胎儿Galen动静脉畸形的彩色多普勒超声诊断及分析

目的探讨彩色多普勒超声诊断胎儿颅内Galen动静脉畸形的价值及临床意义。方法对2004年6月至2010年12月经本院行常规及系统产科超声诊断为胎儿颅内Galen动静脉畸形的3例孕妇进行回顾性分析。结果超声检查发现3例胎儿颅内脑中线附近,第三脑室上方单一囊性灶。彩色多普勒见病灶内彩色血流信号,脉冲多普勒为双相湍流静脉频谱。胎儿心脏超声心动图检查发现2例胎儿右心增大,上腔静脉扩张,三尖瓣返流,其中1例还伴有心包积液、胸腹水,皮肤水肿及羊水过多。结论彩色多普勒超声检查是产前诊断胎儿颅内Galen动静脉畸形必不可少的检查手段。     

右心室粘液瘤一例

患者男，42岁。因活动后气促1年于2006年9月入院。查体：心率92次／分，血压110／70mmHg，颈静脉怒张，心界向左稍扩大，心尖部可闻及2／6级收缩期杂音，肝肋下3cm，质中等，肝颈静脉回流征（＋），双下肢轻度水肿。彩色超声心动图提示：右心室扩大，右室腔内见一大小约4．0cm×3．0cm的回声光团，形态欠规则，有一宽约0．7cm的蒂附着于室间隔右室面，随心动周期在右心室流出道内摆动。三尖瓣口见3．0m／s的反流信号。临床诊断：右心室粘液瘤。     

风湿性心脏病二尖瓣成形中功能性三尖瓣反流的外科治疗

风湿性心脏病联合瓣膜病变中合并功能性三尖瓣反流者占２２％～３５％，目前认为对于其中中度反流以上的应同期行三尖瓣矫治［１］。我们报告我院在二尖瓣成形术中对功能性三尖瓣反流的ＤｅＶｅｇａ成形术。１　临床资料与方法我院从１９８９年１１月～１９９５年１２月共行二尖瓣成形１９３例，合并三尖瓣反流者８４例，同时行功能性三尖瓣反流矫治４１例。男１７例，女２４例；年龄１７～５０岁，平均３３±８－１１岁。术前诊断二尖瓣狭窄１２例，二尖瓣关闭不全７例，二尖瓣狭窄并关闭不全２２例。术前三尖瓣反流的体征：颈静脉怒张３５…     

中晚孕期胎儿静脉导管A波倒置与胎儿心脏畸形

目的探讨中晚孕期胎儿静脉导管A波倒置的临床诊断价值。方法选取资料完整的静脉导管A波倒置胎儿27胎,分析胎儿先天性心脏畸形特点,并与尸体检查及新生儿随访结果相对照。结果 27胎静脉导管A波倒置胎儿中,右心系统发育异常20胎(20/27,74.07%),其中右心发育不良综合征13胎,肺动脉瓣狭窄并三尖瓣重度反流3胎,Ebstein畸形并三尖瓣重度反流2胎,三尖瓣黏液样变性并重度反流1胎,单纯肺动脉瓣轻度狭窄1胎;锥干畸形5胎(5/27,18.52%),其中右心室双出口2胎,永存动脉干1胎,法洛四联症1胎,功能矫正型大动脉转位1胎;扩张型心肌病1例;卵圆孔血流受限1例。结论静脉导管A波倒置高度提示胎儿右心系统发育不良或胎儿锥干畸形。     

双向彩超定量检测腘静脉反流的对比研究

瓣膜结构破坏越严重，经该瓣膜的反流血量越大，反流持续时间越长。依此原理，作者以双向彩超检测静脉的反流持续时间，经４０例的检测证明以反流持续时间大于０．５ｓ为诊断原发性下肢深静脉瓣膜功能不全（ＰＶＩ）的阳性标准；采用站立位，气袖带压迫其胖肠肌（１０．６７ｋＰａ）诱发经静脉瓣膜反流，以脉冲式多普勒扫描和彩色血疏多普勒扫描检测反流的持续时间诊断ＰＶＩ，敏感性为９２％，特异性１００％和精确性９４％。     

