TEE引导下外科封堵卵圆孔未闭合并三房心1例

<正>患者男,56岁,3个月前因脑梗死就诊,经颅彩色多普勒发泡实验阳性,TTE明确卵圆孔未闭。拟行TEE引导下卵圆孔封堵术,术中TEE示卵圆孔未闭,直径3 mm;左心房内探及隔膜,一端连接于卵圆窝上缘(图1A),另一端连接于左心耳上方(图1B),中间连接左心房前后壁,将左心房分为副房和真房,副房接受4条肺静脉血流,真房连接卵圆孔未闭、左心耳和二尖瓣口,隔膜孔(真、副房交通口)最大径约28 mm,血流速度150 cm/s;提示:三房心,临床分类     

急性肠系膜动脉栓塞的诊疗现状

急性肠系膜动脉栓塞是肠系膜缺血性疾病最常见的原因,多发生于老年人。近年来随着人口老龄化和动脉硬化等相关疾病发生率增加,其患病率也在逐年升高。发病原因主要为血管本身的病变、血容量不足等。其临床表现主要为与轻微体征不相符的剧烈腹痛,目前确诊方法尚无统一标准,数字减影血管造影仍然是金标准。临床医生在接诊不明原因腹痛患者时,尤其是与体征不符的严重腹痛,要考虑到该病的可能。早期诊断、早期治疗是关键,对发病高风险和急性肠系膜动脉栓塞手术后的病人,应长期口服抗凝药或活血药,并定期监测凝血指标,可降低发病率并改善预后。     

鱼精蛋白致右→左心内分流

作者报告一例鱼精蛋白引起卵圆孔未闭(PFO)病人肺血管收缩导致急性右→左房内分流。患者男性,64岁,80kg,体外循环下行冠状动脉搭桥和室间隔缺损修补术。转流前超声心动图检查发现有一个很小右→左分     

孤立性右心室发育不全的外科治疗

孤立性右心室发育不全是罕见的紫绀型先天性心脏病，其右室腔明显缩小，因小梁部发育不良致使右室壁变薄而光滑。本病可伴有大的卵圆孔未闭，房间隔缺损及三尖瓣或肺动脉瓣堵塞性病变，但不伴有其他心脏畸形。本组为１９８５年１０月至１９９２年５月我们手术治疗的５例，无早或晚期死亡。５例均修补房隔缺损或卵圆孔未闭。应用补片加宽右室前壁３例，应用单瓣补片加宽右室流出道和改良Ｆｏｎｔａｎ手术各１例。其中１例行三尖瓣狭窄     

多层螺旋CT在诊断法洛四联症中的应用

目的探讨多层螺旋CT对法洛四联症的诊断价值及其临床意义。方法46例经手术病理证实的法洛四联症患者,术前均接受MSCT检查,分析其临床资料及MSCT表现,并与术后结果进行对照。结果MSCT对46例法洛四联症患者均能做出定性诊断。法洛四联症室缺类型:嵴下型室缺44例,嵴上型室缺2例。主动脉骑跨率:骑跨50%为44例,骑跨40%为2例。肺动脉狭窄:46例均有右室流出道狭窄。合并肺动脉瓣二瓣化畸形36例。合并房间隔缺损或卵圆孔未闭14例,动脉导管未闭2例,右位主动脉弓14例,永存左上腔4例,另2例左头臂静脉异常走行。结论MSCT对心外畸形的检出率,肺动脉及段级分支的变异和发育情况有较高的价值。MSCT可以清楚显示冠状动脉起源、走行以及心内畸形。     

