经皮球囊肺动脉瓣成形术治疗单纯性肺动脉瓣狭窄32例

目的 总结1995～2001年我院用经皮球囊肺动脉瓣成形术治疗单纯性肺动脉瓣狭窄32例的经验。方法 本院住院患者32例,单纯性肺动脉瓣狭窄采用经皮球囊肺动脉瓣成形术治疗。结果 本组32例右室收缩压:术前(93.5±28.5)mmHg,术后(42±9.0)mmHg;跨肺动脉瓣压力阶差:术前(76±30)mnHg,术后(24.5±8.5)mmHg;术后跨肺动脉瓣压力阶差<25mmHg达90.6％。结论 经皮球囊肺动脉瓣成形术治疗单纯性肺动脉瓣狭窄是安全有效的,病例和手术方法的选择,精确测定肺动脉瓣直径和选择大小合适的球囊是手术成功的重要环节。     

经皮双球囊肺动脉瓣成形术(附8例报告)

报道经皮双球囊肺动脉瓣成形术8例,全部术前诊断均为单纯先天性肺动脉瓣狭窄,不伴有其他心内畸形。男5例,女3例,年龄以6～55岁。双球囊直径比肺动脉瓣环直径平均大50±35％,最大达89％,每次扩张充盈时间5～10s。术前右室—肺动脉收缩压差4.4～17.6kPa,平均9.7士4.2kPa,术后降至3.2±1.9kPa,有7例平均压差降至2.6±1.1kPa。本组无重要并发症,除1例外疗效均好。文中尚介绍了双球囊导管操作方法和疗效评判标准,并就适应证,狭窄口定位及球囊选择作了讨论。     

经皮肺动脉瓣球囊成形术治疗肺动脉瓣狭窄16例体会

目的　评价经皮肺动脉瓣球囊成形术对肺动脉瓣狭窄的治疗效果。临床资料　我院自1998年9月～2 0 0 4年7月共完成16例肺动脉瓣狭窄球囊扩张,女8例,男8例,年龄2～5 8岁,单纯PS9例,合并房缺1例,术前经病史、体格检查、超声心动图等检查确诊。其中术前经多普勒超声估测跨瓣压差。方法　经皮Seldinger穿刺右股静脉成功后,常规行右心导管检查,测跨瓣压差。用6F猪尾巴导管行右室造影:测量肺动脉瓣环直径来选择球囊大小。前7例用J型钢丝经右心导管送至左上或下肺动脉远端,后9例用左房钢丝盘在扩张的肺动脉内。用扩张管扩张皮下及股静脉,前14例用Inoue左房室瓣球囊,后2例用自制肺动脉瓣球囊,参照造影影像定位,将球囊前囊打起,后撤至肺动脉瓣口上,将后囊打起,腰部消失反复扩张2～3次,听诊杂音,撤出左房钢丝,用球囊连续测压,测术后跨瓣压,再次右室造影(取左侧位)。结果　16例患者手术均获成功,术前跨瓣压差2 5～110mmHg,术后跨瓣压12～4 2mmHg ,术前多普勒超声估测跨瓣压差2 4～112mmHg,术后估测跨瓣压差15～4 0mmHg ,其中以重度狭窄者扩张效果最好,有1例术后跨瓣压差为0。但重度狭窄...     

经皮穿刺球囊扩张成形术治疗肺动脉瓣狭窄

报告8例经皮穿刺球囊肺动脉瓣扩张成形术(PBPV)的结果。本组男性3例,女性5例,年龄5～26岁。7倒用单球囊、1例双球囊扩张。肺动脉瓣口直径由8.4±2.2扩张至16.4±1.5mm,右室收缩压由16.9±5.3下降至9.1±3.8kPa,右室-肺动脉压差由14.9±5.1降至6.6±3.9kPa;心排血指数由3.2±0.3增加至5.1±0.7L/min·m~(-2)(P均<0.001)。治疗后症状消失或基本消失,杂音明显减轻。术后4～5天出院。     

