介入性心脏声学造影对房间隔缺损合并部分性肺静脉异位引流诊断价值的探讨

介入性心脏声学造影对房间隔缺损合并部分性肺静脉异位引流诊断价值的探讨夏伟，王玉玮，杨兴季房间隔缺损（ＡＳＤ）常伴发部分性肺静脉异位引流（ＰＡＰＶＣ）。目前常用的诊断方法局限性较大，误诊及漏诊率较高。本研究旨在探索新的诊断技术以提高ＡＳＤ伴ＰＡＰＶＣ术...     

继发孔房间隔缺损与全肺静脉异位引流的心电图和血流动力学比较

观察１１２例房间隔缺损（ＡＳＤ）和３９例全肺静脉异位引流（ＴＡＰＶＣ）的ＥＣＧ，若ＱＲＳ电轴正常、左偏或右偏伴Ｖ１呈ｒＳ，可排除ＴＡＰＶＣ。电轴右偏，Ｒｖ１≥１５ｍｍ，Ｖ１呈单纯Ｒ或ｑＲ型，而Ｖ５～６导联为ｒＳ型伴ＰⅡ≥０．２５ｍＶ高度提示ＴＡＰＶＣ。ＴＡＰＶＣ的心导管检查诊断依据：１．ＳａＱ２８０～９０％，且与肺动脉血氧饱和度相近，２．轻度肺动脉高压（≥４．１ｋＰａ）伴大的左向右分流（Ｑｐ／Ｑｓ＞３∶１），３．导管进入异常途径并采血化验血氧含量高于正常，４．肺动脉选择造影右房提早显影。     

混合型全肺静脉畸形引流的外科治疗

目的：探讨混合型全肺静脉畸形引流（ＴＡＰＶＤ）的外科治疗方法。方法：５例混合型ＴＡＰＶＤ患者，年龄８～２８岁（平均１５．６岁），术前经肺动静脉造影、核磁共振成像及超声心动图确诊均为心内型与心上型的混合型ＴＡＰＶＤ。手术在低温体外循环下进行，４例患者因术中显露或吻合左上肺静脉和左心房困难，故左上肺静脉及垂直静脉未作处理，１例在完成将各条肺静脉引入左心房后，结扎垂直静脉。结果：５例患者均存活，１～１３年随访中均无明显症状，其中１例术后生育１子。结论：混合型ＴＡＰＶＤ术前如诊断明确，手术方案适当，可取得良好的治疗效果；手术应力求做到心内畸形完全矫治，但遗留一支肺静脉汇入体静脉系统，对手术近、远期效果影响均不大     

双腔右心室的术前与术中诊断对比分析

对１７ 例双腔右心室（ＤＣＲＶ） 患者于术前行经彩色多普勒血流显像（ＣＤＦＩ） 检查, 诊断为单纯ＤＣＲＶ４ 例, ＤＣＲＶ 合并室间隔缺损 （ＶＳＤ） ８ 例、肺动脉瓣狭窄 （ＰＳ） １ 例、房间隔缺损（ＡＳＤ） １ 例, 单纯ＶＳＤ２例, 法乐氏四联症１ 例。均经手术治疗, 术中确诊为单纯ＤＣＲＶ４ 例, ＤＣＲＶ合并ＶＳＤ１１ 例、ＡＳＤ１例、ＰＳ１ 例。认为ＣＤＦＩ对ＤＣＲＶ的诊断有较高的准确性, 但对不典型ＤＣＲＶ的诊断仍有一定困难。     

下肢深静脉血栓形成及肺动脉栓塞

本文报告我们自１９９１年３月至１９９５年４月经下肢深静脉核素造影（ＲＮＶ）及核素肺血流灌注显像（ＬＰＳ）等诊断有下肢深静脉血栓（ＤＶＴ）的内科患者２８例，其中并发肺动脉栓塞（ＰＥ）１５例小２８例中，男２３例，女５例，年龄：５４．３±１３．１岁。慢性充血性心力衰竭（ＣＨＦ）１１例，糖尿病高脂血症３例，脑中风１２例，接受激素治疗的肾病２例。２８例５６条下肢ＲＮＶ，３５条下肢示ＤＶＴ。２８例ＤＶＴ中１５例ＬＰＳ示ＰＥ（５３．４％）。该１５例中仅５例临床疑及ＰＥ，提示：ＤＶＴ常并发ＰＥ，二者在内科患者中并不罕见，临床医生宜对其提高警惕，ＲＮＶ及ＬＰＳ目前是其最佳无创性诊断方法。     

