实时三维经食管超声指导下全胸腔镜技术二尖瓣成形术的中短期随访效果评价

目的探讨实时三维经食管超声心动图（RT3D-TEE）指导下全胸腔镜技术行二尖瓣成形术的意义及术后近中期效果评价。 方法选取2016年1月至2018年12月在空军军医大学第一附属西京医院采用全胸腔镜技术行二尖瓣成形术治疗二尖瓣关闭不全的147例患者临床资料,其中男性97例（66.0%）、女性50例（34.0%）,年龄10~68岁,平均年龄（45.8±14.5）岁,术前均行RT3D-TEE检查,观察二尖瓣病变部位、分析反流机制、测量二尖瓣结构各项指标,帮助手术医师选择成形环型号及手术方式。术后即刻行RT3D-TEE评价二尖瓣成形效果,随诊时记录经胸超声心动图结果。采用单因素方差分析比较术前和术后LA左右径、LV前后径、LVEF、EDV、ESV以及二尖瓣反流或狭窄情况等指标的变化,有统计学意义的组间进行LSD-t检验。 结果全组无围手术期死亡患者,有2例术中成形失败转而选择二尖瓣置换术,二尖瓣成形即刻成功率为98.6%。中期随访超声心动图显示,二尖瓣无或微量反流114例（78.6%）,少量反流19例（13.1%）,少-中量反流10例（6.9%）,中量反流2例（1.4%）。术后出现二尖瓣前叶收缩期前向运动（SAM征）0例;二尖瓣前向血流速度加快8例。与术前比较,术后1个月、3个月、12个月LA左右径、LV前后径、EDV、ESV较术前均缩小[分别为LA左右径（50.9±8.2）mm vs（39.9±7.1） mm vs（39.3±5.4）mm vs（39.8±7.9）mm,F=87.032,P<0.05;LV前后径（56.9±6.8）mm vs（49.0±5.8）mm vs（48.2±4.3）mm vs（48.5±6.3）mm,F=71.042,P<0.05;EDV（135.4±38.6）ml vs（99.1±30.1）ml vs（93.1±21.6）ml vs（98.6±37.3）ml,F=52.639,P<0.05;ESV（58.3±20.9）ml vs（47.7±21.3）ml vs（41.8±13.4）ml vs（44.1±25.8）ml ,F=18.300,P<0.05];与术前比较,术后1个月、3个月LVEF较术前略减低[分别为（57.5±5.1）% vs（53.1±6.5）% vs（55.8±5.6）%,F=14.885,P<0.05];术后12个月与术前LVEF比较差异无统计学意义[术前（57.5±5.1）% vs（56.5±5.9）%,P>0.05]。平均随访时间为（23±10）个月,随访时所有患者均存活,无因反流复发再次行手术治疗的患者。 结论采用RT3D-TEE指导二尖瓣成形术对提高手术成功率、降低并发症的发生率有重要意义。RT3D-TEE指导下胸腔镜技术治疗二尖瓣关闭不全近中期结果满意,值得推广。     

Intermittent premature mitral valve closure in combined acute severe aortic and mitral regurgitation

We have described the clinical, hemodynamic, and echocardiographic features of torn aortic cusps with mitral valve fenestration in a patient with infective endocarditis. Hemodynamic studies showed left atrial pressure intermittently exceeding left ventricular end-diastolic pressure. This phenomenon corresponded with intermittent premature mitral valve closure, which may serve as a marker for M-mode echocardiographic diagnosis in combined severe acute aortic and mitral regurgitation.     

Mitral regurgitation and left ventricular diastolic dysfunction similarly affect mitral and pulmonary vein flow Doppler parameters: the advantage of end-diastolic markers.

Enhanced early mitral flow and reduced systolic pulmonary vein flow may be caused both by increased left ventricular pressure as the result of diastolic dysfunction and by increased transmitral flow as the result of mitral regurgitation. Nevertheless, Doppler parameters are widely used to predict left ventricular filling pressure. We aimed to analyze the interference of mitral regurgitation with Doppler parameters usually used to estimate left ventricular filling pressure and to identify markers independent of mitral regurgitation, which could reliably estimate increased left ventricular filling pressure. Eighty-four patients (age, 62 +/- 9 years; 82% men) had a complete echocardiographic Doppler examination. Transmitral E- and A-wave velocity, E deceleration time and A duration, pulmonary vein systolic and diastolic velocities, and reversal flow duration and maximal and minimal left atrial volumes were measured. The difference between the duration of pulmonary vein and mitral A waves was calculated (A'-A). Mitral regurgitant volume was quantitatively assessed by echocardiography. Left ventricular end-diastolic pressure was measured invasively. Patients had a wide range of left ventricular ejection fraction (14% to 70%), mitral regurgitant volume (0 to 94 mL), and left ventricular end-diastolic pressure (3 to 37 mm Hg). E velocity, E/A, pulmonary vein systolic and diastolic, and systo-diastolic ratios were significantly and independently correlated with both left ventricular end-diastolic pressure and mitral regurgitant volume. A'-A showed a strong correlation with left ventricular end-diastolic pressure (r = 0.70; P <.0001), but the relation with mitral regurgitant volume was not significant (r = 0.19; P =.08). Mitral regurgitation affects the majority of Doppler parameters widely used to predict filling pressure but does not influence Ad'-Ad, which proved to be the strongest predictor of left ventricular end-diastolic pressure.     

