Spontaneous calcific cerebral embolus

Spontaneous calcific cerebral embolus is a rare complication of calcific vascular disease such as calcified aortic plaques, and calcific aortic and mitral stenosis. Fewer than 10 case reports are described in the literature. Cerebral ischaemic symptoms may provide the indication for surgical replacement, even in the absence of valvular insufficiency or stenotic symptoms. We report a case of stroke in a young man with a known bicuspid calcific aortic valve.     

儿童瓣膜性心脏病的外科治疗

报道87例儿童瓣膜性心脏病患者的外科治疗。其中男58例,女29例,年龄4－14（平均10．2）岁,其中二尖瓣置换36例,主动脉瓣置换13例,二尖瓣和主动脉瓣双瓣置换6例,主动脉瓣成形13例,二尖瓣成形19例。所用心脏瓣膜均为机械瓣。同期处理三尖瓣关闭不全41例,室间隔缺损23例,房间隔缺损9例,佛氏窦瘤破裂8例,动脉导管未闭3例。术后早期并发症包括：低心排综合征7例,呼吸衰竭3例,心律失常5例。早期死亡4例,病死率4．60％。随访0．5－14．5（平均6．51）年,晚期死亡3例,病死率3．61％。儿童瓣膜性心脏病手术治疗时,首先应尽量选择瓣膜成形术;对人工心脏瓣膜替换术者,瓣膜尽量选用成人型号,术后常规行华法林抗凝治疗,并要重视对患儿术后风湿活动的治疗。     

老年钙化性心脏瓣膜病的超声心动图表现

目的应用超声心动图研究老年钙化性心脏瓣膜病（CVHD）的特点。方法接受经胸超声心动图检查的9017例50岁以上患者,以二维、M型、彩色多普勒血流图检测CVHD,记录各瓣膜情况,结果共检出CVHD574例,检出率随年龄增加而升高;性别之间无显著性差异;主动脉瓣钙化多于二尖瓣,无冠瓣钙化多于左、右冠瓣;主动脉瓣瓣尖及二尖瓣瓣环钙化检出率高;钙化形态以3-10mm斑状钙化最多见;部分患者出现血流动力学改变;该病常伴随于高血压病、冠心病、主动脉硬化等疾病。结论超声心动图可检出CVHD钙化部位、大小、瓣膜狭窄及关闭不全程度,为CVHD早期诊断提供影像学依据。     

Features of carcinoid heart disease identified by cardiac computed tomography

BackgroundCarcinoid heart disease (HD) is a rare form of valvular heart disease, the features of which have not been fully described by cardiac computed tomography (CT).MethodsAll patients with carcinoid HD that underwent cardiac CT, either preoperatively or for assessment of coronary arteries, between Apr-2006 and Dec-2019 at the Royal Free Hospital, UK, were reviewed.ResultsOf 32 patients with carcinoid HD, 29 (91%) had heart valve involvement. Abnormalities of the tricuspid and pulmonary valves were present in all patients, affecting all three leaflets in 23/26 (89%) unoperated patients for both valves. The aortic valve was affected in 4/29 (14%) patients and the mitral valve in 5/29 (17%). Left heart valves were affected in 6/29 (21%) patients. One patient (1/29; 3%) had all four valves affected. Severe changes with significant valvular regurgitation were seen in ≥75% of patients with tricuspid, pulmonary, and aortic valve abnormalities. Three patients had carcinoid myocardial metastases (3/32; 9%) and one patient had constrictive pericarditis (1/32; 3%). Ten patients had surgery of whom four (40%) had invasive coronary angiography preoperatively. Ten patients had a patent foramen ovale. Cardiac CT allowed an accurate assessment of damage to different leaflets/cusps, particularly of the pulmonary valve, where visualization with echocardiography was often (3/8; 38%) incomplete.ConclusionCardiac CT is a powerful tool for assessment of cardiac valve abnormalities, coronary arteries and the spatial relationship of coronary arteries with myocardial metastasis in patients with carcinoid HD, and should form part of multimodal imaging of this complex pathology.     

