二尖瓣成形术治疗先天性心脏病合并二尖瓣关闭不全

目的总结二尖瓣成形术在合并二尖瓣关闭不全的先天性心脏病中的应用经验,并探讨影响疗效的相关因素。方法对本院收治的合并有二尖瓣关闭不全的先天性心脏病患者147例,分别采用瓣膜裂隙修补、交界环缩、瓣环环缩、人工环成形、人工腱索、腱索延长等方法行成形术,39例(26.5%)同时运用2种以上成形技术。结果术后早期死亡6例(4.1%),术后7个月死亡1例。死亡与手术年龄(≤12岁)、体外循环时间(≥120 min)、主动脉阻断时间(≥80 min)及合并心脏畸形有关。随访结果为2例因二尖瓣反流再发,分别于术后半年和1年行二尖瓣置换术。其余病例术后心功能有不同程度改善,超声心动图检查术后瞬时反流量显著低于术前。结论二尖瓣成形术治疗先天性心脏病合并的二尖瓣关闭不全早、中期疗效满意。     

Traumatic tricuspid regurgitation following equine related blunt chest trauma and review of the literature

Myocardial injury following blunt chest trauma may be difficult to detect. We advocate for cardiac screening in such scenarios. Observation versus intervention should be based on symptoms and the degree of intracardiac disease.     

风湿性心脏病二尖瓣置换术后三尖瓣返流的再手术治疗

目的分析风湿性心脏病二尖瓣置换术后再发三尖瓣返流（TR）患者的临床特点、外科手术方法和疗效,总结围手术期处理经验。方法2000年1月至2011年12月,17例风湿性心脏病二尖瓣置换术后再发三尖瓣返流的患者在我院接受单纯再次三尖瓣手术,行三尖瓣成形术10例,包括单纯DeVega成形术1例、瓣叶成形＋人工瓣环成形9例;行三尖瓣置换术7例,其中置换生物瓣4例,双叶机械瓣3例,回顾性分析其临床表现、诊治经过和预后情况。结果术后早期死亡1例（5．88％,1／17）,死于术后左心功能衰竭。术后发生低心排血量综合征3例,肾功能不全2例,呼吸功能不全2例,均成功救治。随访14例,随访时间3～9年,心功能I级2例,Ⅱ级8例,Ⅲ级4例。失访2例。结论对风湿性心脏病二尖瓣置换术后三尖瓣返流患者再手术治疗效果较好,合理掌握手术指征、手术时机和良好的围手术期处理是提高手术成功率的关键。     

实时三维经食管超声心动图对二尖瓣脱垂瓣器结构与反流程度的定量研究

目的  应用实时三维经食管超声心动图（RT-3D-TEE）评估二尖瓣脱垂病变瓣器结构改变与反流程度之间的相关性。方法  纳入于我院就诊行经胸超声心动图检查确诊为二尖瓣脱垂伴反流的患者40例,另选取10例作为对照组。50例患者均行RT-3D-TEE检查并采集二尖瓣三维图像,使用4D Auto MVQ脱机工作站进行图像后处理和定量分析。结果  瓣环三维面积、瓣环二维面积、瓣环周长、前后直径、前外-后内侧直径、非平面角度、总瓣叶面积、后叶面积随反流程度增加而增大,瓣高联合比随反流程度增加而减小,组间差异均有统计学意义（P < 0.05）。瓣环三维面积、瓣环二维面积、瓣环周长、前后直径、总瓣叶面积与反流程度呈极强相关关系（r=0.847、0.843、0.845、0.854、0.854,P < 0.05)。A Total是导致重度二尖瓣反流发生的危险因素（P < 0.01,B=1.576,OR=4.834）。总瓣叶面积（截点值=8.9 cm²）预测重度二尖瓣反流的敏感度为91.7%,特异性为87.5%,曲线下面积为0.948（P < 0.01）。结论  二尖瓣瓣环大小、扁平程度、瓣叶大小与反流程度呈正相关。总瓣叶面积是导致二尖瓣脱垂患者二尖瓣反流程度加重的危险因素。     

