动脉导管未闭合并二尖瓣反流的治疗策略

摘要 目的：探讨治疗动脉导管未闭合并二尖瓣关闭不全的临床经验。 方法 分析41例动脉导管未闭合并二尖瓣关闭不全的临床资料,男23例,女18例;年龄1～52(9.5±10.7)岁。术前超声心动图提示：动脉导管直径3~11(6.84±2.10)mm,合并二尖瓣反流10例为轻度反流,16例中度反流,15例重度反流。37例患者的二尖瓣未进行处理,其中16例通过左胸侧后切口结扎动脉导管,21例单纯行介入封堵;2例患者因同时伴有重度三尖瓣反流而在体外循环下同期施行了三尖瓣成形术;2例合并重度二尖瓣关闭不全一般情况较差的患者,首先一期行PDA封堵术,封堵术后2周体外下一例行二尖瓣置换,一例二尖瓣成行术。 结果围术期无死亡,PDA术后均无残余分流,3例术前有反复肺部感染的患儿术后呼吸机辅助时间2～5天后顺利脱机,其余患者均恢复顺利。患者出院后门诊随访,术后1周、1月、3月复查瓣膜反流情况。单纯处理PDA的患者（共37例）,术后心彩超提示：术后1周与术前比较二尖瓣反流均明显减少;术后3个月与术后1个月比,二尖瓣反流略有减少。术后3个月时二尖瓣无反流19例,轻度反流13例,中度反流5例,无重度反流病例;行体外循环手术者术后均恢复良好,两例一期手术者术后二尖瓣反流为轻度以下,分期行成形者术后二尖瓣反流为轻中度 结论对动脉导管未闭合功能性二尖瓣关闭不全患者,采取单纯PDA结扎或者封堵,可有效减轻心脏负担,改善二尖瓣反流状况。对于一般情况较重不能耐受一期手术的患者,可行分期手术,一期先行PDA封堵术,缓解了二尖瓣反流和肺动脉高压情况,可有效地降低了二期二尖瓣手术的手术风险。     

动脉导管未闭合并功能性二尖瓣反流的治疗策略

目的：探讨动脉导管未闭合并功能性二尖瓣反流的治疗策略及疗效观察 方法：回顾性分析2008年1月至2015年7月在本中心实施手术治疗的65例PDA合并功能性二尖瓣反流患者的临床资料。其中有轻度二尖瓣反流16例、中度反流26例、重度反流23例,其中41例行介入封堵术,19例行左侧经胸切口动脉导管结扎术。3例成人患者合并重度二尖瓣反流者行体外循环下PDA结扎及二尖瓣成形术,2例左室明显扩大伴重度二尖瓣反流、心功能低下者先行PDA封堵后2周再行体外循环下二尖瓣成形术。术后3月随访复查心脏彩超了解二尖瓣反流情况。 结果：围术期无死亡。PDA术后均无残余分流。8例术前有反复肺部感染的患儿术后呼吸机辅助时间2～5天后顺利脱机,其余患者均恢复顺利。单纯处理PDA的患者（共60例）,术后3月心彩超提示：二尖瓣无反流26例,轻度反流24例,中度反流10例,无重度反流病例。行体外循环手术者术后均恢复良好,3例一期手术者术后二尖瓣反流为轻度以下,2例分期行成形者术后二尖瓣反流为轻度、轻偏中度。 结论：对PDA合并功能性二尖瓣反流患者,单纯处理动脉导管即可获得良好的效果。对合并极重度二尖瓣反流伴左室扩大、心功能不全患者,行分期手术可获得良好的手术安全性。     

动脉导管未闭手术后再通的介入封堵

目的:评价动脉导管未闭(PDA)手术后再通行介入封堵的临床疗效。方法:PDA手术后再通患者3例,降主动脉侧位造影显示PDA最窄处直径分别为2.0mm、2.5mm和5.0mm,均经静脉途径行封堵治疗,术后超声心动图随访。结果:3例患者均成功封堵,随访无残余分流,1例患者术前彩色多普勒超声检查有左心室扩大、二尖瓣和主动脉瓣反流,3个月后复查左心室较前缩小、瓣膜反流减轻。结论:PDA手术后再通行介入封堵是安全可行的方法。     

