心外膜超声心动图在先天性心脏病矫治术中的作用

目的　探讨心外膜超声心动图 (IEE)在先天性心脏病矫治术中的作用。方法　对接受先天性心脏病矫治手术的患者分别在术中体外循环前、后作 IEE,证实或修正术前漏、误诊并即刻评价手术疗效。结果　共对 2 8例先心病手术矫治术患者作了 IEE检查 ,其中 2例患者在体外循环前新发现合并的畸型 ,纠正了 2例患者的术前诊断 ,在体外循环后及时发现 2例患者的手术并发症 ,此 6例患者的 IEE诊断均经手术证实。结论　 IEE能有效修正术前部分患者的漏、误诊 ,即刻评价手术疗效、发现围术期并发症 ,在先心病矫治术中有重要应用价值     

超声心动图评价三尖瓣硬质三维环成形术对继发性三尖瓣关闭不全的疗效

目的 通过超声心动图评价继发性三尖瓣关闭不全患者行三尖瓣硬质三维环成形术的意义及疗效.方法 左心瓣膜手术同期行三尖瓣硬质三维环成形术的患者(TVP阳性组)35例与未能同期行三尖瓣成形术者(TVP阴性组)15例,分别于术前、术后2周、术后1年通过超声心动图测量三尖瓣环直径(TVAD),舒张期三尖瓣口E峰值流速(ⅤE),三尖瓣反流束面积(TRA),三尖瓣反流分数(TRF),右房内径(RAD),右室内径(RVD)及右室射血分数(RVEF),重点比较术后与术前、术后1年与术后2周时各参数的变化.结果 TVP阳性组:术后2周及术后1年TVAD、TRA、TRF、RAD及RVD均显著减低(P＜0.05);ⅤE及RVEF无显著变化(P＞0.05);术后1年与术后2周相比,TVAD、TRA、TRF无明显变化(P＞0.05),而RAD及RVD进一步缩小(P＜0.05).TVP阴性组:术后2周TVAD、TRA、TRF、RAD、RVD、ⅤE及RVEF均无显著变化(P＞0.05);术后1年与术后2周相比,TVAD、TRA、TRF、RAD及RVD均显著增加,RVEF则减低(P＜0.05).结论 继发性中度以上三尖瓣关闭不全的患者应于左心瓣膜手术同期尽早行三尖瓣成形术,三尖瓣硬质三维环成形术有助于患者右心结构和功能的改善,且术后疗效稳定.     

超声心动图评价人工三尖瓣环成形术对继发性三尖瓣关闭不全的疗效

目的：通过超声心动图评价继发性三尖瓣关闭不全患者行三尖瓣硬质三维环成形术的意义及疗效。方法：左心瓣膜手术同期行三尖瓣硬质三维环成形术的患者（TVP+组）35例，于术前、术后2周、术后1年通过超声心动图测量三尖瓣环直径（TVAD）、舒张期三尖瓣口E峰值流速（VE）、三尖瓣反流束面积（TRA）、三尖瓣反流分数（TRF）、右房内径（RAD）、右室内径（RVD）及右室射血分数（RVEF），重点比较术后与术前、术后1年与术后2周时各参数的变化。结果：与术前相比，术后2周及术后1年TVAD、TRA、TRF、RAD及RVD均显著减低（P＜0.05），VE及RVEF无显著变化（P＞0.05）；术后1年与术后2周相比，TVAD、TRA、TRF无明显变化（P＞0.05），而RAD及RVD进一步缩小（P＜0.05）。结论：继发性中度以上三尖瓣关闭不全的患者应于左心瓣膜手术同期尽早行三尖瓣成形术，三尖瓣硬质三维环成形术有助于患者右心结构和功能的改善，且术后疗效稳定。     

完全胸腔镜下心脏手术体外循环管理

目的 总结完全胸腔镜下心脏外科手术的体外循环管理方法。方法 完全胸腔镜下心脏外科手术110例,其中,房间隔缺损修补术79例（合并三尖瓣关闭不全25例）,室间隔缺损修补术16例,部分型心内膜垫缺损矫治术4例,二尖瓣置换10例,三房心矫治1例,并对体外循环建立方法、体外循环过程及手术后结果进行评价。结果 110例患者体外循环转流时间为61～364（133±64）min;升主动脉阻断时间为17～192（82.0±44.5）min;术后呼吸辅助时间4.0～26.5（4.5±1.8）h;术后住院时间5～10 d;92例患者围术期未使用血制品（83.6%）。术中1例患者股动静脉插管时未完全肝素化,更换股动静脉插管后顺利体外循环;1例患者插股静脉管导致腹膜后血肿,其余108例无股动静脉插管相关并发症,全组患者术后均恢复良好,无严重并发症。结论 完全胸腔镜下心脏手术体外循环方法安全、可行,开展此手术的初期体外循环时间和主动脉阻闭时间相对较长,应加强体外循环的管理。     