冠心病合并心脏瓣膜疾病的手术治疗

目的总结冠心病合并心脏瓣膜疾病的外科治疗方法。方法1998年4月-2004年12月，同期治疗57例冠心病合并心脏瓣膜疾病患者，平均年龄60岁（42～78岁）；心功能Ⅱ级9例，Ⅲ级37例，Ⅳ级11例；二尖瓣病变37例，主动脉瓣病变11例，联合瓣膜病变9例；均伴有单支或多支冠状动脉病变。手术在中低温体外循环下进行。心脏停跳后先做静脉桥的远端吻合，然后处理瓣膜。心脏复苏后在升主动脉开放前完成大隐静脉与升主动脉的吻合。乳内动脉的吻合在瓣膜置换或成形后心脏复苏前完成。本组行二尖瓣成形8例，行二尖瓣置换29例，行主动脉瓣置换11例，行双瓣置换9例（其中39例为机械瓣置换，10例为进口生物瓣置换）。冠脉搭桥1～5支，平均2．7支／例。结果术后早期死亡1例，死亡率为1．75％，其余患者住院期间无严重并发症。随访6个月～7年，无死亡，患者生活质量均明显提高，心功能Ⅰ级45例，Ⅱ级11例。结论同期施行冠状动脉旁路术和心脏瓣膜术安全有效。     

Non-rheumatic acute mitral insufficiency caused by ruptured chordae tendineae.

Five patients with proved mitral insufficiency caused by ruptured chordae tendineae were examined. Two patients came to autopsy without cardiac cateterization. Three patients, who had cardiac cateterization and surgical replacement of their mitral valves, improved dramatically. Two additional patients have been clinically diagnosed and have had corroborative cardiac catheterization and are being observed in anticipation of possible future valve replacement. Similar findings in these seven patients include adult onset of a characteristic systolic heart murmur which mimics aortic valvular stenosis, acute pulmonary edema associated with massive mitral insufficiency in the face of a normal sized or only minimally enlarged left atrium, and variable size of the left ventricle. In none of the patients were there historical or physical findings of trauma or rheumatic or bacterial endocarditis. A wide spectrum of clinical courses may be explained by the variable number of ruptured chordae tendineae at the time of clinical presentation. Although the incidence and etiology are uncertain, we believe this entity is not uncommon. Myxomatous degeneration of the connective tissue of the heart was present, but the cause remains unknown.     

Diagnosis and assessment of mitral and aortic valve disease by cine-flow magnetic resonance imaging

Seventy-six aortic and mitral valves, in 44 patients and 5 normal volunteers, were studied by Cine-Flow MRI (on a 0.26-T superconducting magnet system), utilizing compound oblique imaging planes and a Field Echo Even Rephasing sequence. All patients had had cardiac catheterization and echocardiography. All patients with valvular stenosis and aortic sclerosis (n = 45) showed complete signal loss distal to the respective valve. Length of signal loss distal to the aortic valve in those in whom it was measured (n = 15) allowed differentiation of aortic stenosis (n = 9) from sclerosis (n = 6). This also permitted grading of stenosis with highly significant correlation (T = 0.86; P less than 0.002) with pressure gradient measurement. In mitral stenosis (n = 12) calculation of the area of signal loss distal to the mitral valve as a percentage of left ventricular cross-sectional area showed a highly significant correlation (T = 0.77; P = 0.001) with pressure gradient measurement. Clinically significant valvular regurgitation was graded by size and duration of signal loss proximal to the value with concordance with angiocardiography. It is concluded that Cine-Flow MRI has a clinical role in the diagnosis and assessment of valvular heart disease.     

