实时三维超声心动图评价人工瓣膜形态和功能的初步研究

目的评价实时三维超声(Live 3DE)技术观察人工瓣膜形态和功能的可行性和准确性.方法32例行二尖瓣和(或)主动脉瓣以及三尖瓣位人工瓣膜置换的患者,应用Live 3DE的灰阶成像和彩色成像模式,观察人工瓣和支架的结构形态,并评价其相关血流动力学改变.结果Live 3DE灰阶成像可清晰显示二尖瓣位或三尖瓣位上人工瓣膜和支架结构形态以及其空间立体关系,三维成像清晰率为83.33%(15/18);8例二尖瓣合并主动脉瓣置换的患者,受主动脉瓣位机械瓣强回声遮挡的影响,人工二尖瓣的三维成像清晰率为62.5%(5/8);人工主动脉瓣的三维成像清晰率则为50%(7/14).Live 3DE彩色血流成像则可较敏感地显示人工瓣的反流与瓣周漏.结论联合应用Live 3DE的灰阶和彩色成像模式可准确、直观地反映人工瓣膜的形态结构和功能变化,是传统经胸二维超声心动图和经食管超声心动图技术的重要补充.     

实时三维经食管超声心动图在二尖瓣置换术后人工瓣膜功能异常诊断中的应用价值

目的探讨实时三维经食管超声心动图(RT-3D-TEE)在二尖瓣置换术后人工瓣膜功能异常诊断中的应用价值。方法回顾性分析92例经胸超声心动图(TTE)初步诊断为疑似二尖瓣人工瓣膜功能异常患者的临床资料,患者均再次接受RT-3D-TEE检查。比较RT-3D-TEE和TTE检查的结果,分析RT-3D-TEE在二尖瓣人工瓣膜置换术后瓣膜功能异常诊断中的作用。结果92例疑似二尖瓣人工瓣膜功能异常的患者中,82例TTE检查怀疑存在瓣周漏;经RT-3D-TEE检查后,存在1处瓣周漏患者38例,2处瓣周漏患者26例,3处瓣周漏3例,共67例患者99处瓣周漏,瓣周漏发生率87.0%(67/77);15例为正常人工瓣膜生理性反流,TTE假阳性率为18.3%(15/82)。另外10例患者中,5例TTE检查怀疑瓣膜狭窄,经RT-3D-TEE确诊并明确病因,其中3例为血管翳,另2例为血栓;2例TTE检查怀疑感染性心内膜炎,未见赘生物,RT-3D-TEE检测到赘生物;3例TTE检查为生物瓣反流,但不能明确病因,RT-3D-TEE诊断为生物瓣退行性改变。结论RT-3D-TEE技术能够快速、明确二尖瓣人工瓣膜术后瓣膜功能异常原因,定位功能异常发生部位,降低假阳性率,提高诊断的准确性,为治疗的时机选择及手段提供重要依据,值得临床应用。     

经胸超声心动图诊断机械瓣膜功能障碍

目的 观察经胸超声心动图诊断机械瓣膜功能障碍的价值。方法 回顾性分析60例接受二次手术治疗的机械瓣膜功能障碍患者，观察本次术前经胸超声心动图、手术、术后病理及随访资料，分析超声的诊断及评估效能。结果 超声心动图检查共于60例患者中检出67枚机械瓣膜功能障碍，包括二尖瓣23枚、主动脉瓣43枚及三尖瓣1枚；主要表现为瓣周漏、瓣膜狭窄及关闭不全、血栓、瓣环脱位、感染性心内膜炎(IE)及窦部夹层等。手术及病理结果显示，60例67枚机械瓣膜功能障碍分布与超声检查所见一致，表现为瓣周漏16枚、瓣周纤维组织增生50枚、血栓19枚、瓣环脱位5枚、IE 12枚、退行性变6枚。随访期间59例未见明显人工瓣膜功能障碍；1例于二次术后第9年出现瓣周漏，经手术封堵后情况良好。结论 经胸超声心动图对于诊断机械瓣膜功能障碍具有一定价值，有助于判断是否需要进行再次手术治疗。     