50岁以上患者房间隔缺损的外科治疗

目的:总结高龄房间隔缺损(房缺)患者外科治疗的经验。方法:50岁以上成人房缺患者15例,男2例,女13例;年龄50～57岁,平均(51.8±0.9)岁。心功能Ⅱ～Ⅳ级。3例行闭式缝合。12例在中低温体外循环下直视手术,多数采用带孔补片修补房缺,其中二尖瓣成形3例,三尖瓣成形7例。结果:本组无死亡。术后早期室上性心动过速3例,再次开胸止血1例,余恢复顺利。平均住院(15.8±1.9)d。结论:高龄房缺只要无手术禁忌证,手术疗效良好。术中应注意修补方法,二、三尖瓣成形及术后抗心律失常的治疗。     

超声心动图对Ebstein畸形解剖矫治术近期疗效的评价

目的探讨超声心动图诊断Ebstein畸形的准确性及其对解剖矫治术的近期疗效评价.方法16例行Ebstein畸形解剖矫治术的患者,术前超声心动图评价三尖瓣下移的程度、三尖瓣瓣叶及瓣下腱索发育情况、房化右室的大小、三尖瓣反流的程度,并与术中发现比较.所有患者术后均随访超声心动图,与术前结果进行比较分析.结果16例患者中,超声心动图检查三尖瓣前叶均无下移,但发育冗长,瓣叶运动异常.隔叶及后叶均下移,其瓣叶及瓣下结构发育异常.房化右室的大小为2.0cm×3.5cm至6.0cm×8.0cm.所有病例均有右房扩大、三尖瓣瓣环扩张及三尖瓣反流,其中8例中度反流,8例重度反流.术中发现2例三尖瓣前叶的后1/4下移(分别为8mm和11mm),2例后叶呈螺旋样下移,其余与术前超声心动图检查结果相同.术后1～17个月(平均7个月)随访,超声心动图显示右房明显缩小,房化右室消失,三尖瓣叶均在正常瓣环水平,重建的瓣膜均存活、启闭正常.13例三尖瓣反流消失,1例轻度反流,2例残余中度反流.结论超声心动图可全面评价Ebstein畸形三尖瓣及瓣下结构的发育情况及Ebstein畸形解剖矫治术的近期疗效.     

二尖瓣置换术联合三尖瓣成形术的疗效探讨

目的 分析和评价对风湿性心脏痛二尖瓣病变行二尖瓣置换术(MVR)联合三尖瓣成形术(TVP)的治疗效果。方法将 60例风湿性心脏病患者分为两组。观察组为28例联合TVP；对照组为32例同期进行单纯MVR；回顾性分析患者的术前、术中、术后临床资料及心功能恢复和并发症等。结果 观察组术后恢复顺利，无严重并发症，心功能明显改善，来发生急性右心功能不全，且术后辅助呼吸时间较对照组短。结论 MVR联合TVP有利于术后患者心功能恢复，对提高MVR的早期及晚期手术效果有重要意义。     

彩色多普勒超声心动图诊断心脏外伤的体会

将我院近期所见的外伤所致二尖瓣腱索断裂 1例及三尖瓣腱索断裂 2例作一介绍。 3例患者分别有穿透性胸部外伤及闭合性胸部外伤史 ,急诊处理时疏漏心脏损伤。伤后一段时间患者出现症状再次就诊 ,作超声心动图分别可见 :二尖瓣前叶与腱索连续性中断 ,瓣尖活动增大 ,瓣口左房侧见大量返流 ,考虑二尖瓣前叶腱索断裂 (外伤 )伴重度返流 ;三尖瓣活动度大 ,瓣尖对合点消失 ,收缩期脱入右房 ,三尖瓣上大量返流 ,考虑三尖瓣腱索断裂 (外伤 ) ,瓣叶脱垂继发重度返流。检查后明确了心脏损伤 ,行相应心脏手术后得以康复 ,术中所见与超声心动图相同。     