Indium-111-antimyosin antibody imaging for detecting different stages of myocardial infarction: comparison with technetium-99m-pyrophosphate imaging

The diagnostic value of 111In-antimyosin (AM) imaging for identifying myocardial infarction was evaluated in comparison with 99mTc-pyrophosphate (PPi) imaging. Twenty-four patients with various stages of myocardial infarction, ranging from three days to nine months after the onset of infarction, underwent both AM and PPi scans. Of 26 infarct lesions AM scan identified 22 (85%), while PPi scans detected 10 (38%) (p less than 0.01). When less than a week had passed since the onset both scans demonstrated all infarct lesions. For seven subacute lesions studied within one to two weeks of onset, AM scans detected (100%), while PPi scans identified only 2 (29%). Furthermore, AM scans showed discrete myocardial uptake in 7 (64%) of those studied more than two weeks after onset. The intensity of AM uptake in the infarcts studied more than seven days after onset was less than that in acute infarcts studied within seven days of onset (p less than 0.05). These preliminary data indicate that the abnormal myocardial uptake of AM persists beyond the first two weeks when PPi no longer accumulates. Thus, AM scans can be considered to provide a sensitive diagnosis of subacute as well as acute myocardial necrosis.     

Visualization of aortic valve leaflets using black blood MRI.

Although magnetic resonance imaging (MRI) is capable of imaging various physiological parameters associated with the heart valves, it has generally been difficult to visualize the valve leaflets directly. The aortic valve was imaged in 120 patients referred for cardiac MRI to assess myocardial volumes or mass. The average patient age was 37 and ranged from 9 to 75 years. Heart rate ranged from 43 to 100 bpm. Imaging was performed on a 1.5 T scanner equipped with enhanced gradients and a cardiac phased-array coil. A double inversion recovery fast spin-echo sequence was used to acquire short-axis images of the aortic valve in a breath-hold (15 +/- 3 seconds). All three leaflets of the aortic valve were seen in 102 of 120 studies (85%). Two leaflets were detected in another 15 subjects. No leaflets were seen in three individuals. Seven cases of a bicuspid or thickened aortic valves were clearly distinguished from normal valves. The signal-to-noise ratio of aortic leaflets (14 +/- 5) was significantly higher than that of the residual blood signal in the aortic root (7 +/- 4, P < 0.001). MR images showed the aortic valve leaflets in a high fraction of people with suspected normal aortic valves and detected seven cases of abnormal aortic valves. The potential of MRI to study both the anatomic and functional consequences of valvular heart disease warrants further study. J. Magn. Reson. Imaging 1999;10:771-777.     

慢性肾功能衰竭维持性血液透析患者心脏瓣膜钙化相关因素

 目的探讨慢性肾功能衰竭维持性血液透析患者心脏瓣膜病变的性质、病因及对心脏结构和功能的影响.方法通过彩色多谱勒心动超声检查观察82例慢性肾功能衰竭维持性血液透析患者心脏瓣膜钙化的程度、瓣膜面积、狭窄或关闭不全及血生化指标.结果82例中发现二尖瓣钙化14例,二尖瓣反流8例,二尖瓣面积减少致狭窄2例,主动脉瓣钙化17例,主动脉瓣反流9例,二尖瓣并发主动脉瓣钙化11例.且钙化程度与钙磷沉积、继发性甲状旁腺功能亢进和血液透析年限密切相关.结论慢性肾功能衰竭维持性血液透析患者心脏瓣膜钙化相当常见,尤以二尖瓣、主动脉瓣易发.     

Edge enhancement of ECG-gated cardiac images using directional masks

ECG-gated images were processed by a computer using a nonlinear digital filter and directional masks to improve delineation of cardiac chamber boundaries and identification of the aortic and mitral valve planes. This technique proved to be satisfactory in 30 patients with documented coronary or valvular heart disease.     

Comparison of Tc-99m methylene diphosphonate with Tc-99m pyrophosphate in the detection of acute myocardial infarction: concise communication.

Myocardial scans were obtained in ten patients with proven myocardial infarction. Scintigraphy on consecutive days was performed with technetium-99m methylene diphosphonate and technetium-99m pyrophosphate. Images obtained with the two tracers were generally equal in quality. Those with PPi exhibited denser uptake, while background activity was lower with MDP.     