Regurgitant flow in apparently normal valve prostheses: improved detection and semiquantitative analysis by transesophageal two-dimensional color-coded Doppler echocardiography

In 128 patients with apparently normally functioning prosthetic valves (n = 136) in the aortic position (n = 79) and the mitral position (n = 57), the prevalence of transprosthetic regurgitant flow was studied by use of transthoracic and transesophageal two-dimensional color-coded Doppler echocardiography. With the transthoracic approach, regurgitant flow was detected in early systole or diastole for 28% of the mitral prostheses and for 29% of the aortic prostheses. With transesophageal color-coded Doppler echocardiography, regurgitant jets were visualized for 95% of the mitral prostheses and for 44% of the aortic prostheses. In 40% of the Bj?rk-Shiley prostheses and 88% of the St. Jude Medical prostheses in the mitral position, more than one jet with an eccentric origin was detected, whereas in bioprostheses only one centrally localized regurgitant jet was noted. The regurgitant jet length was 22 +/- 2 mm in mitral prostheses and 12 +/- 2 mm in aortic prostheses. The jet area was 154 +/- 31 mm2 in mitral prostheses and 61 +/- 26 mm2 in aortic prostheses. Jets of this size and frequency have to be considered a normal finding and the equivalent of regurgitant flow known from in vitro studies. We conclude that only transesophageal color-coded Doppler echocardiography seems to be a reliable method for following up mitral valve prostheses to detect and differentiate regurgitant jets. For aortic valve prostheses the advantage of transesophageal color-coded Doppler echocardiography does not seem to be as obvious as the advantage for mitral prostheses.     

Right upper lobe pulmonary edema after mitral valve replacement caused by paravalvular leakage recognized by bedside transesophageal echocardiography

OBJECTIVE: To describe an unusual case of right upper lobe pulmonary edema caused by acute paravalvular leakage that was identified by the use of bedside transesophageal echocardiography. DESIGN: Case report. SETTING: University-affiliated hospital. PATIENT: A 59-yr-old male patient underwent prosthetic mitral valve replacement (St. Jude valve) for severe mitral regurgitation and developed sudden onset of dyspnea and change in consciousness with blood pressure decreased to 70/30 mm Hg. Elevation of central venous pressure and images of transthoracic echocardiography led to the diagnosis of cardiac tamponade. CONCLUSION: Acute paravalvular leakage after mitral valvular replacement should be considered as one of the differential diagnoses for unilateral pulmonary edema. Physical findings of a holosystolic murmur and findings from bedside transesophageal echocardiography can confirm the diagnosis, avoiding delay in management.     

Transcatheter closure of paraprosthetic valve leaks after surgical mitral and aortic valve replacements

Prosthetic valve replacement surgery is performed in approximately 210,000 patients annually worldwide. At least 3%, and possibly as many as 12.5%, of these valves will eventually demonstrate a clinically important paravalvular leak. Most of the significantly symptomatic leaks are currently repaired surgically, but the risks of repeat operation and re leak are significantly higher than the original valve-replacement surgical risks. Transcatheter closure of paravalvular leaks has been accomplished using a number of different devices in a relatively small number of centers over the last 16 years. Transcatheter paravalvular leak-closure procedures are still evolving. They are associated with very low procedural mortality rates but are technically challenging, variably effective and may require multiple interventions to be clinically successful. Advances in imaging, such as live 3D transesophageal echocardiography, and the development of better occlusion devices that are specifically designed for closing paravalvular leaks may improve procedure times and outcomes. Further development of effective systems for transcatheter paravalvular leak closure could potentially improve the outlook for a significant population of patients with this difficult and sometimes devastating complication of prosthetic valve replacement.     