超声在定位PICC导管头端位置中的作用

目的 :探讨心脏超声在预防经外周静脉穿刺中心静脉置管(PICC)术后导管异位入右房及护理中的作用。方法 :60例女性乳腺癌需行PICC置管化疗的患者随机分为对照组和试验组,对照组在完成置管术后,仅行X线观察导管位置,以排除导管异位入颈内静脉。试验组在对照组的基础上加用实时心脏超声导向,观察导管头端位置。对于导管过长已进入右房,需要拔出部分导管的患者,应用心脏超声测量PICC进入右房的距离计算需拔出的导管长度。结果:试验组仅1例患者PICC导管进入右房,对照组共有10例异位入右房,两组比较差异显著(P<0.01),对于导管已异位入右房需退管的11例患者,使用心脏超声测量PICC进入右房的距离计算需拔出的导管长度,一次性退管成功率为100%。11例患者中有4例随心脏搏动不同程度碰撞右房壁,有3例收缩期碰撞到三尖瓣,1例患者出现房性早博,未见感染性心内膜炎及三尖瓣穿孔等严重并发症。结论:心脏超声可有效预防PICC导管异位入右房,对于已异位入右房的导管可准确判断需退出长度。     

经食管超声心动图在三尖瓣下移手术中的应用价值

目的 探讨经食管超声心动图在三尖瓣下移手术中的应用价值.方法 回顾性分析69例三尖瓣下移畸形的术中经食管超声特征.结果 三尖瓣下移畸形体外循环前所有病例经食管超声心动图均能清晰显示三尖瓣瓣叶的解剖特性,6例发现三尖瓣前叶下移,6例三尖瓣后叶发育不良,3例后叶缺如;10例三尖瓣下移畸形成形术后经食管超声心动图显示三尖瓣中度反流,指导再次成形至满意.结论 经食管超声心动图在三尖瓣下移手术中体外循环前能够补充修正诊断,评价体外循环后手术效果,增加手术成功率.     

彩色超声心动图评价房间隔缺损封堵术后右心功能的变化

目的　观察房间隔缺损 (ASD)经右心导管行封堵术后 ,右心房 (RA)、右心室 (RV )形态及功能的变化。方法　86例ASD患者 ,均实施右心导管封堵术。封堵器为Amplatzer式封堵器。术前、术中和术后均经胸壁探查 ,观察心尖四腔心切面 ,比较术前、术后 5min及术后 2月时 ,RA和RV容积大小和形态的变化及三尖瓣返流 (TR)的变化。结果　 86例患者术后封堵器位置均良好。其中 83例无明显穿隔血流。 3例因为两孔型ASD封堵其中较大一孔 ,术后 5min残余分流瞬时量平均为 1.6ml。 80例术前与术后 5min比较 ,RA和RV容积明显减小 ,RA容积平均减小了 2 4.4% ,RV容积平均减小了 18.1%。 41例术后 2个月复查 ,其中 3 7例术前轻度肺动脉压力升高者 (小于 45mmHg) ,RA和RV明显减小 ,形态和容积恢复正常。三尖瓣返流明显减少或无。 4例肺动脉压力中至重度升高者 (大于 65mmHg) ,术后RA和RV也有所减小 ,TR减少。结论　ASD经右心导管行封堵术的效果良好。彩色超声心动图能证实心脏的恢复情况     

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads

ObjectiveTo evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non–lead-induced and lead-induced TR patients.Patients and MethodsWe studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non–lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.ResultsFrom the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non–lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non–lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.ConclusionLead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.     

Tricuspid valve prolapse: A common occurrence in the click-murmur syndrome

Isolated mitral valve prolapse (MVP) may represent one end of a spectrum of disease involving dysfunction of multiple cardiac valves. Eighty-nine consecutive patients with MVP diagnosed by two-dimensional echocardiography (2-D echo) were prospectively studied specifically to determine the incidence of tricuspid valve prolapse (TVP) and its clinical correlations. Criteria for prolapse of the atrioventricular (A-V) valves by 2-D echo included extension of the valve leaflets behind an imaginary line defining the valve annulus. Forty-one of 82 patients with MVP had associated TVP. No significant differences existed between patients with isolated MVP and combined A-V valve prolapse with regard to sex, clinical history, symptoms, or physical examination. The parasternal long axis view was more sensitive than the apical four chamber view in diagnosing prolapse of either mitral or tricuspid valves. Thus, TVP is a frequent concomitant of MVP and occurs with equal frequency in both young and old patients.     

