应用PTFE人工单叶肺动脉瓣实施右心室流出道重建术的护理配合

目的总结应用PTFE人工单叶肺动脉瓣实施右心室流出道重建矫治先天性心脏病的手术配合。方法用经修剪的PTFE片缝制人工单叶肺动脉瓣及自体心包片行右心室及主肺动脉补片扩大。结果21例中死亡1例,病死率4.76％,余20例术后恢复良好,除第1例患儿存在中度肺动脉返流外,其余患者均无返流;全部患儿均无肺动脉或右心室流出道梗阻。结论在行跨肺动脉瓣右心室流出道补片扩大术中,应用PTFE人工单叶肺动脉瓣可以有效地避免术后肺动脉瓣返流,改善右心室功能。     

浅低温体外循环心脏跳动下手术治疗肺动脉瓣狭窄

目的：总结肺动脉瓣狭窄于浅低温体外循环心脏跳动下外科治疗经验。方法：回顾分析52例肺动脉瓣狭窄的病例，均于浅低温体外循环心脏跳动下手术，其中，单纯肺动脉瓣交界切开术29例，右室流出道跨瓣环心包补片加宽术15例，肺动脉瓣交界切开术加右室流出道肥厚肌束部分切除术8例。结果：全组无手术死亡。无术后严重并发症。随访6个月-2年，心功能恢复0-Ⅰ级。结论：浅低温体外循环心脏跳动下的手术治疗肺动脉瓣狭窄是一种安全、效果优良的手术方式。     

自体心包衬里涤纶补片右室流出道成形术的手术配合

自体心包衬里涤纶补片右室流出道成形术的手术配合３２３０００浙江省丽水地区医院郑惠明自体心包是近几年各大医院应用于心血管畸形的修补材料之一。我院自１９８８年至１９９４年应用自体心包衬里涤纶补片行右室流出道成形和跨瓣成形术共３６例，治疗法乐氏三联、四联症...     

超声心动图评估法洛四联症术后中远期疗效109例随访

目的：运用超声心动图评价法洛四联症手术后的中远期疗效。方法：从1994年1月至2000年2月共109例法洛四联症手术病例,男性81例,女性28例,年龄5－158月,体重6－43kg。一期根治105例,二期根治4例（首期采用右室流出道跨瓣补片）。79例行右室流出道跨瓣补片,2例采用人造血管连接右心室与肺动脉,其余病例行右室流出道不跨瓣补片。术后超声心动图随1-72月。结果：术后残余分流20例（18．3％）,70％的残余室间隔缺损直径为0．1－0．2cm,不引起左半心内径增大,但有1例发生细菌性心内膜炎。术后残余右室流出道梗阻2例（1．8％）。肺动脉瓣返流85例（77．9％）,返流组右心室扩大率显著高于无返流组（92．9％vs20．8％,P＜0．001）.4例二期根治患者中有3例首期术后出现肺动脉高压。结论：法洛四联症结术后总体中远期疗效满意。较高的肺动脉瓣返流率值得引起重视。对残余分流和姑息术后的病例应加强随访。     

合并单侧肺动脉缺如法乐氏四联症的外科治疗

手术治疗4例合并单侧肺动脉缺如法乐氏四联症。1例因术后急性心功能不全死亡，余3例恢复良好，经随访手术效果满意。手术应用带瓣补片加宽右室流出道，围术期重点处理好低心输出量。     

成人法洛四联征的外科治疗

目的:探讨成人法洛四联征患者的手术方法和效果。方法:对成人法洛四联征18例行右室流出道疏通重建,并以合适大小心包外衬涤纶片加宽(6例行肺动脉跨环补片),其中8例行肺动脉瓣成型,3例三尖瓣反流患者行三尖瓣成型术。结果:18例患者1例因术后低心排和肾衰于术后第3 d死亡,1例因固定胸骨的钢丝刺破右乳内动脉,术后再次大量出血开胸止血,17例顺利康复出院,术后心功能都得到有效的恢复。结论:成人法洛四联征只要得到合理的手术矫正,同样可以取得较好的治疗效果。     