单纯冠状动脉旁路移植术治疗冠心病合并中度缺血性二尖瓣关闭不全中期疗效分析

目的:比较冠心病合并中度缺血性二尖瓣关闭不全(IMR)患者冠状动脉旁路移植术(CABG)和CABG+二尖瓣成形(MVP)两种手术方法的中期临床疗效。方法:根据入排标准选取2013年1月至2018年11月,于行外科手术治疗的冠心病合并中度IMR患者125例,随访时间12个月,根据手术方式分为CABG组和CABG+MVP组,比较两组术后并发症、呼吸机使用时间、ICU时间、住院时间、在院病死率、术前、术后及随访时EF、LVEDD、二尖瓣反流面积、随访期病死率、MACCE事件发生率等指标。结果:两组患者基线资料,差异无统计学意义(P0.05),乳内动脉使用率(69.9%vs. 57.1%,P0.05)、旁路移植支数[(3.05±0.66)vs.(2.95±0.59)支,P0.05]、悬红[(1.73±2.77)vs.(2.57±4.48)U,P0.05]、血浆[(139.7±300.8)vs.(190±375.63)mL,P0.05]、血小板[(0.31±1.31)vs.(0.24±0.7)U,P0.05]使用量上差异无统计学意义,但CABG+MVP组手术时间明显高于CABG组[(348±87.1)vs.(236.79±65.3)min,P0.001]。两组在院病死率差异无统计学意义(3.6%vs. 9.5%,P0.05)。但CABG组IABP使用率(15.7%vs. 33.3%,P0.05)、呼吸机使用时间[26.0(21.0,52.0)vs. 46(24.3,70.5)h,P0.05],ICU滞留时间[42.0(23.2,65.9)vs. 63.4(44.3,118.8)h,P0.05]、术后心房颤动(0 vs. 14.3%,P0.05)、二次开胸(1.2%vs. 9.5%,P0.05)、术后肾衰竭(1.2%vs. 9.5%,P0.05)、低心排发生率(3.6%vs. 19%,P0.05)、总住院时间[(11.1±4.3)vs.(13.8±6.6)d,P0.05]均低于CABG+MVP组。两组随访MACCE事件发生率(6.25%vs. 5.26%,P0.05)、病死率(6.25%vs. 5.3%,P0.05)差异无统计学意义。除去死亡病例,对比两组超声结果发现,两组患者术后EF [(52.2±8.8)%vs.(50±9.8)%,P0.05]、术后LVEDD [(49.7±6.1)vs.(49.8±6.3)mm,P0.05]、术后二尖瓣反流面积[1.7(0,2.7)vs. 0.6(0,2.4)cm~2,P0.05]、随访EF [(56±8.8)%vs.(52.8±9.1)%,P0.05]、随访LVEDD [(49.8±5.6)vs.(50.9±5.6)mm,P0.05]差异无统计学意义,但1年期随访二尖瓣反流面积CABG+MVP组明显少于CABG组[2.4(1.3,3.6)vs. 0.8(0.4,2.2)cm~2,P0.05]。结论:冠心病合并中度IMR患者行OPCABG治疗术后并发症少,中期疗效满意,或可作为此类患者一种可选的手术策略。     

经导管介入封堵动脉导管未闭合并功能性二尖瓣反流的近中期疗效评价

目的评价动脉导管未闭(PDA)合并中、重度功能性二尖瓣反流(MR)患者单纯行经导管介入封堵治疗的近中期疗效,探讨其可行性及安全性。方法回顾性分析2007年1月至2014年6月武汉亚洲心脏病医院PDA合并中、重度功能性MR并接受单纯行经导管介入封堵术的69例患者,其中男20例(29.0%),年龄24(4,45)岁。功能性MR中度45例(65.2%),重度24例(34.8%)。所有患者术后第1、3、6、12个月及之后每年复查超声心动图。评估MR、左心房(LA)直径、左心室(LV)直径、主肺动脉(MPA)直径、左心室射血分数(LVEF)等的变化。结果 69例患者中PDA漏斗型52例(75.4%),管型9例(13.0%),窗型8例(11.6%);PDA直径(8.19±2.64)mm,封堵器直径为(16.67±4.10)mm。手术成功率为100%,未见残余漏、封堵器移位等严重并发症发生。术后随访(15.91±17.73)个月。45例中度MR患者中20例减少为无反流,24例反流程度减少至轻度,1例仍为中度反流;24例重度MR患者中10例减少为无反流,10例反流程度减少至轻度,3例减少为中度反流,1例患者仍为重度反流。MPA直径[(2.54±0.78)cm比(3.27±1.11)cm,P0.001]、LA直径[(3.40±1.03)cm比(4.45±1.21)cm,P0.001]、LV直径[(4.76±1.16)cm比(6.26±1.45)cm,P0.001]均显著小于术前,差异均有统计学意义。将患者按不同年龄段分成3组:A组(0~13岁,26例)、B组(14~41岁,21例)、C组(42~64岁,22例),A组与B组、B组与C组改善率比较,差异均无统计学意义(均P0.05);而A组改善率(100.0%比81.8%,P=0.023)显著大于C组,差异有统计学意义。结论 PDA合并中、重度功能性MR患者在严格把握适应证的前提下单纯行经导管介入封堵术是安全有效的,MR程度均明显减轻,近、中期效果良好。     

