体表超声引导心外科经胸微创动脉导管未闭封堵术的应用价值

目的探讨体表超声经胸骨上窝主动脉弓长轴切面在心外科经胸微创动脉导管未闭（PDA）封堵术中的应用价值。 方法经胸骨上窝主动脉弓长轴切面观测40例单纯PDA患者的类型、大小及分流情况,指导术者选择合适的封堵器并引导封堵术全过程。 结果PDA管型17例,漏斗型23例;长度5～19mm,主动脉端内径5～19mm,肺动脉端内径3.5～15mm;封堵器大小6～22mm;6例术后即刻显示少量分流,4例术后1周复查见少量分流。 结论胸骨上窝主动脉弓长轴切面具有不干扰外科操作和全程监控的特点,在引导心外科经胸微创PDA封堵术中发挥重要作用。     

平片诊断动脉导管未闭一个有价值征象：交角消失征

本文对110例手术证实动脉导管未闭病例作一回顾性复习,并取150名正常人和38例房隔缺损,74例室隔缺损进行对照观察。在动脉导管未闭组交角消失征检出率82％,其中1/3同时兼有漏斗征,而漏斗征检出率为58％,同时兼有消失征达3/4,可见前者比后者检出率高,统计学上差异有非常显著意义(P<0.01),但两者不一定呈平行关系。在正常人,房缺和室缺组中消失征分别为5％、35％、25％。统计学上与动脉导管未闭组对照差异亦有非常显著意义(P<0.01)。结果表明交角消失征对动脉导管未闭诊断敏感性较高和有一定特异性,特别对小的动脉导管未闭病例,结合心脏杂音常可作出较可靠诊断。交角消失征的X线表现为主动脉弓与肺动脉干在正位胸片上投影构成两突出小弧其间交角尖消失或两孤几乎连成一斜行直线影。本文还讨论了消失征形成的病理基础。     

复杂主动脉弓畸形的超声诊断

目的 探讨复杂主动脉弓畸形的超声表现及误、漏诊原因.方法 回顾性分析15例少见主动脉弓畸形的超声图像,包括主动脉弓离断9例、双主动脉弓1例、右位主动脉弓伴左侧动脉导管未闭3例、永存第五对主动脉弓2例.所有病例均经CT检查及术中发现证实.结果 15例患者的超声诊断中,主动脉弓离断1例漏诊(1/9),双主动脉弓1例漏诊(1/1),右位主动脉弓伴左侧动脉导管未闭1例误诊(1/3),永存第五对主动脉弓1例误诊(1/2)、1例漏诊(1/2),其余术前超声均获得正确诊断.结论 超声心动图对主动脉弓离断能做出较准确诊断,但对双主动脉弓、右位主动脉弓合并左侧动脉导管未闭及永存第五对主动脉弓等几类畸形易误诊或漏诊,增强认识并仔细扫查有望提高超声检出率.     

Severe subaortic stenosis that progressed over a 12-year period after cardiac surgery

A 12-year-old girl who had undergone cardiac surgery for ventricular septal defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA) in infancy was referred to our institution for fatigue and excessive sweating. Transthoracic and transesophageal echocardiographic studies revealed tunnel-type subaortic stenosis with aortic valvular stenosis, for which she underwent aortic valve replacement and myomectomy of left ventricular outflow tract. Progression of subaortic stenosis should be considered in patients with only mild aortic valve stenosis after previous cardiovascular surgery. Echocardiography contributed significantly to making the diagnosis and therapeutic decision in our patient.     

室间隔缺损合并主动脉瓣脱垂及瓦氏窦瘤破裂的外科治疗

目的总结室间隔缺损合并主动脉瓣脱垂及瓦氏窦瘤破裂的治疗体会.方法 118例室间隔缺损患者中合并主动脉瓣脱垂80例,主动脉瓣关闭不全为（＋～＋＋＋）;合并瓦氏窦瘤破裂37例;合并动脉导管未闭3例,三尖瓣关闭不全4例;合并亚急性细菌性心内膜炎7例,合并主动脉-右心室通道1例.结果本组无术后早期死亡,无室间隔缺损残余分流,复查部分病例仍有主动脉瓣关闭不全（＋、＋＋）,2例亚急性细菌性心内膜炎术后3个月再次行主动脉瓣置换术.结论室间隔缺损合并主动脉瓣脱垂及瓦氏窦瘤破裂及早手术治疗总体效果好.术中加强心肌保护、正确处理是治疗     

Patent ductus arteriosus during high-frequency ventilation for hyaline membrane disease

