经胸和经食管超声心动图在全机器人二尖瓣修复术中的应用

目的探讨经胸(TTE)和经食管(TEE)超声心动图在全机器人二尖瓣修复术中的作用。方法对22例于我科因重度二尖瓣反流行全机器人二尖瓣修复术患者的超声影像资料进行回顾性分析。在术前,应用TTE评价二尖瓣反流功能解剖(病因、反流发生机制及脱垂瓣叶部位)及反流严重程度。在术中,应用TEE于体外循环(CPB)转机前,进一步明确二尖瓣反流发生机制及脱垂瓣叶部位;建立外周CPB时,引导下、上腔静脉插管及升主动脉内心脏停搏液灌注针的放置;心脏复跳后,即刻评价有无残余二尖瓣反流。在患者出院前,应用TTE再次评价有无残余二尖瓣反流。结果在术前,TTE评价二尖瓣反流病因的准确度为100%;TTE诊断二尖瓣脱垂及其发生部位的准确度分别为100%和97.0%。在术中,TEE诊断二尖瓣脱垂及其发生部位的准确度与术前TTE相同;TEE可准确引导上、下腔静脉插管及升主动脉内心脏停搏液灌注针放置,其成功率为100%;心脏复跳后,TEE显示所有患者手术均成功,无残余二尖瓣反流和手术相关并发症。患者出院前TTE证实所有患者均无残余二尖瓣反流。结论术前TTE可准确评价二尖瓣反流功能解剖,为判断二尖瓣修复可行性及选择手术适应证提供有价值的信息。术中TEE可进一步明确二尖瓣反流功能解剖;准确引导上、下腔静脉内插管及升主动脉内灌注针的放置;即刻评价手术效果。因此,TTE和TEE在全机器人二尖瓣修复术中是不可缺少的检查手段。     

术中经食管超声心动图在全机器人房间隔缺损修补术中的作用

目的 探讨术中经食管超声心动图(TEE)在全机器人房间隔缺损(ASD)修补术中的作用.方法 对24例拟行全机器人ASD修补术的患者进行前瞻性研究.全身麻醉诱导及双腔气管插管后,将TEE探头插入食管中段.①体外循环转机前,进一步明确ASD类型、数目及大小;术者参考上述信息初步拟定手术方案.②建立体外循环时,在TEE引导下,经右股静脉插入-19F或21F股静脉插管至下腔静脉一右心房连接处;经皮经右颈内静脉插入-15F或17F股动脉插管至上腔静脉;于第二肋间经皮将-14G心脏停搏液灌注针插入升主动脉管腔中央偏后、距主动脉瓣口约3 cm处.③心脏复跳后,应用TEE即刻评价房间隔水平有无残余分流及有无手术相关并发症.结果 ①以手术结果为标准,TEE诊断ASD类型、数目的 准确性为1005%;所有患者修补ASD均按术前拟定方案进行.②术中证实,所有患者下、上腔静脉内插管及升主动脉内灌注针均放置于适当位置,TEE引导置管成功率为100%.③心脏复跳后,TEE显示所有患者房间隔水平均无残余分流,均无手术相关并发症.结论 术中TEE在全机器人ASD修补术中必不可少.     

经食管超声心动图在二尖瓣修复术中的应用

目的　探讨经食管超声心动图 (TEE)在二尖瓣反流性病变修复术中的指导作用。方法　对 19例二尖瓣反流 (MR)患者 ,体外循环 (CPB)前及修复术后 ,应用TEE评价二尖瓣结构的异常。在相同的仪器条件和相近的血流动力学状态下 ,以实时目测法估测MR。结果　CPB前TEE检查纠正术前诊断 1例。CPB前MR(3 .4± 0 .5 )级 ,修复后残余MR(1.2± 1.0 )级 (P <0 .0 0 0 1)。 2例因残余MR 3级 ,再次转机行二尖瓣替换术。17例修复术患者出院前经胸超声心动图 (TTE)示残余MR与术中TEE残余反流量无显著性差异 [(0 .9± 0 .7)级vs (0 .9± 0 .8)级 ,P >0 .0 5 ]。后叶病变修复效果明显优于前叶。结论　TEE在二尖瓣修复术前后提供了较为可靠的二尖瓣结构和血流的信息 ,以指导手术治疗。实时目测法半定量评估MR是术中可靠且实用的方法     