改良扩大Morrow手术治疗肥厚梗阻性心肌病12例临床分析

目的:评价外科手术治疗肥厚梗阻性心肌病的临床疗效。方法:2013年1月至2017年5月,12例患者因肥厚梗阻性心肌病行外科手术治疗,男性8例、女性4例,年龄42～56,平均年龄(40±13.3)岁,体质量55～74 kg,平均(60±12.6)kg,手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术(改良扩大Morrow技术),合并主动脉瓣下隔膜切除术4例。围术期UCG或TEE评价左心房(LA)、左心室(LV)、左心室流出道流速及压差(LVOT)、LVEF、二尖瓣结构和功能。结果:体外循环时间82～110 min,平均(71±18.3)min,主动脉阻断时间50～96 min,平均(45±16.4)min,气管插管时间8～22 h,平均(12±13.6)h, ICU住院时间24～72 h,平均(36±23)h,术后住院时间10～14 d,平均(10.4±2.8)d。与术前相比,LA大小[(40±9)vs.(36±4)mm]、LVOT [(111±32)vs.(26±12)mmHg,1 mmHg=0.133 kPa]、室间隔厚度[(26±5)vs.(17±4)mm]、LVEF [(69±11)%vs.(58±8)%]均显著下降(P<0.05)。二尖瓣关闭好或仅轻度反流,SAM征消失。主要并发症:完全性房室传导阻滞1例(安装永久起搏器)。远期随访:所有生存患者症状消失,生命质量明显改善,心功能I～Ⅱ级,无远期死亡或并发症。结论:肥厚梗阻性心肌病外科手术可满意的减轻左心室流出道梗阻,提高患者的生命质量。     

心肌梗死后前间隔和后间隔穿孔患者的临床特征及介入封堵治疗效果比较

目的:对比心肌梗死后不同部位室间隔穿孔患者的临床特征及介入封堵术效果。方法:回顾性分析2015年1月至2020年5月我院心脏中心67例行介入封堵术的室间隔穿孔患者,根据室间隔穿孔部位将患者分为前间隔组(n=44)和后间隔组(n=23),比较两组患者术前、术中临床资料及术后随访结果。结果:封堵手术前,与前间隔组相比,后间隔组二尖瓣反流面积[3.05(1.40)cm~2 vs. 3.09(1.60)cm~2]、三尖瓣反流面积[4.05(3.50)cm~2 vs. 6.60(2.80)cm~2]更大,血压更低[收缩压:(108.86±14.93)mmHg vs.(97.04±11.23)mmHg;舒张压:(68.80±9.46)mmHg vs.(56.09±6.47)mmHg,1 mmHg=0.133 k Pa],差异均有统计学意义(P均0.05)。67例患者中,介入封堵术失败4例。其中,前间隔组2例,原因均为术中心脏破裂;后间隔组2例,1例因术中反复心室颤动而放弃封堵,1例封堵器脱落转外科治疗。63例介入封堵成功的患者中,院内死亡7例。前间隔组6例死亡,其中4例因二尖瓣、三尖瓣大量反流引起心力衰竭,最终死亡;2例严重溶血,导致多器官功能衰竭死亡。后间隔组1例患者于术后第二天因突发心脏骤停而死亡。封堵手术后,后间隔组二尖瓣反流面积仍明显大于前间隔组[3.10(2.40)cm~2 vs. 2.17(1.28)cm~2,P=0.002]。两组在手术时间、X线辐射量、封堵器直径、院内死亡率、术后残余分流、术后三尖瓣反流面积及重症监护室滞留时间等方面的差异均无统计学意义(P均0.05)。远期随访结果显示,两组的再次住院率、脑血管事件及二次冠状动脉事件发生率差异均无统计学意义(P均0.05)。生存曲线分析也显示,两组的远期生存率差异无统计学意义(P0.05)。结论:由于解剖学特点,后间隔穿孔患者较前间隔穿孔患者术前及术后瓣膜反流更严重,但介入封堵术的远期疗效相当。     