Untersuchungstechniken und Stellenwert der MRT bei der Diagnostik von Herzklappenerkrankungen

The main indications for cardiac magnetic resonance imaging (MRI) in the evaluation of valvular heart disease are pathologies of the aortic and pulmonary valve. For mitral and tricuspid valve pathologies MRI is not the first line modality as these are usually well visualized by echocardiography. The advantages of MRI in valvular heart disease are a high reliability in the evaluation of ventricular volumes and function as well as the assessment of the perivalvular arterial or atrial structures. This reliability and the limitless access to any imaging plane partially compensates for the lower temporal and spatial resolution in comparison to echocardiography. In patients with congenital heart disease, cardiac MRI is established as a valuable diagnostic tool in daily clinical management, especially for the evaluation of pulmonary valve defects. Nevertheless, echocardiography remains the first-line diagnostic imaging tool for the foreseeable future.     

复发性心脏瓣膜病的多次手术治疗(附28例报告)

目的 总结复发性心脏瓣膜病行多次心脏瓣膜手术治疗的经验.方法 回顾性分析2004年6月-2015年6月行3次或以上瓣膜手术的28例复发性心脏瓣膜病患者的病例资料,其中男15例,女13例,年龄55.6±6.5(44~67)岁,均有2次或以上二尖瓣和(或)主动脉瓣置换或成形手术史,均行再次心脏瓣膜手术,其中二尖瓣置换18例,三尖瓣置换10例.二尖瓣置换在中低温心脏停搏下进行,均同期行三尖瓣成形;三尖瓣置换在体外循环心脏跳动下进行.10例采用股动静脉结合上腔静脉插管,其余18例均常规行动静脉插管.对心脏停搏患者采用主动脉根部灌注停跳液进行心肌保护.结果 全组患者体外循环时间65~300min,平均125min;18例二尖瓣置换患者主动脉阻断时间55~107min,平均80min.全组死亡2例,死因均为严重低心排综合征.术后早期主要并发症包括呼吸衰竭3例,严重低心排综合征2例,因纵隔出血行二次开胸探查止血2例,重症感染性休克1例.随访6~36个月,患者心功能明显改善,置入瓣膜未发现异常.结论 复发性心脏瓣膜病行3次或以上瓣膜手术虽然具有较高的手术风险,但只要准确把握手术时机、采用正确的手术技术及妥善的围术期处理,仍然能取得满意的手术效果.     

Tc-99m-pyrophosphate accumulation on prosthetic valves

Tc-99m-stannous pyrophosphate myocardial imaging has been one of the most effective and sensitive procedures for detection of acute myocardial infarction since Bonte et al introduced it in 1974. However, many causes of false-positive studies have also been reported since then. Presented here is an abnormal case of a patient with aortic and mitral valve replacement.     

Evaluation of valvular disease by cardiac computed tomography assessment

Cardiac multidetector computed tomography (MDCT) angiography is emerging as a technique to evaluate cardiac valve structure and function. MDCT can provide insights into cardiac valve anatomy and pathologic states, including comparable efficacy in valve area and regurgitant orifice area assessment compared with echocardiography and magnetic resonance imaging. MDCT can also be useful when initial evaluation of valvular disease with echocardiography yields suboptimal images. MDCT provides concurrent visualization of coronary anatomy which may avoid the need for further invasive preoperative testing. Overall, more studies have shown the utility of MDCT in imaging of left-sided valves (aortic and mitral), whereas its ability in assessing right-sided valves (tricuspid and pulmonary) is somewhat limited. MDCT has shown promise as a valuable adjunctive imaging tool to conventional imaging modalities in providing essential anatomic and physiologic data on the sequelae of valvular dysfunction, with the potential of guiding both surgical and percutaneous management. MDCT technology continues to evolve, and more studies are indicated to further refine its precise role in the evaluation of patients with valvular pathology.     