心室间隔缺损合并主动脉瓣关闭不全的外科矫治

目的：探讨心室间隔缺损（ＶＳＤ）合并主动脉瓣关闭不全（ＡＩ）的外科矫治方法。　　方法：总结１０６例ＶＳＤ合并ＡＩ的外科治疗经验。主要有干下型ＶＳＤ６６例（６２．３％ ）,膜周部ＶＳＤ２２ 例（２０．８％ ）。主动脉瓣以单叶右冠状动脉瓣脱垂为主（７８例占７３．６％ ）;本组单纯ＶＳＤ修补１４ 例;主动脉瓣成形７５例,主动脉成形主要采用脱垂瓣叶折叠悬吊法和中心型折叠法;主动脉瓣置换１７例。　　结果：手术死亡１ 例。出院检查脉压差均恢复正常。心胸比率以及左心室舒张末径均有明显缩小。ＶＳＤ修补术后无残余分流。　　结论：强调早期治疗,防止ＡＩ的进一步发展。主动脉瓣成形是首选方法     

国人室上性心动过速的性别特征及逆行P波对其折返径路的诊断价值

对９０例室上性心动过速（ＳＶＴ）患者的性别特征与逆行Ｐ波（Ｐ＇）分析结果发现：国人隐匿性房室旁道（ＣＡＰ）多于房室结双通道（ＤＡＶＮＰ），前者以男性为主，后者以女性为主；约２／３的旁道位于左游离壁（ＬＦＷ），１／３位于间隔及右游离壁，ＬＦＷ男性多见，间隔旁道女性多见；房室折返性心动过速Ｐ＇明显且Ｒ－Ｐ＇≥７０ｍｓ，房室结折返性心动过速多无Ｐ＇或Ｒ－Ｐ＇＜７０ｍｓ；Ｐ＇和Ｒ－Ｐ＇对ＡＶＲＴ和ＡＶＮＲＴ的手术前后诊断符合率为１００％。提示：心电图正常者，ＳＶＴ时Ｐ＇明显的男性，多为ＣＡＰ，且多在ＬＦＷ；ＳＶＴ时无Ｐ＇的女性，多为ＤＡＶＮＰ。     

98例食管心房调搏终止室上速的4种方法比较

目的：比较９８例经食管心房调搏（ＴＥＡＰ）终止室上速（ＰＳＶＴ）的４种方法学疗效，并对其作用机理进行探讨。方法：应用国产的ＸＤ－２或ＤＦ－４Ａ型心脏电生理诊断仪对９８例因频敏发作ＰＳＶＴ的患进行ＰＳＶＴ终止，诱发试验，分别采用（１）亚速刺激法，（２）Ｓ１Ｓ２程控刺激法，（３）短阵超速抑制法，（４）超短阵猝发刺激法，终止ＰＳＶＴ。结果：超短阵发刺激法在上各类ＰＳＶＴ的成功离最高平均达９０．９％，高于Ｓ１Ｓ２法程度控刺激法６２．７％（Ｐ〈０．０５）与亚速刺激法４０．５％（Ｐ〈０．１），略优于短阵超速抑制法８８．６％（Ｐ〉０．０５），结论：ＴＥＡＰ终止ＰＳＶＴ，对心肌收缩力，心脏传导系统无影响，无并发症可重复使用，安全且效果评价直观，可作为终止治疗ＰＳＶＴ的首选方法。     

原发性心脏肿瘤的超声心动图诊断价值

目的：应用超声心动图观察原发性心脏肿瘤的发生部位、大小、形态、活动度等，评估超声心动图诊断原发性心脏肿瘤的价值。方法：报告８２例经手术及病理证实的原发性心脏肿瘤病人超声心动图诊断及分析。超声诊断仪为ＡＳＵ－０１０型，ＡＣＵＳＯＮ－１２８ＸＰ型等，探头频率２．５～３．５ＭＨｚ。结果：超声心动图术前诊断８１例，１例因瘤体＜４ｍｍ而漏诊；总显示率为９８．８％，漏诊率为１．２％。结论：超声心动图对原发性心脏肿瘤的诊断具有独特的临床价值和优越性，依据肿瘤超声病理改变对判断肿瘤性质有重要价值。但超声心动图对某些心脏肿瘤很难作出准确的组织病理学诊断。     