双向彩超定量检测Guo静脉反流的对比研究

瓣膜结构破坏越严重，经该瓣膜的反流血量越大，反流持续时间越长。依此原理，作者以双向彩超检测Ｇｕｏ静脉的反持续时间，经４０例的检测证明以反流持续时间大于０．５ｓ为诊断原发性下肢深静脉瓣膜功能不全（ＰＶＩ）的阳性标准；采用站立位，气袖带压迫其腓肠肌诱发经国静脉瓣膜反流，以脉冲式多普勒扫描和彩色血流多普勒扫描检测反流的持续时间诊断ＰＶＩ，敏感性为９２％，特异性１００％和精确性９４％ 。     

房间隔缺损心包补片修补术后发现右心房间皮瘤一例

<正>临床资料患者,女,6年前因"活动后心悸、气促、咳嗽1个月余"来诊,查体心界稍向左扩大,心律齐,A2=P2,胸骨左缘第2、第3肋间可闻及2/6级柔和的收缩期吹风样杂音,胸骨左缘第4肋间闻及3/6级收缩期杂音。心脏彩色超声心动图提示右心房、右心室扩大,房间隔回声中断,缺损约29.4 mm;彩色多普勒探及经房间隔缺损左向右分流频谱,分流速度约0.88 m/s,三尖瓣口大量反流。患者在气管内插     

双孔三尖瓣畸形的诊断与治疗

目的分析双孔三尖瓣畸形的诊断与治疗特点,总结治疗经验。方法回顾性分析中南大学湘雅二医院2008年8~12月收治的3例双孔三尖瓣畸形患者的病例资料,其中男1例,女2例;年龄20~67岁。1例术前临床诊断为法洛四联症,行法洛四联症矫治术,缝闭三尖瓣副孔;1例术前临床诊断为部分型心内膜垫缺损合并三尖瓣关闭不全,行心内膜垫缺损矫治术,未处理三尖瓣副孔;1例术前临床诊断为风湿性心脏病、二尖瓣重度狭窄、二尖瓣闭式扩张术后、主动脉瓣狭窄合并关闭不全、三尖瓣关闭不全、心房颤动,行二尖瓣置换、主动脉瓣置换、三尖瓣成形术,缝闭三尖瓣副孔。结果 3例患者手术时间170~192 min,体外循环时间120~143 min,主动脉阻断时间77~95 min;术后3~5 d复查彩色超声心动图提示：结果均正常,术后7~8 d均康复出院;出院后分别于1个月、3个月、6个月及1年行常规检查,恢复良好;彩色超声心动图提示：无三尖瓣反流,三尖瓣副孔处无异常血流。结论双孔三尖瓣畸形副孔有独立的瓣叶、腱索和乳头肌,能启闭自如。尸检是其主要诊断手段,其次为手术和彩色超声心动图检查。仅三尖瓣副孔伴有瓣膜关闭不全或狭窄的患者有血流动力学异常时才需手术处理。     