钝性胸外伤致瓣膜腱索断裂的外科治疗

目的探讨钝性胸外伤致瓣膜腱索断裂的临床特点及外科治疗。方法对5例钝性胸外伤致心内结构损伤的临床资料进行回顾性分析。结果二尖瓣腱索断裂行二尖瓣置换术2例，二尖瓣腱索修补术1例。三尖瓣叶破裂或腱索断裂2例行三尖瓣修补成形术。同期室间隔缺损修补术2例，左室修补1例，术中死亡1例。结论瓣膜腱索断裂者，首选方法是瓣膜成形术或瓣膜置换术且早期手术有利于患者的恢复。     

人工瓣膜置换体外循环过程中痰热清注射液的肺保护

背景：体外循环心内直视术不可避免会造成肺损伤,近年来临床上已有中医药应用于该领域减轻肺损伤的研究。目的：观察痰热清注射液对机械瓣置换患者体外循环肺损伤的保护效果。方法：心脏瓣膜置换患者40例随机分为2组,痰热清组患者于术前晚、体外循环前分别予以痰热清注射液20mL入250mL生理盐水静脉滴注,对照组予以生理盐水250mL静滴。于体外循环前、体外循环40min、体外循环停机、停机后2,6,24h共6个不同时间点抽取桡动脉血2mL,全血细胞分析仪测定中性粒细胞数量;双抗体夹心ELISA法测定可溶性细胞间黏附因子1、白细胞介素8血浆浓度。并于体外循环前、体外循环停机时取左右心房血测中性粒细胞并计算跨肺差值。于瓣膜置换切皮前、体外循环结束后10min、瓣膜置换结束时、瓣膜置换结束后4h4个时相计算两组患者的呼吸指数与肺动态顺应性。结果与结论：两组患者体外循环后各个时间点中性粒细胞值、可溶性细胞黏附因子1、白细胞介素8较体外循环前明显升高（P〈0.01）,痰热清组明显低于对照组（P〈0.01）。体外循环停机时中性粒细胞跨肺差值明显高于体外循环前（P〈0.01）,痰热清组明显低于对照组（P〈0.01）。两组呼吸指数较瓣膜置换切皮前明显升高（P〈0.01）,肺动态顺应性较体外循环前明显降低（P〈0.01）,瓣膜置换结束后4h恢复至切皮前水平（P〉0.05）,痰热清组呼吸指数较对照组降低（P〈0.05）,肺动态顺应性瓣膜置换结束时较对照组升高（P〈0.01）。提示痰热清注射液能减轻机械瓣置换后的肺损伤,有较好的肺保护效果。     

Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management

OBJECTIVE: To determine the impact of intraoperative transesophageal echocardiography (IOTEE), an important adjunct in many types of cardiac surgical cases, on the surgical decisions made perioperatively in adult patients undergoing cardiac surgery. PATIENTS AND METHODS: All adult patients who had cardiac surgery between 1993 and 1997 and who also had IOTEE were studied. New findings before and after cardiopulmonary bypass and alterations in the planned surgical procedure or management were documented prospectively. RESULTS: A total of 3245 patients (60% men, 40% women; aged 18-93 years with a mean +/- SD age of 62 +/- 15 years) were included in the study. The most common operations performed were mitral valve repair (26%) and aortic valve replacement (22%). Over the 5-year period, 41% of patients had IOTEE. New information was found before bypass in 15% of patients, directly affecting surgery in 14% of the patients. The most common new prebypass information found was patent foramen ovale resulting in closure in the majority of patients. New information was found after bypass in 6% of the patients, resulting in a change in surgery or hemodynamic management in 4% of the total. The most common postbypass finding was valvular dysfunction with repeat bypass in most patients for re-repair or replacement. No major complications occurred. CONCLUSION: In adult patients undergoing cardiac surgery, IOTEE provides important important information both before and after bypass that affects surgical and hemodynamic management.     

Dilation of the coronary sinus on echocardiogram: prevalence and significance in patients with chronic pulmonary hypertension.

