先天性心脏病心导管及心血管造影检查死亡病例分析

目的:总结先天性心脏病心导管及心血管造影术死亡病例的特点,分析死亡原因及危险因素,为降低先天性心脏病(先心病)心导管心血管造影术病死率提供理论依据。方法:回顾性分析阜外心血管病医院近11年间,先心病行心导管或心血管造影检查术死亡的12例患者的临床资料、超声、胸X线片、心导管及造影检查、尸体解剖结果,分析各种先心病行心导管及心血管造影检查的病死率。结果:先心病行心导管及心血管造影术总病死率1.4‰,58.3%的患者死于缺氧发作,33.3%的患者死于恶性心律失常,8.3%的患者死于心源性休克;在各种先心病中,威廉斯综合征(Williams syndrome,WS)行心导管心血管造影术的病死率最高,达23.1%;83.3%的患者术前有严重的低氧血症,50%的患者临床NYHA心功能分级III-IV;33.3%的患者心血管造影术中经过顺利而死于术后并发症。结论:先心病行心导管心血管造影检查时缺氧发作是引起死亡最常见的并发症,严重的低氧血症及心功能不全是心导管及心血管造影术死亡的重要危险因素,威廉斯综合征行造影检查存在较高的病死率,术后24小时是并发症高发时期,应加强心血管造影术后监护。     

先天性心脏病术后合并肺动脉高压心导管检查及急性肺血管扩张试验分析

目的:探讨先天性心脏病术后(CHD-PO)合并肺动脉高压(PAH)患者,行心导管检查及急性肺血管反应试验的临床价值。方法:研究选自2008年8月至2015年12月,收住北京安贞医院小儿心脏科,行左、右心导管检查及急性肺血管扩张试验的CHD-PO合并PAH的患者,监测血流动力学指标变化。结果:入选40例患者,男性11例(27.5%),女性29例(72.5%),年龄6.61~45.51岁,平均年龄(23.6±9.3)岁,中位手术年龄13.4岁;平均纽约心功能(NYHA)分级(1.88±0.68)[I~II/III~IV,33例(82.5%)/7例(17.5%)],术后最短行心导管检查的时间为0.5年,最长为25.4年,中位时间为3.0年。术中无肺动脉高压危象发生,无低血压现象,其中1例急性肺血管扩张试验阳性。心导管检查:基础状态下,平均肺动脉压力(MPAP)为(58.30±21.32)mm Hg(1mm Hg=0.133k Pa),肺小动脉阻力指数(PVRI)为(16.67±11.64)Wood U·m2,肺动脉收缩压/主动脉收缩压(PP/PS)为(0.75±0.25),肺循环阻力/体循环阻力(RP/RS)为(0.63±0.28),所有患者均被证实仍残存肺动脉高压。吸入伊洛前列素(Iloprost)后,肺动脉收缩压(SPAP)、MPAP、主动脉收缩压(SAOP)、PVRI、RP/RS降低,心指数(CI)增加,且均有显著临床意义(P0.05);平均主动脉压(MAOP)、体循环阻力指数(SVRI)降低,但无明显临床意义。结论:CHD合并重度PAH丧失最佳手术时机的患者,行心脏矫治术后,术后远期随访证实肺动脉压力仍未降至正常,需要长期随访及靶向药物治疗。CHD-PO合并PAH患者,与IPAH相比,其肺血管反应差,心导管检查过程中肺动脉高压危象发生率低。雾化吸入伊洛前列素(Iloprost),在增加或者维持CI不变的前提下,具有良好降低肺循环阻力及压力的作用。     

