彩色多普勒超声心动图诊断心脏三种缺损并存及漏诊原因分析

应用彩色多普勒超声心动图（ＣＤＥ）检查１２例心脏三种缺损并存即继发孔房间隔缺损（ＡＳＤ）、室间隔缺损（ＶＳＤ）和动脉导管未闭（ＰＤＡ）。结果ＣＤＥ对ＶＳＤ检出率最高１００％（１２／１２）、ＡＳＤ次之４１．７％（５／１２）、ＰＤＡ最低１６．７％（２／１２）。其中１０例做了右心导管检查，所有病例均经手术证实。作者分析漏诊原因除技术问题外，ＣＤＥ对心脏三种缺损并存的诊断有一定的局限性。     

心脏瓣膜闭锁二维超声心动图图像特征及规律性研究

目的： 探索心脏瓣膜闭锁（ＣＶＡ） 二维超声心动图（２ＤＥ） 图像特征及规律性。方法： １４５例ＣＶＡ年龄１～２６ （平均９．３） 岁。其中三尖瓣闭锁 （ＴＡ） ９３ 例, 室间隔缺损伴肺动脉闭锁 （ＰＡＶＳＤ） ２８ 例, 二尖瓣闭锁（ＭＡ） １７例, 室间隔完整的肺动脉瓣闭锁（ＰＡＩＶＳ） ７ 例。所有患者均有心血管造影对照, ７８ 例经手术证实。结果：２ＤＥ对１２９ 例作出正确诊断。ＣＶＡ的共同图像特征表现为闭锁的瓣膜呈一条光带状回声无开放运动。房室瓣闭锁还具有三大特征表现： １． 均有房间隔回声中断; ２．闭锁瓣膜的下方心室发育不良; ３． 闭锁瓣膜的对侧心房、心室内径显著增大。在ＣＶＡ中发病率由多到少依次为ＴＡ６４．２％ 、ＰＡＶＳＤ１９．３％ 、ＭＡ１１．７％ 和ＰＡＩＶＳ４．８％ 。结论：ＣＶＡ的２ＤＥ图像特征及规律性明显。２ＤＥ对ＣＶＡ中的ＴＡ、ＰＡＶＳＤ和ＰＡＩＶＳ具有特异性诊断价值。     

100例矫正性大动脉转位超声心动图诊断

目的 探讨矫正性大动脉转位（ＣＴＧＡ）超声心动图（ＥＣＧ）图像特征,材料和方法 应用ＥＣＧ检查１００例ＣＴＧＡ,男５５例,女４５例,年龄３～４７（平均１０,７）岁,９８例做了心血管造影检查,８０例经手术证实,结果：ＥＣＧ诊断正确９４例,误诊右心室双出口２例,２例诊断大动脉转位,但未明角ＣＴＧＡ,误诊肺动脉闭锁和Ｔａｕｓｓｉｎｇ－Ｂｉｎｇ综合征各１例,结论：应用ＥＣＧ诊断ＣＴＧＡ检查者必须熟练掌握本     

银染单链构象多态性技术检测原发性肝癌p53基因的突变

目的建立银染单链构象多态性技术检测原发性肝癌ｐ５３基因突变。方法用银染及单链构象多态性（ＳＳ－ＳＳＣＰ）技术检测１６９例原发性肝癌的癌变及癌旁正常组织ｐ５３基因第７，８外显子（Ｅ７，Ｅ８）的突变，并进行ＤＮＡ测序，鉴定突变位点。结果４例患者ｐ５３基因Ｅ７中第２４９号密码子第３号碱基发生了Ｇ：Ｃ→Ｔ：Ａ的颠换（ＡＧＧ→ＡＧＴ），２例患者Ｅ８中第２７３号密码子第１号碱基发生了Ｃ：Ｇ→Ｔ：Ａ的转换（ＣＧＴ→ＴＧＴ），总的突变率达３８％（６／１６）；６例ｐ５３基因突变的癌变组织中乙型肝炎病毒（ＨＢＶ）的整合率为５／６，８例未发生ｐ５３基因突变的癌变组织中ＨＢＶ的整合率仅为１／８，两者相比差异有显著性（Ｐ＜０．０５）。结论ｐ５３基因突变是原发性肝癌发生发展过程中的常发事件，且与ＨＢＶ的慢性感染密切相关。进一步研究有利于探讨原发性肝癌的发病机制，并为基因治疗提供依据。     