组织运动二尖瓣环位移自动追踪技术定量评估早期心尖肥厚型心肌病的收缩功能

目的应用组织运动二尖瓣环位移自动追踪（TMAD）技术测定二尖瓣环收缩期位移（MAD）,探讨其在评估早期心尖肥厚型心肌病（PAHCM）患者左心室收缩功能中的临床应用价值。 方法分别选择26例PAHCM患者、高血压左心室肥厚（HLVH）患者和健康自愿者。所有研究对象均经常规超声心动图检查并存储相应切面的二维图像,以双平面Simpson法测量左心室舒张末期容积（EDV）、左心室收缩末期容积（ESV）、每搏量（SV）以及左心室射血分数（LVEF）。应用QLAB 9.1工作站,自动获取二尖瓣环各位点相对于心尖处的收缩期峰值位移（SD）,计算3个切面6个位点平均峰值位移。 结果与正常对照组相比较,PAHCM组在各位点的SD以及6个位点平均峰值位移差异有统计学意义［（10.16±1.17）mm vs （13.09±1.25）mm,（9.03±1.35）mm vs （12.45±1.61）mm,（10.25±1.07）mm vs （12.53±1.29）mm,（10.54±1.01）mm vs （12.39±1.52）mm,（9.25±1.13）mm vs （13.09±1.75）mm,（9.95±0.83）mm vs （12.35±0.94）mm,（9.86±0.39）mm vs （12.65±0.68）mm,t=-8.74、-8.98、-6.92、-5.19、-9.37、-9.74、-18.02,P均<0.05］。与HLVH组比较,PAHCM组在后间壁、后壁、前间壁、前壁的SD以及6个位点平均峰值位移差异有统计学意义［（10.16±1.17）mm vs （8.42±1.28）mm,（10.25±1.07）mm vs （8.36±1.20）mm,（10.54±1.01）mm vs （8.84±1.08）mm,（9.95±0.83）mm vs （8.58±1.09）mm,（9.86±0.39）mm vs （8.50±0.46）mm,t=5.10、6.00、5.87、5.11、11.48,P均<0.05］,而在侧壁、下壁的SD差异无统计学差异［（9.03±1.35）mm vs （8.30±1.27）mm,（9.25±1.13）mm vs （8.52±1.21）mm,t=2.25、2.27,P均>0.05］。与正常对照组比较,HLVH组在各位点的SD以及6个位点平均峰值位移差异有统计学意义［（8.42±1.28）mm vs （13.09±1.25）mm,（8.30±1.27）mm vs （12.45±1.61）mm,（8.36±1.20）mm vs （12.53±1.29）mm,（8.84±1.08）mm vs （12.39±1.52）mm,（8.52±1.21）mm vs （13.09±1.75）mm,（8.58±1.09）mm vs （12.35±0.94）mm,（8.50±0.46）mm vs （12.65±0.68）mm,t=-13.27、-10.34、-12.09、-9.71、-10.93、-13.35、-25.59,P均<0.05］。 结论与LVEF比较,使用TMAD测定PAHCM患者的MAD,进而反映左心室收缩功能的变化,是一种更为简单且敏感的新方法。     

Comparison of the Effects of AV Nodal Ablation Versus AV Nodal Modification in Patients with Congestive Heart Failure and Uncontrolled Atrial Fibrillation

Radiofrequency (RF) catheter ablation of the atrioventricular node (AVN) and implantation of a ventricular pacemaker can improve cardiac performance in patients with congestive heart failure (CHF) and uncontrolled atrial fibrillation (AF). Alternatively. RF catheter modification of the A VN has been proposed to slow ventricular response during AF without requirement for permanent pacing. Among 44 consecutive patients (mean age 69.7 ± 10.2 years) with drug resistant chronic AF, 22 (group I) had AVN ablation with permanent ventricular pacemaker implantation, while 22 patients had attempted AVN modification. Complete AV block was obtained in all group I patients while only seven (32 %) A VN modification patients (group II) had permanent slowing of ventricular rate. Among patients in group I, mean left ventricular ejection fraction (EF) increased from 32.2%± 8.8% before ablation to 41.9%± 14.6% 4-weeks postablation (P < 0.01); exercise tolerance time (ETT) increased from 2.9 ± 2.2 minutes to 4.5 ± 2.9 minutes (P < 0.01); and quality-of-life score decreased from 66.1 ± 22.6 to 36.9 ± 17.1 (P < 0.01). By comparison, there was only a small increase in ETT in the seven successful group II patients (2.4 ± 1.8 minutes to 3.0 ± 1.9 minutes; P < 0.05) and there was no significant change in EF or quality-of-life. While AVN ablation can occasionally have transient adverse effects, it is more effective than AVN modification for improving cardiac performance in selected patients with CHF and AF.     