Down综合征并发先天性心脏病的临床分析

目的:总结分析Down综合征(Down’s syndrome)并发的先天性心脏病畸形及血流动力学资料。方法:2008年7月~2012年10月,采用经胸二维超声心动图并彩色多普勒显像及右心导管/心血管造影检查方法,诊断36例并发先心病的Down综合征患者,本文通过36例临床资料分析,探讨Down综合征并发的先心病畸形及其血流动力学。结果:36例患者中室间隔缺损(VSD)10例,房室间隔缺损(AVSD)6例,动脉导管未闭(PDA)6例,房间隔缺损(ASD)2例,ASD+PDA 2例,ASD+VSD 1例,ASD+PDA+VSD 1例,VSD+PDA 4例,PDA+二叶主动脉瓣(BAV)1例,法洛四联症(TOF)2例,TOF+ASD 1例,18例有肺动脉高压者,其中5例为阻力型肺动脉高压。结论:①Down综合征并发的心血管畸形中,以VSD、AVSD和PDA最为常见,并常并发ASD、TOF。②在无肺动脉狭窄的患者中,约50%并发有肺动脉高压。     

Down综合征并发先天性心脏病的临床分析

目的：总结分析Down综合征（Down’s syndrome）并发的先天性心脏病畸形及血流动力学资料。方法：2008年7月-2012年10月,采用经胸二维超声心动图并彩色多普勒显像及右心导管／心血管造影检查方法,诊断36例并发先心病的Down综合征患者,本文通过36例临床资料分析,探讨Down综合征并发的先心病畸形及其血流动力学。结果：36例患者中室间隔缺损（VSD）10例,房室间隔缺损（AVSD）6例,动脉导管未闭（PDA）6例,房间隔缺损（ASD）2例,ASD＋PDA2例,ASD＋VSD1例,ASD＋PDA＋VSD1例,VSD＋PDA4例,PDA十二叶主动脉瓣（BAV）1例,法洛四联症（TOF）2例,TOF＋ASD1例,18例有肺动脉高压者,其中5例为阻力型肺动脉高压。结论：①Down综合征并发的心血管畸形中,以VSD、AVSD和PDA最为常见,并常并发ASD、TOF。②在无肺动脉狭窄的患者中,约50％并发有肺动脉高压。     

右心导管检查配合左心声学造影对左向右分流先心病的诊断价值

近期,我们对47例先心病患儿在行右心导管检查的同时作左心声学造影,初步探讨其对左→右分流先心病的诊断价值,现报告如下。一、检查方法均在局麻下经皮穿刺经股静脉行右心导管检查。所用导管为6～7F普通右心导管或漂浮导管。于各心腔常规测血氧及压力、探查有无异常通道,然后将导管尖端插入肺     

心导管检查（3）：右心导管检查

右心导管检查是将心导管插入周围静脉，沿静脉送至右心房、右心室、肺动脉及其分支，以了解右侧心脏血流动力改变的检查方法。     

重症先天性心脏病患儿心导管及造影检查时的麻醉——369例总结

目的介绍小儿重症先天性心脏病(先心病)患儿心导管及造影检查时的麻醉体会。方法选择369例先心病施行心导管或左右心室造影检查的患儿,其中左向右分流合并重度肺动脉高压86例,肺动脉瓣狭窄和原发性肺动脉高压11例,右向左分流复杂畸形272例。麻醉前常规禁食。入室后监测外周血氧饱和度、心电图及血压,记录基础值。患儿面罩吸氧,建立静脉通路后,静脉注射东莨菪碱0.02mg/kg、氯胺酮1～2mg/kg。待患儿意识消失后肌肉注射氯胺酮6～8mg/kg+氟哌啶0.15～0.30mg/kg维持,或间断静脉注射氯胺酮1～2mg/kg加深麻醉。结果术中经过基本顺利。全组共18例出现不同程度腹胀、呕吐、呛咳、心律失常、顽固性缺氧等并发症,发生率4.88%,其中1例死亡,死亡率0.27%。结论小儿重症先心病行心导管及心血管造影检查时,麻醉有其特殊性。要求麻醉医师掌握心脏病的病理生理,充分给氧,保持呼吸道通畅,防止胃返流、误吸的发生,充分镇静,术后继续吸氧并监测血氧饱和度,尽可能避免并发症的发生。     

心导管检查（2）

心导管检查的适应症随着心导管检查的安全性和检查技术的提高,心导管检查已成为诊断心血管疾患常用的一种诊断方法。它可以测定各心腔和大血管的压力和血氧含量,观察心腔和大血管间有无异常通道,配合一些检查方法,形成一些特殊的检查方法,还可     