三维超声心动图定量评价二尖瓣反流患者瓣膜结构功能和反流程度研究进展

二尖瓣反流（MR）是最常见的瓣膜病变之一。利用超声心动图能够对瓣膜结构功能和反流程度进行评估,为临床诊疗提供依据。三维超声心动图定量技术较常规超声心动图可更好地描述瓣膜结构功能、更准确地评估反流程度,对临床治疗决策和疾病风险分层均具有重要意义。本文就三维超声心动图定量评估MR患者瓣膜结构和反流程度的研究进展做一综述。     

Late cardiac arrhythmias after blunt chest trauma

Objective: Case reports of two patients who developed fatal cardiac arrhythmias several days after blunt chest trauma.¶Design: Case reports.¶Setting: Surgical intensive care unit of a university hospital.¶Patients: A 23-year-old man and a 9-year-old girl with blunt chest trauma and multiple further injuries following car crashes were transferred to our institution. Although ECG on admission was normal, both patients developed fatal cardiac arrhythmias after 6 and 4 days, respectively. In both patients, post-mortem analysis confirmed myocardial contusion without coronary artery lesions. Histological findings included severe interstitial oedema, haemorrhages and infiltration of lymphocytes and neutrophils, fresh myocardial necrosis and fatty degeneration.¶Conclusion: Blunt chest trauma with myocardial contusion may lead to fatal cardiac arrhythmias even after several days, particularly when other severe injuries are present. Thus, a normal ECG on admission and absence of cardiac arrhythmias during the first 24 h of intensive care treatment do not necessarily exclude the occurrence of life-threatening arrhythmias in the further course.     

瓣环扩大在功能性二尖瓣返流机制中的作用

目的探讨瓣环扩大在功能性二尖瓣返流机制中的作用。方法应用超声心动图检查房颤组(20例)、返流组(30例)及正常组(20例)的心脏,测量二尖瓣返流比例、左室射血分数(EF)、左室大小、球形度、收缩期瓣环(MA)面积、收缩期后乳头肌与二尖瓣前瓣环的距离(PPMAMA)。结果房颤组左室大小、球形度、EF、PPMAMA和正常组相比没有统计学差异,但收缩期MA面积较正常组明显扩大,并与返流组相似,分别为(5.3±1.1)cm2、(7.4±1.5)cm2、(8.0±2.0)cm2,但房颤组二尖瓣返流量明显小于功能性二尖瓣返流组,分别为(12±7)%和(30±14)%。结论单纯瓣环的扩张似乎并不引起中或重度二尖瓣返流。     

血流汇聚法定量评价二尖瓣偏心反流

目的探讨血流汇聚法定量评价二尖瓣偏心反流的价值。方法对63例二尖瓣偏心反流患者分别用连续方程法及血流汇聚法(PISA)测量二尖瓣反流程度,以连续方程法结果为标准,分析二者的相关性,建立线性回归方程。结果血流汇聚法与连续方程法的结果之间有明显相关性(r=0.838,P<0.05),并建立了直线回归方程。结论血流汇聚法能较为准确地定量评价二尖瓣偏心反流程度,具有良好的应用前景。     

超声心动图比较缺血性和非缺血性心肌病中功能性二尖瓣反流的发生机制

目的应用超声心动图比较缺血性心肌病(ICM)和非缺血性扩张型心肌病(non-ICM)功能性二尖瓣反流的发生机制。方法超声检测60例ICM与53例non-ICM二尖瓣反流的有效反流口面积(EROA)、左室整体重构参数(内径、容积、收缩功能和球形度)、局部重构参数(乳头肌牵张长度)及二尖瓣形态参数(二尖瓣隆起面积、关闭点心尖位移和瓣环面积)。结果增大的乳头肌牵张长度、二尖瓣隆起面积和关闭点心尖位移是ICM组EROA的独立危险因子,而增大的左室收缩内径、容积和球形度是non-ICM组EROA的独立危险因子。结论左室局部重构使二尖瓣形态改变是ICM二尖瓣反流的主要发生机制,而左室整体重构是non-ICM二尖瓣反流的主要发生机制。     

