Doppler assessment of the interventricular pressure drop in patients with ventricular septal defects

Doppler ultrasound was used to assess the pressure drop between the ventricles in 109 infants and children (61 less than two years old) with a ventricular septal defect who underwent cardiac catheterisation. The pressure in both ventricles was measured at catheterisation in 103 patients either simultaneously through two catheters (41) or with a single catheter withdrawn across the septum or removed from one ventricle to the other (62). When pressure was measured simultaneously with two catheters (41 patients) the peak to peak and instantaneous gradients showed a maximum difference of 20 mm Hg with levels within 10 mm Hg of each other in 36. Comparison of the difference in the gradients with the average of the measurements demonstrated a tendency for Doppler to underestimate the difference when it was high (greater than 50 mm Hg) and overestimate it when it was low. A Doppler estimate of a low pressure difference between the ventricles indicates pulmonary arterial hypertension and a high one low pulmonary artery pressure, but in the intermediate group Doppler is as yet not sufficiently sensitive to allow selection of those patients who require further investigation and possible operation. Doppler ultrasound was found to be a sensitive method of detecting a very small ventricular septal defect. Thus although Doppler is a very useful means of assessing and following patients with a ventricular septal defect, further studies are required to determine its exact place in clinical practice.     

Doppler assessment of the interventricular pressure drop in patients with ventricular septal defects.

Doppler ultrasound was used to assess the pressure drop between the ventricles in 109 infants and children (61 less than two years old) with a ventricular septal defect who underwent cardiac catheterisation. The pressure in both ventricles was measured at catheterisation in 103 patients either simultaneously through two catheters (41) or with a single catheter withdrawn across the septum or removed from one ventricle to the other (62). When pressure was measured simultaneously with two catheters (41 patients) the peak to peak and instantaneous gradients showed a maximum difference of 20 mm Hg with levels within 10 mm Hg of each other in 36. Comparison of the difference in the gradients with the average of the measurements demonstrated a tendency for Doppler to underestimate the difference when it was high (greater than 50 mm Hg) and overestimate it when it was low. A Doppler estimate of a low pressure difference between the ventricles indicates pulmonary arterial hypertension and a high one low pulmonary artery pressure, but in the intermediate group Doppler is as yet not sufficiently sensitive to allow selection of those patients who require further investigation and possible operation. Doppler ultrasound was found to be a sensitive method of detecting a very small ventricular septal defect. Thus although Doppler is a very useful means of assessing and following patients with a ventricular septal defect, further studies are required to determine its exact place in clinical practice.     

5kg以下婴儿室间隔缺损并肺动脉高压的外科治疗

目的总结5kg以下婴儿室间隔缺损（VSD）并肺动脉高压外科治疗的经验。方法2006年6月至2008年8月,外科治疗5奴以下婴儿VSD共34例,年龄12d至9个月,体重2．8-5．5kg。超声心动图提示VSD直径平均（9．1±3．4）mm,均有不同程度的肺动脉高压。术前予充分控制感染、改善营养状况、降低肺动脉压力以及改善心功能不全等治疗。均在浅低温体外循环心脏停跳下行VSD修补手术。术后加强处理肺动脉高压、肺部感染、心功能不全等并发症。结果全组术后无死亡。随访2-26个月,均无严重并发症发生。结论提高手术技巧和加强围术期处理是外科治疗5kg以下婴儿VSD并肺动脉高压成功的关键。     

室间隔缺损合并重度肺动脉高压的诊断性治疗及远期随访

目的:分析室间隔缺损合并重度肺动脉高压(pulmonary hypertension,PH)患者的诊断性治疗及远期随访结果,总结先天性心脏病(先心病)合并重度肺动脉高压患者的诊断性治疗体会。方法:2005年10月至2010年12月,收治室间隔缺损合并重度肺动脉高压患者65例,分别给与选择性扩张肺动脉药物治疗,以不吸氧状态下末梢氧饱和度稳定在95%以上为主要标准,判断手术指征。结果:手术54例,均在体外循环下行室间隔缺损修补术。围手术期死亡1例,无远期死亡,11例不具备手术条件,继续药物治疗。随访12～36个月,平均肺动脉压力低于40 mmHg(1 mmHg=0.133 kPa)。未手术患者肺动脉压力明显降低,心功能明显改善。结论:通过药物对重度肺动脉高压患者进行诊断性治疗,可以对肺动脉高压性质做出准确的判断,能获得良好的疗效。     

Natural histories of atrial septal defect with pulmonary hypertension, and ventricular septal defect with pulmonary hypertension

A study of the natural history of 51 adult patients with atrial septal defect with pulmonary hypertension (ASD + PH) was performed. ASD + PH of less than 14 Um2 of pulmonary artery resistance (PVR) was considered an indication for surgery. The prognosis of surgically treated patients was favorable, but that of medically treated patients was poor. For patients with ventricular septal defect with pulmonary hypertension (VSD + PH), surgery was considered for pulmonary-systemic vascular resistance ratio (Rp/Rs) less than 0.5, and for patients under than 10 years and, ideally, under 2 years of age.     