成人法洛四联症的围术期管理

目的:探讨成人法洛四联症的围术期管理经验.方法:2009年9月至2010年8月,手术矫治大于14岁的成人法洛四联症39例,均采用胸部正中切口、低温体外循环下行一期矫治术.均行右室流出道切口,32例加作右心房切口,用涤纶片修补室间隔缺损,右室流出道切口用自体心包片外加涤纶补片扩大,30例合并肺动脉狭窄或者肺动脉瓣环小者作跨瓣环补片.结果:全组无围术期死亡.1例急性肾功能衰竭用血液滤过治疗后肾功能恢复.Ⅲ度房室传导阻滞1例,术后第3天恢复窦性心律.术后因胸内出血而需再次开胸止血1例.随访1 ～ 12个月,无晚期死亡,患者心功能均恢复至Ⅰ或Ⅱ级.结论:手术矫治成人法洛四联症可取得满意的临床结果,彻底的畸形纠正和合理的围术期处理是手术成功的关键.     

自体心包隔瓣在房室通道缺损矫治手术中的应用

目的报告在房室通道缺损（AVCD）矫治术中应用自体心包片重建人工隔瓣的方法与结果。并与常规成型术式进行对比分析。方法对16例部分型与4例完全型AVCD伴隔瓣发育不良或缺如者进行矫治手术。其中按常规成型术式进行的8例作为对照组，利用修补原发孔型房间隔缺损的自体心包补片末端作成人工隔瓣，同时修补二尖瓣裂和修复房、室间隔缺损的12例作为实验组。结果全部患者无死亡或Ⅲ度房室传导阻滞。实验组术后无返流或轻度返流，心功能恢复良好；对照组术后三尖瓣返流仅3例变为轻度，其余仍为中到重度．右心功能欠佳。2组术后三尖瓣返流改善情况比较差异有统计学意义（P〈0．05）。结论利用自体心包重建人工隔瓣比较符合三尖瓣的解剖结构。能有效地消除术后三尖辩返流。     

自体肺动脉瓣移植术在治疗主动脉瓣病变中的应用

目的:总结我院自体肺动脉瓣移植术的临床经验。方法:1994年10月-2005年1月,共完成自体肺动脉瓣移植术42例;术前诊断:先心病、主动脉瓣病变39例,亚急性细菌性心内膜炎合并主动脉瓣关闭不全1例,主动脉瓣人工机械瓣置换术后心内膜炎合并瓣周漏1例,老年退行性病变1例,为重度主动脉瓣狭窄。全组患者术前UCG示主动脉瓣病变,狭窄和/或关闭不全(中重度),主动脉瓣环径(2.45±0.31)cm;肺动脉瓣发育正常,功能良好,肺动脉瓣环径(2.34±0.21)cm;术前心功能2.12级。所有病例均在全麻中度低温体外循环下进行,手术分三步进行:(1)采取自体肺动脉瓣;(2)切除病变的主动脉瓣并移植自体肺动脉瓣于主动脉位,采用主动脉根部移植法;(3)利用同种动脉瓣重建右室流出道。结果:全组患者无手术死亡;术后主动脉平均跨瓣压差在正常范围(6.11±0.12)mmHg,左室舒张末径明显缩小(P<0.01),LVEF0.49±0.23,心功能I~II级。38例患者接受随访,随访1个月~10年,心功能I级,主动脉瓣、肺动脉瓣均功能良好,末见瓣膜狭窄或关闭不全。1例早期手术患者术后6个月出现同种瓣心内膜炎再次手术死亡,另1例患者术后不明原因突发心脏骤停,复苏后应用体外人工膜肺支持一周后心脏功能明显好转,后因经费问题家属要求自动出院。结论:自体肺动脉瓣移植术是一种临床疗效好的治疗主动脉瓣病变的手术方法。     

