小儿膜周部室间隔缺损封堵术后心电图长期随访

目的 长期随访儿童经导管介入封堵膜周部室间隔缺损(ventricular septal defect,VSD)后心电图(ECG)各值,了解ECG改变规律及其转归.方法 对患膜周部VSD并成功介入封堵的290例患儿进行术后ECG随访.所有患儿术前术后均检查ECG,术后分别于1、3、6个月及1、2、3、5、8年复查ECG,电脑自动测算心率(V)、P-R间期、QRS间期、QT间期及校正的QT(QTc)值,观察心律及ST-T的变化.结果 随访时间:1~96个月[平均(40.16±29.2)个月].行多因素分析发现小儿膜周部VSD引起心电改变的危险因素是年龄在6周岁以内,膜部瘤样VSD,选择封堵器大于VSD直径3 mm以上者.封堵术后290例中115例(39.7%)出现各种轻重不等的ECG改变,进入5年以上长期随访的200例中持续ECG改变者43例(21.5%).但这些患儿均无症状,生长发育良好.随访80例经过应用激素和营养心肌治疗者中仅17例仍存在ECG的改变(21.3%),未经过治疗的35例,持续存在ECG改变者有26例(74.3%).随访5年以上仍需特别关注并定期随访的ECG改变者有25例(25/200例,12.5%).持续ECG改变组与术前组及无ECG改变组的各值对比,均有显著差异.对于出现重度房室传导阻滞(AVB)的患儿及时放置临时起搏器以及激素和营养心肌等治疗的病例预后较好.结论 本组随访提示封堵膜周部VSD慎重选择封堵器型号至关重要.对封堵术后ECG出现异常改变者,应用激素、果糖和维生素等营养心肌治疗,对心律失常的恢复或缓解有帮助.封堵术后早期发生ECG改变大部分轻微或可恢复,对一些明显的ECG改变,随访中未发现有转为三度AVB并影响患儿生长发育的病例,但对于一些ECG值的改变需要更长期随访以了解其转归和预后.     

小儿室间隔缺损封堵术并发心律失常的护理

目的探讨小儿室间隔缺损（VSD）经导管封堵术后心律失常的特征、防治,总结护理措施。方法选择2001年6月-2007年12月在我科住院并成功接受经导管封堵术的166例小儿VSD患者为研究对象,对封堵术中持续心电监护和术后1～7d常规心电图报告进行回顾性分析,总结心律失常发生的类型。结果166例小儿VSD患者术后心律失常明显增加;术后新发不完全性右束支传导阻滞（IRBBB）10例,完全性右束支传导阻滞（CRBBB）8例,加速性交界性心动过速伴干扰性房室分离4例,左前分支阻滞4例,CRBBB加左前分支阻滞2例,高度房室传导阻滞（AVB）5例。结论小儿VSD封堵术后新发生的心律失常以心脏传导阻滞为主,早期激素治疗有效,预后良好。     

室间隔缺损介入封堵并发Ⅲ度房室传导阻滞44例分析

自2002年国内I临床应用Amplatzer或国产封堵器关闭室间隔缺损（VSD）以来，总体结果满意，但部分患者会出现Ⅲ度房室传导阻滞（Ⅲ度AVB），严重者最终需安装永久起搏器。检索并回顾分析国内2002年至今文献报告的VSD介入封堵发生的Ⅲ度AVB病例，探讨VSD封堵时发生Ⅲ度AVB的特点及处理。     

室间隔缺损介入治疗术后Ⅲ度房室传导阻滞的特点及防治

目的探讨经导管介入治疗先天性心脏病室间隔缺损（ventricular septal defect,VSD）发生Ⅲ度房室传导阻滞的特点及防治。方法观察本院先天性心脏病诊疗中心VSD患者763例,男352例,女411例,年龄1．6～18岁,平均（8．2±6．0）岁。分析所有患者封堵术前后心电图的变化、经胸心脏彩色超声多普勒的VSD病变特点及植入的封堵器的情况。结果术后3～5天发生Ⅲ度房室传导阻滞5例,其中1例术中出现Ⅲ度房室传导阻滞,药物治疗后恢复窦性心律;3侧术前心电图即存在右束支传导阻滞;1例封堵器型号偏大。4例经激素治疗、营养心肌治疗在发生Ⅲ度房室传导阻滞7～10天内心电图恢复正常;1例经临时心脏起搏7天后心电图恢复正常,该患者在术后3个月再次间断出现Ⅲ度房室传导阻滞,内科治疗无效,于15个月后安装永久起搏器。结论术前有柬支传导阻滞、术中出现一过性柬支传导阻滞或房室传导阻滞的膜周部VSD是术后发生Ⅲ度房室传导阻滞的高危因素。对于这类患者,在介入操作中要动作轻柔,切忌粗暴牵拉,谨慎选择封堵器,术后强化激素治疗。     

