心脏直视手术中经食管超声心动图描记术的临床研究

目的：探讨术中经食管超声心动图描记术（ＩＴＥＥ）的临床应用价值。方法：回顾性研究总结１０６例接受ＩＴＥＥ检查的患者。结果：６６．０％的患者行瓣膜手术，其中包括二尖瓣成形术、二尖瓣替换术、主动脉瓣替换术、三尖瓣成形术及主动脉瓣、二尖瓣双瓣替换术；１２．３％的患者行左心室流出道疏通术；１１．３％的患者行带瓣主动脉替换术；１０．４％的患者行先天性心脏病矫治术，其中２例患者行经皮穿刺心房间隔缺损钮扣装置封堵术。结论：ＩＴＥＥ能即时评价人工瓣膜位于体内的功能状态，检出瓣周漏；准确地判断左心室流出道疏通的效果；ＩＴＥＥ检查在经皮穿刺缺损封堵术中也有较大的应用潜力。     

拟行神经外科坐位手术患者术前经食管超声心动图检查的应用体会

目的探讨经食管超声心动图(TEE)在拟行神经外科坐位肿瘤切除术患者术前应用中的意义。方法 2010年7月至2013年5月,首都医科大学宣武医院神经外科住院拟行听神经瘤及脑膜瘤切除术患者33例。所有患者均于术前行经胸超声心动图(TTE)及TEE结合右心声学造影检查,观察卵圆孔未闭(PFO)的发生情况。患者行右心房声学造影检查时,左心房内一个切面同时出现3个气泡定义为阳性,即PFO。术后随访脑栓塞情况。结果 (1)所有33例患者中有22例(66.7%)检出PFO;(2)TTE检查:仅1例(3.0%)患者检出PFO;(3)TEE检查:20例(60.6%)患者检出PFO;(4)TEE结合右心声学造影:共有22例(66.7%)患者可见心房水平的右向左分流征;(5)共7例患者行坐位手术,另26例患者行侧卧位手术。无1例患者术后出现脑栓塞。结论合并PFO是神经外科坐位肿瘤切除术的绝对禁忌证。术前TEE结合右心声学造影检查可明确检出PFO,对于及时调整手术方式,避免坐位手术可能出现的空气栓塞有决定性作用,应常规应用。     

经食管三维超声心动图临床应用的新进展

经食管三维超声心动图（three-dimensional transesophageal echocar diography,3D—TEE）于上世纪90年代初期问世并应用于实验室及临床检查。由于探头位置的改变,它能由后向前,近距离扫查心脏深部结构,有效排除肺气干扰、肥胖、胸廓畸形和肋间隙狭窄的影响,明显改善超声图像的清晰度及分辨率。     

侵入性超声心动图检查的概况

侵入性途径扩大了常规超声心动描记方法的临床应用范围。对比超声心动图已广泛用于临床,各种新型对比剂和心肌对比超声心动检查的研究目前相当活跃。经食管超声心动描记术提供了不受胸壁和肺组织干扰的探查途径,并能较好地评价左右心房、房间隔和左室前壁等结构。经静脉心腔内超声心动图和手术过程中心外膜超声心动图检查也均有一定价值。     

超声心动图发展概要

影像学检查通过人体脏器的扫查,提供重要的解剖学信息,而超声心动图能够实时评价心脏解剖结构、功能以及血流动力学信息。三维超声心动图、应变成像等定量评估方法以及超声增强显影不再是纸上谈兵,已经广泛应用于临床并且为患者的诊断和预后提供了丰富信息。本文主要通过超声心动图新技术在心脏移植等新领域的应用来阐述其重要性,从而指导治疗。     

经胸与经食管超声心动图应用的对比分析

目的 :为获取高质量的心脏及大血管超声心动图像。方法 :对比分析北京协和医院 5年来 363例在经胸超声心动图 ( TTE)检查的基础上行经食管超声心动图 ( TEE)的检查结果。结果 :363例检查指征分为心腔内血栓、主动脉夹层、感染性心内膜炎、主动脉瓣膜病变及主动脉粥样硬化等。 TTE仅有 2 2 .3%的病例获得诊断 ,而有 TEE76%的病例可获得明确诊断 ,增加信息量5 3.7%。结论 :TEE检查结果对改进或决定临床处理对策产生了不同程度的影响。     

经食道心脏超声在老年患者中的应用

对３１例老年患者经食道行心脏超声检查均获成功，并取得满意心脏超声图像，对有心房内血栓，心瓣膜钙化或功能不全，主动脉病变，心室壁局限运动障碍等患者取得优于经胸壁心脏超声检查效果（Ｐ＜０．０５或＜０．０１）。检查中并发症轻微，均为一过性，我们认为，经食道心脏超声为一几乎无创伤性的诊断技术，可相对安全地应用于老年患者并具重要的临床实用价值。     