术中经食管超声在心脏瓣膜置换术后异常情况诊疗中的应用

目的评价术中经食管超声心动图(IOTEE)在心脏瓣膜置换术后异常情况诊疗中的作用。方法回顾性分析45例心脏瓣膜置换术后发生异常情况患者,对IOTEE在诊断及治疗心脏瓣膜置换术后异常情况中的作用进行评估及分析。结果 45例心脏瓣膜置换术后发生异常并发症的患者中,IOTEE检出瓣周漏23例(23/45,51.11%),卡瓣4例(4/45,8.89%),室壁运动异常6例(6/45,13.33%),感染性心内膜炎6例(6/45,13.33%),人工瓣膜狭窄4例(4/45,8.89%),升主动脉与胸骨粘连2例(2/45,4.44%),均经手术证实。结论 IOTEE可检出心脏瓣膜置换术后瓣周漏、人工瓣膜卡瓣、感染性心内膜炎等异常情况,帮助术者正确判断并及时处理。     

Thrombosis of a bileaflet prosthetic mitral valve: a real-time three-dimensional transesophageal echocardiography perspective

Rheumatic mitral valve disease being common in India, valve replacement and hence thrombosis of prosthetic heart valves (PHV) are not uncommon. The diagnosis is commonly established by increased gradients across PHV during transthoracic echo and restricted leaflet movement during transesophageal echo or fluoroscopy. We demonstrated both the leaflets of a thrombosed PHV,of which one was stuck in closed position by real-time three-dimensional transesophageal echocardiography.     

Aortic dissection with fistula to left atrium: diagnosis by transesophageal echocardiography with successful repair.

The aorta-atria fistula is an infrequent complication of aortic dissection, and it is rarely diagnosed before death. A 41-year-old man who 8 years previously had undergone prosthetic aortic valve replacement had an aortic dissection complicated by aorta-left atrial fistula. This patient had acute left heart failure associated with a systolic and diastolic murmur at the lower left sternal border suggesting an aortic prosthetic malfunction. The cardiac diagnosis was made with transesophageal echocardiography and Doppler color flow imaging; it was notable that the cardiac lesions were not detected by transthoracic echocardiography. On the basis of the echocardiographic findings, the patient underwent successful emergency replacement of the dissecting ascending aorta with closure of the aorta-left atrial fistula. Transesophageal echocardiography is the procedure of choice for defining this abnormality. In this case a prompt surgical repair consisting of replacement of the affected segment of the aorta with the prosthesis and closure of the fistula provided optimum resolution of the clinical situation.     

Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation.

Preservation of the subvalvular apparatus during mitral valve replacement preserves left ventricular function and improves long-term survival. Complications of subvalvular preservation include left ventricular outflow tract obstruction and prosthesis impingement. We report a case of severe intermittent intraprosthetic mitral regurgitation detected by transesophageal echocardiography after mitral valve replacement by a bileaflet mechanical prosthesis with subvalvular preservation. Intravalvular prosthetic valve regurgitation was caused by remnants of the subvalvular apparatus, which were shown at reoperation to interfere with prosthetic leaflet motion and which were excised. Postoperative transesophageal echocardiography showed neither abnormal mitral regurgitation nor residual mass. The use of intraoperative transesophageal echocardiography could enable the detection of this rare complication.     

实时三维超声在评价人工机械瓣功能中的应用

目的在二维（2D）基础上应用三维实时超声心动图（RT-3DE）,探讨RT-3DE在评价人工瓣功能方面的临床应用价值。方法应用PhilipsIE33型彩色多普勒超声诊断仪,对23例受检者进行了实时三维超声心动图检查,其中二尖瓣位18例,主动脉瓣位5例。结果23例人工瓣均获得较清晰的三维图像。20例人工瓣功能正常。3例功能异常,其中2例为人工瓣瓣周漏,另有1例为二尖瓣位人工瓣血栓导致梗阻。结论RT-3DE在2DE基础上,可获得更丰富的空间信息,可以对2DE做出有益的补充。     