急性心肌梗死早期合并完全性右束支传导阻滞的临床与预后

目的 对288例无合并或同时合并完全性右束支传导阻滞（RBBB）的急性心肌梗死（AMI）患者的临床特点及预后指标作回顾性分析，评估AMI早期合并RBBB的临床意义。方法 非右束支传导阻滞AMI（NRBBB—AMI）组236例，RBBB—AMI组52例。观察AMI患者住院期间与RBBB发生的相关临床及预后指标，包括新发生的RBBB、双束支传导阻滞、短暂或持续状态、溶栓治疗患者比例、溶栓再通率、各种恶性心律失常发生率、左室射血分数（LVEF）、心功能Killip分级患者比例、早期死亡率等，并作对比性分析。结果 合并完全性RBBB-的AMI患者，特别是合并双束支传导阻滞者，大面积心肌梗死患者的比例显著高于无合并RBBB患者（P〈0．05），而接受溶栓治疗的患者比例显著低于无RBBB的患者（P〈0．01），合并RBBB患者发生快速或缓慢心律失常的比例、Killip分级≥Ⅲ的患者比例、心源性休克比例及早期死亡率均显著高于无合并RBBB患者（P〈0．05或P〈0．01），而射血分数（EF）、溶栓再通率低于或显著低于无RBBB患者。结论 完全性RBBB在AMI早期提示预后不良，尽早血管重建如溶栓治疗对改善AMI合并RBBB患者的临床预后有积极的影响。     

超声斑点成像技术评价左心室长轴心肌节段应变与位移

目的 评价生理和病理状态下左心室壁长轴方向心肌节段应变、位移和内径改变及三者之间的相关性。方法 获取心脏起搏组（12例）、右束支传导阻滞组（13例）、对照组（14例）标准心尖四腔观；分别测量计算室间隔、侧壁的心尖和基底四个节段长轴峰值应变和位移以及舒张末和收缩末内径差值；比较各组问测值差异并分别进行各参数间的相关分析。结果 心脏起搏组室间隔基底段峰值应变大于心尖段（P〈0．05）；对照组侧壁基底段峰值位移及相对心尖段峰值位移大于右束支阻滞组和起搏器组（P〈0．05）；右束支阻滞组侧壁应变差与相对位移显著相关（r=-0．607，P=0．037）。结论 起搏导致的拳川隔基底段应变异常增高和右束支传导阻滞导致的心尖和基底节段峰值位移及相对位移降低将会减低左心室射I衄能力。未能在多数节段建立长轴应变、位移和内径的相关关系，表明心尖与基底相对扭转对心室收缩功能更为重要。     

介入封堵治疗膜部室间隔缺损24例临床护理

目的：探讨先天性心脏病介入封堵治疗膜部室间隔缺损（VSD）的临床护理方法。方法：24例膜部VSD患者,超声测量VSD直径3～10 mm,左室造影测量VSD直径3～11（7.6±1.9）mm,选用Judkins右冠状动脉导管和Terumo导丝,通过室间隔建立轨道,用国产膜部室间隔封堵器行封堵治疗。结果：23例封堵治疗成功,1例因发生完全性右束支传导阻滞放弃治疗,2例术后有微量残余分流,6个月后复查超声心动图示1例有微量残余分流,无封堵器脱落及其他并发症。结论：应用国产封堵器治疗膜部VSD操作简便,疗效可靠安全,精湛的手术与优质的护理配合是手术成功的关键。     

小儿膜周部室间隔缺损介入治疗围术期并发症的预防与处理

目的探讨小儿膜周部室间隔缺损（VSD）经导管介入治疗的并发症及其预防。方法对362例行介入治疗后的膜周部VSD患儿临床资料进行回顾性分析。结果所选封堵器大小为4～16mm（平均8．6mm），345例（96．2％）封堵成功。并发症发生情况：Ⅲ度房室传导阻滞5例，Ⅱ度房室传导阻滞3例，交界区性心律4例，室性期前收缩5例，完全性左束支传导阻滞6例,完全性右束支传导阻滞4例，主动脉瓣关闭不全2例，三尖瓣关闭不全3例，残余分流3例，基底节区脑梗死1例，股动脉假性动脉瘤5例，股动静脉瘘5例，股动脉血栓3例，溶血、血尿1例，交换导丝断裂1例，猪尾导管断裂1例。结论经导管介入治疗小儿VSD相对安全，但应进一步加强其并发症的防治。     