冠状动脉介入治疗前后缺血性二尖瓣反流的超声定量比较

目的：应用超声技术评价缺血性二尖瓣反流（Ischemic Mitral Regurgitation, IMR）患者冠脉介入治疗术前、术后左室收缩功能及二尖瓣反流容积变化,探索IMR发生机制,预测IMR发展,从而为临床治疗提供帮助。方法：运用超声技术分析41例患者冠脉介入治疗术前及术后左室应变,并评估二尖瓣反流容积。根据二尖瓣反流变化情况将患者分为非恶化组（Ⅰ组）和恶化组（Ⅱ组）。结果：I组：患者术后纵向和径向应变均较术前改善,其中,术后径向应变及左室射血分数与术前相比显著提高（P＜0.05）;Ⅱ组：患者术后左室射血分数较术前提高无统计学意义（P＞0.05）,左室舒张末期内径有增大趋势。结论：超声技术可以较敏感的评价左室心肌功能。冠状动脉介入治疗通过改善左室收缩功能可以减少IMR。     

Myxomatous mitral valve disease bench to bedside: LDL-density-pressure regulates Lrp5

The myxomatous mitral valve is the most common form of valvular heart disease. The pathologic presentation of myxomatous mitral valve disease varies between valve thickness, degree of leaflet prolapse and the presence or absence of flail leaflets. Recent molecular biology studies have confirmed that the myxomatous changes in mitral valve prolapse equals a cartilage phenotype, which is regulated by the Lrp5 receptor. Clinically, echocardiography defines the valve pathology to determine the surgical approach to valve repair or replacement. Furthermore, the timing of surgical valve repair is controversial and is the subject of a current multicenter trial. The results will resolve the timing of whether watchful waiting versus early surgical valve repair decreases morbidity and mortality of this disease process. This review will summarize the current understanding of the cellular and hemodynamic mechanisms of myxomatous mitral valve disease, which may have future implications in the targeted therapy of this disease process.     

Ongoing and future directions in percutaneous treatment of mitral regurgitation

Introduction: Mitral regurgitation (MR) is one of the major valvular disease. Although surgical mitral valve (MV) repair is the standard of care for patients with severe MR, an unmet need exists in the management of patients with severe symptomatic MR and high surgical risk. Transcatheter MV therapies are alternative treatment option in such patients with moderate to severe and symptomatic MR.

Areas covered: Literatures to direct the reader to important further reading were searched with relevant websites; www.ncbi.nlm.nih.gov/pubmed using search word ‘transcatheter mitral intervention’.

Expert commentary: A variety of transcatheter techniques have emerged for the percutaneous treatment of MR. We should carefully select one or combination procedure for each patient as an ideal tailor-made transcatheter MV therapy in order to improve the outcomes.     

儿童钝性胸部创伤后主支气管断裂临床分析

目的　探讨儿童钝性胸部创伤后主支气管断裂的临床特点和早期诊治。方法　本组 11例 ,年龄 3～ 7岁 ,平均 (5 1± 1 4 )岁。患者均为闭合性损伤后主支气管完全性断裂 ,左侧 7例 ,右侧 4例。 4例伤后 2 4h内急诊行支气管断裂吻合术 ;7例延误诊断患儿于伤后 2～ 12个月内晚期手术 ,其中 3例行支气管断裂吻合术 ,4例行全肺切除术。结果　本组无手术死亡 ,7例行支气管断裂吻合术 ,恢复顺利 ,术后1个月胸片复查 ,肺组织复张良好。结论　认识儿童钝性胸部创伤后气管支气管断裂的临床特点 ,可提高早期诊断水平 ,明显降低其并发症和病死率。     

Ischemic mitral regurgitation: pathophysiology,diagnosis and surgical treatment

Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, ‘edge-to-edge’ technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.     