介入封堵治疗室间隔缺损合并轻中度右冠状瓣脱垂的疗效观察

目的评价介入封堵治疗室间隔缺损(VSD)合并轻、中度右冠状瓣脱垂的有效性及安全性。方法选择2015年5月至2018年4月湖南省儿童医院收治的VSD患儿作为研究对象,术前经胸超声心动图(TTE)和(或)经食管超声心动图(TEE)诊断VSD合并轻、中度右冠状瓣脱垂,采用经导管介入封堵治疗75例(男40例,女35例)。术中通过造影及TTE检查有无残余分流、新发主动脉瓣反流或原有主动脉瓣反流加重,体表心电图评估介入封堵后是否影响传导系统。术后通过TTE和体表心电图对患儿进行随访,重点观察主动脉瓣反流程度和有无心脏传导阻滞。结果 75例患儿平均年龄(51.8±34.6)个月,平均体重(16.7±7.3)kg;嵴内型VSD 31例,膜周型VSD 44例;右冠状瓣脱垂轻度53例,中度22例。其中术前三尖瓣轻度反流3例,主动脉瓣轻度反流1例;应用对称型VSD封堵器24例,偏心型VSD封堵器30例,ADOⅡ封堵器21例。术后三尖瓣反流3例(同术前),主动脉瓣轻度反流7例(其中1例同术前),残余漏4例(术后6个月消失),室性早搏1例,三度房室传导阻滞1例(外科取伞并修补VSD后恢复窦性心律),封堵器脱落1例(紧急外科取伞并修补VSD),无左束支传导阻滞、机械性溶血发生。不同程度右冠状瓣脱垂VSD封堵术后主动脉瓣反流比较,差异有统计学意义(P=0.002);不同类型VSD封堵术后主动脉瓣反流比较,差异无统计学意义(P0.999)。嵴内型VSD与膜周型VSD患儿手术时间[(15.00±12.66)min比(19.68±13.48)min,P=0.028]、辐射剂量[(93.97±51.45)m Gy比(123.93±58.85)m Gy,P=0.005]比较,差异均有统计学意义。术前与术后6个月左心室舒张末期内径[(31.20±3.59)mm比(27.45±2.96)mm,P=0.096]、左心室收缩末期内径[(19.60±2.22)mm比(16.71±1.87)mm,P=0.098]比较,差异均无统计学意义;而左心室射血分数[(63.85±4.77)%比(66.37±3.05)%,P=0.010]比较,差异有统计学意义。结论通过介入封堵治疗合并轻、中度右冠状瓣脱垂VSD是可行的,但仍需长期随访评价其远期疗效,及更大样本量评估术后效果。     

改良扩大Morrow术治疗肥厚型梗阻性心肌病近中期结果分析

目的:总结改良扩大Morrow术治疗肥厚型梗阻性心肌病的临床经验,分析其近中期结果。方法:回顾性分析2012年5月至2019年6月,在我院行改良扩大Morrow术的26例肥厚型梗阻性心肌病患者临床资料。其中女性18例,男性8例,年龄31~67岁,平均年龄(45.6±13.5)岁。所有患者均经主动脉切口行改良扩大Morrow术,合并心脏病变同期处理,比较术前、术后及随访时超声心动图、心电图结果及并发症情况。结果:全组无手术死亡,单纯行改良扩大Morrow术18例,同期冠状动脉旁路移植术1例,二尖瓣成形或置换术5例,主动脉瓣置换术1例,心房颤动改良迷宫术1例。随访3~90个月,左心室流出道压差[(20.3±17.5)vs.(65.2±27.5)mm Hg,1 mm Hg=0.133 k Pa]、最大室间隔厚度[(18.6±6.4)vs.(26.3±5.1)mm]均较术前明显降低,LVEDD[(43.3±4.1)vs.(38.7±4.9)mm]较术前增加,差异均有统计学意义(P<0.05);24例(92.3%)患者NYHA心功能分级Ⅰ或Ⅱ级,较术前明显改善(P<0.01),二尖瓣反流程度减轻(P<0.01),二尖瓣收缩期前向运动现象消失。术后并发症包括:III°房室传导阻滞2例(8.3%);2例患者因切除范围不够致术后残余左心室流出道压差,1例再次行改良扩大Morrow术。结论:肥厚型梗阻性心肌病患者行改良扩大Morrow术可获得良好的近中期效果,不良事件发生率低,远期结果有待进一步随访观察。     