心脏瓣膜置换术中心脏不复跳1例体外循环处理分析

体外循环(CPB)广泛用于心脏直视手术,一般升主动脉开放后,冠脉循环恢复,心脏自动复跳,但是特殊情况下会遇到心脏复苏困难者,需要经过一定处理方能复跳[1]。对心脏瓣膜置换术中心脏不复跳1例体外循环处理分析如下。1病历摘要女,17岁,32kg,身高145cm,术前Hct0.42,术前诊断二尖瓣关闭不全,三尖瓣关闭不全,2006-05在全麻下行二尖瓣置换、三尖瓣成形术。体外循环过程:国产膜肺,常规预充,经升主动脉、上下腔静脉插管建立体外循环,血流降温,鼻咽温29.5度阻断升主动脉,人工心肺机经主动脉根部灌注4:1(4份血:1份晶体)停跳液,每25~30min灌注一次,心…     

实时三维经食管超声心动图在二尖瓣成形术中的应用研究

目的 探讨术中实时三维经食管超声心动图(RT-3D TEE)判断二尖瓣病变区域的准确性,以及评价二尖瓣成形术效果的价值.方法 19例因二尖瓣反流(MR)拟接受二尖瓣成形术患者,采集术前、术后RT-3D TEE图像,将术前所见与术中发现进行比较,并在术后即刻评价手术疗效.结果 RT-3DTEE诊断二尖瓣叶病变与术中发现完全相符16例,3例不符合,其中1例术前诊断前叶中间段、后叶中间段脱垂,术中仅发现瓣环扩大,瓣膜黏液退行性变;1例术前诊断后叶后内段脱垂,术中发现后叶中间段及后内段腱索断裂;1例术前提示瓣环扩大,术中发现后叶中间段脱垂.2D TEE诊断二尖瓣病变与术中发现完全相符仅10例,且对二尖瓣脱垂患者难以明确脱垂的确切瓣区和范围.术后即刻观察成形术效果,其中18例RT-3DTEE显示微量至少量二尖瓣反流,1例术后仍为中重度反流,改行二尖瓣置换术,二尖瓣成形术的成功率为94.7%.结论 RT-3D TEE明显提高了二尖瓣反流病因及病变部位定位的诊断准确性,在二尖瓣成形术手术方案制定及疗效的即刻评估方面发挥了非常重要的作用.     

胸腔镜下二尖瓣手术的体外循环管理（附80例报告）

目的总结胸腔镜下二尖瓣心脏外科手术的体外循环(CPB)管理经验和方法。方法 2013年1月-2017年6月80例胸腔镜下二尖瓣置换术,CPB采用中、浅低温,全部采用股动静脉插管,并在CPB中予以负压辅助静脉吸引,术中全部采用HTK液灌注心肌予以心肌保护,对CPB建立方法、CPB过程及手术后结果进行评价。结果 80例心脏二尖瓣疾病患者全部予以痊愈出院。全部患者CPB转流时间为97~308(192.2±54.2)min;升主动脉阻断时间为50~233(130.8±46.9)min;辅助转流时间为30~53(41.8±8.1)min。术后呼吸辅助时间6~24(20.6±14.1)h;术后ICU时间为2~6(3.3±2.6)d;术后住院时间7~10 d;术中及术后无股动静脉插管相关并发症,患者术后均恢复良好,脱机良好,无严重并发症。出院随访时间3~12个月,结果满意。结论胸腔镜下二尖瓣手术中,CPB方法安全、可行,开展此手术的初期CPB时间和主动脉阻断时间较传统手术时间较长,应加强CPB的管理,避免术中术后产生CPB相关性并发症。     