Bentall手术后早期并发症的发生原因及处理

目的总结Bentall手术后并发症发生的原因及早期处理经验。方法48例马方综合征（Marfan syndrome）或升主动脉瘤合并主动脉瓣关闭不全患者均行Bentall手术治疗。主动脉瓣置换采用连续缝合5例，其余患者采用间断缝合。冠状动脉开口直接吻合于人工血管上42例，游离成纽扣状后吻合6例，对动脉夹层采用三明治法缝闭。结果全组死亡3例，分别死于严重低心排血量不能脱离体外循环机、脑出血和心室颤动。存活的45例中，术后24h胸腔引流量280-1180ml，发生低心排血量12例，严重心律失常9例，肺功能不全11例，左侧胸腔积血7例等，均经强心、止血、扩张血管、呼吸机辅助呼吸等对症处理治愈。术后住院9～23d。出院时心功能Ⅰ级29例，Ⅱ级15例，无明显改善1例。结论改进手术方法和缝合技术，可减少心肌缺血和体外循环时间，有利于减少Bentall手术后并发症的发生。     

原位心脏移植治疗终末期心脏病141例

目的分析总结原位心脏移植治疗终末期心脏病的临床疗效及经验。方法为141例终末期心脏病患者施行原位心脏移植术,原发病包括扩张性性心肌病118例,肥厚性心肌病2例,限制性心肌病2例,缺血性心肌病9例,原发性心脏恶性肿瘤4例,瓣膜性心肌病3例,其它病因3例。供心冷缺血时间为(191.0±28.5)m in,供心卵圆孔未闭者9例,大室间隔缺损者1例,冠状动脉开口异常者1例。9例卵圆孔未闭的供心,先行卵圆孔缝闭术,然后再行移植;1例大室间隔缺损的供心,先行室间隔缺损修补术,然后再行移植;1例冠状动脉开口异常的供心,复跳后心肌收缩乏力,遂施行右冠状动脉松解术,其后复跳良好。120例行双腔静脉吻合法原位心脏移植术,19例行标准Stanford原位心脏移植术,2例行全心脏移植术。主动脉阻断时间为(53.0±4.5)m in,吻合时间为(41.5±5.5)m in。术后应用环孢素A(或他克莫司)、激素及霉酚酸酯预防排斥反应,28例患者同时应用达利珠单抗1~5剂。结果手术成功率为97.9%,术后随访1~65个月,1年、3年、5年存活率分别为90.8%、84.6%、81.4%,术后1年内的主要死因是急性排斥反应、感染、移植物功能衰竭及心脏肿瘤转移,术后中远期的主要死因是急性排斥反应、感染、肾功能衰竭及移植心脏冠状动脉硬化。术后并发症以急性排斥反应、感染、肾功能异常、移植心脏功能衰竭多见。结论终末期心脏病行原位心脏移植的临床疗效良好;远期需注意对急性排斥反应、感染及移植心脏冠状动脉硬化的监测及治疗。     

艾勃斯坦心脏畸形的手术配合体会

艾勃斯坦畸形是一种少见的先天性心脏畸形。其病理解剖,主要是三尖瓣下移和三尖瓣畸形。三尖瓣下移至右心室腔内,致使一部分心室腔形成房化心室。常有三尖瓣关闭不全,并有房间隔缺损或卵圆孔未闭。多数伴有完全或不完全右束枝传导阻滞,10％的病人伴有预激综合征。     

三尖瓣囊肿1例

病儿男,６岁。出生６个月发现心脏杂音。查体：发育正常,心界不大,胸骨左缘第３、４肋间可闻及全收缩期粗糙吹风样杂音３／ＶＩ级。超声心动图示左室增大,心尖五腔心图可见室间隔高位回声缺损２～３ｍｍ,诊断为先天性室间隔缺损,卵圆孔未闭。于１９９２年１月手术。...     

术后猝死4例分析

目的栓塞是手术后猝死的常见并发症，提高术前栓塞疑诊率，能有效避免猝死。方法回顾性提取我县2007年至2009年发生术后猝死，纠纷案例4例，进行医学鉴定。结果3例肺栓塞，1例心房纤颤血栓致冠状动脉左前支栓塞，大面积心肌梗死。结论加强围术期风险评估，凡存在高凝状态、静脉血流淤滞或血管损伤，都应做相关检查确诊。     