风湿性二尖瓣狭窄病人血浆肾上腺髓质素水平变化的初步研究

肾上腺髓质素（ＡＤＭ）是参与心血管活动调节的舒血管活性肽,对病变的心脏有代偿性的保护作用。经皮二尖瓣球囊成形术（ＰＢＭＶ）能使有症状的二尖瓣狭窄病人的短、长期症状及血液动力学状况明显改善。通过测量ＰＢＭＶ术前、后静脉血浆ＡＤＭ浓度值和血液动力学参数,分析二者的关系,来探讨ＡＤＭ在二尖瓣狭窄中的作用和意义。１资料与方法 对象：２０例行ＰＢＭＶ的二尖瓣狭窄病人,年龄３６±岁,心功能（ＮＹＨＡ）分级Ⅱ级１５例,Ⅲ级５例;正常对照１２例,年龄３５±７岁。 方法：ＰＢＭＶ术前及术后第５天常规 Ｈｐ－１５００…     

Respiratory variations in the right ventricular diameter: an echocardiographic element in the diagnosis of partial isolated pulmonary venous return anomaly

Isolated partial anomalous pulmonary venous drainage (PAPVD), in contrast to atrial septal defect (ASD), does not cancel out the effects of respiration on blood flow in the right ventricle. The aim of this study was to see whether this difference could contribute to the diagnosis of PAPVD without ASD on M mode echocardiography. The diastolic dimensions of the right ventricle on expiration and inspiration were compared in 4 groups of patients aged 2 to 17 years. Group 1 comprised 6 children with PAPVD without ASD; Group 2: 10 children with PAPVD and ASD; Group 3: 11 children with isolated non-restrictive ASD, and Group 4: 10 normal children. Groups 1 and 4 were comparable with a respiratory variation of RV dimension of 10 to 29%. On the other hand, in Groups 2 and 3 the percentage variation was less than 6%. The finding of isolated RV dilatation with normal respiratory variation of its internal dimension should therefore alert the operator to the possible diagnosis of PAPVD without ASD.     

Is routine preoperative cardiac catheterization necessary before repair of secundum and sinus venosus atrial septal defects?

Between January 1976 and July 1983, 217 patients with atrial septal defect underwent surgical repair at Children's Hospital. Thirty with a primum atrial septal defect and 26 who underwent cardiac catheterization elsewhere before being seen were excluded from analysis. Of the 161 remaining patients, 52 (31%) underwent preoperative cardiac catheterization, 38 because the physical examination was considered atypical for a secundum atrial septal defect and 14 because of a preexisting routine indication. One hundred nine (69%) underwent surgery without catheterization, with the attending cardiologist relying on clinical examination alone in 5, additional technetium radionuclide angiocardiography in 5, M-mode echocardiography in 13 and two-dimensional echocardiography in 43; both M-mode echocardiography and radionuclide angiography were performed in 24 and two-dimensional echocardiography and radionuclide angiography in 19. Since 1976, there has been a trend toward a reduction in the use of catheterization and use of one rather than two noninvasive or semiinvasive techniques for the detection of atrial defects. Of the 52 patients who underwent catheterization, the correct anatomic diagnosis was made before catheterization in 47 (90%). Two patients with a sinus venosus defect and one each with a sinus venosus defect plus partial anomalous pulmonary venous connection, partial anomalous pulmonary venous connection without an atrial septal defect and a sinoseptal defect were missed. Of 109 patients without catheterization, a correct morphologic diagnosis was made before surgery in 92 (84%). Nine patients with a sinus venosus defect, three with sinus venous defect and partial anomolous pulmonary venous connection, four with partial anomalous pulmonary venous return without an atrial septal defect and one with a secundum defect were incorrectly diagnosed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Routine use of the hydrogen platinum electrode system in shunt detection.

Routine use of the hydrogen platinum electrode system (HPES) in 1,375 consecutive cardiac catheterizations facilitated shunt detection in 171 patients, led to the diagnosis of unsuspected shunts in 18 patients, and was of particular value in accurately localizing unusual left-to-right shunts. Left-to-right shunts were detected in 171 patients (12% of the total catheterizations). Eighteen unsuspected shunts (10% of the total shunts, or 1% of the total catheterizations) were found. Atrial septal defect (ASD), partial anomalous pulmonary drainage (PAPVD), ventricular septal defect (VSD), and ruptured Valsalva aneurysm were demonstrated, usually associated with other congenital or acquired lesions. HPES was of particular value in accurately localizing the venous drainage of 38 unusual or complex lesions with left-to-right shunting. Five patients with rheumatic mitral valve disease had PAPVD, a higher incidence (1.2% of rheumatic mitral valve disease) than had previously been reported. The rationale for use of a sensitive shunt detection method as a routine part of the catheterization procedure is discussed.     