预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂

目的:回顾预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂,探讨此手术对二尖瓣脱垂的治疗效果。方法:2008年1月至2012年12月间,回顾性分析北京安贞医院收治的15例二尖瓣脱垂患者,其中男性10例,女性5例,年龄(48.5±3.2)岁,SBE后腱索断裂导致关闭不全2例,单纯腱索断裂导致关闭不全8例,腱索延长导致关闭不全5例。术前超声心动图(TEE)显示:根据Carpentier标准,前叶脱垂10例,后叶脱垂3例,前叶合并后叶脱垂2例。所有患者二尖瓣均为重度关闭不全,反流面积(11.0±0.9)cm2,1例合并三尖瓣重度反流。术前射血分数(EF)平均(64.9±1.9)%,左心室舒张末直径(LVDD)平均(54.9±1.4)mm,左心房直径(LA)平均(42.9±1.7)mm。所有患者均经胸正中切口,体外循环下行预制人工腱索环移植,移植腱索数量为(3.6±0.3)根,腱索长度(15.4±1.5)mm,平均体外循环时间(113±11.7)min,平均主动脉阻断时间(86±9.8)min。3例患者置入SJ成形环,12例患者置入爱德华成形环,1例患者同时行三尖瓣成形术。结果:术后无死亡,无恶性心律失常及其他严重并发症。术后复查TEE显示少量反流3例,微量反流8例,未见反流4例。术后EF平均(60.2±2.9)%,未见明显改变。LVDD平均(46.5±1.1)mm,LA平均(32.9±1.2)mm,均较术前明显改善。随访12~57个月,平均(35.7±4.3)个月,少量反流3例,无或微量反流12例。结论:预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂近中期效果确切,但是远期预后尚需进一步观察。     

Study on the mitral valve prolapse. I. Incidence in Kobe University students. II. Follow up study

Incidence of mitral valve prolapse (MVP) in 4517 students of Kobe University, and clinical features in cases with MVP were studied. MVP was detected in 42 cases by two-dimensional echocardiography, and the prevalence of MVP was 0.93 percent (42 of 4517 cases). Among 42 cases with MVP, apparent mitral regurgitation (MR) was noted in one case with severe MVP, ventricular tachycardia was detected in one and ST-T wave abnormalities were detected in 10 respectively. In another follow up study of our hospital, 14 of 85 patients followed more than one year were noted to be deterioration in echocardiographic parameters. Eight of 14 patients had severe prolapse with severe MR, but remaining 6 had mild or moderate prolapse with mild or absent of MR. However, ST-T wave abnormalities, serious arrhythmias, and low response of %FS increase on exercise were found in high incidence in 6 of mild or moderate prolapse as well as in severe prolapse. So these follow up results suggested that not only students with severe MVP but also students with mild or moderate MVP with ST-T wave changes or VPC found in university medical examination must be followed up carefully.     

The relationship between clinical and echocardiographic findings in mitral valve prolapse

Incorporating prognostically related auscultatory, M-mode, 2DE and recent Doppler echocardiographic features, the following strict criteria for establishing the diagnosis of mitral valve prolapse (MVP) have been advanced: 1. auscultatory; mid-to-late systolic clicks and a late systolic murmur at the apex or mid-to-late systolic clicks at the apex which move appropriately with maneuvers that alter LV volume or late systolic murmur at the apex in young patients (coinciding that a similar murmur in elderly population is non-specific for MVP); 2. two-dimensionally "targeted" M-mode criterion: marked (greater than 3 mm) late systolic buckling posterior to C-D line (moderate 2 mm late systolic buckling or 3 mm holosystolic displacement "arouse suspicion" but do not establish MVP); 3. two-dimensional echocardiographic criteria: severe bowing of leaflet(s) on the parasternal long axis and four-chamber view (mild to moderate bowing alone are unacceptable) or left atrial coaptation point; 4. Doppler echocardiographic criteria: moderate or severe Doppler mitral regurgitation with any degree of leaflet bowing or mild Doppler mitral regurgitation with at least moderate bowing of one leaflet (mild leaflet bowing and mild mitral regurgitation can be regarded as "probable MVP"). The concept of mitral valve prolapse syndrome encompasses that which was earlier described in patients with a high prevalence of symptoms. In controlled studies, however, it has become apparent that cardiac and psychiatric symptoms can be found as frequently in normal subjects as in those with MVP. These results indicate that clinicians may have erroneously diagnosed patients with MVP because of premature acceptance that MVP is the cause of a distinctive syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)     