重度右室流出道狭窄的外科治疗

目的：探讨重度右室流出道狭窄的手术适应证、手术方式及手术标准，方法；总结１９８５年１月－１９９７年１０月期间收治的１２８例重度右室流出道狭窄患者手术治疗情况。其中单纯右室流出道狭窄４５例，法乐四联症４９便，法乐三联症３４便，结果：单纯心内修复５２例，应用右室漏斗部补片３９例，跨肺动脉瓣环补片３７例，其中８例补片达左、右肺动脉分叉部。死亡７例，结论：正确掌握跨肺动脉瓣环片指征是手术成功的关键。     

Substrate characterization of ventricular tachycardia in a porcine model of tetralogy of Fallot using noncontact mapping

BACKGROUND: Ventricular tachycardia (VT) in patients following tetralogy of Fallot (TOF) repair is challenging to map because of the presence of scar, patch material, and hemodynamic residua of surgery. This study investigates whether noncontact mapping can identify the arrhythmia substrate in a porcine model that involves a right ventricular outflow tract (RVOT) patch and either chronic volume or pressure load on the right ventricle. METHODS: Nine infant pigs (3-5 kg) underwent surgery involving an RVOT patch and creation of pulmonary insufficiency (PI, n = 4) or pulmonary stenosis (PS, n = 5). After a mean of 4.2 months, pigs underwent invasive electrophysiology studies (EPS) with noncontact mapping (Ensite, St. Jude Medical, St. Paul, MN USA) of the right ventricle. Automated, unipolar voltage maps (VM) were constructed during sinus rhythm. Threshold for substrate was set at -0.5 mV and incrementally adjusted to higher values until a contiguous region of low voltage was delineated. Programmed stimulation was performed to induce VT. VT activation was correlated to location of VM defined substrate. Three control pigs underwent EPS and VM. RESULTS: Free-wall RVOT substrate was identified in each of the model animals, correlating to location of the patch. The mean voltage threshold was -1.1 mV. VT was induced in 6/9 animals. Diastolic activation approximated the inferior or lateral border of the substrate in all animals. No RVOT substrate was identified in the control pigs. CONCLUSION: Automated voltage mapping of sinus beats identifies substrate for VT in a porcine model of TOF. Consistent diastolic activation of the substrate border was found during VT. Targeting this area may be useful in the ablation of VT after repair of TOF.     

18例成人法洛四联症矫治术经验总结及效果评价

目的本文旨在探讨成人法洛四联症矫治术的经验及本院18例成人法洛四联症矫治术后效果。方法2001-2008年间18例法洛四联症患者,手术时平均年龄（22．5±3）岁,纽约心脏学会心功能分级12例为Ⅱ级,6例为Ⅲ级。本组所有患者中11例患者施行了跨肺动脉瓣环补片,余7例患者实施了右室流出道补片。术后随访时间（35±22）月,定期复查彩色超声心动图、心电图了解患者心功能情况及生存质量。结果院内死亡1例,死于术后多器官功能衰竭,死亡率5．6％,远期死亡1例,死于感染性心内膜炎。3例患者随访中出现肺动脉瓣中等量返流,13例患者随访中心功能明显改善,生存质量显著提高。结论成人法洛四联症矫治术可达到比较满意的效果,跨肺动脉瓣环补片对远期心脏功能恢复无明显影响。     

20例右室双出口临床分析

目的分析20例右室双出口矫治术的临床效果。方法 20例右室双出口患者室间隔缺损均为主动脉瓣下型,均采用心内隧道连接室间隔缺损与主动脉开口,自体心包片加宽右室流出道及肺动脉。结果全组无死亡,术后无左室流出道狭窄或右室流出道狭窄。随访3月-9年,临床效果满意。结论右室双出口解剖类型复杂,室间隔缺损的位置决定手术方案。手术的主要目的是重建左室流出道及右室流出道。     

多普勒超声右室流出道血流参数评价肺心病右室收缩功能

目的：探讨多普勒超声右室流出道血流参数对评价肺心病右室收缩功能的价值。方法：在22例肺心病患者中,利用脉冲多普协超声记录右室流出道（RVOT）血流频谱参数,与放射性核素心室造影测算的右室射血分数（RVEF）对比分析。结果：在RVOT血流参数中右室收缩时间间期（STI）,射血期流速积分（VTI）和平均血流速度（Vm)与核素造影所测RVEF仅有轻度相关,其余测值无相关。结论：肺心病患者的RVOT血流参数难以反映右室收缩功能情况。     

Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension

Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1–5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36?% died overall, 10?% per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5?% change in RAEF: 0.83 [95?% CI 0.73–0.94], p?=?0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.     