室间隔缺损和动脉导管未闭合并中重度肺动脉高压的分期复合治疗

目的 评价经导管介入封堵加择期外科手术的分期复合治疗应用于室间隔缺损和动脉导管未闭合并中重度肺动脉高压患者的安全性及有效性.方法 自2004年7月至2009年7月,对22例室间隔缺损和动脉导管未闭合并中重度肺动脉高压患者进行了先经导管介入封堵动脉导管未闭,随后择期行开胸室间隔缺损修补术的分期复合治疗.术后进行随访,观察心律改变、残余分流、封堵器形态、有无瓣膜反流及主动脉狭窄等情况,测量肺动脉压变化,评价治疗效果.结果 经导管介入封堵治疗后,患者肺动脉收缩压由(76.2±25.8)mm Hg(1 mm Hg=0.133 kPa)降至(55.4±20.6)mm Hg(P=0.005),肺动脉平均压由(53.5±23.5)mm Hg降至(36.2±17.8)mm Hg(P=0.049),全肺动脉阻力由(8.2±4.9)wood单位降至(6.9±4.3)wood单位(P=0.037),肺循环血流量与体循环血流量的比值(Qp/Qs)由2.8±2.3升至3.4±1.7(P=0.045).外科手术后,肺动脉收缩压由(64.5±22.3)mm Hg降至(43.1±18.9)mm Hg(P=0.001),肺动脉平均压由(40.2±18.7)mm Hg降至(29.5±15.8)mm Hg(P=0.040).随访中所有患者均未出现右心衰竭和死亡.结论 室间隔缺损和动脉导管未闭合并中重度肺动脉高压的经导管介入封堵加择期外科手术的分期复合治疗安全、有效.

Abstract：

Objective To evaluate the safety and efficacy of staged hybrid approach in treating ventricular septal defect (VSD) patients combined with patent ductus arteriosus (PDA) and pulmonary artery hypertension (PAH). Methods From July 2004 to July 2009, 22 VSD patients with PDA and PAH were enrolled and received staged hybrid approach treatment( transcatheter PDA occlusion and elective open surgery for VSD several lays after PDA occlusion). All patients were followed up to examine rhythm change,residual shunt, shape of occlude, possible valve regurgitation, and aortic stenosis by echocardiography. Results After transcatheter PDA occlusion, pulmonary arterial systolic pressure decreased from (76. 2 ± 25. 8 ) mm Hg ( 1 mm Hg = 0. 133 kPa) to ( 55.4 ± 20. 6 ) mm Hg ( P = 0. 005 ),mean pulmonary artery pressure decreased from ( 53.5 ± 23.5 ) mm Hg to ( 36. 2 ± 17. 8 ) mm Hg ( P=0. 049), total pulmonary resistance decreased from (8. 2 ±4.9)wood units to (6.9 ±4. 3)wood units (P =0. 037), and pulmonary-to-systemic flow ratio (Qp/Qs) increased from 2. 8 ± 2. 3 to 3.4 ± 1.7 ( P = 0. 045 )post transcatheter interventional PDA occlusion. After VSD repair, pulmonary arterial systolic pressure decreased from (64. 5 ± 22. 3 ) mm Hg to (43. 1 ± 18. 9) mm Hg ( P = 0. 001 ) and mean pulmonary artery pressure decreased from (40. 2 ± 18. 7 ) mm Hg to (29. 5 ± 15. 8) mm Hg ( P = 0. 040). There was no death or right heart failure during the follow-up. Conclusion Staged hybrid approach is an effective and safe strategy for treating VSD patients with PDA and PAH.     

Doppler echocardiographic determination of the degree of tricuspid valve insufficiency in patients with ventricular septal defects]

Prior to and following the surgical plasty of ventricular septal defects, the tricuspid valve was evaluated in 106 patients, by employing two-dimensional and Doppler echocardiographies. Seventy-seven patients were followed up for 6 months to 2 years after the operation. Tricuspid valve failure was regarded to be pansystolic turbulent regurgitation blood flow which had been revealed only in 4 patients before the operation. Two weeks following the operation, most patients were found to have tricuspid valvular pansystolic turbulent regurgitation blood flow which remained only in 29% of the cases in late follow-up periods. Tricuspid valve failure failed to be clinically evident in these patients. It is concluded that Doppler echocardiography is an effective and highly sensitive tool in the diagnosis of tricuspid valve failure even when it runs, showing no clinical signs.     