宽QRS波左心室节段应变与容积相关性的超声研究

目的 应用动态三维超声心动图和组织多普勒成像（TDI）技术评价不同病因宽QRS波左心室节段应变与容积的相关性。方法 采用彩色多普勒超声诊断仪对18例正常健康人、8例束支传导阻滞患者及11例安置起搏器患者分别采集心脏三维容积灰阶图像和组织多普勒二维图像，并应用QLAB分析软件，自动计算左心室17个节段容积和室壁心肌应变值。结果 正常组（除前壁心尖段和后壁基底段，11％节段P〉0．05）和右束支阻滞组（除室间隔基底段、前壁心尖段和后壁中段，22％节段P〉0．05）各节段心肌容积与应变呈负相关（P（0．05），其回归方程中截距依节段递减（基底段〉中段〉心尖段）；左束支阻滞组各节段心肌容积与应变的相关性差（P〉0．05），室间隔最明显；起搏器组大部分节段应变与容积无良好相关性（前壁51％节段及后壁36％节段P〉0．05），前壁最明显。结论 右束支阻滞组左心室心肌收缩运动协调，左束支阻滞组、宽QRS波和窄QRS波起搏组心肌收缩运动不协调，导致节段容积呈不规则改变。     

急性心肌梗死并发传导阻滞的演变、转归及对策分析

目的：分析急性心肌梗死并发传导阻滞的分布、演变、近期转归并探讨其临床对策。方法：对139例急性心肌梗死并发传导阻滞情况进行回顾性统计研究。结果：下壁心肌梗死时AVB的发生率明显高于前壁心肌梗死（P〈0．01），进展为渐进性，且多在数日内自行恢复；前壁。心肌梗死时室内阻滞的发生率明显高于下壁心肌梗死（P〈0．01），进展多为突发性，猝死率极高。结论：下壁心肌梗死并发Ⅲ°AVB应以药物治疗为主；前壁心肌梗死并发双束支阻滞应及时安装临时起搏器。     

Complete Atrioventricular Block Following Mediastinal Irradiation: A Report of Six Cases

Complete atrioventricular block (AVB) following radiotherapy has been reported rarely, usually after high dose mediastinal irradiation for Hodgkin's disease or lung or breast carcinoma. We report six new cases of episodic complete infranodal AVB, requiring permanent pacemaker implantation. The mean age was 48-years old (ranging from 25-60) at the first Adams Stokes attack, mean delay was 12 years after irradiation (10-18), and mean radiation dose was 5,200 rads (4,000-6,500). All patients had abnormal interval electrocardiograms (right bundle branch block in two, left bundle branch block in three, alternating left and right bundle branch block in one). Electrocardiograms during the episode of AVB or Holter recordings were consistent with infranodal block in all patients; electrophysiological study performed in five patients confirmed infranodal AVB in four, and one was normal. Pericardial disease was constant, which included pericardial constriction in four patients. Two patients died after failure of pericardiectomy to improve congestive heart failure, due to epicardial, myocardial, and endocardial involvement. Noncardiac mediastinal lesions were present in four cases. Since this delayed complication may occur in patients of such age that the relation between the AVB and the chest irradiation is questionable, we propose the following etiologic criteria; high radiation dose (over 4,000 rads); delay of 10 years or more; abnormal interval tracings; pericardial involvement; and associated cardiac or mediastinal radiation-induced lesions.     

连续缝合与间断缝合法在膜周型大室间隔缺损修补术中的应用

目的 比较应用连续缝合法与间断缝合法修补膜周型室间隔缺损(VSD)的外科技术并进行疗效评价.方法 膜周型室间隔缺损患者158例,其中102例(65%)应用连续缝合法(连续缝合组),56例(35%)应用间断缝合法(间断缝合组).手术均在浅低温体外循环下矫治.结果 连续缝合组体外循环时问和主动脉阻断时间分别为(31±14)、(18±12)min,间断缝合组体外循环时间和主动脉阻断时间分别为(42±16)、(25±11)min,2组比较差异均有统计学意义(t=4.49,3.61;P均<0.01).全部患儿手术后无死亡.主要并发症有:暂时性Ⅲ度房室传导阻滞(AVB)2例,连续缝合组及间断缝合组各发生1例,均于术后1周内消失;残余分流2例,连续缝合组发生1例,间断缝合组发生1例,分流束<3 mm,术后3~6个月复诊时自行闭合;完全性右束支传导阻滞(CRBBB)9例,连续缝合组发生3例(2.94%)、间断缝合组发生6例(10.71%),其中3例于手术后1个月复查时消失,2例于手术后1年复查时消失.随访1~3年,所有患者手术效果良好.结论 连续缝合法修补膜周型大VSD具有简化手术操作技术、减少体外循环时间和主动脉阻断时间、减少心内异物存留、降低传导阻滞及残余分流发生率等优点.     