Routine use of the Hydrogen Platinum Electrode System in Shunt Detection

Routine use of the hydrogen platinum electrode system (HPES) in 1,375 consecutive cardiac catheterizations facilitated shunt detection in 171 patients, led to the diagnosis of unsuspected shunts in 18 patients, and was of particular value in accurately localizing unusual left-to-right shunts. Left-to-right shunts were detected in 171 patients (12% of the total catheterizations). Eighteen unsuspected shunts (10% of the total shunts, or 1% of the total catheterizations) were found. Atrial septal defect (ASD), partial anomalous pulmonary drainage (PAPVD), ventricular septal defect (VSD), and ruptured Valsalva aneurysm were demonstrated, usually associated with other congenital or acquired lesions. HPES was of particular value in accurately localizing the venous drainage of 38 unusual or complex lesions with left-to-right shunting. Five patients with rheumatic mitral valve disease had PAPVD, a higher incidence (1.2% of rheumatic mitral valve disease) than had previously been reported. The rationale for use of a sensitive shunt detection method as a routine part of the catheterization procedure is discussed.     

Partial Anomalous Pulmonary Venous Connection and the Nature of Associated Sinus Venosus Defect

Background: Partial anomalous pulmonary venous connection (PAPVC) is frequently associated with atrial septal defect (ASD), especially sinus venosus defect (SVD). Although Waggstaffe described the pathology of SVDs in 1868, the exact anatomic features and the nature of SVD remains controversial. SVDs with no posterior atrial rim were observed in recent years. However, no studies suggested that absence of the residual posterior atrial septal tissue might be the key feature of SVD. The aims of this study were to investigate if absence of posterior rim of atrial septum played a crucial role in patients with SVD. Methods: From January 2011 to December 2019, 256 children with PAPVC combined ASD and 878 children with isolated ASD who underwent corrective cardiac surgery were consecutively enrolled. Comprehensive review of preoperative transthoracic echocardiography, computed-tomography images and surgical findings were performed by experienced pediatric cardiologists. The subtypes of PAPVC, locations and types of ASD, and presence of posterior atrial rim of associated ASD were investigated. Results: PAPVC was right-sided in 244 children, left-sided in 6 children, and bilateral in 6 children. In PAPVC cases, ASD without posterior atrial rim existed in 226 SVD cases. ASD without posterior atrial septum only existed in cases with one or more right pulmonary veins returning to right atrium (RA) or to RA-superior vena cava junction. In cases with isolated ASD, there were 3 SVD, and the other 875 cases were secundum ASD. Conclusions: ASD without posterior atrial rims was associated with one or more right pulmonary veins returning to RA or RA-superior venous cava (SVC) junction. For SVD, the key feature is that the defect is in the posterior of the interatrial septum with no posterior septal rim, rather than adjacent to the SVC or to the inferior vena cava.     

Partial atrioventricular septal defect assessed by real-time three-dimensional echocardiography: a case report

A 48-year-old woman was admitted with a heart murmur and increased difficulty in breathing. Two-dimensional echocardiography revealed a defect in the lower part of the atrial septum [(primum atrial septal defect (ASD)] and a pouch at the interventricular septum. Color Doppler echocardiography detected grade 3/4 mitral regurgitation. Real-time three-dimensional echocardiography (RT-3DE) revealed a cleft in the anterior leaflet of the mitral valve toward the tricuspid valve, and the ASD located near the atrioventricular valves with 14mm in minor axis. Color Doppler three-dimensional echocardiography disclosed left-to-right ASD shunt toward the atrial posterior wall. No shunt through the pouch at the membranous part, left ventricular outflow obstruction, or partial anomalous pulmonary venous connection was observed. RT-3DE is quite useful to describe complicated congenital heart disease.     