Doppler echocardiography in the assessment of arteriovenous blood ejection in patients with ventricular septal defects]

To assess Doppler echocardiography used to determine blood ejection through ventricular septal defect, this procedure and cardiac catheterization were performed in 32 patients. Comparison of the findings showed a high correlation (r = 0.81; p < 0.05). To determine whether echocardiographic accesses are correctly chosen, volumetric greater circulation was measured from the suprasternal access in the ascending aorta and aortic arch, but volumetric lesser circulation was measured from the parasternal access in the pulmonary trunk and from the apical access of the projection of 4 chambers through the mitral orifice. The comparison of the findings showed a high correlation in this group. Twenty one patients were examined after plastic surgery of ventricular septal defect, who had been clinically suspected to have a residual shunting. An analysis of the findings made it possible to develop Doppler echocardiographic criteria for differential diagnosis of graft vibration due to arteriovenous blood ejection.     

Small ventricular septal defect associated with severe pulmonary hypertension

A small ventricular septal defect in an 18 year old man was shown by serial cardiac catheterisation to be associated with a progressive increase in pulmonary arterial pressure. Surgical closure of the defect had no effect on the increased pulmonary arterial pressure. Whether pulmonary hypertension occurred secondary to the haemodynamics of the ventricular septal defect or as an independent event is uncertain.     

Doppler echocardiographic assessment of impaired left ventricular filling in patients with right ventricular pressure overload due to primary pulmonary hypertension

In patients with primary pulmonary hypertension, competition between the right and left ventricles for the limited pericardial space results in distortion of left ventricular geometry reflected in displacement of the ventricular septum toward the left ventricular cavity. Left ventricular shape is most dramatically deranged at end-systole and early diastole, suggesting the possibility that the distribution of left ventricular diastolic filling might be altered. To investigate this hypothesis, nine patients with primary pulmonary hypertension and nine normal individuals were studied with echocardiographic techniques. Left ventricular isovolumic relaxation time was significantly prolonged in patients with primary pulmonary hypertension by comparison with normal individuals (129 +/- 36 versus 53 +/- 9 ms, p less than 0.005) and the fraction of the transmitral flow velocity integral occurring in the first half of diastole was significantly less than in normal individuals (38 +/- 14% versus 70 +/- 9%, p less than 0.005). Measurement of fractional changes in short-axis left ventricular cavity area similarly demonstrated that in patients with primary pulmonary hypertension fractional early diastolic cavity expansion (32 +/- 11%) was significantly less than in normal individuals (78 +/- 9%, p less than 0.005). In patients with primary pulmonary hypertension, the ventricular septum was abnormally flattened toward the left ventricular cavity at end-systole (normalized septal curvature 0.04 +/- 0.19) and remained that way throughout early diastolic filling but returned toward normal at end-diastole (normalized septal curvature 0.68 +/- 0.19, p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional studies in rest and during exertion in children and adolescents with ventricular septal defects and pulmonary hypertension]

7 children from 7-15 years of age, who had a large VSD with pulmonary arterial hypertension, were investigated on a bicycle ergometer during stepwise increasing load. In 5 cases a pulmonary artery banding had been performed earlier in spite of distinctly increased pulmonary vascular resistance. In two cases with Eisenmenger-syndrome no operative measures had been attempted. The measurements, which were carried out at rest and during two submaximal loads, comprised beside determination of oxygen uptake and heart frequency also the arteriovenous oxygen difference as well as mean arterial pressure in the pulmonary and the systemic circuit so that flow and resistance could be calculated for both circuits. During exercise a linear increase of flow in the pulmonary circuit was achieved in all cases, accompanied by a distinct rise of the mean pulmonary arterial pressure. The pulmonary vascular resistance stayed, however, generally constant. Systemic vascular resistance, on the contrary, decreased to about one third of the resting values so that the ratio of pulmonary arterial to systemic vascular resistance increased considerably. The result was a progressive increase of the right to left shunt during exercise, and in 3 cases with predominant left to right shunt at rest in spite of the band, a reversed shunt resulted, partially due to the effectiveness of the band, but substantially brought about by the undiminished high pulmonary vascular resistance. The results show that ergometric investigations in children with pulmonary arterial hypertension may contribute to clarify the indication for surgery, but they also confirm that generally a final operation is not possible in children whose banding-operation has been performed at the age of more than 2 years.     