Clinical Comparison of Acute Single to Dual Chamber Pacing in Chronotropically Incompetent Patients with Left Ventricular Dysfunction

Dual chamber, rate responsive (DDDR) pacing is felt to be superior to ventricular, rate responsive (VVIR) pacing since it more closely mimics the normal electrical and hemodynamic activity of the heart. This reasoning has been used to justify the higher initial costs and increased complexity of dual chamber systems. This study was designed to determine if objective criteria could be identified during acute testing to justify implanting a dual chamber instead of a single chamber system in patients with left ventricular dysfunction. Eight patients with DDDR pacemakers (implanted for chronotropic incompetence) and left ventricular dysfunction underwent exercise radionuclide angiography and graded exercise treadmill testing. Each patient performed the tests in the single (VVIR) and dual (DDDR) chamber modes in a randomized, blinded fashion. We found that objective parameters such as ejection fraction (31%± 13% vs 31%± 10%), exercise tolerance (6.1 ± 2.7 min vs 6.3 ± 2.9 min), oxygen consumption (VO₂) (941 ± 286 mL/min vs 994 ± 314 mL/min), carbon dioxide production (VCO₂) (995 ± 332 mL/min vs 1054 ± 356 mL/min), and maximum attainable workload (43 ± 24 W vs 46 ± 22 W) did not differ between the single and dual chamber pacing modes. These findings suggest that in the acute setting, the additional cost and complexity of dual chamber, rate responsive pacing cannot be justified by objective improvements in exercise tolerance in patients with underlying left ventricular dysfunction.     

超声心动图诊断左心室射血分数减低的左冠状动脉异常起源于肺动脉的效果分析

目的探讨左心室射血分数（LVEF）减低的左冠状动脉异常起源于肺动脉（ALCAPA）的超声心动图特点及手术效果。 方法选取2008年10月至2018年9月首都医科大学附属北京儿童医院ALCAPA患者28例，根据LVEF分为LVEF减低组（LVEF＜50%）19例和LVEF正常组（LVEF≥50%）9例，比较2组患者超声心动图表现，应用两独立样本t检验比较2组患者间超声参数的差异。手术患者（17例）分别于术后1 d、1个月、6个月、1年进行超声心动图随访，应用配对t检验与术前超声参数进行对比。 结果LVEF减低组患者LVEF为30%~48%，平均年龄5.4个月；LVEF正常组LVEF为60%~73%，平均年龄2.5岁。LVEF减低组与LVEF正常组相比，左心室舒张末期内径大［（131.95±24.24）mm/m² vs（85.67±20.26）mm/m²］，右冠状动脉内径小［（3.06±0.51）mm vs（4.01±0.62）mm］，差异具有统计学意义（t=-4.465、4.075，P均＜0.001），易形成室壁瘤。LVEF减低组中10例行手术治疗，7例超声心动图随访至术后1年；与术前相比，术后1 d开始左心室舒张末期内径逐渐回缩［（109.98±16.06）mm/m²、（99.49±12.02）mm/m²、（89.48±10.90）mm/m²、（80.03±8.09）mm/m² vs（123.26±12.40）mm/m²］，差异具有统计学意义（t=-2.668、-7.519、-5.413、-6.526，P=0.004、0.001、0.012、0.007），LVEF术后1个月开始恢复，术后6个月达正常水平［（45.50±9.57）%、（66.25±10.34）%、（67.25±4.50）% vs（38.83±7.05）%］，差异具有统计学意义（t=3.162、3.683、5.869，P=0.025、0.014、0.002）。 结论LVEF减低的ALCAPA患儿年龄小、心脏病变重，超声心动图可以准确作出诊断，但需要与心内膜弹力纤维增生症、扩张型心肌病相鉴别。ALCAPA手术治疗远期效果较好，超声心动图在术后随访中有重要作用。     

心肌做功技术评估急性心肌梗死患者左心室收缩功能

目的 探讨心肌做功（MW）技术评估急性心肌梗死（AMI）患者左心室收缩功能的应用价值。方法 对比30例AMI患者（AMI组）与30名健康志愿者（对照组）的常规超声心动图参数及MW参数，分析AMI患者左心室整体有用功（GCW）与左心室射血分数（LVEF）、整体长轴应变（GLS）之间的相关性。结果 与对照组比较，AMI组左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、室间隔舒张末期厚度（IVSD）、左心室舒张末期容积（LVEDV）、左心室收缩末期容积（LVESV）、二尖瓣口舒张早期峰值流速（E）/二尖瓣后叶瓣环组织多普勒速度（e）、左心室质量（LVM）、左心室质量指数（LVMI）及二尖瓣反流面积（MR）均增大，LVEF、E及e值均减低（P均<0.05）；左心室GCW、整体做功效率（GWE）、整体做功指数（GWI）均降低，整体无用功（GWW）、GLS、峰值应变离散度（PSD）均增高（P均<0.05）。AMI患者GCW与LVEF呈正相关（r=0.573，P=0.001），GCW与GLS呈负相关（r=-0.880，P<0.001）。结论 MW技术可用于评估AMI患者左心室收缩功能变化。     