孤立性右心室发育不全彩色多普勒超声心动图诊断

应用彩色多普勒超声心动图（ＣＤＥ）检查５例孤立性右心室发育不全（ＩＲＶＨ），均经手术证实，结果５例ＣＤＥ均正确诊断。本病ＣＤＥ表现是二维超声心动图（２ＤＥ）显示右心室内径明显变小，左心室内径不同程度增大。彩色多普勒（ＣＤ）显示右心室内血流信号明显减少。作者认为ＣＤＥ对本病有特异性诊断价值，诊断关键是２ＤＥ显示右心室内径明显变小。     

彩色多普勒显像对室间隔缺损合并主动脉瓣脱垂的诊断和鉴别

目的： 分析室间隔缺损 （ＶＳＤ） 合并主动脉瓣脱垂 （ＡＶＰ） 的超声心动图特征和与主动脉窦瘤的鉴别。方法： １８ 例ＶＳＤ 合并ＡＶＰ 患者进行二维超声心动图 （２ＤＥ） 和彩色多普勒血流显像 （ＣＤＦＩ） 检查并被手术证实。结果： 超声检查发现ＡＶＰ 右瓣１３ 例, 无瓣３ 例; 右瓣和无瓣及左瓣各１ 例。１８ 例２０ 个ＶＳＤ, 超声漏诊干下ＶＳＤ１ 个,分型错误 ２ 例。室间隔缺损类型以干下型多见, 其次为膜周型。超声测定ＶＳＤ 大小１０ 例小于手术。当ＡＶＰ 明显时,超声表现为瓣叶延长、变形、移位和主动脉瓣返流。结论： ２ＤＥ 和ＣＤＦＩ可评价主动脉瓣病变程度, 对外科手术修复ＶＳＤ 和ＡＶＰ 提供有价值的信息。     

心内膜心肌纤维化的诊断和治疗

目的评价超声心动图（ＵＣＧ）、核磁共振成像（ＭＲＩ）、心血管造影（ＡＣＧ）、心内膜心肌活检（ＥＭＢ）和尸检对心内膜心肌纤维化（ＥＭＦ）的诊断价值,以及外科手术的疗效。方法对有不明原因的心力衰竭和（或）心包填塞表现并考虑为ＥＭＦ的３１例患者施行ＵＣＧ、ＭＲＩ、ＡＣＧ、ＥＭＢ、尸检以及外科手术。结果ＵＣＧ、ＭＲＩ、ＡＣＧ、ＥＭＢ和尸检对获得ＥＭＦ诊断的病例数分别为５／２２、４／５、２１／２１、１３／１８和８／８。３例患者施行了右室心内膜切除术加三尖瓣置换术,手术死亡２例,１例术后恢复良好,随访４年,心脏缩小,心功能改善,并能恢复轻度工作。结论ＵＣＧ、ＭＲＩ、ＡＣＧ、ＥＭＢ和尸检对ＥＭＦ的诊断具有重要作用,但其诊断率不同。目前外科治疗可能是这些病人最好的选择。     

螺旋CT在梗阻在黄疸诊断中的应用

目的：分析梗阻性黄疸的ＣＴ表现,探讨螺旋ＣＴ在鉴别诊断中的作用。材料与方法对经手术、病理证实的梗阻性黄疸６２例进行螺旋ＣＴ、ＥＲＣＰ＋螺旋ＣＴ联合检查,结果：肝内胆管呈枯枝状扩张多见于胆总管结石（２４／２８）少数可见于肿瘤性病变（３／２８）;呈软藤状扩张,胆管壁见软组织肿块为肿瘤性病变。但不能区分良恶性。病因诊断符合率Ｂ超７３％、螺旋ＣＴ８７％、ＥＲＣＰ＋螺旋ＣＴ联合检查１００％。结论：梗阻性黄疸     

