+/-3 mmHg; cardiac output=0.7+/-0.3 l/min. The coefficient of variation for fluctuations in pulmonary artery systolic pressure was 6.7%, in pulmonary artery diastolic pressure was 9.3%, in pulmonary capillary wedge pressure was 9.2%, and in cardiac output was 7.2%. CONCLUSIONS: Values that vary <8% for pulmonary artery systolic pressure, <11% for pulmonary artery diastolic pressure, <12% for pulmonary capillary wedge pressure, and <9% for cardiac output from baseline represent normal fluctuations in these parameters in patients with left ventricular dysfunction.     

法洛四联症术后肺动脉分支口逆向血流的临床意义

目前．法洛四联症（TOF）的术前渗断以及术岳复查仍以彩色多普勒超声心动图（CDE）为主要手段、但对于TOF术后彩超检测到肺动脉左右分支口的异常血流情况，文献少有报道，本文就此影像的特征及其临床意义作一初步探讨。     

孕中期左心发育不良综合征胎儿的肺动脉血流参数特征的价值

目的探讨孕中期左心发育不良综合征（HLHS）胎儿肺动脉血流参数特征。 方法选取2015年8月至2017年5月在南京医科大学附属苏州医院确诊HLHS胎儿54例,将中孕期HLHS胎儿按照其房间隔血流模式分为血流通畅组（41例）与梗阻组（13例）,并与正常胎儿（健康对照组,55例）在肺动脉主干内径、右肺动脉内径和右肺动脉第一级分支血流频谱参数3个层面进行对比,采用LSD-t检验分析通畅型和梗阻型HLHS胎儿的肺动脉内径、收缩期峰值流速（PSV）、舒张期末期速度（EDV）、平均速度（TAMXV）、速度-时间积分（VTI）和肺动脉搏动指数（PA PI）等血流参数特征。 结果肺动脉主干内径方面,三组间均值比较（5.4±0.6 vs 6.7±0.8 vs 6.8±0.9）,差异有统计学意义（F=198.56,P<0.05）,且通畅组和梗阻组的肺主干内径均大于健康对照组,差异均有统计学意义（t=-18.501、-13.97,P均<0.05）,而通畅组和梗阻组的均值比较,差异无统计学意义（P=0.85）;右肺动脉内径方面,三组间均值比较,差异无统计学意义（P=0.59）;右肺动脉第一级分支血流频谱参数方面,三组间在PSV比较,差异无统计学意义（P=0.34）,而在EDV、TAMXV、VTI和PA PI方面,差异均有统计学意义（F=62.98、38.45、13.19及12.46,P均<0.05）,且通畅组和梗阻组胎儿EDV、TAMXV和VTI均值小于健康对照组,差异均有统计学意义（t=4.273和10.353、3.546和7.978、-0.441和5.418,P均<0.05）,且梗阻组均值小于通畅组,差异均有统计学意义（t=5.542、7.033及4.098,P均<0.05）;而通畅组和梗阻组HLHS胎儿PA PI均值大于健康对照组,差异均有统计学意义（t=-2.638、-6.474,P均<0.05）,且梗阻组大于通畅组,差异均有统计学意义（t=-2.541,P<0.05）。 结论HLHS胎儿肺动脉分支血流前向阻力增加,且房间隔血流梗阻型相对于通畅型表现更为显著,这可能与梗阻型肺血管床受损程度相对较重有关。     

Normal sizes of internal genitals in girls before and after the menarche

Knowledge of the average size of the organs of the true pelvis is a prerequisite for the diagnosis and treatment of suspected disorders of the uterus and ovaries in children and adolescents. 76 girls in the premenarche (age = 1 to 14 years) and 31 girls in the postmenarche (age = 13 to 18 years) underwent ultrasound investigation of the inner genitals. Firstly, measurements of the uterus were taken in three dimensions. The volumes of the ovaries were calculated from 3-dimensional measurements of ovarian size. The results of measurements and calculations were used to establish median values and 10th and 90th percentile. Our results show nearly linear growth of the uterus and the ovaries between the 2nd and the 14th year of age. After the menarche accelerated growth of the organs of the true pelvis was detectable in all dimensions.     