成人再次二尖瓣成形术的临床特征分析

目的分析二尖瓣成形术后复发性病变的病因,总结再次二尖瓣成形术的手术技术和效果。方法回顾分析2012年1月至2019年10月阜外医院19例行再次二尖瓣成形术的成人患者的临床资料,男12例,女7例,首次手术年龄4~66岁,平均(34.9±22.6)岁。先天性二尖瓣关闭不全7例,退行性二尖瓣关闭不全12例。再次手术时年龄18~81岁,平均(43.5±19.1)岁。两次手术间隔2~430个月,平均(118±116)个月。再次手术同期进行三尖瓣成形术5例,冠状动脉搭桥手术2例,左房血栓清除1例。术前心胸比0.56±0.07,左房内径(LA)为(49.4±8.5)mm,左室舒张末径(LV)为(56.6±5.9)mm,左室射血分数(LVEF)62.6%±7.8%。结果手术失败组包括瓣叶缝线撕脱5例,瓣叶裂未完全缝合2例、人工瓣环瓣周漏2例、人工腱索撕脱1例。病变进展或新发病变组包括新发瓣叶脱垂4例,瓣环明显扩张2例,自体腱索断裂1例,感染性心内膜炎1例,二尖瓣相对性狭窄1例。本组患者体外循环时间(109±53)min,阻断时间(70±29)min,术后呼吸机使用时间(16±5.8)h。围术期无死亡。出院时有2例二尖瓣少中量反流,LA为(42.9±6.1)mm,LV为(53.4±6.3)mm,LVEF为59.3%±3.8%。术后随访(21.0±14.9)个月。1例术后2个月出现感染性心内膜炎,二尖瓣中量反流。另有1例术后10个月发生脑梗死。无死亡、再次手术患者,心功能均为Ⅰ级或Ⅱ级。结论二尖瓣成形术后出现复发性二尖瓣病变患者,在瓣叶条件良好,反流原因明确情况下,行再次二尖瓣成形手术可以获得满意的围术期结果,近中期疗效良好。     

改良Morrow手术治疗21例肥厚梗阻型心肌病临床分析

目的 评价改良Morrow手术治疗肥厚梗阻型心肌病(HOCM)的临床疗效。方法 回顾性分析我院2013年8月~2014年7月应用改良Morrow手术治疗的21例HOCM患者临床资料。所有患者均为药物治疗效果不佳,其中男9例,女12例,年龄22~64(45.3±11.9)岁。所有患者均行改良Morrow手术,包括扩大的肥厚心肌切除和游离肥厚的二尖瓣前乳头肌,其中2例患者同时行二尖瓣前叶折叠。对比研究所有患者手术前后左室流出道梗阻、二尖瓣功能和临床症状改变,评价改良Morrow手术疗效。结果 全组21例患者无死亡。术中切除心肌质量8.5~22.8（14.9±3.8） g。术中Ⅲ度房室传导阻滞1例,安置心脏永久起搏器。术后患者左室流出道压差显著降低〔术前（101±41）mmHg vs.术后（10±8）mmHg〕（P<0.01）,左室流出道最狭窄内径显著增宽〔术前（5.0±2.1）mm vs.术后（16.6±3.6）mm〕（P<0.01）,左房内径明显减小〔术前（47±5）mm vs.术后（42±5）mm〕（P<0.01）,二尖瓣返流量显著减少〔术前（5.9±3.7）ml vs.术后（1.8±1.5）ml〕（P<0.01）。18例术前SAM征阳性患者术后SAM征均消失,19例患者胸闷、气短症状消失,90%患者心功能为Ⅰ级。结论 改良Morrow手术能够有效解除左室流出道梗阻,改善二尖瓣功能,是治疗药物无效HOCM的有效手段。     