右心室流出道多普勒血流频谱和肺毛嵌压对老年肺心病的临床诊断价值

为了评价脉冲多普勒记录右心室流出道（ＲＶＯＴ）及左室流入道（ＬＶＩＴ）血流频谱以检测肺动脉压（ＰＡＰ）和肺毛嵌压（ＰＣＷＰ）对老年肺心病的临床意义。研究老年肺心病（ＣＰ）２１例、老年慢性支气管炎（ＣＢ）２２例、健康老人（Ｈ）１５名。结果和结论：１）在ＲＶＯＴ比在肺动脉主干内记录血流图容易成功，在ＬＶＩＴ测定左室等容舒张时间比心机图容易；２）ＲＶＯＴ血流频谱可将ＣＰ与ＣＢ及Ｈ区别开来（Ｐ＜０．０１）。ＣＰ的ＲＶＯＴ血流图的特点是，加速时间缩短，＜１００ｍｓ；右心室收缩时间间期异常，ＲＰＥＰ／ＲＶＥＴ＞０．４；由血流曲线计算的肺动脉压及即血管总阻力增高；３）有气短和肺湿性罗音，如ＰＣＷＰ不高，则不支持左心功能不全或舒张型心力衰竭；４）ＣＰ患者的血浆心钠素（ＡＮＰ）显著升高。这反映肺动脉压和右心房压力升高；５）本文ＲＶＯＴ血流图诊断ＣＰ的敏感性为９０．５％，特异性９４．６％。     

Right ventricular outflow tract pacing: practical and beneficial. A 9-year experience of 460 consecutive implants

BACKGROUND: Pacing from the right ventricular apex (RVA) in patients with ventricular dysfunction has been identified as a possible contributor to deterioration of ventricular function. Therefore, alternative pacing sites such as the right ventricular outflow tract (RVOT) are receiving intensified scrutiny. An unresolved question is whether technical, procedural, and stability issues are comparable for the RVA and the RVOT. METHODS: This report details 460 consecutive ventricular pacing lead implants with the primary intended site in the RVOT. Patients were evaluated for success, complication rates, and followed-up for stability of pacing parameters. The total patient implant population included 300 male and 170 female patients with a mean age of 70.6 years. Ten patients were excluded from the analysis, since there was a primary indication and intention to implant in the RVA, leaving a total of 460 patients for analysis. The indications for pacing were symptomatic bradycardia due to any cause and/or Mobitz II or complete heart block. There was no clinical evidence of heart failure in 420 patients. In 40 patients with heart failure, the indication for pacing was cardiac resynchronization therapy using the RVOT as an alternate site when pacing from a branch vein of the coronary sinus was not possible. Outcome information was obtained from the implanter's clinic. RESULTS: The overall success rate in the RVOT was 84% over the total 9-year period with a 92% success rate in the last 4(1/2) years, using the RVOT technique described. At 20 months in a subgroup comparison of RVOT and RVA implants, there was no significant difference in pacing threshold, R-wave sensing, or pacing lead impedance. Dislodgment occurred in only 1 of 460 patients. Reasons for failure to implant in the RVOT include inability to find a stable position with adequate pacing and sensing thresholds (related to anatomy, scarred myocardium, pulmonary hypertension, tricuspid regurgitation), hemodynamic instability limiting time for implant, and a learning curve. Long-term stability and lead performance were excellent, and certain acute and chronic complications of RV pacing did not occur.     