BACKGROUND: Although rarely seen in healthy patients, the coronary sinus (CS) is often visualized on echocardiography in patients with right-sided heart disease. However, the prevalence of this finding and its relation to right-sided heart structure and pressure remains undefined. METHODS: We examined the transthoracic echocardiograms of 43 consecutive patients referred for the evaluation of pulmonary hypertension (26 men, 17 women) with a mean age of 53 +/- 15 years (range 21 to 82 years). Structural abnormalities of the tricuspid valve were absent. All patients underwent right heart catheterization within 48 hours of their echocardiogram, which revealed the following pressures: mean pulmonary artery (50 mm Hg, range 31 to 84 mm Hg) and right atrial (RA) (mean 10, range 1 to 24 mm Hg). Echocardiograms were analyzed for CS size (identified as the smallest diameter of a circular structure in the left atrioventricular groove in the parasternal long-axis view), as well as RA and right ventricular (RV) sizes. The presence and severity (grades 1 through 3) of tricuspid regurgitation (TR) were also recorded. RESULTS: The CS was visualized in 35 (81%) of 43 patients, and measurements ranged from 0.4 to 1.6 cm (mean 0.8 cm). No difference in RA size, RV size, TR grade, RA pressure (RAP), RV pressure (RVP), mean pulmonary artery pressure (PAP), or pulmonary vascular resistance (PVR) was observed between patients with a visualized and nonvisualized CS. Coronary sinus size correlated significantly with RA size (r = 0.60, P <.001) and pressure (r = 0.59, P <.001), but not with RV size, degree of TR, RVP, PAP, or PVR. Nineteen of 35 patients with a visualized CS underwent pulmonary artery thromboendarterectomy (PTE), and their CS size and RAP were unchanged (0.8 cm and 12 mm Hg, respectively, preand post-PTE; both P = NS [not significant]), though a decrease was observed in other measurements: RA size (4.2 versus 4.8 cm, P =.02), RV size (4.2 versus 5.1 cm, P =.0004), mean PAP (37 versus 72 mm Hg, P <.0001), and PVR (230 versus 899 mm Hg, P <.0001). CONCLUSIONS: Coronary sinus dilation was observed in 81% of a selected group of patients with pulmonary hypertension in the absence of structural disease of the tricuspid valve. Coronary sinus dilation is related to RAP and RA size, but not to RV size, degree of TR, RVP, PA pressure, or PVR. Once dilated, CS size does not change shortly after decreases of RA size, RV size, or PA pressure produced by PTE.     

室间隔缺损封堵术并发三尖瓣反流的原因分析

目的探讨经导管膜部室间隔缺损（membranous ventricular septal defect，mVSD）封堵术并发三尖瓣反流的可能原因及注意问题。方法对542例成功行mVSD封堵术患者术前、术后即刻行超声心动图检测，术后5d，1、3、6、12个月随访。结果术后14例出现三尖瓣反流，其中11例术后即刻及3d出现少量反流。22例术前超声心动图显示三尖瓣前叶腱索附着异常中3例最短术后4d、最长1个月发现三尖瓣前叶腱索断裂，出现中量反流。三尖瓣隔叶、腱索和（或）缺损周缘增生的组织粘连融合，形成缺损口右室侧多孔及不同形态，其中7例呈较大的囊袋样不规则形或瘤形，缺损口周缘部分由三尖瓣隔叶和（或）腱索构成。结论mVSD封堵并发三尖瓣反流的原因可能为导管损伤腱索、输送杆损伤腱索和封堵器磨损腱索。术前选择适应证时，除常规观察项目外，还应注意观察三尖瓣前叶腱索位置、缺损周缘构成的组织结构及缺损口右室侧形态，以减少并发症。     

膜周部室间隔缺损合并三尖瓣关闭不全的超声诊断分析和封堵术效果观察

目的利用超声心动图二维和三维图像诊断先天性膜周部室间隔缺损(VSD)合并三尖瓣关闭不全(TI),并总结分析经导管封堵术的效果。方法选择已进行VSD封堵术的患者37例,入选条件是术前有明显的三尖瓣关闭不全(TI)。诊断依据:彩色多普勒显示三尖瓣上收缩期高速由右室向右房的逆行血流(TR),运用Simpson法测量TR的容积。疗效评估:比较术前、术后TR容积的变化。结果超声二维和三维图像可清晰显示VSD;37例行封堵术的患者均存在三尖瓣瓣膜或腱索与VSD边缘粘连的情况,比较患者封堵术前后的TR,术前平均为(4.56&#177;1.5)ml,术后减少平均为(1.77&#177;0.86)ml,P&lt;0.05有统计学意义。结论超声心动图二维和三维图像的结合会进一步提高超声诊断的立体定位准确性,封堵术对因粘连引起的TR有明显的治疗效果。