糖尿病患者的超声心动图检查

应用二维、M型及脉冲多普勒超声心动图对24例糖尿病患者的心脏进行了检查。与42例正常对照者相比,发现前者EPSS_b增加,EF斜率及室间隔增厚率降低。左室和右室的充盈早期流速积分(EVI)、充盈早期与晚期的最大流速比值(EPV/APV)及充盈早期与整个充盈期流速积分比值(EVI/TVI)均降低。左室和右室的充盈晚期流速积分(AVI)及PEP/ET增加。表明糖尿病患者的左室和右室均有亚临床舒张及收缩功能障碍。24例中有1/3的患者显示心肌瘢痕改变。上述异常的主要原因可能是糖尿病性心肌病。     

老年急性心肌梗死患者的组织谐波超声心动图检查

目的探讨组织谐波超声心动图(THE)在老年人急性心肌梗死诊断中的应用价值。方法对本院136 例经THE检查的老年初发Q波急性心肌梗死患者的临床及超声心动图资料进行分析。结果男95例,女41例,年龄60-89岁,平均(68±7)岁。THE图像满意率92％(125/136)。THE图像满意者中检出急性心肌梗死117例(94％)。 THE与心电图判断心肌梗死的部位及范围基本一致,尤其是对于急性广泛前壁和前壁心肌梗死,两者的判断高度一致。THE所示心肌梗死部位与冠状动脉造影所示梗死相关动脉供血区域符合率93％。结论 THE能够敏感、准确地检出老年急性心肌梗死患者,可作为早期诊断老年人急性心肌梗死的补充手段。     

心力衰竭患者超声心动图检查标准化的思考

<正>心力衰竭(heart failure,HF)是各种心脏疾病的严重表现或晚期阶段,死亡率和再住院率居高不下,造成严重的公共卫生经济负担,是21世纪我国最重要的心血管疾病之一。对于HF,全面准确的诊断是患者有效治疗的前提和基础。根据《中国心力衰竭诊断和治疗指南2018》,HF的诊断和评估依赖于病史、体格检查、实验室检查、心脏影像学检查和功能检查,其中经胸超声心动图是评估心脏结构和功能的首选方法[1]。超声心动图检查可提供心脏结构和功能的     

经食管超声心动图在微创室间隔缺损封堵治疗中的应用

目的 评价经食管超声心动图(transoesophageal echocardiography,TEE)在微创外科室间隔缺损封堵治疗中的临床价值.方法 经胸超声心动图检查粗筛27例室间隔缺损(VSD)患者,拟行微创外科非体外循环下封堵治疗.术前行TEE,根据VSD位置、类型、大小选择合适的封堵器;术中TEE引导封堵器放置,评价即刻封堵效果;术后1周内复查.结果 3例患者术前TEE剔除,20例患者封堵成功,TEE显示19例无残余分流,1例微量残余分流;4例患者转体外循环进行VSD修补,其中2例有残余分流,2例出现主动脉瓣反流;20例微创封堵成功患者术后1周内超声随访,均见封堵器位置正常,无残余分流,左心室重构改善,三尖瓣反流程度减轻,肺动脉压力下降.结论 TEE对选择适合行微创封堵的VSD患者、选择封堵器大小、协助封堵器的释放、评价疗效均有重要作用.微创VSD封堵安全、有效.     

Association of atheroma as assessed by intraoperative transoesophageal echocardiography with long-term mortality in patients undergoing cardiac surgery.

AIMS: To determine whether the presence and severity of aortic atheroma predict long-term all-cause mortality among patients undergoing cardiac surgery. METHODS AND RESULTS: We followed 8,581 patients who underwent cardiac surgery and had routine intraoperative transoesophageal echocardiography for 2.8 years (range 0.06-6.0 years). Data regarding multiple potential confounders were prospectively collected and electronically recorded. There were 2,878 (34%) patients with no atheroma; 4,129 (48%) patients with mild atheroma; 1,215 (14%) with moderate atheroma; and 359 (4%) with severe atheroma. There were 1000 deaths. Death rates were increased in patients with moderate [relative risk (RR) 3.29, 95% CI 2.50-4.32, P < 0.0001) and severe atheroma (RR 5.21, 95% CI 3.65-7.41, P < 0.0001). After adjusting for multiple other confounders, severe atheroma remained modestly predictive of risk (adjusted RR 1.46, 95% CI 1.07-2.00, P = 0.02); but moderate atheroma and mild atheroma were not predictive of increased risk. In a propensity analysis that matched patients with comparable range of variables, severe atheroma was no longer predictive of risk (adjusted RR 1.39, 95% CI 0.87-2.23, P = 0.17). CONCLUSION: Our study shows that severe atheroma is associated with increased long-term mortality in patients undergoing cardiac surgery; however, the relationship is weak using propensity analysis, suggesting no causal association.     