经食管超声心动图在机器人辅助心脏手术中的应用价值

目的应用经食管超声心动图（TEE）监测、指导机器人辅助心脏手术，在微创环境下，使手术完美成功。方法8例机器人辅助心脏手术患者均在手术切口前将探头插人食管内，待机器人辅助手术开始，整个手术过程中与机器人的监视器同步进行TEE监测、指导机器人辅助手术。结果4例房间隔缺损修补、3例房间隔缺损封堵和1例二尖瓣置换术均获得成功，术后即刻TEE检查均未见残余分流、瓣周漏及瓣膜反流。结论机器人辅助心脏手术，在TEE监测和指导下机械手能准确、无误地到位缝合、修补，释放封堵器，同时可观察有无残余分流、瓣周漏及瓣膜反流，一旦缝合、修补不足可及时纠治，确保手术成功。     

术中经食管超声心动图在二尖瓣关闭不全术式选择和术后监测中的作用

目的　评价术中多平面经食管超声心动图 (TEE)在二尖瓣关闭不全患者术式选择、术后疗效监测中的作用。方法　对 72例行二尖瓣手术的患者 (其中 5 8例二尖瓣重建术患者和 14例二尖瓣置换术患者 )术中予以TEE监测。结果　 5 8例二尖瓣成形术患者术后即刻疗效评估显示 :无或轻微二尖瓣反流 (MR) 2 8例 ,轻度MR 2 2例 ,轻中度以上MR 8例 (前叶病变 7例 ,均合并瓣下结构受损 ,后叶病变仅 1例 )。二尖瓣成形术的患者术后共有 5 6例接受超声随访 ,平均随访期为 (9.86± 6 .32 )个月。手术即刻 2 8例无或轻微MR的患者术后短期随访中 1例 (3 .6 % )出现轻度MR ,1例出现中度MR (3 .6 % ) ,2 2例术后即刻示轻度MR患者 ,1例失访 ,5例出现轻中度MR(2 2 .7% )。术后即刻示轻度MR在以后出现轻中度MR的机会高于手术即刻无或仅有轻微MR者(P <0 .0 5 )。结论　以二尖瓣前叶病变为主引起二尖瓣关闭不全的患者 ,成形术后出现轻中度以上反流的机会高于二尖瓣后叶病变的患者。成形术后即刻示轻度二尖瓣反流的患者在以后出现轻中度反流的机会高于手术即刻无或仅有轻微反流的患者     

经食管超声心动图在体外循环下小儿肌部室间隔缺损镶嵌治疗中的应用

目的 探讨经食管超声心动图(TEE)在体外循环(CPB)下小儿肌部室间隔缺损(mVSD)镶嵌治疗中的应用价值.方法 经TEE指导、监测共完成49例CPB下mVSD的镶嵌治疗,其中9例为单纯mVSD,40例为mVSD合并心内其他畸形.心脏停跳前TEE详细观察mVSD的部位、大小、数量、范围及与周边的解剖关系,提示术者选择合适的封堵器,心脏复跳后TEE评价其疗效.结果 49例行镶嵌治疗的患儿中,44例置入单枚封堵器,5例置入双枚封堵器.术后TEE均显示封堵器位置无偏移,2例出现细小残余分流,无加重二尖瓣、主动脉瓣反流等并发症.术后1例患儿因重症感染放弃治疗,其余患儿随访6个月～2年,均见封堵器位置正常;除1例仍存在微量残余分流,其余患儿未出现残余分流及瓣膜反流等并发症.结论 经TEE指导、监测,体外循环下镶嵌治疗小儿肌部室间隔缺损可以缩短体外循环时间,降低外科手术创伤的并发症及风险性,提高手术成功率.     