The use of balloon-tipped pulmonary artery catheters in children undergoing cardiac surgery

Percutaneous pulmonary artery (PA) catheterization via the internal jugular vein was studied in 58 children undergoing cardiac surgery. Central venous cannulation, which succeeded in all children, was associated with a 10% incidence of inadvertent carotid artery puncture without untoward effects. Successful placement of the PA catheter was achieved in 47 (92%) of the 51 children in whom it was anatomically possible to enter the pulmonary artery at the time of the catheterization. Four (8%) catheter tip cultures were positive. The PA catheter yielded important information in diagnosing low cardiac output, severe pulmonary hypertension or residual cardiac defects in 27 (47%) children. Twenty (35%) children had critical therapeutic interventions because of the PA catheter information. The high yield of important data and the low incidence of major complications seem to justify the use of percutaneously inserted PA catheters in children with an increased operative risk.     

Normal CT in children

We report herein the various measurements on the CT of 110 normal Japanese children among 10,000 patients examined at Kyoto University Hospital from 1976 to 1979. The usefulness of our newly calculated basal cistern index was proved, as standard deviation was small and could be readily identified.     

Sonographic measurements of normal gallbladder sizes in children

PURPOSE: Our goal was to establish the range of sonographic measurements of normal gallbladders in children. METHODS: Six hundred ten children aged 0-16 years (male:female ratio, 1.5:1) with normal clinical and laboratory findings were included in this study. The sonographic parameters were the length, width, and calculated volume of the gallbladder, and the clinical parameters were the age, height, weight, and body surface area of the children. Statistical significance was determined through correlation and regression analyses. RESULTS: The length of the gallbladder showed significant positive correlations with age (r = 0.65), height (r = 0.67), weight (r = 0.63), and body surface area (r = 0.65; p < 0.01). The calculated volume of the gallbladder also showed moderate correlations with age (r = 0.53), height (r = 0.55), weight (r = 0.61), and body surface area (r = 0.57; p < 0.01). The gallbladder width showed modest but significant correlations with age (r = 0.48), height (r = 0.53), weight (r = 0.53), and body surface area (r = 0.55; p < 0.01). The highest correlation coefficients were found between the gallbladder length and subject age (r = 0.65; p < 0.01) and between the gallbladder length and subject height (r = 0.67; p < 0.01). For all correlations, statistical significance remained after regression analysis (p < 0.01). CONCLUSIONS: Values for the size of the normal pediatric gallbladder are defined and will be helpful in the diagnosis of gallbladder abnormalities.     

儿童肾动脉多普勒超声正常参考值及其临床意义

目的 探讨多普勒超声测量正常儿童肾动脉血流参数的正常参考值及其临床意义。方法 随机选取319名1天~16岁正常儿童,男192名,女127名,以多普勒超声测量双侧肾脏的肾动脉血流参数,包括收缩期峰值流速(V_s)、舒张末期峰值流速(V_d)、平均血流速度(V_m)、收缩期峰值流速与舒张末期峰值流速比值(S/D)、搏动指数(PI)、阻力指数(RI)和收缩期血流加速时间(AT);分析各参数随年龄、体表面积(BSA)的变化趋势。结果 男性与女性儿童及左侧与右侧肾动脉各项血流参数差异均无统计学意义(P均>0.05);正常儿童BSA与年龄呈正相关(r=0.96,P<0.01),与肾动脉血流速度及RI分别呈正相关与负相关(P均<0.05);除AT外,肾动脉血流速度和RI以肾主动脉、段动脉、叶间动脉依次递减(P<0.05)。结论 正常儿童肾动脉多普勒超声血流参数与BSA相关,可作为儿童肾脏疾病诊断的正常参考值。     