介入封堵术及西地那非对成人室间隔缺损合并中重度肺动脉高压患者血浆脑钠肽水平的影响

目的 探讨成人室间隔缺损(VSD)伴中、重度肺动脉高压(PAH)患者经导管封堵治疗后肺动脉平均压(mPAP)及血浆脑钠肽(BNP)浓度变化以及西地那非的干预作用.方法 选择20008年1月～2012年8月在我科住院并行介入封堵治疗的VSD伴中、重度PAH患者共60例,随机分为西地那非组、贝那普利组及无药物干预组各20例,术后在常规强心、利尿、抗凝治疗基础上,分别予以西地那非、贝那普利或无其他药物口服.分析介入封堵术后24 h及3个月时血浆BNP浓度及mPAP的变化.结果 三组术后24 h mPAP均较术前降低,BNP较术前升高,具有统计学意义(P均＜0.05).与无药物干预组相比,术后3个月西地那非组及贝那普利组mPAP及BNP均降低,且西地那非组疗效优于贝那普利组(P均＜0.05).结论 经导管封堵治疗成人VSD合并中、重度PAH可有效降低肺动脉压力及血浆BNP,西地那非治疗封堵术后PAH疗效优于贝那普利,且短期内安全、有效.     

Echocardiographic assessment of right ventricular contractile reserve in patients with pulmonary hypertension

Introduction and AimRight ventricular function is a major determinant of prognosis in pulmonary hypertension. The aim of this study was to assess and compare right ventricular contractile reserve in healthy subjects (controls) and in subjects with pulmonary hypertension (cases).MethodsIn this prospective study of seven cases and seven controls undergoing treadmill stress echocardiography, right ventricular S-wave velocity, tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC) and stroke volume index were assessed at rest and with exercise. The increase in each parameter between rest and exercise for cases and controls was analyzed and the magnitude of change in each parameter with exercise between cases and controls was compared.ResultsA significant increase in S-wave velocity was observed in cases (rest: 9.4±3.1; exercise: 13.7±4.8 cm/s [p<0.05]). In controls there was a statistically significant increase in S-wave velocity (12.9±2.3 to 23.0±7.2 cm/s [p<0.005]), TAPSE (25.7±2.4 to 31.0±3.5 mm [p<0.05]) and RVFAC (53.8±14.7% to 64.4±9.9% [p<0.005]). The magnitude of change in S-wave velocity (cases: 4.3±3.3; controls: 10.1±5.5 cm/s [p<0.05]), TAPSE (cases: 0.6±2.5; controls: 5.3±3.8 mm [p<0.05]) and RVFAC (cases: −0.4±11.8; controls: 10.6±5.9% [p<0.05]) was significantly different between cases and controls.ConclusionsS-wave velocity, TAPSE and RVFAC increased significantly with exercise in controls. S-wave velocity was the only parameter that showed a significant increase in cases, although the magnitude of this increase was significantly less than in controls.     

小儿室间隔缺损合并重度肺动脉高压的麻醉管理

目的探讨室间隔缺损合并重度肺动脉高压患儿的麻醉管理。方法回顾室间隔缺损合并重度肺动脉高压75例、年龄4个月～3岁,美国麻醉医师协会分级Ⅲ级。采用静脉和吸入复合全麻及浅低温体外循环下行室间隔缺损修补术,复温后常规给予多巴酚丁胺、硝普钠及米力农,停体外循环后适当过度通气维持稍低的动脉血二氧化碳分压。结果开放升主动脉后心脏均自动复搏,顺利停体外循环辅助,术中血流动力学稳定,术前超声提示5例有心室水平双向分流的患儿术后2d拔除气管导管,其余患儿均于术后1d拔除气管导管,全组患儿均顺利出院。结论在保证前负荷足够的前提下,体外循环前保持一定的肺循环阻力、体外循环后降低肺循环阻力并合理使用血管活性药物是维持术中血流动力学平稳的关键。     

Small ventricular septal defect associated with severe pulmonary hypertension.

A small ventricular septal defect in an 18 year old man was shown by serial cardiac catheterisation to be associated with a progressive increase in pulmonary arterial pressure. Surgical closure of the defect had no effect on the increased pulmonary arterial pressure. Whether pulmonary hypertension occurred secondary to the haemodynamics of the ventricular septal defect or as an independent event is uncertain.     

Valved patch for ventricular septal defect with pulmonary arterial hypertension

From March 1998 to December 2004, 16 acyanotic patients aged 2 to 22 years (mean, 7 +/- 5.7 years) with a large ventricular septal defect and elevated pulmonary vascular resistance (9.6 +/- 3.8 Wood units) underwent surgery. A Gore-Tex patch with a 5-8 mm longitudinal slit in the center was used. A piece of pericardium was sewn around the slit on one side of the patch, except for the upper quarter. In all patients, the defect was closed with a trimmed patch and the pericardial aspect was placed on the left ventricular side to allow right-to-left shunting. Echocardiography on the day of operation revealed a right-to-left shunt in 6 cases. Two patients (12.5%) died in the early postoperative period due to frequent episodes of pulmonary hypertensive crisis and persistent severe pulmonary hypertension. In 3 years of follow-up, pulmonary vascular resistance gradually decreased in all but one patient in whom it increased with a right-to-left shunt and cyanosis. Insertion of a valved patch seems to be a promising technique to decrease morbidity and mortality in severe pulmonary arterial hypertension.