成形环在三尖瓣成形术治疗三尖瓣关闭不全中的临床应用

目的 观察利用人工瓣环行三尖瓣成形术治疗风湿性心脏病继发性三尖瓣关闭不全患者的近、中期效果. 方法 2009年12月至201 1年9月四川省简阳市人民医院共有41例风湿性心脏病患者接受左心瓣膜置换术并同期置人人工瓣环行三尖瓣成形术,其中男12例、女29例,平均年龄49(21～67)岁.术前合并心房颤动38例,合并左心房血栓13例;三尖瓣微量反流2例,轻度反流5例,中度反流11例,重度反流23例;行二尖瓣置换术28例,二尖瓣+主动脉瓣置换术13例.所有患者术后均经门诊随访(术后每3个月门诊复查1次),术后6个月复查心脏彩色超声心动图观察三尖瓣反流情况. 结果 术后心功能较术前改善2～3级,心功能Ⅰ级和Ⅱ级共39例,差异有统计学意义(P＜0.05);全组患者随访6～27个月,随访期内无死亡.术后6个月心脏彩色超声心动图检查提示:三尖瓣反流程度较术前明显减轻,微量反流和轻度反流共39例,差异有统计学意义(P＜0.05);术后右心测值较术前明显缩小,右心室横径由术前20 mm降至术后17mm,差异有统计学意义(P＜0.05). 结论 利用人工瓣环行三尖瓣成形术治疗继发性三尖瓣关闭不全,其近、中期疗效明确,远期疗效需要继续随访观察.     

彩色多普勒超声对成人心肌致密化不全的诊断价值

目的探讨彩色多普勒超声心动图对成人心肌致密化不全的诊断价值。方法总结28例成人心肌致密化不全的超声及临床特点。结果 28例患者均符合超声诊断心肌致密化不全的诊断标准,其中单独左心室受累者18例,单独右心室受累者7例,双侧心室均受累者3例,1例合并三尖瓣脱垂,2例合并二尖瓣脱垂,未见合并其他的先天性心脏畸形。结论彩色多普勒超声心动图对成人心肌致密化不全具有重要的诊断价值,对早期治疗、预防并发症的发生具有指导性的意义。     

彩超监测脐动脉与子宫螺旋动脉对高危妊娠的研究

目的：通过彩色多普勒超声联合监测晚孕期高危妊娠患者胎儿脐动脉（UA）及子宫螺旋动脉（SA）血流参数指标,探讨晚孕期高危妊娠胎儿脐动脉、子宫螺旋动脉血流动力学的变化,以及两者联合监测对预测围产儿结局的临床应用价值。方法应用彩色多普勒超声对120例单胎晚期妊娠妇女胎儿的脐动脉及母体子宫螺旋动脉的血流进行检测,分别测量以下血流参数：收缩期峰值速度与舒张期末速度之比值（S/D）,阻力指数（RI）及搏动指数（pulsatility index,PI）,80例高危妊娠与40例正常妊娠组作对照分析。结果（1）高危妊娠组胎儿脐动脉及子宫螺旋动脉血流S/D、RI、PI值高于正常妊娠组,差异有统计学意义（P＜0.05）;（2）高危妊娠组围产儿结局异常的百分比明显高于正常妊娠组,差异有统计学意义（P＜0.05）;（3）当胎儿脐动脉和子宫螺旋动脉血流参数指标都异常时,围产儿结局不良发生率为80.00%,明显高于胎儿脐动脉或子宫螺旋动脉单独异常组,且各组间比较差异均有统计学意义（P＜0.05）。结论妊娠晚期彩色多普勒超声检测胎儿脐动脉、子宫螺旋动脉的血流状态,对预测妊娠结局的发生有临床价值;两者联合检测比单纯胎儿脐动脉或子宫螺旋动脉监测对预测高危妊娠胎儿不良结局更有价值;子宫螺旋动脉可以作为脐动脉预测不良妊娠结局的补充。     

Closed mitral valvotomy during pregnancy. A 20-year experience

Closed mitral valvotomy for rheumatic mitral stenosis was performed on 126 pregnant women (average duration of pregnancy c. 21 weeks), 91% of whom were in NYHA functional class III or IV. Associated functional tricuspid regurgitation was present in 47 (37%) of the women, and 102 (81%) had critical mitral stenosis (digitally assessed valve area less than 1 cm2). There was no surgical mortality. Postoperatively 84% of the women were in NYHA class I. Clinical evidence of pulmonary artery hypertension and tricuspid regurgitation regressed postoperatively in most patients. Full-term normal delivery was achieved in 82% of the pregnancies, with total fetal mortality 6%. There were no congenital abnormalities and the infants' progress was normal. At 5-year follow-up 86% of the women were in NYHA class I or II and at 10 years the figure was 60%. The restenosis rate was 2%/year and the late mortality 3.3%. Closed mitral valvotomy during pregnancy thus was safe and reliable, giving significant functional and clinical improvement without adversely affecting the fetus.     

Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping

Severe tricuspid regurgitation may produce significant morbidity and mortality if not corrected, but commonly used methods of intraoperative assessment may be unreliable. Tricuspid regurgitation was evaluated by a new intraoperative technique, Doppler color flow mapping, in 85 patients before and after cardiopulmonary bypass. Regurgitation grade by intraoperative color Doppler mapping correlated well with right ventricular angiography (kappa value = 0.92, p less than 0.01; n = 8) and with preoperative color Doppler studies (kappa = 0.71, p less than 0.05; n = 51). The right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before (r = 0.30) and after (r = -0.05, p = no significant difference) cardiopulmonary bypass. Advanced (3+ or 4+) tricuspid regurgitation was found in 40% (21) of 52 patients requiring mitral valve repair or replacement. Tricuspid annuloplasty with a prosthetic ring provided a significant (greater than or equal to 2 grade) reduction in regurgitation severity in 94% (17/18; p less than 0.05). Without repair, tricuspid regurgitation decreased to a similar degree after mitral valve operations in 14% (5/36); only one of the five patients had advanced tricuspid regurgitation prepump. Fluid filling of the arrested right ventricle after the surgical procedure did not predict regurgitation severity (false negative rate 50%, 2/4; false positive rate 22%, 2/9). Regurgitation grade remained unchanged after the initial postpump study, up to 60 weeks postoperatively. In conclusion, color Doppler flow mapping provides more accurate intraoperative assessment of tricuspid regurgitation than the right atrial V wave or fluid filling of the right ventricle. This semiquantitative technique aids in the selection of patients appropriate for surgical repair of the tricuspid valve and is useful in judging the adequacy of tricuspid valve repair before chest closure. Advanced (3+ or 4+) tricuspid regurgitation is a common occurrence in patients undergoing mitral valve repair or replacement and rarely responds to conservative (nonoperative) management. Ring annuloplasty provides a highly effective and durable reduction in tricuspid regurgitation.     

妊娠中晚期伴发急性胰腺炎的临床特点及治疗经验

目的探讨妊娠中晚期伴发急性胰腺炎（AP）的临床特点和治疗方法。方法回顾性分析26例妊娠中晚期伴发AP的临床资料。18例非手术治疗治愈；8例手术治疗。手术以清除坏死组织和终止妊娠为主。结果2例母婴死亡；24例母亲痊愈出院。保胎成功15例，流产或死胎9例。结论妊娠中晚期内分泌变化容易导致胰腺炎的发生。特别是既往有胆囊或胆道疾患病史者。治疗方法主要是积极的非手术治疗，必要时采取手术治疗，以减少母婴共亡惨剧的发生。     

人工血管环代成形环治疗三尖瓣关闭不全56例

目的探讨以人工血管环代替成形环治疗三尖瓣关闭不全的临床效果。方法回顾性分析第二军医大学长海医院2000年7月至2010年7月收治三尖瓣关闭不全56例患者的临床资料,其中男24例,女32例;年龄14～73(45.7±21.8)岁;均经心脏彩色多普勒超声心动图明确诊断为三尖瓣中度至大量反流(瞬时反流量>6 ml),其中风湿性心脏瓣膜病47例,先天性心脏病三尖瓣下移畸形9例。均采用人工血管环代替成形环治疗三尖瓣关闭不全。结果全组患者无早期死亡。术后1个月心脏超声心动图提示无三尖瓣关闭不全或轻度关闭不全,发生并发症3例,其中术后呼吸功能衰竭1例,肾功能不全1例,开胸止血1例。远期随访48例,平均随访3.8(1.0～9.5)年,无晚期死亡,发生抗凝并发症(脑梗死)1例;心功能分级(NYHA):Ⅰ级16例,Ⅱ级26例,Ⅲ级6例。随访期间超声心动图检查提示:三尖瓣无关闭不全36例,轻度关闭不全10例,中度关闭不全2例,无严重并发症。结论人工血管环代替成形环治疗三尖瓣关闭不全可以取得较满意的早期和中期的临床疗效,可作为治疗三尖瓣关闭不全的手术方法之一。     