比较心脏不停跳与停跳行二尖瓣置换术心肌酶谱及线粒体的变化

目的比较心脏不停跳与停跳行二尖瓣置换术心肌保护的效果。方法将12例浅低温心脏不停跳二尖瓣置换术(BH)与12例冷晶体灌注心脏停跳下二尖瓣置换术(CCP)做比较,在麻醉后10 min,术后42、4、48、72 h这5个时点抽取周围静脉血测定血清CK、CK-MB、cTnI,MYO的变化。其中随机在BH组及CCP组各抽取10例,分别于体外循环(CPB)前和体外循环后取右心房心肌标本,在透射电子显微镜下观察线粒体形态并进行量化计分。结果 BH组术后各项指标虽较麻醉后增高,但增高幅度小于CCP组,在术后24 h均开始下降,72 h已基本接近正常。CCP组在术后24 h时各项指标除MYO外仍持续增高,72 h尚未恢复。体外循环后CCP组肌线粒体计分均高于BH组(P<0.01),BH组心肌超微结构优于CCP组。结论浅低温心脏不停跳较冷晶体灌注心脏停跳下行二尖瓣置换术具有更好的心肌保护效果。     

Acute myocardial infarction delineated by noninvasive thallium-201/technetium-99m pyrophosphate tomography

The purpose of this study was to validate different scintigraphic approaches for assessing acute myocardial infarctions. 201Tl, 99Tcm pyrophosphate (PPi) and combined 201Tl/99Tcm PPi tomograms were evaluated in 115 consecutive patients, in 85 of whom clinical examination revealed acute myocardial infarction. The overall sensitivity and specificity for infarct detection was 80% versus 56% for 201Tl alone, 61% versus 97% for 99Tcm PPi alone, and 100% each for the combined 201Tl/99Tcm PPi imaging. The sensitivity for nontransmural infarcts was 57% for 201Tl, 37% for 99Tcm PPi and 100% for combined imaging. The overlay of 201Tl and 99Tcm PPi images increases the observer's confidence in the diagnosis and provides better localization of the infarction. 201Tl alone could localize the infarction in 80%, 99Tcm PPi alone in 49% and 201Tl/99Tcm PPi in 100% of the cases. ECG and 201Tl/99Tcm PPi tomography concurred upon infarct localization in 98% of the patients. Based on the 201Tl/99Tcm accumulation pattern, 94% of the Q-wave infarctions were judged to be transmural and 83% of the non-Q-wave infarctions were judged to be nontransmural. It is concluded that combined 201Tl/99Tcm PPi tomography is highly accurate for determining the presence and location of acute myocardial infarction. This technique appears to be superior to studies where only one radioisotope is used.     

Pathophysiology of valvular heart disease: Implications for nuclear imaging

Summary  In general, the echocardiogram has become the mainstay of diagnosis in patients with valvular heart disease. Its strength is that it provides information about valve pathoanatomy and about the severity of stenosis and regurgitation not available by other techniques. However, radionuclide studies offer a more precise gauge of left and right ventricular ejection performance, which is useful in the timing of surgery. Because, at present, most cardiac catheterization procedures in patients with valve disease are performed to evaluate coronary anatomy, a noninvasive technique for detecting coronary disease could obviate the need for invasive studies prior to surgery. The presence of left ventricular hypertrophy especially in aortic stenosis has made myocardial imaging less than perfect in this preoperative evaluation, but clearly this is an area of potential fruitfulness in the use of radionuclide techniques. Additional studies regarding the utility of exercise RNA seem warranted and might be of particular interest in mitral regurgitation, in which little is known about the ability of such studies to help time mitral valve surgery. The addition of estimates of loading during exercise studies is an attractive pathophysiologic adjunct and should be helpful in the interpretation of such studies. The potential role for targeted “hot spot” imaging of ischemia, apoptosis, and necrosis in patients with valvular heart disease remains undefined, although such imaging represents another potential area of investigation that warrants further evaluation.