The relationship between mitral regurgitation and asynergy of the left ventricle in old myocardial infarction

To elucidate the mechanism of mitral regurgitation (MR) in patients with old myocardial infarction, two-dimensional (2D) and 2D Doppler echocardiographic examinations were performed in 92 patients. According to the sites of asynergy in the short-axis view of the left ventricle at the papillary muscle level, the patients were classified in three groups; i.e., anteroseptal (AS) group (49 cases), inferoposterior (IP) group (29 cases), and the AS + IP group (14 cases). The existence and severity of MR were evaluated by 2D Doppler echocardiography and the presence of mitral valve prolapse (MPV), by 2D echocardiography. The mitral valve ring diameter was also measured. The incidence of MR was significantly higher in the IP group (41%) and AS + IP group (43%) than in the AS group (20%) (p less than 0.05, respectively). In the IP group, 21 patients had left ventricular asynergy at the base of the posterior papillary muscle; eight did not. In the former 21 patients with asynergy, MR was detected in 12 (57%) and MVP in nine (43%), whereas neither MR nor MVP was detected in the eight patients without asynergy. The grade of MR assessed by 2-D Doppler echocardiography was significantly more severe in patients with MVP than in those without MVP (MR distance: 23 +/- 6 mm with MVP vs 11 +/- 1 mm without MVP; p less than 0.05, MR area; 312 +/- 217 mm2 with MVP vs 64 +/- 29 mm2 without MVP; p less than 0.05). MR appeared at the mitral orifice between its middle portion and the posteromedial commissure, which coincided with the site of MVP in the majority of cases. In the AS and AS + IP groups, however, such close relationships between MR and MVP were absent. In these groups, mitral valve ring diameters were significantly larger in patients with MR than in those without MR (AS group: 32 +/- 3 mm with MR vs 24 +/- 2 mm without MR; p less than 0.01, IP group: 26 +/- 2 mm with MR vs 25 +/- 2 mm without MR; NS, AS + IP group: 30 +/- 3 mm with MR vs 24 +/- 1 mm without MR; p less than 0.05). Mitral valve ring diameters in the IP group with MR (26 +/- 2 mm) were smaller than in those in the AS and AS + IP groups with MR, and did not differ from those in the IP group without MR (25 +/- 2 mm). In conclusion, posterior papillary muscle dysfunction was mainly responsible for MR in the inferoposterior infarction and the dilatation of the mitral valve ring in the infarction involving the anteroseptal wall.     

High Occurrence of Mitral Valve Prolapse in Cardiac Catheterization Patients with Pure Isolated Mitral Regurgitation

ABSTRACT. Danielsen R, Nordrehaug JE, Vik-Mo H (Department of Clinical Physiology, Haukeland Hospital, University of Bergen, Bergen, Norway). High occurrence of mitral valve prolapse in cardiac catheterization patients with pure isolated mitral regurgitation. Acta Med Scand 1987; 221:33–8. The aetiological spectrum of angiographically verified pure isolated mitral regurgitation (MR) was studied in 48 consecutive adult patients (35 males). Severe MR was found in 35 patients (73%) and moderate MR in 13 patients (27%). Mitral valve prolapse (MVP) syndrome was found in 21 patients (44%). These were younger than the rest of the study population (55±13 vs. 62±6 years, p<0.05) and 15 (71%) of them were men. Endocarditis and chordal rupture occurred in 19% and 43% of the MVP patients. Sixteen patients (33%) had MR secondary to myocardial infarction while only three patients (6%) had MR of rheumatic aetiology. Bacterial endocarditis, hypertensive heart disease, hypertrophic obstructive car-diomyopathy and mitral annulus calcification were less frequently found. Mitral valve replacement was done in 20 (57%) of the patients with severe MR and MVP was the underlying disease in 15 (75%) of these patients. In conclusion, MVP is a frequent cause of pure isolated MR and of mitral valve replacement. In contrast to the preponderance of young females amongst MVP patients in population surveys, most of the MVP patients with MR in this study are middle-aged and elderly men.     