The cardiovascular effects of a patent ductus arteriosus (PDA) in a premature baboon model of hyaline membrane disease treated with conventional positive-pressure ventilation (CPPV) or high-frequency ventilation (HFV) were studied. Twenty-seven (84%) of 32 infant baboons delivered at 75% gestation had positive retrograde aortograms at one hour of life. Eleven (34%) of these infant baboons had persisting evidence for retrograde flow over the first 24 h by Doppler examination. Significantly higher fluid requirements and bicarbonate requirements were present in the animals with a persisting PDA. Mean aortic BP values were significantly lower in these same animals. No significant differences were found between groups when mean airway pressure, heart rate, urine output, or form of ventilation were compared. The only significant differences found between the conventional and high-frequency ventilated animals with PDA were higher peak airway pressures and lower PEEP levels in the conventionally ventilated infants. The premature baboons can be a useful primate model to study the PDA. There appears to be no significant difference regarding the clinical effects of HFV and CPPV on PDA.     

Echocardiographic detection and management of patent ductus arteriosus in neonates with respiratory distress syndrome: a two-and one-half year prospective study.

A prospective 2 1/2 year study of 50 infants with combined respiratory distress syndrome (RDS) and patent ductus arteriosus (PDA) was undertaken to determine whether echocardiographic measurements combined with clinical assessment could be used to select those infants who needed cardiac treatment. From a pilot study, criteria were adopted to use digoxin in the treatment of infants with evidence of congestive cardiac failure and/or a left atrial dimension 1.5 times normal size, and to ligate the PDA in those with unremitting congestive cardiac failure and a left atrial dimension persistently twice normal. Left atrial, left ventricular, and aortic dimensions, left atrial to aortic ratio, and mean Vcf were echocardiographically determined. Forty-six per cent of the 50 infants with PDA required digoxin administration, and 18 per cent of the total group was operated. The long-term mortality for the total group was 12 per cent (6 of 50) and mortality was 33 per cent (3 of 9) for the operated group. Results showed that absolute left atrial dimension, particularly if recorded in two dimensions, most accurately predicted those infants who would develop congestive cardiac failure or failure that would become medically unmanageable.     

腹主动脉“小慢波”用于评价儿童主动脉弓缩窄

目的 探讨主动脉弓缩窄（COA）产生小慢波的相关因素及腹主动脉小慢波对于评价儿童COA的价值。方法 纳入71例超声心动图提示后经CT血管成像证实的COA患儿,将超声心动图发现小慢波者归入阳性组（n=30）,其余归入阴性组（n=41）;根据动脉导管闭合情况分为动脉导管闭合组（阳性亚组20例,阴性亚组18例）及动脉导管未闭（PDA）组（阳性亚组10例,阴性亚组23例）;纳入同期41名健康儿童作为对照组。对比组间血流动力学参数差异,分析各参数与小慢波的相关性;以二元Logistic回归分析各参数对小慢波频谱的影响;绘制受试者工作特征（ROC）曲线计算曲线下面积（AUC）,比较主动脉弓缩窄率、缩窄长度、缩窄处主动脉弓血流速度、腹主动脉血流速度等参数判断小慢波的效能。结果 阴性组缩窄处主动脉弓血流速度高于对照组（P<0.05）,腹主动脉血流速度低于对照组（P<0.05）。动脉导管闭合组中,阳性亚组缩窄率及缩窄长度均大于阴性亚组（P均<0.05）,腹主动脉血流速度低于阴性亚组（P<0.05）;小慢波形成与缩窄率、缩窄长度均呈正相关（r=0.59,0.71,P均<0.01）;以缩窄率及缩窄长度判断小慢波的AUC分别为0.839和0.907。PDA组2亚组缩窄长度、动脉导管内径差异均有统计学意义（P均<0.05）;小慢波形成与动脉导管内径呈负相关（r=－0.62,P<0.01）,与缩窄长度呈正相关（r=0.52,P<0.01）;以动脉导管内径判断小慢波的AUC为0.889。结论 腹主动脉出现小慢波与主动脉弓缩窄率、缩窄长度及动脉导管内径密切相关;观察腹主动脉血流频谱可以间接推断COA,具有良好的筛选及预测价值。     

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.     

布洛芬治疗早产儿动脉导管未闭53例的临床研究

目的探讨口服布洛芬治疗早产儿动脉导管未闭（PDA）的疗效以及安全性,同时研究相关因素对疗效影响。方法符合入选标准的PDA患儿53例给予口服布洛芬治疗,观察患儿动脉导管关闭情况以及不良反应。结果本组首次治疗有效率为84．91％,治疗失败者8例,经第2疗程治疗后有2例PDA关闭,因此,PDA关闭总有效率为88．68％。研究表明布洛芬的用药时间和患儿出生体重对PDA关闭率均有积极显著的影响,且无严重不良反应发生。结论布洛芬治疗早产儿动脉导管未闭疗效确切,用药安全。早期应用布洛芬,可显著提高早产儿的PDA关闭率。     

The value of contrast echocardiography in the diagnosis of patent ductus arteriosus with Eisenmenger's syndrome.

