Staged Fontan procedure for mitral atresia associated with severe tricuspid regurgitation, pulmonary hypertension, and pulmonary artery distortion

Optimal initial palliation and a subsequent staged approach is mandatory for high-risk Fontan candidates. We describe the case of mitral atresia with severe tricuspid regurgitation and pulmonary hypertension successfully managed by repeated palliation from the neonatal period and 2-stage Fontan surgery. A 1-month-old boy diagnosed with mitral atresia and double-outlet right ventricle underwent pulmonary artery banding at 1 month of age, followed by repeated pulmonary artery banding accompanied by tricuspid annuloplasty and atrial septal defect enlargement at 6 months. Because of the presence of pulmonary artery distortion, right ventricular dysfunction, and borderline pulmonary vascular resistance, a hemi-Fontan procedure was conducted with extended pulmonary artery plasty when the boy was 3 years and 8 months old. Cardiac catheterization done 3 months after showed improvement in risk factors, and the final Fontan operation (total cavopulmonary connection) was successfully done in conjunction with repeated tricuspid annuloplasty when the boy was 4 years and 5 months old. The patient remains in excellent clinical condition at the last follow-up 5 years after the final Fontan procedure with sinus rhythm and good ventricular function.     

Repair of tricuspid valve with pulmonary valve replacement in repaired tetralogy of fallot

Objectives: We aimed to investigate the outcome of tricuspid valve repair (TVR) performed concomitantly with pulmonary valve replacement in repaired tetralogy of Fallot (TOF) patients. Design: This retrospective study included all patients who underwent pulmonary vale replacement from 2000 to 2016 after TOF correction. TVR patient data were compared to those of patients who underwent pulmonary vale replacement alone. Results: Thirty-eight patients were enrolled. The degree of tricuspid regurgitation was significantly decreased after operation in the TVR group. Tricuspid valve annulus and annuloectasia before operation did not vary between groups (21.1?±?6.3 and 41.4% in no TVR vs. 21.3?±?4.8 and 52.6% in TVR). However pre-operative right ventricular volumes were larger in the TVR group. Normal tricuspid valve coaptation (body to body) was observed less frequently in the TVR group than in the other group (52.6% vs. 93.1%, p < .001). Pre-operative tricuspid regurgitation had a linear correlation with right ventricular volume, but not with tricuspid annulus size. Conclusion: Tricuspid annulus diameter decreased significantly regardless of TVR. Abnormal coaptations were observed more in patients group and the degree of pre-operative tricuspid regurgitation was linearly correlated with right ventricular volume rather than tricuspid annulus size.     

Impact of systolic pulmonary artery pressure on all-cause mortality in elderly cardiac patients

Objective. Elevated systolic pulmonary artery pressure (sPAP) is common among elderly patients with cardiac and pulmonary diseases. The lowest level of sPAP associated with increased mortality rate in octogenarians with cardiac diseases is however not sufficiently studied. Therefore, the present study aimed to identify the lowest level of sPAP associated with increased 5-year all-cause mortality in this patient group. Design. Of 538 octogenarians presented at the three Sahlgrenska University Hospitals (Sahlgrenska, Östra and Mölndal) with either congestive heart failure (CHF) or acute coronary syndrome (ACS), only 302 patients who had undergone echocardiography with data on sPAP were included in the present study. In order to identify the lowest level of sPAP associated with increased mortality rate, Cox proportional-hazard regression multivariable models were built for sPAP levels as low as 30?mmHg and upward with 5?mmHg intervals. Results. sPAP?>35?mmHg was identified as the lowest level associated with increased 5-year all-cause mortality (HR?=?1.7, 95% of CI?=?1.1–2.6 and p?=?.013). Every increase of 5?mmHg in sPAP was associated with a 10% increased relative risk for all-cause mortality. Conclusions. In octogenarians with cardiac diseases the lowest level of sPAP associated with increased all-cause mortality was >35?mmHg and the mortality rate increased with increasing sPAP.     

Inaccuracy of pulse oximetry in patients with severe tricuspid regurgitation

The accuracy of pulse oximetry was studied in a group of patients with severe tricuspid regurgitation. Measurements of arterial oxygen saturation from a finger and an ear probe were compared with those from a radial arterial blood sample analysed in vitro. Lower values were obtained using the pulse oximeter; the difference ranged from +2% to -11%. The discrepancies between pulse oximeter and laboratory oximeter readings were greater in this group of patients than in a control group who did not have tricuspid regurgitation. There was, however, no correlation between the magnitude of this discrepancy and either the peak central venous pressure or the venous pulse pressure.     