加与不加人工瓣环Danielson成形术矫治Ebstein畸形的比较

目的 比较应用Danielson成形术与Danielson加人工瓣环矫治Ebstein心脏畸形的效果,以确定后者在治疗Ebstein心脏畸形中的作用.方法 2006年1月1日至2009年12月31日,31例10岁以上的青少年及成年A或B型Ebstein心脏畸形患者中19例采用单纯Danielson成形术矫治(A组),12例采用Danielson成形术加人工瓣环矫治(B组),回顾分析两组临床资料及治疗效果.结果 围术期A组死亡1例(1/19例),B组无死亡,组间差异无统计学意义(P=0.510).所有术后生存患者随访5～41个月,平均(23.0±18.5)个月.A组术后1年1例因中重度三尖瓣关闭不全再次行三尖瓣成形术后死亡;B组术后无晚期死亡,组间远期病死率差异无统计学意义(P =0.724).超声复查显示患者房化心室均消失;三尖瓣反流结果,A组轻度11例,中到重度7例,B组轻度2例,无中到重度,组间差异显著(P=0.026).心功能NYHA A组Ⅰ级11例,Ⅱ～Ⅲ级7例;B组均为Ⅰ级,P=0.024.随访期内B组的6 min步行距离(6MWD)显著优于A组[(415±41)m对(382±46)m,P=0.047].结论 Danielson成形术加用人工瓣环矫治有助于提高A或B型Ebstein心脏畸形患者的中、远期疗效.     

Reduction of tricuspid annular doppler tissue velocities in pediatric heart transplant patients.

BACKGROUND: Orthotopic heart transplantation is a life-saving therapy for children with end-stage heart disease. However, 50% of these transplanted children die or require re-transplantation 12 years later. Progressive deterioration of cardiac function is a common feature of long-term survivors; however, quantitative evaluation of the state of the right ventricle has been lacking. Tissue Doppler imaging (TDI) has been used to measure alterations in right ventricular (RV) function in other illnesses. The purpose of this study was to quantitate abnormalities in tricuspid annular systolic and diastolic velocities as an indicator of RV dysfunction, and to evaluate if time since transplantation and the presence of tricuspid regurgitation are associated with quantitative changes in tricuspid annular velocities in pediatric heart transplant recipients. METHODS: TDI was performed and velocities recorded during systole and early and late diastole at the tricuspid annulus, septum and mitral annulus in transplanted patients and in a control group with normal hearts. Pulsed wave Doppler mitral and tricuspid inflows were also measured and the severity of tricuspid regurgitation was estimated using color flow mapping. Patients with biopsy evidence of active cellular rejection or left ventricular ejection fraction of <60% were excluded from study. RESULTS: Thirty-five patients were divided into a normal heart group (n = 14) and a transplant group (n = 21), aged from 1 to 23 years. Systolic and early diastolic velocities at the tricuspid annulus and septum in the transplant group were reduced significantly compared with the normal group (p < 0.05): tricuspid annular systolic, 5.8 +/- 1.4 vs 9.4 +/- 1.7 cm/sec; early diastolic, -6.4 +/- 2.6 vs -9.7 +/- 2.6 cm/sec; septum systolic, 3.9 +/- 1.5 vs 5.8 +/- 1.4 cm/sec; and early diastolic, -6.3 +/- 2.4 vs -9.1 +/- 2.5 cm/sec. Patients were divided into early (<5 years) and late (>5 years) term groups since transplantation. Tissue velocities at the tricuspid annulus in the late term group had further reduction in systole, 4.9 +/- 1.4 vs 6.4 +/- 1.1 cm/sec, and early diastole, -5.3 +/- 1.5 vs -7.1 +/- 2.9 cm/sec (p < 0.05). Patients with severe tricuspid regurgitation had systolic and early diastolic velocities at the tricuspid annulus that were further reduced. Left ventricular mitral inflow Doppler early/late diastolic ratios became significantly different from the normal group 5 years after transplantation (p < 0.05). CONCLUSIONS: TDI demonstrated that tricuspid annular systolic and early diastolic velocities were abnormal in children after transplantation and became significantly more abnormal with prolonged time after transplantation. These alterations were not dependent on the presence of severe tricuspid regurgitation but appeared to be exacerbated by its presence. Evidence of diastolic left ventricular dysfunction was not detected before 5 years after transplantation in this unselected group. A prospective study may be required to define the evolution and progression of right and left ventricular dysfunction in children after heart transplantation.     