多平面经食管超声及彩色血流显像对人工瓣膜正常及病理性反流的诊断价值

目的 旨在评价多平面经食管超声及彩色血流显像对人工金属瓣膜正常和病理性反流的诊断价值。方法 经本院心外科进行瓣膜替换术的连续患者37例,男性19例,女性18例,平均年龄47.41±9.89岁,其中单瓣替换患者21例(二尖瓣替换患者17例,主动脉瓣替换患者4例),双瓣替换患者16例。所有患者均进行经胸超声和多平面经食管超声检查。 结果 (1)单纯二尖瓣替换患者,经胸超声和彩色血流显像诊断人工金属二尖瓣正常及病理性反流的准确性为64.7％,漏检率为18.1％,低估率为11.8％。(2)单纯主动脉瓣替换患者,经胸超声和彩色血流显像诊断人工主动脉瓣正常及病理性反流的准确性为50％,漏检率为25％,高估率为50％。(3)双瓣替换患者:经胸超声和彩色血流显像诊断二尖瓣正常及病理性反流的准确性为56.2％,高估率为25％,漏检率为31.2％,误诊率为18.8％。经胸超声和彩色血流显像诊断主动脉瓣正常及病理性反流的准确性为56.2％,高估率为43.7％,低估率为6％,漏检率6％,误诊率为31.3％。 结论 多平面经食管超声及彩色血流显像在评价人工金属瓣膜病理性反流方面优于经胸超声。     

二尖瓣位人工瓣的四维经食管超声心动图显示

为了显示二尖瓣位人工瓣的动态立体结构，我们对１６例行二尖瓣置换术的患者进行了四维经食管超声心动图重建研究，建立了二尖瓣位人工碟瓣的立体剖面图，可分别从侧面，左房面观察人工瓣的形态结构及活动状况，同时还建立了人工瓣返流的四维多普勒血流图。结果表明，二尖瓣位人工瓣的四维重建能直观地显示人工瓣膜的解剖结构，协助鉴别人工瓣返流与瓣周漏。     

Catastrophic mitral prosthesis dehiscence diagnosed by three‐dimensional transesophageal echocardiography

In emergency situations, real‐time three‐dimensional transesophageal echocardiography (RT 3‐dimensional TEE) may provide unique anatomic insights on prosthetic valves when two‐dimensional imaging is inconclusive. We report the case of a 76‐year‐old woman, in cardiogenic shock, who had undergone mitral valve replacement 3 months ago. RT 3‐dimensional TEE revealed almost total, catastrophic prosthesis dehiscence following infective endocarditis, the prosthesis being perpendicular to the normal mitral plane. Corrective surgery was not feasible, and the patient died shortly after admission. Although the outcome was unfortunate, RT 3‐dimensional TEE helped rapidly reach a definitive diagnosis, essential for decision‐making. Three‐dimensional TEE should be used as a complementary technique in difficult cases. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:249–251, 2014     

经食管三维超声心动图评价人工二尖瓣瓣周反流

目的 探讨经食管三维超声心动图评价人工二尖瓣术后瓣周反流的可行性、准确性.方法 2007年12月至2011年8月本心脏中心因二尖瓣置换术后瓣周反流行再次心脏手术的病例24例,男17例.女7例,年龄30~65岁,平均(48±9)岁,24例均术前行经胸二维超声检查,ll例行经食管二维超声检查.9例行经食管三维超声检查.以外科术中所见为金标准,分别对比经胸二维超声、经食管二维超声、经食管三维超声评价瓣周反流存在与否、位置、程度及病因的准确性.结果 经胸二维超声、经食管二维超声、经食管三维超声评价瓣周反流存在与否准确性分别为87.5%(21/24),100%(11/11),100%(9/9);判断瓣周反流位置准确性:经胸二维超声62.5%(15/24),经食管二维超声81.8%(9/11),经食管三维超声100%(9/9);判断反流程度准确性:经胸二维超声70.8%(17/24),经食管二维超声72.7%(8/11),经食管三维超声100%(9/9);判断病因准确性:经胸二维超声54.2%(13/24),经食管二维超声63.6%(7/11),经食管三维超声88.8%(8/9).结论 经食管三维超声心动图能实时提供人工二尖瓣瓣周立体信息,在评价二尖瓣置换术后瓣周反流存在与否、位置、程度、病因中起到重要作用,具有更高的准确性.     

Spontaneous drainage of paravalvular abscess diagnosed by transesophageal echocardiography

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.     