Management of Patent Foramen Ovale and Stroke

Paradoxical embolization is a rare but well-recognized cause of stroke. Some studies have suggested a link between patent foramen ovale (PFO) and a higher risk of ischemic stroke through this mechanism. PFO is more commonly seen in patients with cryptogenic stroke, but a clear causative relationship between the two is not well established. Other anatomic features associated with a PFO could increase the risk of a recurrent stroke, including an atrial septal aneurysm (ASA), a large PFO, and spontaneous right-to-left shunt at rest. An underlying hypercoagulable state should be ruled out if a PFO is found in a patient with a stroke or transient ischemic attack who has no other identifiable source. Options for secondary prevention in these patients include antiplatelet therapy, anticoagulation, and surgical or endovascular closure. Studies have not shown any advantage of warfarin over aspirin. Surgical closure is a less favorable option because of its high perioperative risks. To date, retrospective studies show variable results of endovascular closure for prevention of stroke. Several randomized prospective studies currently under way are expected to conclusively answer this question. Until these data is available, antiplatelet therapy remains the first-line treatment and endovascular closure should be considered in selected cases.     

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long-term results

OBJECTIVE: It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of the PFO in patients with paradoxical embolism. PATIENTS AND METHODS: Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2 +/- 8.7 years; range, 37-74) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow-up at 99 +/- 30 months (range, 10-111 months) was 100% complete. RESULTS: All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97 +/- 3%, 97 +/- 5% and 94 +/- 8%, respectively. At long-term follow-up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery. CONCLUSION: Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.     

Surgical closure of combined symptomatic patent foramen ovale and atrial septum aneurysm for prevention of recurrent cerebral emboli

BACKGROUND: Patients with patent foramen ovale (PFO) have an undefined but certainly considerable risk of repeated cerebral ischemia due to paradoxical embolism. Especially, if a cerebrovascular event has already occurred and the combination with an atrial septum aneurysm (ASA) is present this risk increases tremendously. The aim of this study was to demonstrate that surgical closure of PFO in combination with an ASA is safe and useful in preventing recurrent strokes. METHODS: Ten patients with previous cerebral ischemia, proven by CT or MRI, and PFO in combination with an ASA were prospectively scheduled for surgical closure. Patients with extracardiac sources of embolic disease were excluded from this study. However, one patient suffered from a hypercoagulability syndrome. RESULTS: All patients (mean age 35.5 +/- 19.1 years) underwent direct suture of the PFO and plication of the ASA with the aid of cardiopulmonary bypass and cardioplegic arrest (n = 3) or ventricular fibrillation (n = 7). Mean operation time was 123.1 +/- 20.2 minutes; mean bypass time was 34.5 +/- 9.9 minutes. There was no mortality or significant postoperative morbidity. Mean hospital stay was 5.1 +/- 1.5 days. During a follow-up of >4 years, no recurrent stroke or transient ischemic attack occurred and no patient received anticoagulation therapy. CONCLUSION: Our data suggest that surgical closure of PFO in combination with ASA in patients with previous stroke is safe and efficacious to prevent recurrent strokes and avoids lifelong anticoagulation.     

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long‐term results

Objective—It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of PFO in patients with paradoxical embolism.

Patients and methods—Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2?±?8.7 years; range, 37–74 years) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow‐up at 99?±?30 months (range, 10–111 months) was 100% complete.

Results—All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97?±?3%, 97?±?5% and 94?±?8%, respectively. At long‐term follow‐up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery.

Conclusion—Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.     

Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?

A best evidence topic was written according to a structured protocol. The question addressed was whether incidentally found patent foramen ovale (PFO) during isolated coronary surgery should be closed. A total of 573 papers were found using the reported searches of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. There is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival. The most significant study identified examined the outcomes of 2277 patients with incidentally found PFO during cardiac surgery of whom 639 underwent closure. After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival. A recent survey of 438 cardiac surgeons from the USA showed no consensus on decision-making behind closure, but that factors taken in to account include PFO size, right atrial pressure and a history of paradoxical embolism. This is not surprising given that morphological research has confirmed that larger PFO size is indeed associated with cryptogenic stroke.     

Diagnosis and treatment of paradoxical embolus.