超声心动图对复杂紫绀先心病行牛颈静脉带瓣管道重建右心室流出道的结构及血流动力学评价

目的应用彩色多普勒超声心动图（UCG）观察复杂紫绀先心病行牛颈静脉带瓣管道重建右心室流出道的结构及血流动力学变化。方法应用UCG观察牛颈静脉带瓣管道（BJVC）重建右心室流出道结构及血流动力学在术后7天、1年的变化，对18例患者行右心室（RV）与主肺动脉（MPA）连接状况，测定重建后右心室流出道（RVOT）各截面的直径，右室、肺动脉吻合口的宽度、压差、速度；评价牛颈静脉带瓣管道生物材料有无变性、退行性变及通畅情况；以及自身RVOT、MPA闭合情况。结果术后7天，18例UCG检查肺动脉瓣开放、关闭良好；重建术后1年，18例患者均存活，BJVC瓣膜仍无病理性返流，跨瓣压差小，管道通畅，未见明显血栓形成。结论超声心动图在复杂紫绀先心病行牛颈静脉带瓣管道重建右心室流出道的结构及血流动力学变化中起着非常重要的作用。     

Changes in intracardiac hemodynamics during of the natural course of isolated stenoses of pulmonary artery and the right ventricular outflow tract

AIM: To study alterations in intracardiac hemodynamics in patients with isolated stenosis of the pulmonary artery (ISPA) and right ventricular outflow tract (RVOT). MATERIAL AND METHODS: The disease course was studied by means of repeated probing of the heart chambers, angiocardiography and echocardiography in 32 patients with ISPA and RVOT. Follow-up was performed for 14 years (mean 44.3 +/- 7.47 months). RESULTS: ISPA and RVOT run differently in adults and children. In initial gradient of systolic pressure (GSP) between the right ventricle (RV) and pulmonary artery (PA) under 25 mmHg, its rise with time in the adults is insignificant while in patients with marked stenosis especially in children GSP elevates greatly. Natural course of ISPA and RVOT depends also on the type of obstruction and the degree of hemodynamic disorders. In isolated valvular PA stenosis if systolic overload of RV is absent, the disease course is favourable and expectation policy is possible. In valvular-infundibular stenosis of RVOT compensating ability of the RV depletes quicker and therefore urgent operation is required. CONCLUSION: Congenital ISPA and RVOT are progressive diseases natural course of which depends on the type of obstruction, severity of hemodynamic disorders and age of the patients.     

Variations in right ventricular outflow tract morphology following repair of congenital heart disease: implications for percutaneous pulmonary valve implantation.

OBJECTIVE: Our aim was to identify sub-groups of right ventricular outflow tract morphology that would be suitable for percutaneous pulmonary valve implantation and to document their prevalence in our patient population. MATERIALS AND METHODS: Eighty-three consecutive patients with right ventricular outflow tract dysfunction (5-41 years, 76% tetralogy of Fallot) referred to our center for cardiovascular magnetic resonance were studied. A morphological classification was created according to visual assessment of three-dimensional reconstructions and detailed measurement. Diagnosis, right ventricular outflow tract type, surgical history and treatment outcomes were documented. RESULTS: Right ventricular outflow tract morphology was heterogeneous; nevertheless, 5 patterns were visually identified. Type I, a pyramidal morphology, was most prevalent (49%) and related to the presence of a transannular patch. Other types (II-V) were seen more commonly in patients with conduits. Two patients had unclassifiable morphology. Ninety-five percent of patients were assigned to the correct morphological classification by visual assessment alone. Percutaneous pulmonary valve implantation was performed successfully in 10 patients with Type II-V morphology and in 1 patient with unclassifiable morphology. Percutaneous implantation was not performed in patients with Type I morphology. Only right ventricular outflow tract diameters < 22 mm in diameter were suitable for the current device. CONCLUSIONS: We have created a morphological classification of the RVOT in patients referred for assessment of RVOT dysfunction. Though only 13% of our patients underwent percutaneous implantation, > 50% of outflow tract morphologies may be suitable for this approach, in particular with the development of new devices appropriate for larger outflow.