主动脉手术中经食管超声心动图的应用研究

目的 :探讨主动脉疾患手术中 ,经食管超声心动图 (TEE)补充或修正术前诊断、即刻评价手术效果及对选择手术方式的影响。方法 :19例患者 ,行 Bentall手术 17例 (其中 2例并全弓置换术 ) ,Wheat手术 2例 ,升主动脉置换术 (AOR) 8例 ,主动脉瓣置换 (AVR) 升主动脉成形 (AOP) 1例 ,假性动脉瘤切除并 AOP1例。术中 TEE在体外循环 (CPB)前后对心脏和大血管的结构及功能作全面检查和监测。结果 :体外循环转机前 TEE检查补充术前诊断 3例。转后 TEE发现 1例 AVP后中度主动脉瓣返流 ,再次转机行 AVR;发现左室蓄积型积气 1例。结论 :术中 TEE在主动脉根部及升弓部手术中 ,尤其在有可能保留或修复主动脉瓣时 ,有较大的应用价值     

Undiagnosed inferior vena cava type of sinus venosus atrial septal defect in a middle-aged woman: A rare case report

Sinus venosus atrial septal defect (ASD) accounts for 5% to 10% of ASDs. In contrast with the more common superior vena cava (SVC) type, the inferior vena cava (IVC) type of sinus venosus ASD with overriding IVC is extremely rare. The sinus venosus defect occur posterior to the fossa ovalis and is not regarded as true ASD. Transesophageal echocardiography (TEE) is a diagnostic procedure of choice due to close proximity of atrial septum to TEE transducer. However; it may not constantly yield detailed anatomical and functional characterization, and other imaging modalities such as cardiac magnetic resonance imaging (MRI) may be needed. We report the case of a 45-year-old woman with an undiagnosed hemodynamically significant IVC-type ASD without any anomalous drainage of pulmonary veins, who presented with progressive dyspnea.     

3.0TMR相位对比法测量正常人肺、体循环血流

目的 观察3.0T MR相位对比法成像(PC-MRI)在体测量血流的准确性。方法 采用PC-MRI对15名健康志愿者的肺动脉主干、左、右肺动脉、主动脉、上、下腔静脉进行血流测量,计算各血管一个心动周期的平均血流量(AF)和反流分数(RF)。采用配对样本t检验分析肺、体循环血流差异。结果 肺动脉主干与主动脉的AF和RF差异无统计学意义,右肺动脉AF显著大于左肺动脉(t=3.092,P=0.004),左肺动脉RF明显大于右肺动脉(t=－5.502,P=0.001)。上腔静脉AF明显低于下腔静脉(t=－6.866,P＜0.001),下腔静脉RF明显大于上腔静脉(t=4.250,P＜0.001)。肺动脉主干、主动脉及腔静脉AF比为1∶1.009∶0.974(r=0.939~0.991,P＜0.05)。结论 PC-MRI 能够准确测量肺、体循环大血管血流量。     

Slow pathway ablation for atrioventricular nodal reentry using a right internal jugular vein approach: a case series

BACKGROUND: Inferior venous access to the right heart is not possible in some patients due to congenital or acquired obstruction of the inferior vena cava (IVC). Although right-sided electrophysiology procedures have been performed successfully in patients with a previously placed IVC filter by direct placement of catheters through the filter, an alternative approach is necessary in some patients. METHODS: This case series describes three patients with an IVC filter who underwent successful ablation of the slow pathway for typical atrioventricular (AV) nodal reentrant tachycardia using a superior vena cava (SVC) approach via the right internal jugular (IJ) vein. Two separate introducer sheaths were placed into the IJ vein using separate punctures. This permitted placement of a standard deflectable ablation catheter and an additional catheter in the right atrium to monitor for ventriculoatrial conduction during the junctional rhythm associated with ablation of the slow AV nodal pathway. RESULTS: Catheter ablation was successful in each patient. The number of radiofrequency current applications was 7, 17, and 27. There were no procedural complications and no patient had recurrent tachycardia during follow-up. CONCLUSIONS: Catheter ablation of the slow AV nodal pathway can be performed successfully and safely in patients with inferior venous barriers to the right heart using an SVC approach via the right IJ vein.     

A misfired Greenfield filter; 21 years later!