Tricuspid valve repair in hypoplastic left heart syndrome

OBJECTIVES: Currently, the survival for the Norwood procedure for hypoplastic left heart syndrome is approximately 90% in selected centers. However, the development of tricuspid regurgitation remains a significant obstacle to successful staged repair in a subset of these patients. The results of tricuspid valve repair in this challenging patient population remain largely unknown. METHODS: Twenty-eight patients with significant (3-4+) tricuspid regurgitation after the Norwood procedure required tricuspid valve repair from August 1995 through December 2002. The clinical and Doppler-echocardiographic data were reviewed to determine the efficacy of repair and patient outcome. RESULTS: Follow-up was 96% complete (27/28). Patients were divided into 2 groups on the basis of tricuspid regurgitation at late follow-up: those with a successful late outcome (0-2+) and those with a poor outcome (3-4+). There were 17 (63%) patients with a successful result and 10 (37%) with an adverse outcome. Age, weight, follow-up duration, valve anatomy, and stage of palliation were not significantly different between groups. Early postoperative 0 to 2+ regurgitation was associated with a durable result (P =.012) and preserved ventricular function (P =.04). Need for repair other than a partial annuloplasty was predictive of a poor outcome (P =.04). Overall survival was 67% (18/27). Survival was 94% (16/17) for patients with a successful late result versus 20% (2/10) for those with a poor outcome (P =.0002). CONCLUSIONS: Tricuspid valve repair can be accomplished in this challenging patient population with excellent results. Successful tricuspid valve repair is predictive of continued good valve function and preserved right ventricular function. Successful valve repair at late follow-up predicts excellent late survival.     

The Impact of Preoperative and Postoperative Pulmonary Hypertension on Long-Term Surgical Outcome after Mitral Valve Repair for Degenerative Mitral Regurgitation

Purpose: The aim of this study is to elucidate the impact of preoperative and postoperative pulmonary hypertension (PH) on long-term clinical outcomes after mitral valve repair for degenerative mitral regurgitation.Methods: A total of 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010 were retrospectively reviewed. Patients were divided into PH(+) group (137 patients) and PH(–) group (517 patients). Follow-up was complete in 99.0%. The median follow-up duration was 7.5 years.Results: Patients in PH(+) group were older, more symptomatic and had higher tricuspid regurgitation grade. Thirty-day mortality was not different between 2 groups (p = 0.975). Long-term survival rate was lower in PH(+) group; 10-year survival rate after the operation was 85.2% ± 4.0% in PH(+) group and 89.7% ± 1.8% in PH(–) group (Log-rank, p = 0.019). The incidence of late cardiac events were not different between groups, however, the recurrence of PH was more frequent in PH(+) group. The recurrence of PH had an adverse impact on survival rate, late cardiac events and symptoms. Univariate analysis showed age and preoperative tricuspid regurgitation grade were the predictors of PH recurrence.Conclusion: Early surgical indication should be advocated for degenerative mitral regurgitation before the progression of pulmonary hypertension and tricuspid regurgitation.