Cross sectional echocardiographic diagnosis of total anomalous pulmonary venous connection

Total anomalous pulmonary venous connection can be diagnosed by cross sectional echocardiography. Information is, however, lacking concerning the diagnostic accuracy of this imaging method and any factors which may influence it. To predict the pulmonary venous connection 463 patients with congenital heart disease who had angiographic confirmation were prospectively examined. Total anomalous pulmonary venous connection was present in 34 (7%) patients and correctly detected in 33 (97% sensitivity). There were two false positive results (99% specificity). All 23 patients with atrial situs solitus with or without associated congenital heart defects were correctly detected. One false negative result occurred in a patient with right atrial isomerism and complex congenital heart disease with decreased pulmonary blood flow. Diagnosis of the type of total anomalous pulmonary venous connection, including the site and other anatomical details, was analysed and was correct in 24 of 34 (71%) patients. Errors included incorrect prediction of the site of total anomalous pulmonary venous connection in five patients with right atrial isomerism, atrioventricular canal defect, and pulmonary atresia, details of confluence interconnection in three of four patients with the mixed type of connection, undiagnosed pulmonary venous obstruction in three of the patients with right atrial isomerism, and failure to predict common pulmonary vein atresia in one patient. Factors which were related to incorrect echocardiographic diagnosis were abnormal atrial situs, mixed total anomalous pulmonary venous connection, and associated congenital cardiac defects, whereas age, weight, sex, clinical condition, and time during the study were not related. It is concluded that cross sectional echocardiography can be used to diagnose accurately total anomalous pulmonary venous connection. This method can be the definitive imaging and diagnostic method in symptomatic infants with total anomalous pulmonary venous connection who have atrial situs solitus, unifocal pulmonary venous connection, and no evidence of other major congenital cardiac defect.     

Cross sectional echocardiographic diagnosis of total anomalous pulmonary venous connection.

Total anomalous pulmonary venous connection can be diagnosed by cross sectional echocardiography. Information is, however, lacking concerning the diagnostic accuracy of this imaging method and any factors which may influence it. To predict the pulmonary venous connection 463 patients with congenital heart disease who had angiographic confirmation were prospectively examined. Total anomalous pulmonary venous connection was present in 34 (7%) patients and correctly detected in 33 (97% sensitivity). There were two false positive results (99% specificity). All 23 patients with atrial situs solitus with or without associated congenital heart defects were correctly detected. One false negative result occurred in a patient with right atrial isomerism and complex congenital heart disease with decreased pulmonary blood flow. Diagnosis of the type of total anomalous pulmonary venous connection, including the site and other anatomical details, was analysed and was correct in 24 of 34 (71%) patients. Errors included incorrect prediction of the site of total anomalous pulmonary venous connection in five patients with right atrial isomerism, atrioventricular canal defect, and pulmonary atresia, details of confluence interconnection in three of four patients with the mixed type of connection, undiagnosed pulmonary venous obstruction in three of the patients with right atrial isomerism, and failure to predict common pulmonary vein atresia in one patient. Factors which were related to incorrect echocardiographic diagnosis were abnormal atrial situs, mixed total anomalous pulmonary venous connection, and associated congenital cardiac defects, whereas age, weight, sex, clinical condition, and time during the study were not related. It is concluded that cross sectional echocardiography can be used to diagnose accurately total anomalous pulmonary venous connection. This method can be the definitive imaging and diagnostic method in symptomatic infants with total anomalous pulmonary venous connection who have atrial situs solitus, unifocal pulmonary venous connection, and no evidence of other major congenital cardiac defect.     

先天性二尖瓣瓣上狭窄的诊断和外科治疗

先天性二尖瓣瓣上狭窄是一种罕见的心脏畸形，常伴有其它心内病变，临床表现为充血性心力衰竭、肺静脉高压。超声心动图检查对诊断有重要意义，一经诊断，均应在体外循环心内直视下纠治。本文报道３例，均伴继发孔房间隔缺损，手术效果满意。     

新鲜自体心包在心脏手术中应用的经验

目的介绍新鲜自体心包在心脏手术中应用的经验。 方法我院在321例心脏手术中应用了未经戊二醛处理的新鲜自体心包作为修复材料,应用范围广泛,包括先天性心脏病、风湿性心脏病和心脏肿瘤。 结果术后早期死亡20例,手术死亡率6.1%。并发症1例法乐四联症根治术后室间隔缺损残余漏,经二次手术修补治愈出院。3例室间隔缺损修补术后少量残余漏,随诊观察。全组75.7%的病人获得随诊,无术后溶血、栓塞、感染性心内膜炎、补片钙化及心包片瘤样膨出等并发症。 结论新鲜自体心包是心脏手术的优良修复材料。