超声检查胎儿肺动脉瓣缺如的临床分析

目的探讨产前超声诊断胎儿肺动脉瓣缺如的临床价值。方法回顾性分析8例经引产后尸检证实的肺动脉瓣缺如胎儿的声像图资料及尸检结果,总结其声像图特征及病理改变。结果 8例胎儿右室流出道切面均显示主肺动脉扩张与肺动脉瓣环狭窄,呈"沙漏状"征象,无肺动脉瓣叶回声及启闭活动,其中5例主肺动脉及左、右肺动脉呈瘤样扩张;彩色多普勒均显示肺动脉瓣口往返的五彩镶嵌血流信号,频谱多普勒显示肺动脉瓣口全收缩期湍流和全舒张期反流频谱。8例肺动脉瓣缺如胎儿中3例伴发法洛四联症,2例伴发三尖瓣闭锁、右心发育不良,伴发右室双出口、三尖瓣下移畸形各1例,1例为孤立性肺动脉瓣缺如。伴发法洛四联症及右室双出口的4例胎儿均显示室间隔缺损、动脉导管缺如,另4例胎儿室间隔完整并显示动脉导管。结论产前超声诊断胎儿肺动脉瓣缺如具有重要临床价值,应注意其合并症的诊断。     

球囊瓣膜成形术治疗钙化性主动脉瓣狭窄

作者报告应用球囊瓣膜成形术治疗9例钙化性主动脉瓣狭窄的经验。使用球囊直径8～25mm,长3或5cm的聚乙烯9F球囊导管。术时从小到大使用不同球囊直径的导管,经股动脉送入,使不透X线的球囊标志位于钙化的主动脉瓣两侧,然后充盈扩张。术前术后测压力、心排血量以判定效果。大多数病人进行3次以上扩张,每次持续5～8秒。作者见到,该组病例最大主动脉瓣压术前为68±8mmHg,术后降至35±5mmHg,平均主动脉瓣压差自57±7mmHg降至30±5mmHg,心排血量自3.4±0.2L/分增至4.1±0.3L/分,主动脉瓣口面积自0.42±0.04cm~2增至0.81±0.06cm~2。多数病例术后血流动力学改善可同主动脉瓣人工瓣膜置换     

经皮肺动脉瓣球囊成形术的疗效观察

目的　观察经皮肺动脉瓣成形术 (PBPV)治疗先天性心脏病单纯肺动脉瓣狭窄 (PS)或合并肺动脉瓣狭窄的疗效。方法　选自 1997年 5月至 2 0 0 3年 6月我科经PBPV治疗 2 7例单纯肺动脉瓣狭窄 ,1例法洛三联症 ,1例Ebstein畸形合并肺动脉瓣狭窄。术中经右心导管测得肺动脉右心室收缩压差 (PPG) :平均PPG为 (77.6± 2 4 .8mmHg) ,其中轻度狭窄(2 0mmHg相似文献   

52例锁骨下动脉经皮腔内血管成形术(PTA)长期疗效观察

作者观察了52例锁骨下动脉狭窄(43例)和闭塞(9例)患者PTA后的长期疗效。年龄38～66岁,都有上肢缺血的症状,39例有椎基底动脉供血不足的表现,患肢收缩压均较健侧低,38例低30～50mmHg(4～6.7kPa,1kPa=7.5mmHg),14例低50mmHg(6.7kPa)以上。25例锁骨下动脉狭窄部位在推动脉开口近侧,并有椎动脉血液逆流;19例在椎动脉开口远侧;9例在椎动脉起始部。49例经股动脉,3例经腋动脉插管。先将导管插入近狭窄部位,再用“J”形导丝通过狭窄区,用球囊导管替换血管造影导管,球囊长度2～4cm,直径8mm、9mm或10mm,扩张压力为5个大气压(506.5kPa,1kPa=101.3atm)。所有病例球囊     

经皮球囊肺动脉瓣成形术的临床应用

目的:观察经皮球囊成形术治疗肺动脉瓣狭窄的疗效和安全性。方法:男性4例,女性2例,年龄8～19岁,平均11.7岁,均行经皮肺动脉瓣球囊成形术治疗。结果:肺动脉至右心室平均收缩压差由术前9.1kPa降至术后3.6kPa。结论:经皮肺动脉瓣球囊成形术是治疗肺动脉瓣狭窄的首选方法。     