确定封堵部位选择合适封堵器封堵膜部瘤型室间隔缺损的效果

背景:对于大入口多出口的膜部瘤型室间隔缺损,如果采用对称型或偏心型室间隔缺损封堵器,有时难以完全封堵.目的:观察A4B2封堵器封堵膜部瘤型室间隔缺损的可行性,根据膜部瘤大小选择合适封堵器对封堵效果的影响.设计:病例分析.单位:河北医科大学第一医院.对象:2004-08/2006-05拟在河北医科大学第一医院行介入治疗的室间隔缺损伴膜部瘤形成226例患者中,对造影术显示膜部瘤为大入口多出口的36例患者应用A482封堵器封堵治疗.36例室间隔缺损伴膜部瘤形成患者,造影测量室缺左室面破口(入口)直径平均为(10.6±8.7)mm(8-21 mm),右室面均有多个出口,最大右室面破口(出口)直径平均为(3.1±2.9)mm(2-8mm).主要材料:封堵器与输送装置由上海形状记忆合金材料有限公司和北京华医圣杰科技有限公司生产.采用医用镍钛形状记忆合金等材料,经特殊工艺加工制作成双盘形,专用于先天性心脏病室间隔缺损的封堵治疗.封堵器的型号大小以腰部直径来表示,可选型号为4-16 mm.方法:①应用7～10 F输送鞘管从右心系统送入相应封堵器.②选择不同型号A4B2封堵器,置入封堵器直径为4～16mm,平均(6.3±2.4)mm.⑨封堵后15 min 重复左心室造影和经胸心脏超声检查,观察封堵的即刻效果.封堵后l,3,6,12个月定期进行心电图、心脏超声检查.主要观察指标:封堵后有无残余分流、心律失常以及心脏各瓣膜功能是否受到影响.结果:①封堵膜部瘤左室面破口16例,封堵器完全置于瘤体内封堵瘤体16例,封堵膜部瘤右室面破口4例.②36例患者封堵后15 min左心室造影、经胸心脏超声检查显示32例完全封堵,3例造影示少量分流(<3 mm),(其中2例发生在封堵器完全置于瘤体内:1例发生在封堵膜部瘤右室面破口封堵后),其中2例24 h后心脏超声复查无残余分流,1例1个月后超声复查无残余分流.⑨术中并发左、右束支传导阻滞分别为3例和2例,均为一过性,1周内恢复.④封堵器置入体内后血小板黏附较少,凝血功能检查、免疫系统反应(免疫球蛋白、补体)、材料表面再内皮化反应均正常,未发生炎症等宿主反应.无封堵器脱落等材料反应发生.结论:经导管采用A4B2封堵器治疗膜部瘤型室间隔缺损,关键在于对膜部瘤大小、形态、位置及膜部瘤组织粘连牢固程度判断并以此来确定封堵部位及选择合适的封堵器.     

A case of complete atrioventricular block associated with primary cardiac lymphoma reversed without cardiac pacemaker implantation

Primary cardiac lymphoma (PCL) is a rare malignant lymphoma that is characteristically confined to the heart and/or pericardium. Here, the case of a 70-year-old male patient with complete atrioventricular block (AVB) associated with PCL is presented. The patient had a 10-month history of palpitation and electrocardiogram (ECG) showed a complete AVB. Additionally, transthoracic echocardiography indicated pericardial effusion where atypical lymphoid cells were identified by pericardiocentesis. Subsequent mediastinal lymph node biopsy revealed non-germinal centre diffuse large B-cell lymphoma. Therefore, a diagnosis of PCL was confirmed. As the patient’s vital signs were stable, he was prescribed chemotherapy without pacemaker implantation. After chemotherapy, the patient achieved remission and dynamic ECG demonstrated no recurrence of AVB. The present case demonstrates that although PCL initially manifesting as complete AVB is rare, this possibility should not be ignored when a new AVB without definite aetiology is encountered. In addition, if the vital signs of the patient are stable, pacemaker implantation may be postponed until the treatment effect of chemotherapy has been assessed.     