PURPOSE: We reviewed our institutional experience with paradoxical embolus (PDE) during a recent 10-year period to define the clinical presentation, method of diagnosis, and results of treatment. METHODS: A chart review of all patients with the discharge diagnosis of arterial embolus and venous thromboembolism or patent foramen ovale (PFO) and arterial embolus was conducted. Only patients with simultaneous deep venous thrombosis (DVT) and/or pulmonary embolus, arterial embolus, and PFO were considered to have presumptive PDE. Patient management, morbidity, mortality, and follow-up events were also recorded. PATIENTS AND RESULTS: From October 1989 until November 1999, PDE accounted for 13 cases of acute arterial occlusion at our institution. There were seven men and six women (mean age, 57 +/- 11 years). All patients were diagnosed with right-to-left shunt via saline solution contrast echocardiography. Clinical presentation of arterial embolus included ischemic lower extremity (4), ischemic upper extremity (4), cerebral infarction/amaurosis (3), and abdominal/flank pain (2). Five patients also presented with concomitant respiratory distress. Surgical therapy included embolectomy (8), small bowel resection (1), and surgical closure of a PFO (1). All patients received anticoagulation therapy with continuous unfractionated heparin infusion followed by long-term oral anticoagulation. Five inferior vena caval filters were placed.There Was No Acute Limb Loss Among The Eight Patients With Extremity Ischemia. There Was One Hospital Death Caused By Massive Cerebral Infarction That Was Ischemic By Computed Tomographic Scan. Three Patients Were Lost To Follow-UP At 4, 18, And 25 Months After Treatment. Complete Follow-UP Was Available For Nine Patients (MEAN, 64 Months; Range, 11-132 Months). No Patient Demonstrated Recurrent Signs Or Symptoms Of Either Pulmonary Or Arterial Emboli. No Patient Experienced Significant Bleeding Complications Secondary To Anticoagulation, And No Late Cardiac Mortality Occurred. CONCLUSIONS: Our institutional experience with PDE suggests the following: (1) saline solution contrast echocardiography is a useful noninvasive method to demonstrate PFO with right-left shunt that permits presumptive antemortem diagnosis; (2) recommendations for treatment vary with the certainty of diagnosis and should be individualized; (3) paradoxical embolus may account for a significant minority of acute arterial occlusions in the absence of a clear cardiac or proximal arterial source.     

A traveler in transit: A case of an impending thrombus entrapped in a patent foramen ovale

Thrombus across a patent foramen ovale (PFO), also referred to as a pending paradoxical embolus is a rare condition. We report a case of a 50‐year‐old male taxi driver who was diagnosed with a massive saddle pulmonary embolism, leg deep venous thromboembolism, and pending paradoxical embolus through a PFO with systemic embolization. The patient had an inferior vena cava (IVC) filter inserted immediately followed by surgical thromboembolectomy and closure of PFO. He was discharged home 1 month after surgery. Surgery is the treatment of choice for preventing systemic embolization particularly cryptogenic stroke and its sequelae from pending paradoxical embolus. Preoperative IVC filter is a useful adjunct to prevent ongoing thromboembolism in the perioperative period. The case report presented at the Annual Cardiothoracic Meeting, 10 November 2017, Royal Society of Medicine, London.     

Patent foramen ovale as a possible risk factor for cryptogenic brain abscess: report of two cases.

OBJECTIVE AND IMPORTANCE: Patent foramen ovale (PFO) has been suggested as a potential source of paradoxical embolism. A higher prevalence of PFO in ischemic stroke of unexplained cause has been recognized. Brain abscesses are commonly associated with a contiguous focus of infection, hematogenous spread from a distant focus, or cranial trauma. However, no predisposing factors, including a distant focus with unknown cause, are identified in approximately 15 to 30% of reported cases. CLINICAL PRESENTATION: We encountered two patients with brain abscess presumably caused by dental infections. Both patients displayed PFO, through which right-to-left atrial contrast shunting was revealed by transesophageal echocardiography. Although the radiological location of the abscesses suggested hematogenous spread as a cause, the patients had no arteriovenous shunting other than the PFO, despite exhaustive investigations for a potential infectious route. The patients displayed no definite focal orofacial inflammatory signs during the postoperative course despite diagnosis of pyorrhea alveolaris or periodontitis. INTERVENTION: In Patient 1, the abscess was aspirated stereotactically, and in Patient 2, the abscess disappeared radiologically after high-dose antibiotic treatment. CONCLUSION: The mechanism of brain abscess formation putatively related to PFO should be different from that related to common dental sepsis. Analysis of these cases suggested that infectious embolism from a latent or even identifiable focus through the PFO may be an underrecognized cause of brain abscess, in contrast to simple seeding of the brain via transit of the infecting bacteria through the valveless emissary veins.     