Role of intraoperative transesophageal echocardiography in pediatric cardiac surgery

Background

Intraoperative transesophageal echocardiography (TEE) has a major role in detecting residual lesions during and/or after pediatric cardiac surgery.

Methods

All pediatric patients who underwent cardiac surgery between July 2001 and December 2008 were reviewed. The records of surgical procedure, intraoperative TEE, and predischarge transthoracic echocardiograms were reviewed to determine minor and major residual cardiac lesions after surgical repair.

Results

During the study period, a total of 2268 pediatric cardiac patients were operated in our center. Mean age was 21 months (from 1 day to 14 years). Of these patients, 1016 (48%) had preoperative TEE and 1036 (46%) were evaluated by intraoperative echocardiography (TEE or epicardial study). We identified variations between TEE and preoperative transthoracic echocardiography in 14 patients (1.3%). Only one surgical procedure was cancelled after atrial septal defect exclusion. The other 13 patients had minor variation from their surgical plan. Major residual lesions requiring surgical revision were detected in 41 patients (3.9%), with the following primary diagnoses: tetralogy of Fallot in 12 patients (29%), atrioventricular septal defect in seven patients (17%), ventricular septal defect in seven patients (17%), double outlet right ventricle in two patients (5%), Shone complex in two patients (5%), subaortic stenosis in two patients (5%), mitral regurgitation in two patients (5%), pulmonary atresia in two patients (5%), and five patients (12%) with other diagnoses.

Conclusion

Intraoperative TEE has a major impact in pediatric cardiac surgery to detect significant residual lesions. Preoperative TEE has a limited role in case of a high quality preoperative transthoracic echocardiography. We recommend routine use of intraoperative TEE during and/or after intracardiac repair in children.     

Aspirin-induced platelet inhibition in patients undergoing cardiac surgery

Platelet function and response to pharmacological inhibition are altered by cardiac surgery. For example, aggregation is increased early after aortic valve replacement (AVR) and platelet response to aspirin is often insufficient after coronary artery bypass grafting (CABG). We hypothesized that the effect of aspirin administration after cardiac surgery might be impaired due to platelet activation. Therefore, the antiplatelet effect of aspirin was compared in patients (n?=?20 per group) after CABG and AVR surgery (bileaflet prosthesis). Arachidonic acid-induced aggregation (turbidimetry) and thromboxane formation (radioimmunoassay) were determined before and 1, 5, and 10 days after surgery. In CABG-patients, antiplatelet treatment had been discontinued 10 days before surgery. Oral aspirin was started on day 1 after CABG. AVR-patients did not receive oral aspirin. Before surgery, platelet aggregation and thromboxane formation were significantly higher in patients with aortic stenosis. After CABG, thromboxane formation was not significantly changed from control values before surgery (66?±?13% on day 10) despite oral aspirin treatment, whereas thromboxane formation in patients undergoing AVR significantly increased compared to values before surgery (216?±?29% on day 10). In both groups of patients, 100?µmol/l aspirin in vitro largely inhibited platelet function before surgery, with markedly attenuated effects after surgery. In conclusion, thromboxane formation increased after AVR but not after CABG. The antiplatelet effect of aspirin, therefore, may be impaired after CABG by increased platelet activity. An additional in vitro “resistance” of platelets was seen after both CABG and AVR.     

Effects of postoperative dietary intake on functional recovery of patients undergoing cardiac surgery

Background and aim

Among elderly patients undergoing cardiac surgery, malnutrition is very common and related to muscle wasting known as sarcopenia. Cardiac surgery causes a further decline of nutritional status due to reduced dietary intake (DI); however, the impact of postoperative DI on functional recovery is unclear.

老年心血管高危患者非心脏手术后肌钙蛋白T的变化

目的 探讨监测肌钙蛋白T(cTnT)水平的变化对老年心血管高危患者围术期安全性的意义.方法 接受腹部手术全身麻醉的老年心血管高危患者52例,按术后cTnT监测结果分为2组:cTnT阴性组24例(46.2%),cTnT阳性组(≥0.01 ug/L)28例(53.8%),回顾性分析围术期患者心脏事件发生情况.结果 49...     