吸入伊洛前列素在儿童先天性心脏病肺血管扩张试验中的应用

目的:该研究在心导管检查中通过对先天性心脏病(CHD)合并肺动脉高压(PAH)儿童,吸入伊洛前列素前后的血流动力学参数的测定,评价吸入伊洛前列素在CHD相关性PAH儿童急性肺血管扩张试验的安全性、有效性。方法:研究选择2007年6月至2010年5月,于北京安贞医院小儿心脏科住院的左向右分流型CHD合并重度PAH患儿,所有患儿行左、右心导管检查,并采用雾化吸入伊洛前列素,监测吸药前后血流动力学参数改变及不良反应。结果:该研究入选43例左向右分流型CHD合并重度PAH患儿,年龄(8.52±4.76)岁。吸入伊洛前列素后肺动脉平均压由(77.14±12.14)mmHg(1 mmHg=0.133 kPa)降至(69.35±12.14)mmHg(P<0.05);肺体循环血流量比值(Qp/Qs)由1.80±1.26升至3.06±2.90(P<0.05);肺血管阻力指数(PVRI)下降约5 Wood unit.m2〔吸入前(14.51±8.46)Wood unit.m2,吸入后(9.58±7.43)Wood unit.m2,P<0.05),体循环血压无明显变化〔吸入前(83.16±13.69)mmHg,吸入后(83.09±11.03)mmHg,P>0.05〕。以吸入伊洛前列素后PVRI较基础水平下降至少20%以上作为急性肺血管扩张试验阳性标准。肺血管反应阳性患儿31例,占72%,阴性反应患儿(PVRI下降<20%)12例,占28%。结论:对左向右分流型CHD合并重度PAH儿童在心导管检查中吸入伊洛前列素可明显降低肺血管阻力,体循环血压无明显变化,无明显不良反应发生,可作为安全有效的急性肺血管扩张试验的用药。     

Interventional cardiac catheterization in congenital heart disease

Cardiac catheterization has proved its value as a major tool in the diagnosis of congenital cardiac defects. The advent of non-invasive imaging of various sorts has altered the role of diagnostic catheterization. Within the past two decades cardiac catheter instruments to provide therapy have been applied to many lesions. Improvements in design and methods will expand the use of therapeutic catheterization. It is inevitable that better results will be obtained for those defects currently being treated that way, and that the method will be applied to other conditions.     

The role of cardiac catheterization in adult congenital heart disease

The role of heart catheterization continues to evolve as the sophistication of cardiac MRI and CT improves and the breadth of interventional catheter techniques widens. This analysis is approached from four perspectives: (1) planning of the procedure, including information required, potential pitfalls, and equipment; (2) performance of the procedure, including sample run, coronary arteriography, chamber angiography, and angiography of selected lesions; (3) current role of heart catheterization, considering the impact of echo, MRI, and CT on indications for catheterization procedures and current interventional procedures; and (4) new and emerging interventions and speculation as to the future role of diagnostic heart catheterization in patients who have adult congenital heart disease.     

Interventional catheterization in congenital heart disease

Balloon dilation is now an established treatment for many congenital heart defects. Recent papers deal with the extension of this approach to more complex anomalies, such as tetralogy of Fallot and transposition of the great arteries; the results are variable. Another area of investigation is balloon valvoplasty in more contentious settings, such as neonatal aortic stenosis. The catheter method appears to be as effective as surgery in these cases. Attention has also been directed to the determinants of success or failure in, for example, aortic recoarctation. Here, as in aortic stenosis, basic anatomy plays an important role. Catheter closure procedures also figure in the literature. Closure of persistent ductus now appears to be established everywhere except in the United States. Also of interest are early reports of the "button device" for closure of atrial septal defects. The use of stents appears to offer effective treatment for peripheral pulmonary stenosis, a condition with disappointing results from surgery and balloon angioplasty. Stents may also offer an alternative method for long-term maintenance of duct patency. Catheter interventions now constitute a major part of the work of pediatric cardiologists, and the present status has been summarized in the past year.     