赘生物的经食管超声心动图特征对感染性心内膜炎并发症的预测价值

目的探讨赘生物（Ｖｅｇ）的经食管超声心动图（ＴＥＥ）特征对感染性心内膜炎（ＩＥ）并发症的预测价值。方法对３２例ＩＥ患者进行ＴＥＥ检查。ＩＥ并发症包括充血性心力衰竭（ＣＨＦ）、栓塞及需要外科治疗。结果ＴＥＥ检查Ｖｅｇ的阳性率为９３．７５％（３０／３２）。随着Ｖｅｇ最大径、活动度、范围和回声强度分级级别的增加,其ＩＥ并发症发生率也随之增加。结论ＩＥ患者各因素与并发症的回归分析表明,Ｖｅｇ的活动度、范围、回声强度、Ｖｅｇ大小的三个测值（长度、宽度、最大径）和瓣膜返流均与ＩＥ并发症呈显著的相关关系,它们均是ＩＥ并发症的独立预测因素（均Ｐ＜０．０５）,而患者的年龄和性别均与ＩＥ并发症无显著的相关关系（均Ｐ＞０．０５）。当Ｖｅｇ总体评分≥９～≥１１时,其预测准确性最高（７０％～８０％）,其相应的敏感性（６０％～９３．３３％）及特异性（６６．６７％～８６．６７％）也较高。     

重型颅脑损伤后内皮素,降钙素基因相关肽的动态变化及其意义

目的：探讨重型颅脑损伤后内皮素（ＥＴ）、降钙素基因相关肽（ＣＧＲＰ）的动态变化及其意义。方法：对２９例重型颅脑损伤病人（ＧＣＳ≤８分）在伤后６小时内,３天,７天测定血浆ＥＴ、ＣＧＲＰ含量,并与３６你正常人对照,分析其变化及与预后的关系。结果：重型颅脑损伤后６小时ＥＴ及ＣＧＲＰ含量即急剧升高,并在一周内始终维持在较高的水平。预后良好者（ＧＯＳ３～５组）,早期ＥＴ含量及Ｅ／Ｃ比值均明显低于预后不良者（     

静脉药瘾者心内膜炎13例临床分析

目的：探讨静脉药瘾者心内膜炎（EIDA）的临床特点。方法：回顾性分析我院近10年13例EIDA患者的临床资料。结果：所有患者均有2～5年的静脉吸毒史，起病前无基础心脏病；主要临床表现为发热，呼吸道症状，心脏杂音；12例血培养阳性，以金黄色葡萄球菌多见；超声心动图显示所有患者三尖瓣受累，12例三尖瓣赘生物形成；10例患者经抗生素或外科手术治疗后痊愈，1例死亡，2例放弃治疗。结论：静脉药瘾者心内膜炎多为右心感染，表现为发热、肺部及全身多部位感染，致病菌多为金黄色葡萄球菌，经敏感抗生素或手术治疗预后相对良好，超声心动图对本病的诊治具有重要价值。     

超声心动图诊断感染性心内膜炎赘生物的价值

目的探讨感染性心内膜炎赘生物的超声心动图特点及诊断价值。方法应用超声心动图观察心脏赘生物的形态、大小、回声、分布及其瓣膜损害情况,对30例感染性心内膜炎心脏赘生物进行诊断。结果赘生物主要附着主动脉瓣10例,其次是二尖瓣8例,同时累及主动脉瓣和二尖瓣5例,三尖瓣1例,肺动脉瓣2例,动脉导管未闭主肺动脉2例,室间隔缺损右室面2例。赘生物长径约3～27mm,呈低回声至强回声。超声心动图对心脏赘生物的位置、大小、形态及数量的判断与手术所见基本相符,超声心动图还能对心脏基础病变及继发心血管血流动力学改变进行诊断。结论超声心动图对感染性心内膜炎赘生物能进行准确定位,并能确定其大小、形态、数目及评估心脏情况,对治疗决策及预后判断有重要的意义。     

Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis

Background: The aim of this study was to investigate whether transvenous lead removal is safe and effective in patients with lead vegetations greater than 1 cm in size. Methods: From 1991 to 2005, a total of 53 patients underwent pacemaker or ICD lead removal for vegetations. Transvenous lead removal using locking stylets and sheaths was performed in 30 patients (56.6%) and was found to be effective in 29 of those patients. In 1 patient, due to rupture of the lead, open heart removal of the ventricular lead remnant and tricuspid valve repair had to be performed due to persistent infection. In 23 of these patients, transesophageal echocardiography (TEE) verified vegetations greater than 1 cm in size. The remaining patients underwent primary lead removal using sternotomy and extracorporeal circulation (ECC). Pacemaker pocket infection was found in 16 patients (55.2%) of the transvenous study group and in 11 patients (45.8%) of the ECC group (P = 0.72). Results: Perioperative mortality was 5.7% (3 patients); all of them underwent primary ECC removal and had severe endocarditis of the tricuspid valve. None of the patients who underwent transvenous lead removal died and there were no further complications such as pericardial tamponade or major pulmonary embolism requiring further interventions, even in patients demonstrating large vegetations. Conclusions: This study demonstrates that transvenous lead removal is a safe and highly effective procedure for the removal of infected pacemaker and ICD leads, even in patients with large vegetations. Embolism to the lung proceeds mainly without further complications; however, patients with vegetations that might obstruct a main stem of the pulmonary artery should undergo ECC removal.     

超声心动图诊断感染性心内膜炎的意义

目的　探讨感染性心内膜炎 (IE)患者的超声心动图的特征性改变及诊断意义。方法　 17例IE患者进行了经胸超声心动图检查 ,探测赘生物的位置 ,大小 ,活动度及瓣膜功能。结果　男 11例 ,女 6例。平均年龄 3 4岁 (年龄范围 2～76岁 )。超声心动图检查发现 16例自身瓣膜和 1例人工瓣膜有赘生物形成 ,其中 7个二尖瓣 ,9个主动脉瓣和 1个三尖瓣上有赘生物。平均赘生物大小 0 .8cm (范围 0 .3～ 1.6cm)。血培养葡萄球菌 4例 ,链球菌 4例 ,类酵母菌 1例 ,血培养阳性率 5 3 %。住院期间 4例死亡 (2 3 % ) ,11例充血性心衰 (64 % ) ,6例体循环栓塞 (3 5 % ) ,4例接受了瓣膜置换术 (2 3 % )。结论　超声心动图检测IE声像图观察比较直观 ,尤其在血培养阴性的IE患者尤为有用。超声心动图能探测到瓣膜的赘生物 ,提示严重心衰 ,对于需要早期外科手术的IE患者提供重要依据     

Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era.

BACKGROUND: Thirteen years ago, transthoracic echocardiography (TTE) was found to be less sensitive than transesophageal echocardiography (TEE) for native valve vegetations. Since then, harmonic imaging and other advances have improved TTE. How this affects the sensitivity of TTE is unknown. METHODS: Fifty patients with echocardiography-diagnosed endocarditis had TTE and TEE examinations on high-end machines. These were matched for date of study with 50 patients who had TTE and TEE examinations that were negative for vegetations. RESULTS: A total of 51 vegetations were seen on TEE. The sensitivity of TTE for vegetations was only 55% (aortic 50% [12/24]; mitral 62% [16/26]; tricuspid 0% [0/1]). Anatomic valvular abnormalities did not alter the sensitivity of TTE (P =.42 for mitral; P =.97 for aortic valves). However, larger vegetations were more likely to be found by TTE. CONCLUSION: Despite advances in imaging during 12 years, TTE is still insensitive compared with TEE for the detection of native valve vegetations, and fails to demonstrate nearly half of them.     