Prevalence of postoperative delirium with different combinations of intraoperative general anesthetic agents in patients undergoing cardiac surgery: A retrospective propensity-score-matched study

Postoperative delirium (PD) remains an issue in cardiac surgery despite the constant efforts to reduce its incidence. In this retrospective study, the incidence of PD was evaluated in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) according to different primary anesthetic agents: sevoflurane and dexmedetomidine- versus propofol-based anesthesia.A total of 534 patients who underwent heart-valve surgery or coronary artery bypass graft surgery with CPB between January 2012 and August 2017 were divided into 2 groups according to the main anesthetic agent: sevoflurane with dexmedetomidine (sevo-dex group, n = 340) and propofol (propofol group, n = 194). The incidence of PD was evaluated as the primary outcome. Patient-, surgery-, and anesthesia-related factors and postoperative complications were investigated as secondary outcomes. To reduce the risk of confounding effects between the 2 groups, 194 patients were selected from the sevo-dex group after propensity-score matching.After propensity-score matching, the incidence of PD was not significantly different between the sevo-dex (6.2%) and propofol (10.8%) groups (P = .136). In comparisons of the incidence of each type of PD, only hyperactive PD occurred significantly less frequently in the sevo-dex group (P = .021). Older age, lower preoperative albumin levels, and emergency surgery were significant risk factors for PD.The overall incidence of PD after cardiac surgery with CPB did not differ between patients receiving sevoflurane and dexmedetomidine-based versus propofol-based anesthesia. Only hyperactive PD occurred less frequently in patients receiving sevoflurane and dexmedetomidine-based anesthesia.     

实时三维超声心动图评价永久起搏患者左心室收缩同步性和心功能

目的 探讨应用实时三维超声心动图(RT-3DE)评价永久起搏患者左心室收缩同步性和心功能.方法 15例病态窦房结综合征置入双腔起搏器患者,分别将起搏模式程控为心房抑制型按需起搏(AAI)、房室按需型起搏(DDD)、心室抑制型按需起搏(VVI),每种起搏模式稳定5 min后,在RT-3DE下取左心室全容积图像.应用Qlab4.2脱机分析软件,获得左心室整体与17节段容积-时间曲线和比较左心室16、12、6节段心电图QRS波起点至左心室最小容积点时间的标准差和最大时间差(即Tmsv16-s、Tmsv12-s、Tmsv6-s、Tmsv16-dif、Tmsv12-dif、Tmsv6-dif)、左心室舒张末期容积、左心室收缩末期容积、左心室射血分数、左心室舒张早期峰值充盈率、左心室17节段的舒张末期容积、收缩末期容积和节段射血分数.结果 心室同步性指标容积-时间曲线和Tmsv16-s、Tmsv12-s、Tmsv6-s、Tmsv16-dif、Tmsv12-dif、Tmsv6-dif在AAI模式明显优于DDD、VVI模式(P<0.05),心功能指标左心室射血分数、左心室舒张早期峰值充盈率在AAI模式下显著高于DDD和VVI模式(P<0.05);DDD和VVI模式的上述指标差异无统计学意义(P>0.05);DDD与VVI模式时左心室前间隔、下壁和后壁基底段、心尖段节段射血分数较AAI模式明显降低(P<0.05).结论 采用RT-3DE可客观准确地评价永久起搏患者左心室收缩同步性和心功能.     

Platelet reactivity in overweight and obese patients undergoing cardiac surgery

Body mass index (BMI) and specifically overweight and obesity have been associated with an increased platelet reactivity in different series of patients. This information is derived by different laboratory platelet function tests (PFTs) like mean platelet volume (MPV), platelet microparticles, thromboxane B2 metabolites, and others. Point-of-care PFT, which are often used in cardiac surgery, are rarely addressed. The present study aims to verify platelet reactivity using multiple-electrode aggregometry (MEA) as a function of BMI in cardiac surgery patients. One-hundred ninety-eight cardiac surgery patients free from the effects of drugs acting on the P2Y₁₂ receptor and undergoing cardiac surgery received MEA-PFT immediately before surgery. Platelet reactivity was compared between normal weight and overweight–obese subjects. There were 99 underweight/normal (BMI < 25), 60 overweight (BMI ≥ 25) and 39 obese (BMI ≥ 30) patients. Overweight–obese patients did not show higher platelet counts nor a clear platelet hyper-reactivity, when tested with MPV and MEA ADP test. At TRAPtest, the overweight/obese patients had a significantly (P = 0.011) higher platelet reactivity (median 118, interquartile range 106–136) than controls (median 112, interquartile range 101–123) and a higher rate of platelet hyper-reactivity (odds ratio 2.19, 95% confidence interval 1.15–4.16, P = 0.016) in a multivariable model. A minor association was found between the BMI and platelet reactivity at TRAPtest, with a higher degree of activity for increasing BMI. The BMI determines an increased thrombin-dependent platelet reactivity in cardiac surgery patients. Thrombin is extensively formed during cardiac surgery, and this may explain the lower postoperative bleeding observed in obese patients in previous studies.