A 35-year-old male developed deep vein thrombosis (DVT) andpulmonary emboli in 1986. He was subsequently diagnosed withprotein S deficiency. As a high risk for further thromboembolicevents, the patient underwent inferior vena cava (IVC) and superiorvena cava (SVC) Greenfield filter placement at an outside institution(in 1986). At the age of 56 years     

Intravascular Lead Extraction Using Locking Stylets and Sheaths

BYRD, C.L., ET AL.: Intravascular Lead Extraction Using Locking Stylets and Sheaths. Chronic lead extraction using intravascular countertraction techniques was studied in patients with over 65 different lead models including passive and active fixation devices. Indications for removal of 115 leads implanted 5 days to 264 months (mean 58 months) in 62 patients (mean 65 years) included septicemia, subcutaneous tissue infection, preerosion, free-floating lead, lead trapped in valve, too many leads, pain, and vein thrombosis. The superior vena cava (SVC) approach was attempted in 101 leads and was successful in 82 attempts (71% of total leads). The inferior vena cava (IVC) approach via the femoral vein was required to extract 14 (12%) leads inaccessible to the SVC approach and the 19 leads that failed the SVC approach (29% of total leads). The SVC procedure includes a sized stylet locked at the tip and telescoping sheaths advanced over the lead to the heart. An IVC procedure includes placement of a 16 F sheath workstation via a femoral vein into the right atrium. A deflection catheter and Dotter snare in an 11 F sheath were advanced through the workstation into the right atrium. The lead was maneuvered into position, snared, and pulled into the workstation. For both the SVC and IVC approaches, the leads were removed by applying traction on the lead and countertraction with the sheaths. In experienced hands, these techniques have proven safe and effective for removing chronic transvenous leads.     

Upper turnover portion of the reentry circuit for typical and reverse typical atrial flutter

Background: The posteromedial right atrium (PMRA) forms a block line during typical atrial flutter (AFL). However, whether upper turnover portion exists at the anterior or posterior superior vena cava (SVC) has not been determined.
Methods: We performed right atrial mapping during AFL in 20 patients (typical AFL, n = 17; reverse typical AFL, n = 3) using an electroanatomical mapping system.
Results: Mean AFL cycle length was 224 ± 20 ms and mean number of mapping points was 140 ± 27. PMRA formed a block line during both typical and reverse AFL in all patients. However, in 16 of 17 patients mapped with typical AFL, PMRA did not extend superiorly to the orifice of the SVC and AFL wave propagated between the upper limit of the PMRA and the posterior SVC. In the remaining patient mapped with typical AFL, a double potential was recorded along the PMRA continuously between the orifices of the inferior vena cava (IVC) and SVC. In the three patients mapped with reverse typical AFL, a posterior barrier was detected from IVC to the upper limit of the PMRA and AFL wave propagated between the upper limit of the PMRA and the posterior SVC. Mean length from IVC to upper limit of the PMRA was 81 ± 8% of the length from IVC to SVC.
Conclusions: PMRA forms a functional block line during both typical and reverse typical AFL. The upper turnover portion of reentry circuit for AFL was observed between the upper limit of the PMRA and the posterior SVC in the majority of isthmus-dependent AFL patients .     

The first four cases of successful NeoChord procedure in Chinese mainland

BACKGROUND: Transapical off-pump NeoChord procedure is a novel minimally invasive surgical repair of degenerative mitral regurgitation (MR). Here, we report the first four cases of NeoChord procedure in patients with mitral valve prolapse in Chinese mainland. METHODS: Four patients, aged 86, 84, 80 and 60 years, with severe MR due to posterior middle scallop prolapse (P2), underwent transapical off-pump artificial chordae implantation on April 9 and 10, 2019. The procedure was performed by left mini-thoracotomy under general anaesthesia and guided by 2D and 3D dimensional transoesophageal echocardiography (TEE). RESULTS: Mitral valve repair via NeoChord procedure was successfully performed with implantation of 3 artificial chordae in the first patient and 3, 2, and 3 artificial chordae in the following patients, respectively. Intraoperative TEE and pre-discharge transthoracic echocardiography (TTE) showed only mild to moderate MR of these four patients and no postoperative complications were noted. There were no changes of TTE finding between one-month follow-up and pre-discharge. CONCLUSION: The successful NeoChord procedures in four Chinese indicate that the valve repair using the NeoChord system for Chinese population is feasible.