Interstage evaluation of homograft-valved right ventricle to pulmonary artery conduits for palliation of hypoplastic left heart syndrome

Objective

Palliation of hypoplastic left heart syndrome with a standard nonvalved right ventricle to pulmonary artery conduit results in an inefficient circulation in part due to diastolic regurgitation. A composite right ventricle pulmonary artery conduit with a homograft valve has a hypothetical advantage of reducing regurgitation, but may differ in the propensity for stenosis because of valve remodeling.

The second peak of the radial artery pressure wave represents aortic systolic pressure in hypertensive and elderly patients

Background. Simultaneous measurement of ascending aorta andradial artery pressure shows that mean and diastolic pressures(DP) are in close agreement in normotensive adults, while systolicpressures (SP) are not. However, in the aortic pressure wave,a second systolic peak appears with increasing age and increasesto represent the SP by age 32 yr, while in the radial artery,a second systolic deflection appears by age 40 yr. We suggestthat the second radial systolic wave, sometimes seen duringradial arterial pressure monitoring in older hypertensives,represents the aortic SP. We set out to evaluate whether theaortic and radial second systolic peaks agree, and since doubtsexist about the agreement between aortic and radial DP in elderlyhypertensive patients, we also assessed that relationship. Methods. We compared simultaneously recorded radial and aorticpressures from 21 anaesthetized adult patients using identicalfluid-filled pressure measuring systems. Conclusions. The second radial pressure peak agreed with thatin the aorta within a mean of 0.6 (SD 1.5) mm Hg. The differencebetween DP in the aorta and radial artery was –1.4 (2)mm Hg. The radial–aortic SP and pulse pressure differenceswere 5.9 (7.6) and 7.3 (7.6) mm Hg, respectively. These resultsconfirm that when the radial artery pressure wave shows a firstand second, or only a second systolic shoulder/peak (on theright side of the pressure wave), the second represents themaximal ascending aortic SP, and that the radial and aorticDP are equivalent, even in older hypertensive patients. Br J Anaesth 2004; 92: 651–7     

终末期心力衰竭合并可逆性肺动脉高压患者心脏移植指征的探讨

心脏移植是挽救终末期心力衰竭患者生命并改善其生活质量的方法,但并非所有的终末期心力衰竭患者都适合心脏移植。肺动脉高压作为终末期心力衰竭的常见并发症,可能会增加心脏移植术后右心衰竭的发生率,其与心脏移植术后受者的早期和晚期死亡风险相关。在临床实践中,不同移植中心对终末期心力衰竭合并肺动脉高压患者心脏移植指征的评判标准不一。术前正确地评估手术指征是决定心脏移植能否成功的重要因素。本文综述了肺动脉高压的定义、病因及其对心脏移植的影响、诊断方法及其可逆性的判断,可逆性肺动脉高压的诊断性治疗及终末期心力衰竭合并可逆性肺动脉高压患者心脏移植指征。     

肺动脉高压幼犬肺动脉压力与肺动脉结构的关系

目的 探讨肺动脉高压（ＰＨ）时肺动脉压力（ＰＡＰ）与结构的关系。方法 实验幼犬１５条,分２组：分流组（ｎ＝１２）,正常对照组（ｎ＝３）。分流术后９０ｄ两组行血流动力学检测后,放血处死,肺组织切片行病理学检测。结果 （１）分流组左下肺动脉压（ＰＬＬＰＡ）由１．３６ｋＰａ（１ｋＰａ＝０．７５ｍｍＨｇ）升至１１．１３ｋＰａ,左下肺血管阻力（ＬＬＰＶＲ）由５．６５Ｗｏｏｄ’ｓ单位升至１４．３１Ｗｏｏｄ’ｓ     

Repair of tetralogy of Fallot associated with anomalous origin of right pulmonary artery and accessory left anterior descending coronary artery

We present an unusual combination of lesions in an 8-month-old child diagnosed with tetralogy of Fallot, anomalous origin of right pulmonary artery, and anomalous coronary artery crossing the pulmonary annulus. The association of anomalous origin of branch pulmonary artery from aorta and tetralogy of Fallot (TOF) is extremely rare with an incidence of 0.4%. The incidence of anomalous coronary artery in TOF is 10.3%. However, a combination of all three lesions poses challenges to surgical repair and has not been previously reported.     