Paradoxical embolism and acute arterial occlusion: Rare or unsuspected?

Purpose: The high prevalence of clinically silent venous thrombosis and the presence of a patent foramen ovale (PFO) in up to 35% of the general population suggests that paradoxical emboli may be the cause of an ischemic stroke or a peripheral thromboembolic occlusion more often than is presently considered. This study was undertaken to review our experience with presumed paradoxical embolism. Methods: Hospital records were reviewed for all patients diagnosed with both a documented PFO and a thromboembolic event between January 1970 and June 1993. Patients with a ventricular or an atrial septal defect or a probable pulmonary arteriovenous fistula were excluded. Results: The presumptive diagnosis of paradoxical embolism was made in seven patients. There were five men and two women, with a median age of 43 years. Four patients were admitted with an acute cerebral ischemic event, and in three others hospitalization was prompted by the development of an acutely ischemic limb (two upper extremity; one lower extremity). In none was there evidence of angiographically significant peripheral or extracranial atherosclerotic occlusive disease. Symptoms suggestive of pulmonary emboli were noted in two patients, and in only one patient was there evidence on physical examination of a deep venous thrombosis. Before 1988 the diagnosis of paradoxical embolism had been made in only one patient after postmortem examination. All six patients who were discharged were available for follow-up (mean 20 months; range 6 to 60 months). There was one late death from lung cancer. Recurrent paradoxical emboli have not been documented during the follow-up period. Conclusions: The incidence of presumed paradoxical embolism has increased dramatically in the recent past as a consequence of our improved ability to unequivocally detect PFO with associated physiologic shunting. The suspicion of this heretofore "rare" event should be raised, particularly in the young or middle-aged adult diagnosed with an acute thromboembolic event. Until the risk of recurrent ischemic events in the presence of a PFO is better defined, we currently recommend closure of the foramen ovale after a significant or recurrent paradoxical embolus. Otherwise, the selective use of intracaval filters, antiplatelet therapy, and oral anticoagulation remain undefined. (J VASC SURG 1994;20:377-84.)     

Analysis of the interatrial septum by transesophageal echocardiography in adult cardiac surgical patients: anatomic variants and correlation with patent foramen ovale

OBJECTIVES: The purpose of this study was to document the perioperative prevalence of anatomic variants of the interatrial septum (IAS), to classify atrial septal aneurysm based on mobility pattern, and to correlate anatomic variants of IAS with patent foramen ovale (PFO). DESIGN: A prospective observational study. SETTING: University hospital (single institution). PARTICIPANTS: Patients presenting for cardiac surgery requiring transesophageal echocardiography. INTERVENTIONS: Multiplane TEE in 2 atrial views with color-flow Doppler and contrast echocardiography with a provocative respiratory maneuver. MEASUREMENTS AND MAIN RESULTS: The cohort size was 206. PFO prevalence was 30.1%. The prevalence of IAS lipomatous hypertrophy was 43.2%, atrial septal flap (ASF) 43.2%, and atrial septal aneurysm (ASA) 28.6%. ASF and ASA were significantly ( p < 0.05) associated with PFO. Selected ASA subtypes are significantly associated with PFO ( p < 0.05). CONCLUSIONS: IAS anatomic variants are common in adult cardiac surgical patients undergoing multiplane TEE. The presence of ASF and ASA predicts enhanced PFO detection. ASA mobility patterns significantly correlate ( p < 0.05) with the presence of PFO.