3D打印技术辅助Liwen术式治疗梗阻性肥厚型心肌病8例

目的探讨应用3D打印心血管模型在Liwen术式治疗梗阻性肥厚型心肌病术前评估中的可行性及有效性。 方法回顾性研究2018年10月至2019年5月于空军军医大学西京医院诊治的梗阻性肥厚型心肌病并施行Liwen术式治疗的患者8例。术前采集患者CT检查影像学数据,将其导入Mimics软件进行重建,结合3D打印技术制作患者全心解剖模型,即进行术前影像学评估。患者均在超声引导下行经皮心肌内室间隔射频消融术,经胸超声行术中监测并评价手术情况,术后1、3、6个月及每年进行随访观察,结合影像学及3D打印技术进行术后评估。采用配对t检验比较术前术后左心室射血分数、二尖瓣反流量的差异,采用Wilcoxon符号秩检验比较术前术后静息和负荷时左心室流出道压差数据差异。 结果8例患者成功施行了Liwen术式,3D打印模型能够准确复制患者心脏的个体化解剖结构,辅助Liwen术式治疗梗阻性肥厚型心肌病术前评估,术中手术情况和术后3D打印模型与实际手术情况相符。与术前比较,术后6个月左心室射血分数增加［（58.36±6.21）% vs （46.25±7.62）%］,最大室间隔厚度减小［（13.92±3.56）mm vs （25.42±4.93）mm］,二尖瓣反流量减小［（1.04±0.41）ml vs （10.14±3.72）ml］,差异均具有统计学意义（t=7.998、14.539、4.726,P=0.015、0.005、0.041）,静息时和负荷后左心室流出道压差均减小［90.45（90.00,110.00）mmHg vs 7.00（6.00,10.00）mmHg;141.00（89.25,150.00）mmHg vs 16.50（15.00,17.85）mmHg］,差异均具有统计学意义（Z=2.521,P=0.012;Z=2.521,P=0.012）。术前纽约心脏协会心功能分级Ⅲ级者5例,Ⅳ级者3例,术后6个月纽约心脏协会心功能分级Ⅰ级为6例,Ⅱ级2例。 结论3D打印技术辅助Liwen术式术前评估对治疗心肌肥厚具有可行性与有效性。     

扩张型心肌病与缺血性心肌病患者冠心病危险因素、血脂及心脏超声特征对比分析

目的对比分析扩张型心肌病(DCM)和缺血性心肌病（ICM）患者冠心病危险因素、血脂以及心脏超声特征,为基层医师诊断和初步鉴别这两种心脏疾病提供参考。 方法入选2015年1月至2017年8月在汕头大学医学院第二附属医院心内科住院的心脏扩大且合并左室收缩功能降低的53例患者,患者均行冠状动脉造影。按照冠状动脉造影结果将患者分为DCM组（34例,33~79岁）和ICM组（19例,41~77岁）,回顾性分析两组患者冠心病危险因素、血脂及心脏超声特征。采用χ²检验比较两组患者年龄构成情况、冠心病危险因素（性别、高血压、糖尿病、吸烟史）构成情况、右心系统增大构成情况,采用t检验比较血脂检查结果（总胆固醇、甘油三酯、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇）和超声检查结果［左心房直径、左心室舒张末期内径（LVd）、左心室收缩末期内径（LVs）、射血分数］。 结果在年龄构成方面：DCM组中青年患者（<40岁）比例明显高于ICM组,差异具有统计学意义（20.59% vs 0,χ²=4.51,P=0.034）;而DCM组老年患者（≥60岁）比例明显低于ICM组,差异具有统计学意义（32.35% vs 68.42%,χ²=6.40,P=0.011）。在冠心病危险因素方面,所有心脏扩大患者中,男性患者占所有患者的81.13%;但是DCM组和ICM组在男性比例方面差异无统计学意义（82.35% vs 78.95%,χ²=0.09,P=0.761）;ICM组患者合并高血压、糖尿病的比例均明显高于DCM组,差异具有统计学意义（73.68% vs 38.24%,χ²=6.13,P=0.013;52.63% vs 20.59%,χ²=5.74,P=0.017）;DCM组和ICM组患者吸烟史比例差异无统计学意义（58.82% vs 57.89%,χ²=0.00,P=0.948）。在血脂水平方面,DCM组和ICM组患者甘油三酯、高密度脂蛋白胆固醇水平差异无统计学意义［（1.26±0.59）mmol/L vs （1.46±1.02）mmol/L,t=-0.91,P=0.369;（1.02±0.40）mmol/L vs （1.06±0.27） mmol/L,t=-0.39,P=0.699］;DCM组患者总胆固醇、低密度脂蛋白胆固醇水平低于ICM组,差异具有统计学意义［（4.37±1.10） mmol/L vs （5.23±1.32）mmol/L,t=-2.54,P=0.014;（2.80±0.82）mmol/L vs （3.43±1.02）mmol/L,t=-2.46,P=0.018］。在心脏超声检查方面,DCM组患者左心系统扩大程度较ICM组明显,DCM组患者左心房直径、LVd、LVs均大于ICM组,差异具有统计学意义［（43.29±6.19）mm vs（38.58±4.82）mm,t=2.86,P=0.006;（65.94±7.30）mm vs（58.94±9.16）mm,t=3.05,P=0.004;（54.68±8.43）mm vs （48.16±7.61）mm,t=2.79,P=0.007］;DCM组患者与ICM患者比较,右心系统扩大的比例更高,差异具有统计学意义（44.12% vs 15.79%,χ²=4.36,P=0.037）,射血分数下降更为明显,差异具有统计学意义［（31.65±7.18）% vs （36.89±9.10）%,t=-2.31,P=0.025］。 结论综合分析冠心病危险因素、血脂及心脏超声特征可初步鉴别DCM和ICM。     