Echocardiographic versus cardiac catheterization diagnosis of infants with congenital heart disease requiring cardiac surgery

The success of noninvasive preoperative evaluation of infants with congenital heart disease using cardiac ultrasound depends not only on diagnostic accuracy, but also on risk of morbidity and mortality as compared with infants who undergo cardiac catheterization. Fifty-six infants (age 10 weeks or younger) with coarctation of the aorta (n = 16), coarctation with ventricular septal defect (n = 12), valvar aortic stenosis (n = 10) or total anomalous pulmonary venous connection (n = 18) were examined. Thirty-one underwent noninvasive preoperative assessment and 25 underwent evaluation including cardiac catheterization. Age, level and duration of support, pH, renal function, mortality, complications of cardiac catheterization and errors of diagnosis were compared. Significant differences between the 2 groups were more frequent preoperative use of prostaglandin E1 and shorter hospital stay in the noninvasively evaluated coarctation group. Of the infants with coarctation and ventricular septal defect, 1 who had cardiac catheterization required renal transplantation and 1 evaluated noninvasively required surgery at age 3 months for mitral stenosis not discovered on preoperative evaluation. One noninvasively evaluated infant with total anomalous pulmonary venous connection had a stenotic communication between the pulmonary venous confluence and the left atrium not detected by ultrasound. Surgery was successful in the latter 2 infants. Noninvasive preoperative diagnosis of some infants with congenital heart disease can be performed without increasing the risk of operative morbidity and mortality. Eliminating cardiac catheterization reduces hospital costs, decreases total numbers of catheterizations performed and influences the structure of training programs.     

Monitoring unfractionated heparin in pediatric patients with congenital heart disease having cardiac catheterization or cardiac surgery

Determine the effect of age and congenital heart disease (CHD) on whole blood tests for monitoring unfractionated heparin (UFH) in children. Determine correlation with anti-Xa levels in children undergoing cardiac catheterization or cardiac surgery. A prospective cross-sectional study of 211 healthy children about to have minor surgery (median age 3.5 years) and 110 CHD patients (median age 2.1 years) undergoing cardiac catheterization or cardiac surgery. Commonly used whole blood tests (two activated clotting times and an activated partial thromboplastin time; ACT+, ACT-LR, and APTT, respectively) were obtained before procedures and after UFH in CHD patients. Data were analyzed for effect of age and CHD and correlation with anti-Xa levels. In healthy subjects the ACT+ was lower in younger (<3 years) patients while the ACT-LR and APTT were unaffected. CHD patients exhibited an opposite trend with higher values in the younger patients. After bolus heparin the ACT+ exhibited the strongest correlation (r = 0.89) with anti-Xa levels in both locations (the APTT was too sensitive at post-bolus levels). When anti-Xa levels were below 1.0 IU/ml (range of thromboembolism therapy 0.35–0.7 IU/ml), the APTT correlation coefficient was 0.72. Some whole blood coagulation tests are affected by age in healthy children similar to laboratory tests and are variably influenced by the presence of CHD. ACT+ is the most reliable predictor of anti-Xa levels in both catheterization and surgery for pediatric patients. The APTT exhibited stronger correlation with antiXa than previous reports of laboratory APTT and warrants further evaluation for monitoring heparin thromboembolism therapy.     

The adult with congenital heart disease: cardiac catheterization as a therapeutic intervention

The adult with congenital heart disease who undergoes cardiac catheterization at the present time is most likely to have complex heart disease and is left with clinically important sequelae or residual defects, ventricular dysfunction or arrhythmias. Residual defects such as paravalvular leaks, coronary fistulas and pulmonary artery narrowings may be corrected with transcatheter techniques. Patients with simple forms of congenital heart disease (for example, atrial septal defect, patent ductus arteriosus, aortic valve stenosis, pulmonary valve stenosis) will go to the catheterization laboratory for treatment, not diagnosis. Certain lesions previously considered benign (for example, patent foramen ovale) may require definitive interventional therapy to reduce the risk of stroke from paradoxic embolism.