Inhaled nitric oxide lowers pulmonary capillary pressure and changes longitudinal distribution of pulmonary vascular resistance in patients with acute lung injury

In acute lung injury (ALI), where pulmonary microvascular permeability is increased, transvascular fluid filtration depends mainly on the hydrostatic capillary pressure. In the presence of intrapulmonary vasoconstriction pulmonary capillary pressure (PCP) may increase thereby promoting transvascular fluid filtration and lung oedema formation. We studied the effect of 40 ppm inhaled nitric oxide (NO) on PCP and longitudinal distribution of pulmonary vascular resistance (PVR) in 18 patients with ALI.
PCP was estimated by visual analysis of the pressure decay profile following pulmonary artery balloon inflation. Contribution of venous pulmonary resistance to total PVR was calculated as the percentage of the pressure gradient in the pulmonary venous system to the total pressure gradient across the lung.
Inhalation of 40 ppm NO produced a prompt decrease in mean pulmonary artery pressure (PAP) from 34.1 6.8 to 29.65.7 (s.d.) mmHg; ( P < 0.0001). PCP declined from 24.86.2 to 21.65.2 mmHg; ( P < 0.0001) while pulmonary artery wedge pressure (PAWP) did not change. PVR decreased from 16673 to 12850 dyn sec cm^-5; ( P < 0.0001). Pulmonary venous resistance (PVRven) decreased to a greater extent (from 7641 to 5028 dyn. sec. cm^-5; ( P < 0.001) than pulmonary arterial resistance (PVRart) (from 9036 to 7929 dyn sec cm^-5; ( P < 0.01). The contribution of PVRven to PVR feU from 44.310.8 to 37.811.9%; ( P < 0.01). Cardiac output (CO) remained constant. The findings demonstrate that NO has a predominant vasodilating effect on pulmonary venous vasculature thereby lowering PCP in patients with ALI.     

静脉输注米力农抑制慢性肺动脉高压患者使用苯肾上腺素后的肺动脉压增高

慢性肺动脉高压患者施行心脏手术时,由于其心功能较差,长期进行利尿和术前禁食使血容量不足等原因,在麻醉诱导的过程中可发生血压过低,此时常用α受体激动剂苯肾上腺素提升血压。一些有关急性肺动脉高压的动物实验和临床研究报道：苯肾上腺素可以有效地升高血压,增加心输出量,同时降低肺动脉压力（PAP）和肺血管阻力指数（PVRI）。然而对于慢性肺动脉高压患者来说,苯肾上腺素可能增加PAP和PVRI。米力农为腺苷-3＇,5＇-cAMP选择性磷酸二酯酶抑制剂,可以有效地降低严重的肺动脉高压。本研究旨在探讨米力农对于慢性肺动脉高压的作用,观察在慢性肺动脉高压患者行心脏手术时米力农能否抑制苯肾上腺素引发的PAP和PVR增高。     

地氟醚对颅脑手术病人脑脊液压力及大脑中动脉血流速度的影响

目的 观察地氟醚以不同ＭＡＣ值维持麻醉期间对脑脊液压力（ＣＳＦＰ）和大脑中动脉血流速率（ＶｍＭＣＡ）的影响。方法 ６０名颅内肿瘤病人，随机分为２组，Ａ组选用地氟醚维持麻醉，Ｂ组选用异氟醚维持麻醉。每组病人又按维持麻醉的不同ＭＡＣ值分为三小组：分组ＭＡＣ值为０．５、０．８和１．１。通过蛛网膜下腔导管监测ＣＳＦＰ的变化，分别于麻醉前、诱导插管时观察记录，并于ＭＡＣ值稳定于预定值开始，每５分钟测量一次直     

Cavernous artery intima-media thickness predicts the response to sildenafil in erectile dysfunction patients as a morphological parameter

While the intima-media thickness (IMT) of the cavernous artery was used for diagnosis for vascular erectile dysfunction (ED) with more accuracy than the peak systolic velocity, the role of the IMT in predicting treatment responses remained unexamined. A total of 136 patients with ED were enrolled. The baseline clinical and laboratory characteristics were collected. Penile Doppler ultrasonography (PDU) was performed on all patients by a blinded sonographer. Sildenafil was administrated to all patients with an adjusted dose of 50 or 100 mg on demand over a period of 3 months. A follow-up was conducted on all patients using the Erectile Hardness Score (EHS) questionnaire along with the visual and tactile version of the standardised EHS tool. The peak systolic velocity (PSV) and IMT were compared between sildenafil responders and sildenafil nonresponders, while receiver operator characteristic (ROC) curves were used to calculate the cut-off values and compare the test power respectively. There was no statistical difference from the baseline characteristics. The IMT of cavernous artery was more accurate than PSV to predict the sildenafil response (AUC = 0.809, 0.626 respectively). IMT could predict sildenafil responders more accurately than PSV, and the cut-off value of the IMT of the cavernous artery was less than 0.22 mm.