介入封堵治疗儿童室间隔缺损并主动脉瓣脱垂疗效分析

目的探讨不同类型室间隔缺损（ventricularseptaldefect,VSD）并主动脉瓣脱垂（aorticvalveprolapse,AVP）介入治疗的个体化治疗方案。方法28例VSD并AVP患儿行经皮封堵术,经胸超声心动图及左心室造影进行诊断及分类。结果15例为膜周流出道型,7例为隔瓣后型,6例为膜周部型;患者均伴有局限AVP;VSD直径2．5～9．2mm,20例缺损口上缘距主动脉瓣〈2mm;介入治疗成功率89．3％（25／28）;未出现三尖瓣、主动脉瓣狭窄及主动脉瓣穿孔,无Ⅲ度房窀传导阻滞等严重心律失常发生。结论介入治疗不同类型VSD并AVP安全、有效。     

Relationship between polymorphism of non-coding regions of human mitochondrial genome and primary cardiac conduction disorders

AIM: Analysis of associations between idiopathic disturbances of cardiac conduction (DCC) and polymorphism of mitochondrial genome. MATERIAL AND METHODS: A family examination was performed in 431 probands with various DCC and 1347 relatives of the first, second and third degree of kinship (the study group). All the examinees were divided into four subgroups. These included 158 probands with atrioventricular block (AVB) of various degree and their 518 relatives (subgroup 1); 50 probands with a complete right bundle-branch block (BBB) and their 161 relatives (subgroup 2); 108 probands with a complete left BBB and left anterior branch of the His bundle and their 152 relatives (subgroup 3); 115 probands with sick sinus syndrome (SSS) and their 327 relatives (subgroup 4). The control group consisted of 104 probands without clinical ECG manifestations of cardiac diseases and their 321 relatives. All the examinees have undergone ECG, atropin test, echocardioscopy, electrophysiological examination of the heart and mitochondrial DNA (mDNA). RESULTS: Comparison of the incidence of mDNA D-loop restriction sites in the group of patients with idiopathic DCC and controls has found higher frequency of the Hae III 16517 site in the group of the patients (p = 0.0480). By location of the blocks (atrioventricular and intraventricular), the site occurred more frequently in patients with AVB (86.36%). The variant "+" by the site of Hae III 16517 mDNA was found to associate with disturbances of cardiac conduction, more closely in AVB. CONCLUSION: Variability of mDNA may be an etiological factor of idiopathic DCC pathogenesis.     

Transient Complete Heart Block During Radiofrequency Ablation of a Left Lateral Bypass Tract

RF catheter ablation of accessory bypass tracts associated with the Wolff-Parkinson-White: syndrome has become an accepted and widespread therapy. When bypass tracts are located in the free wall of the left ventricle, a single catheter technique may be utilized. A single catheter is placed via the femoral artery, across the aortic valve into the left ventricle. Mapping is performed during sinus rhythm, and ablation performed at the site of recording of Kent bundle activation. We describe a case of a patient with Wolff-Parkinson-White syndrome presenting with rapid atrial fibrillation requiring cardioversion. This patient subsequently underwent catheter ablation of a left free-wall bypass tract using the single catheter technique. At baseline, preexcitation and right bundle branch block (RBBB) were present on the ECG. During catheter ablation of the accessory pathway, transient complete AV block was seen. This was felt likely to be due to trauma to the His bundle, or more likely to the left bundle branch, as the ablation catheter crossed the aortic valve. The bypass tract was successfully ablated after placement of a temporary right ventricular pacemaker. AV conduction resumed with a pattern of RBBB. A temporary right ventricular pacing catheter should be placed prior to RF ablation of left-sided bypass tracts when the ECG is also suggestive of RBBB.     

特勤人员右束支阻滞心电图特点及其健康鉴定

目的分析特勤人员右束支阻滞心电图特点，为其健康鉴定提供参考依据。方法逐例分析右束支阻滞心电特点及临床体检资料。结果右束支阻滞患病率为0.8％（47／5952），其中不完全性右束支阻滞29例（0．5％），完全性右束支阻滞18例（0．3％）；完全性右束支阻滞QRS时限在0．12～0．14s者12例（66．7％）、0．15～0．16s者6例（33．3％）；完全性右束支阻滞者QTc间期〉0．44s有5例（27培％），但JTc间期均正常（〈0．36s）；45例（95．7％）右束支阻滞存在多年无变化，健康鉴定结论合格，2例（4．3％）出现动态变化，定为暂不合格。结论特勤人员右束支阻滞绝大多数为非病理性，健康鉴定结论合格，但对右束支阻滞有动态变化或40岁以上发生者，应注意结合临床体检资料综合鉴定。