使用PT-Valve行经皮肺动脉瓣植入术初步结果

目的 初步总结使用PT-Valve行经皮肺动脉瓣植入术(PPVI)的安全性及有效性。方法 选取2021年5—12月于北部战区总医院顺利完成PPVI的6例患者为研究对象。初步总结手术经验,评价术后早期瓣膜功能及症状改善情况。结果 6例患者均顺利完成经皮肺动脉PT-Valve植入,X线透视时间为16～41 min,平均(24.2±7.3)min。所有患者瓣膜完全释放后均位置满意,未出现移位。使用PT-Valve型号为44-26(2例)和36-26(4例)。术后即刻食道心脏超声检查未见瓣周漏,无轻度以上肺动脉瓣反流,跨瓣压差4～17 mmHg,平均跨瓣压差为(12.0±5.2)mmHg。术后胸片显示瓣膜支架位置良好,结构完整,未出现移位。术后早期检查结果满意。结论 使用国产PT-Valve行PPVI治疗跨瓣环右室流出道补片加宽术后慢性肺动脉瓣反流患者早期结果满意,手术操作安全简单,术后即时效果良好,长期效果还需要大样本随访结果的检验。     

Angiographic features associated with percutaneous balloon valvotomy for pulmonary valve stenosis

Changes in the mobility of the pulmonary valve were determined by a retrospective review of right ventricular cineangiograms from 25 balloon pulmonary valvotomy (BV) procedures in 23 infants and children. The angiographic changes were compared with the post-BV catheter and Doppler pressure gradients across the right ventricular outflow tract. Angiographic features felt to indicate valve tearing were present following 17 of 25 procedures and included increased excursion or straightening of leaflets, localized change in leaflet motion (flail leaflet), and the presence of an additional contrast jet through the valve. There was no statistically significant relationship between any of the angiographic parameters and the pressure data. Most patients with marked increase in angiographic valvemobility had low residual right ventricular to pulmonary artery gradients. However, the absence of angiographic change was not always associated with a high residual gradient.     

Pulmonary artery tears following balloon valvotomy for pulmonary stenosis

Terars involving the anterior supravalvar anhulus developed in 2 children and an infant following percutaneous balloon pulmonary valvotomy using oversized balloons. The 3 patients had angiographic features of three different types of stenotic valves: usual pulmonary valve stenosis in 1, a form of dysplastic pulmonary valve with supravalvar narrowing in a second, and a doming valve in a neonate. All had a successful reduction in right ventricular outflow tract gradient following the procedure. The pulmonary arterial tears were not associated with balloon rupture or clinical symptoms. It is postulated that the relative deficiency of elastic fibers in the supravalvar commissure makes this site relatively vulnerable to intimal tearing     

Aortic valvoplasty: comparison of the techniques and results of transeptal and retrograde methods

Balloon aortic valvoplasty is used in some patients with aortic valve stenosis who are unsuitable for aortic valve replacement. Complications associated with the retrograde approach can be avoided using an antegrade approach which has been less widely described. Experience of these two methods is reported and aspects of the differences in technique are emphasized. Aortic valvoplasty was attempted in 21 patients with severe aortic valve stenosis (mean gradient 65 mmHg). A significant reduction in gradient was achieved in 20 (mean reduction 59% transeptal group [four patients], 50% retrograde group [16 patients]) with symptomatic improvement in 18 patients which was maintained at follow-up (mean interval of 5.2 months, range 1-17 months) in 8/15 patients. There were only two significant, resolvable early complications and increases in aortic regurgitation were not seen. There were six late deaths but three patients improved sufficiently to undergo successful aortic valve replacement. Aortic valvoplasty provides good palliation of symptoms. In patients who are unsuitable for the retrograde approach the antegrade, transeptal approach is a satisfactory and effective alternative.     

Echocardiographic estimation of mean pulmonary artery pressure in critically ill patients

Background

Indirect assessment of mean pulmonary arterial pressure (MPAP) may assist management of critically ill patients with pulmonary hypertension and right heart dysfunction. MPAP can be estimated as the sum of echocardiographically derived mean right ventricular to right atrial systolic pressure gradient and right atrial pressure; however, this has not been validated in critically ill patients.