心肌梗死后室壁瘤形成伴严重二尖瓣返流对左室附壁血栓形成的影响

目的:探讨心肌梗死后室壁瘤形成伴严重二尖瓣返流对左室附壁血栓形成的影响。方法: 回顾性分析340例心肌梗死后室壁瘤形成患者的临床资料,根据是否并发严重二尖瓣返流分为严重二尖瓣返流组与非严重二尖瓣返流组,严重二尖瓣返流组84例,二尖瓣返流较轻或无返流256例,归为非严重二尖瓣返流组,比较两组左房直径、左室舒张末期直径、左室收缩末期直径、室间隔及左室后壁厚度、左室射血分数及左室附壁血栓发生率。结果: 分析结果显示,严重二尖瓣返流组的左室附壁血栓发生率明显低于非严重二尖瓣返流组(11% vs. 22%,P<0.05)。严重二尖瓣返流组的左房直径、左室舒张末期直径、左室收缩末期直径均大于非严重二尖瓣返流组（均P<0.01)。严重二尖瓣返流组的左室射血分数低于非严重二尖瓣返流组。左室舒张期室间隔厚度及后壁厚度两组无显著差异。结论: 心肌梗死后室壁瘤形成伴严重二尖瓣返流时可能有降低左室附壁血栓形成的作用。     

Changes in mitral regurgitation after balloon aortic valvuloplasty

The coexistence of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) is not infrequent and has been associated with adverse outcome. The aims of this study were to evaluate the change in MR severity and to identify the correlates of MR improvement in patients with severe AS and moderate to severe MR who underwent balloon aortic valvuloplasty (BAV). Patients with severe AS and at least moderate MR who underwent their first BAV procedures (n = 74) were divided into 2 groups: patients with improved- (n = 34 [46%]) and those without improved (n = 40 [54%]) MR after BAV on transthoracic echocardiography. The population had a mean age of 84 years and was more frequently female (63.5%), with a high risk profile (mean Society of Thoracic Surgeons score 15%, mean European System for Cardiac Operative Risk Evaluation score 57%). Baseline characteristics were balanced between the 2 groups. Patients with improved MR after BAV had smaller left atrial dimensions (45 ± 7 vs 49 ± 7 mm, p = 0.01) and lower peak aortic velocities (3.7 ± 0.6 vs 4.0 ± 0.8 m/s, p = 0.05) and mean transaortic valve gradients (33.2 ± 12.1 vs 40.6 ± 17.4 mm Hg, p = 0.05) at baseline. Left atrial dimension [odds ratio (OR) 3.37, p = 0.006], left ventricular end-diastolic dimension (OR 2.7, p = 0.04), and mean transaortic valve gradient (OR 1.04, p = 0.05), but not left ventricular systolic function or functional MR, were correlated with MR improvement by logistic regression analysis. In conclusion, nearly half of the patients with severe AS and coexistent MR showed improvement in the magnitude of MR after BAV. Larger left atrial and left ventricular end-diastolic dimensions and higher transaortic valve gradients were associated with lack of MR improvement.     

Mitral valve prolapse secondary to right ventricular enlargement in patients with pulmonary hypertension after toxic rapeseed oil ingestion

A high incidence of mitral valve prolapse (MVP) has been reported in various entities which produce important right ventricular (RV) enlargement with normal or decreased left ventricular (LV) volume. To evaluate the importance of RV enlargement in the genesis of MVP in these cases, we analyzed the echocardiographic studies from 176 patients with 'Síndrome Tóxico'. These patients underwent M-mode, cross-sectional and pulsed Doppler examination because of the suspicion of having dietary pulmonary hypertension, a complication which occurred in almost 20% of patients with this epidemic poisoning and which showed a course of gradual resolution in most of them. RV size was classified according to the RV/LV maximal short-axis dimension ratio as normal, border-line, moderately enlarged and severely enlarged. MPV was diagnosed according to standard M-mode and cross-sectional echocardiographic criteria. A second echocardiographic examination was obtained in 38 patients 12.5 +/- 5.3 months after the first one. The incidence of MVP was 9.3% in patients with normal RV size (N = 107), 9.5% in patients with border-line RV size (N = 23), 30% in patients with moderate RV enlargement (N = 30) and 56% in patients with severe RV enlargement (N = 16) (P less than 0.001). Fourteen (77%) of the 18 patients with MVP and moderate or severe RV enlargement (N = 16) (P less than 0.001). Fourteen (77%) of the 18 patients with MVP and moderate or severe RV enlargement had holosystolic MVP. At pulsed Doppler examination, no patient showed signs of mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)