Video-assisted endoscopic removal of infected endocardial pacemaker lead with large floating vegetation

The best management of pacemaker lead related endocarditis is complete surgical or percutaneous removal of the pacemaker system. Although the traditional surgical approach is via median sternotomy, we present two cases in which the lead and vegetations were removed using a video-assisted endoscopic technique through a limited right submammary incision. In each case the patient was supported by partial extracorporeal perfusion. Additional tricuspid valve repair and atrial septal defect closure was performed in one case. The postoperative courses were uneventful, illustrating that, when compared to the conventional open heart surgical approach, the less invasive approach can be a safe and effective way to remove an infected foreign body from the right heart with increased comfort, fast recovery, and a better cosmetic result.     

Echocardiography--prognosis of the course of infectious endocarditis and long-term survival in this disease

AIM: To determine prognostic opportunities of echocardiography (ECG) in infectious endocarditis (IE) basing on the assessment of microbial vegetations size and degree of valvular failure. MATERIAL AND METHODS: Of 114 patients with definite IE (72 male, 42 female), 90 ones had primary and 24 secondary endocarditis. The prospective study included all the survivors in the IE active stage--78 patients. RESULTS: Vegetations > 1 cm in size were detected in 50.8% patients, < 1 cm--in 49.2%. Hospital lethality in vegetations > 1 cm and < 1 cm was 25.8 and 16.1%, respectively. Thromboembolism rate was 81 and 64.2%, respectively. One-year survival was 78.7 and 71.4%, two-year survival 66.5 and 61.7%, three-year survival 66.5 and 49.4%, five-year survival--51.7 and 32.9% in vegetations < 1 cm and > 1 cm, respectively. Valvular regurgitation of the first degree was in 17.5%, of the second degree--in 41.9%, third-fourth degree--in 36.6% patients. Hospital lethality in mitral valve failure was 32.1%, in aortic and tricuspid failure--17.8 and 11.4%, respectively. CONCLUSION: EchoCG was most effective for predicting thromboembolism and cardiac failure. Valvular regurgitation of the third-fourth degree significantly correlates with severe cardiac failure. ECG is less informative for predicting hospital lethality.     

Successful treatment of polymicrobial multivalve infective endocarditis

A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.     

20例先天性心脏病的再次外科处理

自1991年4月至1996年11月收治20例先心病再次手术。病种有一孔型房间隔缺损合并二尖瓣畸形4例,室间隔缺损3例,法乐氏四联症3例,二孔型房间隔缺损2例,三尖瓣下移畸形2例,完全性心内膜垫缺损2例,二尖瓣脱垂、完全性大血管转位、肺动脉狭窄和三房心各1例。再次手术的病因有漏诊,技术缺点,病变发展,心内膜感染并发瓣膜病变。 本组中17例为第二次手术,3例为第三次手术。本组17例长期存活,死亡3例。死亡3例中,2例为三次手术,1例为巨大心脏,心功能均为Ⅳ级。     

三尖瓣病变外科手术的疗效评估

目的:探讨三尖瓣病变的不同手术方法和术后长期疗效。方法:1979年7月至1998年6月施行三尖瓣病变外科手术51例中,三尖瓣病变中有三尖瓣下移畸形33例,三尖瓣发育不全10例,感染性三尖瓣内膜炎3例,外伤性三尖瓣关闭不全、人工瓣膜功能异常各2例和Uhl’s病1例。51例中,瓣膜替换术37例,瓣膜成形术14例。附加手术有房缺修补术、室缺修补术、房化心室折叠术和缝补术。结果:住院死亡5例,死亡率为9.8％。死亡病例中3例为低心排综合征,2例气管套管并发症。长期随访生物瓣膜死亡4例,为心力衰竭、心律失常;机械瓣死亡1例,为瓣膜栓塞;瓣膜成形术14例无死亡,心功能明显改善。讨论:超声多普勒可明确诊断三尖瓣病变,三维超声可了解瓣叶、瓣下结构和瓣叶下移程度。病变中—重度、瓣叶发育较好、前瓣叶足够大小可施行瓣膜成形术。瓣膜发育不全、严重关闭不全可施行瓣膜替换术。成形手术疗效好,无瓣膜替换术潜在并发症。瓣膜成形术尽可能作为首选手术方案。