When patent ductus arteriosus (PDA) is complicated by pulmonary hypertension resulting in a right-to-left shunt, an erroneous diagnosis of primary pulmonary hypertension may be made, even after echocardiographic examination. Among the 8 patients referred to our echocardiography laboratory with the diagnosis of primary pulmonary hypertension between June 1994 and November 1999, 2 patients were found to have PDA with Eisenmenger's syndrome. Patent ductus arteriosus with Eisenmenger's syndrome can be diagnosed by the opacification of the abdominal aorta without opacification of the left-sided chambers during contrast echocardiography.     

Fetal echocardiographic diagnosis of vascular rings.

OBJECTIVE: The purpose of this series is to describe the prenatal echocardiographic findings of vascular rings. METHODS: The 3-vessel and trachea view consists of the axial view of the upper mediastinum. The normal left aortic arch appears as a V-shaped confluence of the ductus arteriosus and aortic arch, with the trachea situated posterior and to the right. No vessel should encircle the trachea. The diagnoses of vascular rings were made prenatally and were confirmed in all patients postnatally. RESULTS: Six fetuses had diagnoses of vascular rings. The mean gestational age at diagnosis was 23.3 weeks (range, 18-31 weeks). The indications for fetal echocardiography were family history of congenital heart disease, echogenic focus in the left ventricle, and abnormal 4-chamber view. There were 2 fetuses with a double aortic arch; 3 fetuses with a right aortic arch, an aberrant left subclavian artery, and a left ductus arteriosus; and 1 with a right circumflex aortic arch with a left ductus arteriosus and an aberrant left subclavian artery. Two fetuses had associated structural cardiac defects, 1 with an unbalanced atrioventricular septal defect and trisomy 21 and the other with a double-outlet right ventricle, pulmonary atresia, and multiple other congenital anomalies. CONCLUSIONS: Vascular rings can be accurately diagnosed prenatally with recognition of a vascular structure that courses around the trachea and absence of the usual V-shaped relationship of the aortic and ductal arches. The color Doppler findings and the presence of a ductus arteriosus aid in identifying various components of the vascular ring.     

Diagnosis of patent ductus arteriosus by serendipity in the adult

Seven patients with patent ductus arteriosus (PDA) were seen in our adult echocardiography laboratory. In five of seven patients the diagnosis was made on color Doppler when it was not suspected clinically. The diagnosis became apparent because of a turbulent retrograde jet seen on color Doppler in the main pulmonary artery. One of the patients had known congenital heart disease and heart surgery in the past, and the diagnosis of PDA was missed both on catheterization and in the operating room. PDA may be unsuspected in adult patients and may be missed by techniques other than color Doppler echocardiography. The striking findings on color Doppler may help to make this important diagnosis in such patients.     

Ischemic stroke with left hemiparesis or shock should be evaluated by computed tomography for aortic dissection

An 82-year-old woman with consciousness disturbance, left hemeparesis, and dysarthria was discovered at home by her family and was transported to a hospital. On arrival, she remained in a sleepy and disorientated and shock state. She complained of nausea but no chest or back pain. She obtained stable circulation after infusion. Her chest roentgen results showed widening of the mediastinum and the existence of a separation of the intimal calcification from the outer aortic soft tissue border, thus suggesting a Stanford A–type aortic dissection. Her head computed tomography depicted no signs of cerebral infarction. Because she did not complain of any pain, the possibility of acute phase aortic dissection was rejected. A permissive hypertensive therapy was initiated. Next day, she suddenly died. We diagnosed that she had died of a Stanford A–type aortic dissection based on the following facts: (1) patients presenting with stroke due to a Stanford A–type aortic dissection tend to have left hemiparesis because of malcirculation of the innominate artery and (2) a patient presenting with stroke by aortic dissection may have hypotension, which is unusual in standard stoke cases. Ischemic stroke induced by aortic dissection is not common among the patients with aortic dissection. However, given the high morbidity and mortality after misdiagnosis of aortic dissection, patients with ischemic stroke with left hemiparesis or shock should be evaluated by enhanced truncal computed tomography.     

Complicated persistent patent ductus arteriosus with acute pneumonia in an adult

Patent ductus arteriosus (PDA) is a malady usually identified during childhood. Prompt surgical correction provides definitive therapy with long-term survival. When not corrected, PDA leads to significant morbidity and mortality, making it a rare condition in the adult population. We report the case of a 44-year-old man with a history of persistent PDA admitted for worsening dyspnea and fever. Radiographic studies are illustrative of this complex syndrome. We review the complications and treatment alternatives in these patients.     

Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

An innominate truncal dissection and rupture into the right pleural cavity with massive hemothorax is the initial presentation in this 66-year-old lady with type A dissection of the aorta complicated by right coronary ostial avulsion and inferior STEMI. She underwent supracoronary interposition graft replacement of the ascending aorta and hemiarch, interposition graft replacement of the innominate trunk and saphenous vein bypass grafting of the right coronary artery successfully. Innominate truncal rupture following aortic dissection is practically unknown and has not been described before in the absence of aortic rupture. Innominate truncal rupture secondary to other pathologies presents with supraaortic and mediastinal hematomas, but almost never with right hemothorax. On the backdrop of this unusual presentation with no neurological injury, we review the literature for innominate truncal dissection and rupture, other etiologies for innominate truncal rupture, the complex interplay of factors determining neurological injury and discuss the changes in the strategies and conduct of arterial return during cardiopulmonary bypass and selective antegrade perfusion imposed by this previously undescribed instance of innominate truncal rupture due to dissection.     

儿童动脉导管未闭介入治疗的护理

目的:总结儿童动脉导管未闭介入手术的护理要点,提高手术成功率。方法:回顾性分析126例行动脉导管未闭介入封堵术患儿的护理要点,包括术前访视、了解病情,术中严密监护、密切配合,术后优质的护理。结果:术前准备充分,术中严密监护、配合默契,术后优质的护理,可提高手术成功率,也能及时发现并减少术后并发症的发生。结论:有效的护理是儿童动脉导管未闭介入封堵术成功的重要保障之一。     

动脉导管弓与主动脉弓间距及夹角在胎儿右位主动脉弓诊断中的应用价值

目的探讨胎儿超声心动图三血管气管（3VT）切面定量测量动脉导管弓与主动脉弓之间的距离与夹角在胎儿右位主动脉弓（RAA）诊断中的应用价值。 方法选取单纯RAA左位动脉导管胎儿52例作为研究组（RAA组）,随机选取正常胎儿121例作为对照组,分别测量2组胎儿超声3VT切面上动脉导管弓与主动脉弓内径及两者之间的间距与夹角（AP角）,将RAA组与对照组间的各超声测量参数进行统计学分析。 结果RAA组与对照组比较,动脉导管弓与主动脉弓之间间距增大［4.86（4.16~5.74）mm vs 1.59（1.38~1.76）mm］,AP角减小［（12.96±1.83）° vs（22.14±1.35）°］,差异均有统计学意义（Z=-10.416、P<0.05,t=32.481、P<0.05）;RAA组与对照组的动脉导管弓内径、主动脉弓内径、动脉导管弓/主动脉弓内径比值、主动脉内径、肺动脉内径、主动脉流速、肺动脉流速比较,差异均无统计学意义（P均>0.05）。2组的AP角、动脉导管弓/主动脉弓内径比值与孕周均无相关性（RRA组：r=0.148、0.029,P=0.294、0.818;对照组：r=0.060、0.108,P=0.514、0.180）。2组的动脉导管弓与主动脉弓间距、动脉导管弓内径、主动脉弓内径、主动脉内径、肺动脉内径、主动脉流速、肺动脉流速均与孕周呈线性正相关（P均<0.05）。 结论胎儿超声心动图3VT切面测量动脉导管弓与主动脉弓间距及夹角的方法简单可行,能够为胎儿RAA左位动脉导管的诊断提供更为准确的定量参考,具有一定的临床应用价值。     

Prediction of ductus arteriosus closure by neonatal screening echocardiography

AIMS: We reported the incidence, clinical manifestations and outcome of patent ductus arteriosus (PDA) in full-term infants by screening echocardiography. METHODS AND RESULTS: Total 1230 infants received echocardiographic screening and periodic follow-up. On the third day of life, there were 109 infants with isolated ductus arteriosus aneurysm (DAA), those with persistent patency of the ductus arteriosus (DA) in 26. The DA closed within 48 h in 828 infants, and persisted beyond 48 h in 180. The incidence of PDA in full-term infants was 0.91, 0.83 and 0.66% at 1, 4 and 6 months follow-up, and 0.82, 0.73 and 0.64% if infants with DAA were excluded. Infants with PDA had lower birth body weight (BBW) than those with closed DA (p = 0.02). The DA width on the third day of life ranged from 0.23 to 0.43 cm (0.32 +/- 0.08 cm) and 0.08 to 0.44 cm (0.16 +/- 0.06 cm) in infants with or without PDA, respectively, which was significantly different (p < 0.05). The sensitivity, specificity, predictive positive and negative values were 87.5, 92.5, 36.8 and 99% respectively for the cuff-off point at 0.25 cm of DA width. CONCLUSIONS: Risk factors in infants with PDA included lower BBW and larger measured DA width at the third day of life. We predicted the arterial duct would close if DA width <0.25 cm, and suggested follow up earlier if >0.25 cm on the third day of life.