二维斑点追踪成像技术对超重及肥胖女性孕中晚期胎儿心室构型变化的评估

目的应用二维斑点追踪成像（2D-STI）评价孕前超重及肥胖女性孕中晚期胎儿心室构型变化。 方法回顾性选取2019年6月至2020年3月于空军军医大学唐都医院进行胎儿超声心动图检查的孕妇80例,根据孕前体质量指数（BMI）将其分为正常对照组30例、超重组27例和肥胖组23例。应用胎儿超声心动图获得常规胎儿心脏形态学指标,采用2D-STI技术并利用Fetal HQ软件获得孕24周及孕32周胎儿双侧心室24节段舒张末期横径及球形指数（SI）,3组间进行单因素方差分析,并采用LSD-t检验进一步行组间两两比较。 结果常规方法测量肥胖组、超重组与正常对照组孕妇胎儿的左、右心室舒张末期横径,左、右心室舒张末期长径,心胸面积比及左心室每搏输出量,3组间差异均无统计学意义（P均＞0.05）。孕中期（孕24周）肥胖组室间隔厚度较正常对照组增厚［（2.10±0.41）mm vs（1.85±0.33）mm］,孕晚期（孕32周）肥胖组室间隔厚度较正常对照组及超重组均增厚［（3.10±0.65）mm vs（2.46±0.52）mm、（2.55±0.53）mm］,差异均有统计学意义（P均＜0.05）。2D-STI测得肥胖组左心室横径孕24周第6~12节段及孕32周第7~12节段分别较同孕龄正常对照组明显增宽,肥胖组左心室SI孕32周第4~12节段较正常对照组明显降低（P均＜0.05）。2D-STI测得肥胖组右心室横径孕24周第3~10节段及孕32周第1~8节段分别较同孕龄正常对照组明显增宽,肥胖组右心室SI孕32周第1~9节段较正常对照组明显降低（P均＜0.05）。 结论孕前肥胖的孕妇胎儿左心室中间段、右心室基底段节段性横径增宽,与正常对照者相比更接近球形,提示测量左心室中间段及右心室基底段横径可更敏感地反映孕前肥胖孕妇胎儿心室形态的改变。     

Controlled Ventilation Enhances Catheter Stability During Radiofrequency Ablation

Variations in the amplitude of the atrial and ventricular depolarization waves of the intracardiac electrogram occur during different phases of respiration. Therefore, we tested whether controlled ventilation would reduce ablation attempts and increase the rate of success in patients undergoing radiofrequency ablation with general anesthesia. Thirty-eight children were divided into two groups: (1) controlled and (2) noncontrolled or cyclic ventilation. In the controlled ventilation group, the mapping electrogram was recorded during sustained inspiration, sustained expiration, and cyclic ventilation. Ablation was done in the phase of ventilation that had the least variability in atrial and ventricular amplitudes. Seventeen patients in the controlled ventilation group had tracings adequate for review. In eight patients, ablation was done during sustained inspiration with the percentage change of atrial and ventricular amplitudes (15%± 16% and 13%± 16%, respectively) being < that during sustained expiration (38%± 27%, P = 0.04 and 20%± 21 %) or during cyclic ventilation (57%± 27%, P < 0.01 and 54%± 26%, P = 0.003). In nine patients, ablation was done during sustained expiration with the percentage change of atrial and ventricular amplitudes (5%± 5% and 5%± 2%) being less than that during sustained inspiration (21%± 14%, P = 0.01 and 11%± 6%, P = 0.01) or during cyclic ventilation (68%± 23%, P < 0.001 and 48 ± 26%, P = 0.001). We achieved success with each patient in both groups, but the number of ablation attempts were less in the controlled ventilation group 1 (3 ± 2), as compared to the cyclic ventilation group 2 (8 ± 8; P < 0.02). We concluded that controlled ventilation reduced the number of ablation attempts and facilitated the ablation procedure.     

Left Atrial Linear Ablation to Modify the Substrate of Atrial Fibrillation Using a New Nonfluoroscopic Imaging System

Linear left atrial ablation is performed in combination with pulmonary vein (PV) isolation to improve the clinical results of atrial fibrillation (AF) ablation. These procedures require long procedures and fluoroscopic exposure. The aim of the present study was to evaluate the performance of a new, nonfluoroscopic, real-time, three-dimensional navigation system for linear ablation at the left atrial roof and mitral isthmus. The study included 44 patients (54 ± 10 years of age, 5 women) with drug-refractory AF, who underwent roof line or mitral isthmus linear ablation after 4-PV isolation. In 22 patients, ablation was performed with the navigation system (test group), and in the remainders linear ablation was performed with fluoroscopic guidance alone (control group). Conduction block was achieved in 20 patients (91%) in test group, and 21 patients (95%) in the control group (ns). Use of the navigation system was associated with a shorter fluoroscopic exposure for roof line (5.6 ± 3.0 minutes vs 8.7 ± 5.0 minutes, P < 0.05), and a trend for mitral isthmus ablation (7.8 ± 7.8 minutes vs 12.1 ± 5.9 minutes). It was also associated with a trend toward shorter procedure times for roof line (15.3 ± 8.6 minutes vs 22.9 ± 16.8 minutes) and mitral isthmus line (20.2 ± 15.8 minutes vs 32.0 ± 7.6 minutes) but no difference in duration of radiofrequency delivery. There was no procedural complication. The use of this new nonfluoroscopic imaging system was associated with a shorter fluoroscopic exposure as well as a trend toward shorter duration of linear ablation procedures for AF.     