Methods

This prospective validation study was conducted in patients undergoing pulmonary artery catheterisation during intensive care admission. Pulmonary artery catheter (PAC) measurements of MPAP were contemporaneously compared to MPAP estimated utilising transthoracic echocardiography (TTE)-derived mean right ventricular to right atrial systolic pressure gradient added to invasively measured right atrial pressure.

Results

Of 53 patients assessed, 23 had estimable MPAP using TTE. The mean difference between TTE- and PAC-derived MPAP was 1.9 mmHg (SD 5.0), with upper and lower limits of agreement of 11.6 and −7.9 mmHg, respectively. The median absolute percentage difference between TTE- and PAC-derived MPAP was 7.5%. Inter-rater reliability assessment was performed for 15 patients, giving an intra-class correlation coefficient of 0.96 (95% confidence intervals, 0.89 to 0.99).

Conclusions

This echocardiographic method of estimating MPAP in critically ill patients was not equivalent to invasively measured MPAP, based on our predefined clinically acceptable range (±5 mmHg). The accuracy of this method in critically ill patients was similar to the results obtained in ambulatory patients and compared favourably with regard to the accuracy with echocardiographic estimation of systolic pulmonary arterial pressure. The utility of this technique is limited by frequent inability to obtain an adequate tricuspid regurgitant time-velocity integral in critically ill patients.     

Left coronary angiography in the pre-operative diagnosis of thrombosis of the left atrium or its appendage in rheumatic mitral stenosis

We studied the utility of pre-operative selective left coronary angiograms for detecting thrombosis in the left atrium or its appendage in 81 patients with rheumatic mitral stenosis, who subsequently underwent open-heart surgery. Thrombus was predicted by the angiographic demonstration of neovascularity seen as a bunch of small vessels arising from the circumflex branch of the left coronary artery coursing superiorly to the region of the left atrial appendage and terminating in a network of smaller vascular channels with a blush of contrast medium coalescing into small 'lakes'. This pooling of contrast medium was considered essential for positive angiographic diagnosis. Based on these criteria, the angiographic diagnosis of thrombus was made in 27 patients. Thrombus was found in 33 patients at surgery. Selective left coronary angiography had a sensitivity of 72.7%, specificity of 92.7% and predictive value of 88.8% for detecting thrombi in the left atrium or its appendage. Coronary angiography should be performed in all the patients with mitral stenosis who are undergoing cardiac catheterization especially if balloon mitral valvoplasty or closed mitral valvotomy are planned.     

New generation aspiration catheter: Feasibility in the treatment of pulmonary embolism

AIM: To report our preliminary experience with a new generation aspiration catheter in the treatment of symptomatic pulmonary embolism (PE).METHODS: A retrospective database search for pulmonary artery embolectomy since introduction of the Pronto .035” and XL extraction catheter (Vascular Solutions, Minneapolis, MN) at our institution in 10/2009 was performed. Ten consecutive patients were identified in which the Pronto .035” or XL catheter was used between 01/2010 and 03/2013. All patients were referred for catheter based embolectomy due to contraindications to systemic lysis, or for being in such a critical clinical condition that immediate percutaneous treatment deemed warranted. The computed tomography (CT) right to left heart ratio as predictor for the severity of the PE was retrospectively evaluated on standard axial views. The difference between pre- and post-procedure pulmonary pressure measures was taken to assess the procedural effect.RESULTS: Extensive PE was confirmed angiographically in all patients. Measured right- to left ventricle (RV/LV) ratios were elevated beyond one in seven of the eight available CTs. Acute procedural success defined as clinical removal of visible thrombus and improvement in mean pulmonary artery pressure was seen in all recorded patients (n = 8), the mean pulmonary pressures declined from a median (range) of 35.5 (19-46) to 23 (10-37, P = 0.008) mmHg. Neither death nor other complications occurred intra- or immediately periprocedural, yet short term mortality within 30 d was found in 6 out of 9 patients, one patient was lost in follow up. The cause of death within 30 d in the 6 patients was identified as: Circulatory failure in direct connection with the PE (n = 2), stroke, sepsis, or succumbing to malignancy in a hospice setting (n = 2).CONCLUSION: Success in thrombus removal with improved pulmonary hypertension and systemic hypotension suggests this aspiration technique to be effective. Aspiration catheters should be part of further trials.     