人工腱索移植和马鞍环环缩修复退行性二尖瓣关闭不全

背景：人工腱索移植是二尖瓣成形的难点,瓣环环缩也是二尖瓣成形术式中的关键步骤之一,而目前国内相关此类治疗方法的安全性、有效性和中期疗效的较大样本报道较少。目的：总结二尖瓣人工腱索移植和马鞍环环缩技术治疗退行性二尖瓣关闭不全的有效性和安全性。 方法：2009年1月至2013年5月间解放军沈阳军区总医院心血管外科应用人工腱索移植和马鞍环环缩技术治疗退行性二尖瓣关闭不全患者85例。用Gore-Tex缝线作为人工腱索,马鞍环用SJMTM刚性鞍形成形环。共行人工腱索移植41例、人工腱索移植＋后叶楔形切除21例、人工腱索移植＋后叶楔形切除＋Sliding技术23例。均行人工瓣环环缩术。结果与结论：治疗后随访78例,随访率为91.7%（78/85）。随访时间为6个月-4年。78例中,1例于治疗后13个月死于脑梗死,1例死于交通事故,余76例均存活。NYHA心功能分级Ⅰ级59例,Ⅱ级17例。复查心脏彩超示微量及以下反流67例,轻度反流9例。超声心动图显示左心房直径明显减少（P＜0.05或P＜0.01）,左心室舒张末期内径明显减少（P＜0.05或P＜0.01）,左心室收缩末期内径明显减少（P＜0.05或P＜0.01）,反流速面积/左房面积明显减少（P＜0.05或P＜0.01）,肺动脉平均压明显降低（P＜0.05或P＜0.01）,射血分数明显增加（P＜0.05或P＜0.01）。未出现二尖瓣收缩期前向运动现象（SAM征）。并发症情况：治疗后出现窦性心动过缓12例,阵发性室上性心动过速25例。1例治疗前伴快-慢综合征患者,治疗后安装永久起搏器。1例治疗后1周出现延迟性心包填塞,经心包穿刺置管引流后治愈。无成形环断裂或撕脱、无溶血、左室流出道梗塞、人工腱索断裂或劈裂发生。无再次手术行瓣膜置换患者。结果可见二尖瓣人工腱索移植和马鞍环环缩治疗退行性二尖瓣关闭不全安全、有效,近中期疗效满意。     

实时三维超声心动图对正常二尖瓣与功能性反流二尖瓣闭合线的对比研究

目的 应用实时三维超声心动图对正常人和功能性反流者的二尖瓣闭合线形态进行对比,探讨功能性反流状态下二尖瓣闭合线形态的变化规律.方法 二维超声筛选功能性二尖瓣反流的成年患者20例,随后进行实时三维超声心动图检查,采集二尖瓣数据导入TomTec三维工作站进行脱机分析;并与20例正常人二尖瓣闭合线数据进行对照,对照指标包括：闭合线两端点之间的直线距离,投影平面上的闭合线曲线长度,闭合线高度（h）,α和β角,并计算｜α-β｜.结果 显著功能性二尖瓣反流的闭合线形态不规则且不对称,与正常人比较,功能性反流二尖瓣闭合线直线距离、α角、β角测值差异均有统计学意义（P〈0.05）,曲线长度、高度（h）及计算所得的｜α-β｜值差异均有统计学意义（P〈0.01）.结论 显著功能性反流二尖瓣闭合线相对正常状态下有显著差异,这种改变与功能性反流时瓣环形状改变和瓣下牵拉状态异常有关.