Clinical Utility of Routine Transthoracic Echocardiographic Studies After Uncomplicated Radiofrequency Catheter Ablation: A Prospective Multicenter Study

Unsuspected cardiac complications have been occasionally identified on postablation echocardiographic studies; however, the clinical utility of route echocardiographic studies following uncomplicated radiofrequency catheter ablation procedures has not been established. Two-dimensional/Doppler echocardiographic studies obtained preablation (within 3 months of the procedure) in 355 consecutive patients (180 males and 175 females, mean age 37 ± 21 years) were compared to postablation (within 24 hours of the procedure) studies obtained after a total of 387 uncomplicated RF catheter ablation procedures for AV node slow pathway (n = 120), accessory AV pathways (n = 214), and complete AV junction (n = 39). Postablation studies identified 6 new cases (1.5%) of new wall motion abnormalities, and 3 additional patients had septal wall motion abnormalities during ventricular pacing. LVEF remained unchanged from baseline (62 ± 10 vs 62 ± 11). A small pericardial effusion was detected after 11 procedures (2.8%), and there were 9 (2.3%), 21 (5.4%), and 20 (5.2%) new findings of mild (1 +) aortic, mitral, and tricuspid regurgitation, respectively; and no cases of significant valvular dysfunction in any patient. There were no new cases of cavity thrombus. There was no clear relationship between postablation echocardiographic findings and the type and approach to ablation, and no patient had any clinical sequelae possibly related to any of the new echocardiographic findings during a mean follow-up of 15 ± 6.0 months (range 1–26 months). Routine transthoracic echocardiographic studies after uncomplicated RF catheter ablation procedures identify occasional minor abnormalities that (1) may or may not be procedure related, (2) are of no apparent clinical consequence, and (3) thus appear to be of limited value.     

eSie Valves三维自动定量技术评估肥厚型梗阻性心肌病改良扩大Morrow围术期主动脉根部变化

目的应用eSie Valves三维自动定量技术评估改良扩大Morrow术患者围术期主动脉根部相关参数，探讨其变化规律。 方法选取2019年3月至9月于中国医学科学院阜外医院确诊为肥厚型梗阻性心肌病（HOCM），并进一步行改良扩大Morrow术的患者23例（HOCM组）和正常对照组23例。应用经食管三维超声心动图采集主动脉根部三维图像，eSie Valves三维自动定量分析系统重建主动脉根部三维模型，自动测量相关参数并进行组间比较分析。 结果HOCM组患者术后梗阻部位厚度及左心室流出道压差较术前明显降低，差异均有统计学意义（P均＜0.001）。所有患者术后二尖瓣反流量明显减少，与术前相比，差异有统计学意义（P＜0.001）；10例（43.5%，10/23）患者术后出现少量中心性主动脉瓣反流，其中4例为新发。HOCM组术前与正常对照组主动脉根部高度比较［（20.2±3.5）mm vs（23.5±1.8）mm］，差异有统计学意义（P＜0.05）。HOCM组术后较术前主动脉瓣缘对合高度减低［（11.7±1.3）mm vs（13.0±1.6）mm］，差异有统计学意义（P＜0.05），而主动脉根部高度增加，差异有统计学意义［（25.0±4.8）mm vs（20.2±3.5）mm，P＜0.05］。 结论HOCM患者存在主动脉根部结构部分异常，改良扩大Morrow术可以改善主动脉根部形态，eSie Valves三维自动定量技术可通过重建HOCM患者主动脉根部模型为其形态结构分析提供依据。     