Fragmentation of massive pulmonary embolism by pigtail rotation catheter: possible complication

Fragmentation by pigtail rotation catheter may be a therapeutic option in acute massive pulmonary embolism, especially in patients with high risk of right ventricular failure. We report a patient with an occlusion of the right intermediate pulmonary artery by a large embolus, slightly protruding into the perfused right upper lobe artery. After initial catheter fragmentation, part of the embolus dislocated and produced an additional occlusion of the upper lobe artery. Hemodynamic parameters deteriorated. Continuation of catheter fragmentation finally provided for a hemodynamic stabilization and partial recanalization. Inadvertent occlusion of a major pulmonary arterial branch by dislocated embolus material may be considered as a complication of catheter fragmentation, which can be successfully managed by continuation of the fragmentation therapy.     

Catheter fragmentation of acute massive pulmonary thromboembolism: distal embolisation and pulmonary arterial pressure elevation

The aim of this study was to evaluate the relationship between pulmonary arterial pressure and distal embolisation during catheter fragmentation for the treatment of acute massive pulmonary thromboembolism with haemodynamic impairment. 25 patients with haemodynamic impairment (8 men and 17 women; aged 27-82 years) were treated by mechanical thrombus fragmentation with a modified rotating pigtail catheter. After thrombus fragmentation, all patients received local fibrinolytic therapy, followed by manual clot aspiration using a percutaneous transluminal coronary angioplasty (PTCA) guide catheter. Pulmonary arterial pressure was continuously recorded during the procedure. The Friedman test and Wilcoxon test were applied for statistical analysis. Distal embolisation was confirmed by digital subtraction angiography in 7 of the 25 patients. A significant rise in mean pulmonary arterial pressure occurred after thrombus fragmentation (before: 34.1 mmHg; after: 37.9 mmHg; p<0.05), and this group showed a significant decrease in mean pulmonary arterial pressure after thrombus aspiration (25.7 mmHg; p<0.05). No distal embolisation was seen in 18 of the 25 patients, and a significant decrease in mean pulmonary arterial pressure was confirmed after thrombus fragmentation (before: 34.2 mmHg; after: 28.1 mmHg: p<0.01), and after thrombus aspiration (23.3 mmHg; p<0.01). In conclusion, distal embolisation and a rise in pulmonary arterial pressure can occur during mechanical fragmentation using a rotating pigtail catheter for the treatment of life-threatening acute massive pulmonary thromboembolism; thrombolysis and thrombus aspiration can provide partial recanalization and haemodynamic stabilization. Continuous monitoring of pulmonary arterial pressure may contribute to the safety of these interventional procedures.     

特殊情况的左房室瓣球囊扩张术疗效分析

目的　分析和总结伴有特殊情况的左房室瓣狭窄球囊扩张术(PBMV)的临床疗效和安全性。方法　收集我院自1986年12月至2 0 0 5年1月施行的2 30 0例风湿性心脏病左房室瓣狭窄(MS)病例,其中有特殊情况者6 2 1例。包括非单纯MS(合并左房室瓣关闭不全或主闭)者32 8例;非单纯的MS伴巨大左房者15例;巨大左房者10 6例;左房血栓者5 2例;巨大左房及左房血栓者4例;PBMV或左房室瓣闭式分离术后者79例;PBMV或左房室瓣闭式分离术后非单纯的MS者34例;妊娠大咯血者2例。采用Inoue球囊技术。结果　手术成功率98.5 % ,失败率0 .2 % ;发生严重并发症8例,并发症为1.3% ,其中急性左心衰2例,低心排1例,脑栓塞2例,心脏压塞3例。因急性左心衰、低心排、心脏压塞、脑栓塞造成的死亡各1例。结论　随着操作技巧的不断完善,许多伴有特殊情况的PBMV可安全、有效的接受手术。但术前一定要全面评价瓣膜、心功能、血栓情况