双源CT术前定量分析肺动脉闭锁患者固有肺动脉及体肺侧支

目的 评价双源CT(DSCT)术前定量评估先天性心脏病肺动脉闭锁患者肺动脉及体肺侧支发育的价值.方法 20例肺动脉闭锁伴室间隔缺损(PA-VSD)患者同期接受DSCT、心血管造影(CA)和超声心动图检查(ECHO),以临床诊断为标准,对照分析3种检查对各种心脏畸形的检出率;着重对照同一患者肺动脉和体肺侧支相同位置的DSCT和CA测量值,并分别计算相应McGoon比值、肺动脉指数(PAI)和总体新生肺动脉指数(TNPAI)比值,对结果进行对照研究.结果 本组患者各种心脏畸形共55处,其中DSCT检出52处(94.55%),ECHO检出43处(78.18%),差异有统计学意义(P=0.012).体肺侧支DSCT检出14例(共37支),CA检出13例(32支),差异无统计学意义(P=0.500).肺动脉融合部DSCT检出16例,CA检出10例(P=0.047);DSCT和CA测量肺动脉、体肺侧支及膈水平胸主动脉直径的定量比较具有高度相关性(r＝0.95～0.98,P<0.01);相应McGoon比值(DSCT:1.18±0.60;CA:1.23±0.64)、PAI[DSCT:(130.96±99.38)mm2/m2;CA:(140.91±107.87)mm2/m2]和TNPAI[DSCT:(160.31±125.62)mm2/m2;CA:(169.14±122.81)mm2/m2]差异均无统计学意义(P均＞0.05).结论 在无需获取压力等血流动力学资料的情况下,DSCT结合多普勒超声能够初步取代CA,成为肺动脉闭锁患者术前常规检查方式.     

Common artifacts of pulmonary artery and pulmonary artery wedge pressures: Recognition and interpretation

Bedside measurement of pulmonary artery pressure and pulmonary artery wedge pressure has an important role in the management of critically ill patients. Unfortunately, waveform abnormalities and artifacts commonly distort numeric values and lead to incorrect therapeutic decisions. The clinical impact of these artifacts is magnified by the digital pressure displays used in most intensive care units. We present here an atlas and an analysis of the artifacts that commonly occur. Use of analog rather than digital pulmonary artery wedge pressure data, when combined with an understanding of the physiological characteristics of patients, can prevent critical errors in patient management.     

Doppler echocardiographic evaluation of pressure in the pulmonary artery in children with congenital heart defects

In children with congenital heart disease serial noninvasive assessment of the pulmonary vascular bed is desirable in order to determine the appropriate timing of cardiac catheterization and corrective surgery. To assess the value of pulmonary Doppler echocardiography for the estimation of pulmonary arterial pressure we correlated the rightsided systolic time intervals (preejection period, acceleration period, ejection period) derived from pulmonary artery Doppler traces with catheterization data (systolic, mean and diastolic pulmonary arterial pressure, total and vascular pulmonary resistances). 62 children aged from 1 month to 15 years suffering from congenital heart disease (n = 52), from rheumatic heart disease (n = 4), from cardiomyopathy (n = 5) or from primary pulmonary hypertension (n = 1) were investigated. The major finding was a highly significant correlation between the acceleration period and the systolic pulmonary arterial pressure (r = 0.79; p less than or equal to 0.0001). However the acceleration period could not be used for prediction of pulmonary arterial pressure in children with poor myocardial contractility.     

肺动脉内隧道术治疗婴幼儿左冠状动脉起源于肺动脉:超声心动图随访

目的探讨超声心动图评价肺动脉内隧道术治疗婴幼儿左冠状动脉起源肺动脉(ALCAPA)疗效.方法对5例肺动脉内隧道术矫治ALCAPA患儿,于手术后出院前及门诊随访时行超声心动图检查.结果全部患儿重建之左冠状动脉/肺动脉内隧道通畅,左心室功能明显改善,射血分数显著增加,术后2～3个月恢复正常.结论肺动脉内隧道术可以显著改善ALCAPA患儿左心功能.超声心动图随访能够显示内隧道通畅情况、心功能恢复程度、并发症及术后残留异常.     

右下肺动脉直径联合肺动脉压力值在肺心病的诊断价值

目的探讨右下肺动脉直径联合肺动脉压力值在肺心病诊断中的应用价值。方法随机选取我院2014年6月~2016年5月49例确诊肺心病患者为肺心病组;以同期收治的诊断为慢性阻塞性肺疾病的31例患者为COPD组;以及无心肺疾病的30例就诊患者为对照组。分别使用CT测量上述各组的右下肺动脉直径,心脏彩超测量肺动脉压力,比较各组的指标变化,并分析各指标与肺心病病程的关系。结果随着肺心病病程的进展,右下肺动脉直径增大;对照组和肺心病组的主肺动脉直径及肺动脉压力值差异有统计学意义;肺心病组与COPD组、对照组组间的右下肺动脉直径/肺动脉压力值比较,差异均有统计学意义。结论右下肺动脉直径/肺动脉压力值变化与肺心病病程进展程度有关, 右下肺动脉直径/肺动脉压力值是诊断肺心病及其进程的CT监测指标。