二维斑点追踪技术及实时三维超声心动图评估心房功能性二尖瓣反流患者导管消融疗效及其影响因素分析

目的 应用二维斑点追踪技术（2D-STI）联合实时三维超声心动图（RT-3DE）评估心房功能性二尖瓣反流（AFMR）患者导管消融疗效,并探讨术后二尖瓣反流改善的影响因素。方法 选取于我院首次接受导管消融治疗的AFMR患者47例,术后6个月均复查超声心动图,根据术后AFMR是否改善分为改善组（22例）和未改善组（25例）。应用常规超声心动图测量左房前后径（LAD）、二尖瓣环前后径（MAD）、左室收缩末期内径（LVESD）、左室舒张末期内径（LVEDD）、左室射血分数（LVEF）;应用2D-STI测量左房存储期应变（LASr）、管道期应变（LAScd）、辅泵期应变（LASct）;应用RT-3DE测量左房最大容积（LAVmax）、左房最小容积（LAVmin）,计算左房射血分数（LAEF）及左房扩张指数（LAEI）,比较两组术前、术后上述参数的差异,分析导管消融术对左房结构与功能重构的影响。采用多因素Logistics回归分析导管消融术后二尖瓣反流改善的影响因素;绘制受试者工作特征（ROC）曲线分析各因素预测导管消融术后疗效的诊断价值。结果 与导管消融术前比较,术后两组心脏结构参数（LAD、MAD及LAVI）均减小,功能参数（LASr、LAScd、LASct、LAEF及LAEI）均增大,差异均有统计学意义（均P＜0.05）。多因素Logistics回归显示,MAD（OR=5.552,95%可信区间：1.796～9.791,P=0.031）、LASr（OR=0.733,95%可信区间：0.552～0.973,P=0.031）均为导管消融术后二尖瓣反流改善的独立预测因子。ROC曲线分析显示,MAD预测二尖瓣反流改善的曲线下面积为0.775,(95%可信区间：0.643～0.908, P=0.001),最佳截断值为 3.35cm,LASr预测二尖瓣反流改善的曲线下面积为0.735,(95%可信区间：0.590～0.881, P=0.006),最佳截断值为18.05%。结论 2D-STI联合RT-3DE可以准确评估AFMR患者导管消融术后疗效;MAD、LASr均为导管消融术后二尖瓣反流改善的独立预测因子。     

左心室压力变化率评价心脏再同步化治疗术后短期疗效价值

目的 探讨左心室压力变化率评价心力衰竭患者心脏再同步化治疗术后短期疗效的价值。方法 有二尖瓣反流、接受心脏再同步化治疗的心力衰竭患者17例,测量术前、术后1个月左心室舒张末期内径和收缩末期内径、左心室舒张末期容积和收缩末期容积、二尖瓣反流面积,采用双平面Simpsons法测量左室射血分数,在连续多普勒频谱图上测量二尖瓣反流压差速率1~3m/s两点间时间,估测左心室压力变化率。结果 心脏再同步化治疗后1个月,左心室舒张末期内径、收缩期末期内径、左心室舒张末期容积、收缩末期容积（（76.3±8.7）mm、（64.7±9.3mm、（232±54）mL、（168±48）mL）较治疗前（（78.3±8.5）mm、（69.2±8.4）mm、（270±59）mL、（207±47）mL）明显降低（P〈0.01）;二尖瓣反流面积（6.5±3.9）mm2较治疗前（9.2±4.1）mm2明显缩小（P〈0.05）;左室射血分数、左心室压力变化率（（27.4±8.6）%、（598±141）mm Hg/s））较治疗前（（21.5±5.1）%、（473±132）mm Hg/s）明显升高（P〈0.01）。结论 左心室压力变化率是目前评价心肌再同步化治疗术后短期疗效的有效指标之一。     

阵发性房颤患者射频消融术后血清FGF-21水平及心功能变化

目的研究射频消融术对于阵发性房颤患者血清成纤维细胞生长因子-21（FGF-21）水平及心功能的影响。 方法选取青岛市中心医院2015年11月至2017年12月收治的阵发性房颤患者80例,采用随机数字表法分为治疗组40例和对照组40例;对照组采取药物治疗,治疗组采取射频消融术治疗,术后6个月采用独立样本t检验比较治疗组与对照组左心房内径（LAD）、右心房内径（RAD）、左心室射血分数（LVEF）以及血清FGF-21水平的差异。 结果治疗组的LAD、RAD小于对照组［（36.2±7.5）mm vs （42.5±8.3）mm;（35.3±7.2）mm vs （39.4±8.1）mm］,LVEF高于对照组［（59.3±8.2）% vs （52.1±7.5）%］,差异均具有统计学意义（t=3.586,P<0.001;t=2.393,P=0.019;t=4.098,P<0.001）。治疗组血清FGF-21水平低于对照组［（145.2±25.6）ng/Lvs （197.6±30.4）ng/L］,差异具有统计学意义（t=4.879,P<0.001）。 结论射频消融术可明显降低血清FGF-21水平,改善患者心功能;血清FGF-21水平对房颤患者预后有一定预测价值。     