Comparison of transesophageal color flow Doppler imaging of normal mitral regurgitant jets in St. Jude Medical and Medtronic Hall cardiac prostheses.

Transesophageal color flow Doppler imaging of mitral mechanical prostheses is now widely used. This method eliminates the frequent problems of acoustic shadowing and flow masking that are commonly seen with a transthoracic Doppler study of mechanical mitral prostheses. Transesophageal color flow Doppler imaging was performed postoperatively in seven patients who had received St. Jude Medical mitral prostheses (St. Jude Medical, Inc., St. Jude, Minnesota) and in six patients who received Medtronic Hall mitral valves (Medtronic, Inc., Minneapolis, Minnesota). Maximal systolic regurgitant jet length and area determinations were obtained in all patients. A comparison of maximal jet lengths and areas for each type of mechanical prosthesis demonstrated that the Medtronic Hall prostheses produced longer maximal jet lengths (p = 0.0001) and larger jet areas (p = 0.0009) than those produced by the St. Jude Medical mitral valves. Medtronic Hall prostheses produce a large centrally directed jet, whereas St. Jude Medical prostheses typically generate three smaller jets. Recognition of these differences in transesophageal color flow Doppler images in these commonly used cardiac valve prostheses is necessary to avoid misinterpretation of the normally large systolic regurgitant jet of the Medtronic Hall prosthesis as representing prosthetic dysfunction.     

Successful thrombolysis of a partially obstructed bileaflet prosthetic heart valve in the mitral position

We describe the case of a woman who presented with dyspnea of abrupt onset and who had recently undergone replacement of the mitral valve with a bileaflet mechanical prosthesis. Transthoracic echocardiographic examination with spectral Doppler recording of transvalvular blood flow revealed a velocity spectrum consistent with obstruction. Transesophageal echocardiography demonstrated partial obstruction of the prosthetic valve due to immobilization of 1 hemidisc in the closed position. This immobilization was apparently caused by a small mass whose appearance was consistent with that of a thrombus. The patient was successfully treated by intravenous administration of a thrombolytic agent. This case demonstrates the value of transesophageal echocardiography in the selection of candidates for thrombolytic treatment in cases of thrombosis of a left-sided valve prosthesis.     

超声心动图在人工机械瓣卡瓣诊断中的临床应用

目的分析人工机械瓣卡瓣的超声图像特点,探讨超声心动图在人工机械瓣卡瓣诊断中的临床价值。方法 7例人工机械瓣卡瓣患者,超声心动图观察以下内容:1机械瓣瓣叶回声及活动情况;2通过机械瓣口的血流情况;3瓣口血流频谱,估算机械瓣口面积。结果人工机械瓣卡瓣位于二尖瓣6例,主动脉瓣1例。其中6例超声心动图即可清晰显示人工机械瓣叶活动受限,瓣环或瓣叶增厚,回声不光滑,血流束减少或变细,流束与瓣环平面夹角变小。频谱显示瓣口峰值流速及压差较正常增加,瓣口面积减小,术中所见与超声探查结果完全相符。患者均行再次换瓣手术。结论超声心动图是无创、快速诊断人工机械瓣卡瓣的首选方法。     

实时三维超声心动图在评价人工瓣膜结构和功能中的应用

目的 探讨实时三维超声心动图评价人工瓣膜结构和功能的临床应用价值.方法 应用彩色多普勒超声对33例人工瓣膜置换术后患者进行实时三维超声心动图检查,其中二尖瓣位人工机械瓣19例,生物瓣3例;主动脉瓣位人工机械瓣11例.结果 30例(91%)能够清楚显示人工瓣膜和支架结构及其周邻的解剖结构,其中26例功能正常,4例功能异常,其中3例为二尖瓣机械瓣瓣周漏,另1例为二尖瓣位生物瓣赘生物形成伴瓣叶穿孔破裂.结论 联合应用实时三维和全容积成像模式可以直观、准确地评价人工瓣膜的结构和功能.是对经胸二维超声和经食管超声心动图的有益补充.