系统性红斑狼疮亚临床左心室心肌功能不全的四维超声系统性定量研究

目的采用斑点追踪超声心动图定量技术可视化评估系统性红斑狼疮（SLE）患者左心室四维应变和扭转等心肌力学参数变化,揭示该类患者可能存在的亚临床左心室心肌功能损伤。 方法选取2017年7月至2018年1月在四川省人民医院就诊的无心脏受累常规证据的SLE确诊患者59例（SLE组）和同期体检中心年龄、性别相匹配的健康志愿者37例（健康对照组）,两组均行常规超声心动图（TTE）、超声组织多普勒成像（TDI）和四维超声自动左心室定量技术（4D Auto LVQ）检测,获取左心室几何构型相关参数：左心室后壁舒张末期厚度（LVPWT）、左心室舒张末期内径（LVEDD）、室间隔舒张末期厚度（IVST）、左心室舒张末期容积（EDV）、左心室收缩末期容积（ESV）;左心室心功能相关参数：射血分数（EF）、每搏量（SV）、左心室心肌做功指数（MPI）;左心室心肌收缩期整体纵向应变（GLS）、收缩期整体圆周应变（GCS）、收缩期整体径向应变（GRS）、收缩期整体面积应变（GAS）、旋转角度（twist）和扭转（torsion）。采用独立样本t检验比较两组相关参数测量值的差异。 结果（1）左心室构型相关参数：SLE组LVPWT、IVST测值均在正常参考值范围内,但较健康对照组测值增大,差异均有统计学意义（t=5.816、5.366,P均<0.05）;SLE组左心室心肌质量和质量指数均较健康对照组测值增加：［LVM：（122.3±30.8）g vs （95.8±22.3）g,LVMI：（82.3±17.6）g/m² vs（65.0±13.5）g/m²,EDmass：（109.3±13.3）g vs（100.7±10.6）g,ESmass：（110.0±13.3）g vs（101.1±10.7）g］,差异均有统计学意义（t=4.880、5.421、3.357、3.439,P均<0.05）;两组LVEDD比较,差异无统计学意义（P>0.05）;（2）SLE组与健康对照组LVEF均>60%,两组LVEF、FS、SV差异均无统计学意义（P均>0.05）;TDI相关参数：SLE组MPI和平均E/e均较健康对照组测值增大：［MPI：0.47±0.10 vs 0.38±0.07,平均E/e：8.0±1.7 vs 6.9±0.9］,差异均有统计学意义（t=4.352、4.009,P均<0.05）;（3）SLE组GLS、GCS、GRS及GAS均显著低于健康对照组测值：［GLS：（-16.4±2.7）% vs（-20.6±2.1）%,GCS：（-15.0±2.8）% vs（-17.7±2.5）%,GAS：（-27.4±4.0）% vs（-32.5±2.9）%,GRS：（43.7±8.2）% vs（55.4±7.5）%］,差异均有统计学意义（t=8.210、4.724、7.277、7.029,P均<0.05）。 结论四维超声自动左心室定量技术结合组织多普勒成像技术可定量系统性检出SLE患者亚临床型心肌功能损伤,有可能为SLE患者心脏疾病的早期诊断、干预决策和疗效评价提供系统性可视化证据。     

超声心动图对慢性阻塞性肺疾病患者早期右心功能异常的评估

目的采用超声心动图评估慢性阻塞性肺疾病（COPD）患者早期右心功能异常。 方法选取2016年4月至2017年4月于首都医科大学附属北京安贞医院就诊的稳定期COPD患者44例（COPD组）。其中16例合并肺动脉高压（PH,合并PH的COPD组）,28例未合并PH（未合并PH的COPD组）。选择同期该院体检的健康志愿者12名作为健康对照组。所有受检者均行经胸超声心动图常规检查,并参照2010年美国超声心动图学会（ASE）颁布的超声心动图评估成人右心功能的指南（ASE指南）完成所有受试者右心功能指标的测量、计算及录入。采用独立样本t检验比较COPD组患者与健康对照组受检者超声心动图常规参数、ASE指南推荐参数;采用单因素方差分析比较合并与未合并PH的COPD组患者及健康对照组受检者超声心动图常规参数、ASE指南推荐参数,进一步组间两两比较采用SNK-q检验。 结果COPD组患者右心室前后径（RVD）较健康对照组受检者增宽[（20.68±4.21）mm vs（18.17±1.75）mm],且差异有统计学差异（t=2.92,P=0.005）;而COPD组患者与健康对照组受检者右心室流出道内径（RVOT）、肺动脉主干内径（MPAD）、左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、左心室射血分数（LVEF）差异均无统计学意义。与健康对照组受检者比较,COPD组患者右心室基底段内径增宽[（35.92±8.12）mm vs（27.75±3.17）mm],三尖瓣收缩期位移（TAPSE）减少[（19.61±4.08）mm vs （22.67±2.67）mm],右心室心肌工作指数（RIMP）增加[（0.52±0.10）cm/s vs（0.43±0.04）cm/s],且差异均有统计学意义（t=3.39,P=0.001;t=-2.44,P=0.019;t=4.31,P<0.001）;而COPD组患者与健康对照组受检者右心房面积、E/A、E/E′、S′差异均无统计学意义。合并与未合并PH的COPD组患者及健康对照组受检者RVOT、RVD、MPAD、LVEDD、LVESD、LVEF差异均无统计学意义,且右心房面积、E/A、E/E′、TAPSE、S′差异也均无统计学意义。合并与未合并PH的COPD组患者右心室基底段内径、RIMP均高于健康对照组受检者[（37.99±9.66）mm、（34.47±6.70）mm vs （27.75±3.17）mm;（0.54±0.13）cm/s、（0.51±0.08）cm/s vs （0.43±0.04）cm/s],且差异均有统计学意义（q=6.960、4.905、5.796、4.348,P均<0.05）;而合并与未合并PH的COPD组患者右心室基底段内径、RIMP差异均无统计学意义。合并PH的COPD组患者RVWT高于未合并PH的COPD组患者[（5.29±0.69）mm vs （4.54±0.70）mm],且差异有统计学意义（t=3.313,P=0.002）。 结论本研究采用的ASE指南所推荐的方法对于右心结构变化的评估较常规测量方法敏感。COPD患者右心受累首先表现为右心室结构的变化,之后才是右心室收缩功能的减退。PH的长期作用使早期右心室趋于发生室壁增厚,而后右心室进行性增大。