医用牛颈静脉带瓣管道重建右室流出道临床应用研究

目的应用牛颈静脉带瓣管道（BJVC）进行心脏右室流出道的重建,探讨BJVC对复杂先天性心脏病外科治疗的效果。方法2005年10月至2009年5月共应用BJVC治疗复杂先天性心脏病15例。结果BJVC重建右室流出道15例患者均痊愈出院。随访3～24个月,患者心悸、气促消失,活动耐力明显提高,心功能恢复至I～Ⅱ级,超声检测发现15例置入的管道通畅,无扩张,未见血栓形成,瓣叶活动良好,无明显反流,肺动脉跨瓣压差不大,吻合口无狭窄。结论BJVC用于复杂先天性心脏病右室流出道的重建可获良好的近期治疗效果,但远期效果仍有待进一步观察。     

活性同种带瓣管道补片在右室流出道重建术中的应用

对42例复杂先天性心脏患者行右室流出道(RVOT)重建术,按跨环补片方法加宽RVOT及肺动脉,实验组(21例)采用同种带瓣管道补片,对照组(21例)采用心包补片,术毕测中心静脉压,术后用超声心动图测右心功能主要参数等指标。结果两组手术均无死亡,主要临床指标两组比较有显著差异(P<0.01),实验组优于对照组。采用液氮冻存的活性同种带瓣管道补片跨肺动脉瓣环加宽RVOT及肺动脉,可取得满意的防止肺动脉瓣反流效果,术后早期右心功能恢复良好。     

新型无支架生物瓣带瓣管道用于右室流出道重建

目的:验证新型无支架生物瓣带瓣管道应用于右室流出道重建术中的有效性和安全性。方法:2007年11月～2008年5月,全组7例复杂先天性心脏病患者使用了新型无支架牛心包带瓣管道重建右室流出道,其中Rastelli手术6例、Nikaidoh手术1例。通过术后不同时期超声检查结果,记录肺动脉压、血流速度、新建肺动脉瓣跨瓣压差及开口面积和返流情况,了解肺动脉管道直径、有无瘤样扩张以及远端吻合口压差等,对移植的无支架生物瓣带瓣管道的临床性能进行评价。结果:所有患者住院期间均无吻合口渗血、心内膜炎、血栓栓塞等带瓣管道相关并发症发生,恢复顺利,均治愈出院。术后1～4月和6月以上超声检查均提示移植的管道通畅,管壁无变薄、钙化,无瘤样扩张,无明显肺动脉瓣返流等。结论:新型无支架生物瓣带瓣管道具有管壁弹性好、易于缝合、术后排斥反应少等优点,且有良好抗返流作用,早期疗效满意。     

应用单瓣补片解除右室流出道梗阻

作者对单瓣补片解除右室流出道梗阻的应用价值,组织材料,适应证和外科技术,补片加宽标准等方面进行文献复习,指出应用单瓣补片加宽右室流出道可有效地防止肺动脉瓣返流,但仍存在着组织钙化、衰坏、右室流出道加宽标准等问题尚待深入研究。     

右室流出道性心动过速的诊治

本文主要综述了右室流出道性心动过速的分型、发生机理、诊断、治疗与预后等内容。     

右室流出道室性早搏的研究现状

室性早搏是一种相当常见的心律失常 ,过去对室性早搏 (室早 )有各种分类方法 ,由于循证医学的出现使心律失常的病因及治疗等方面发生了根本性的变化。ＣＡＳＴ试验结果公布以后[1] ,研究者们开始从预后角度对室早进行分类。目前主要分为三类 :(1)恶性室性心律失常 ;(2 )潜在恶性室性心律失常 ;(3)良性室性心律失常[2 ] 。对恶性及潜在恶性室性心律失常的病因及治疗已基本达成共识 ,但对良性室性心律失常 ,尤其是起源于右室流出道室早的病因、发生机制及治疗等仍存在争议。一、病因目前对起源于右室流出道室早的病因并不十分清楚 ,部分学者进…     

小儿右室流出道起搏

对于一些需要安装永久起搏器的患者来讲,由于易于固定,起搏阈值低等优点,右心室起搏常将起搏电极置于心尖部,但长期随访发现,心尖部起搏可改变心室激动顺序,导致心室收缩不同步,造成二尖瓣反流、心房颤动和心功能不全。研究发现右室流出道起搏对左室功能的保护较右室心尖部起搏有利,由于右室流出道起搏靠近His束,电活动近似正常生理状态,可使左右心室电-机械活动更协调,从而抑制心室重构并保护心功能,因此,右室流出道起搏是替代右室心尖部起搏的较好选择。     

右室流出道间隔部起搏的临床应用进展

随着对生理性起搏认识的深入,研究发现右室心尖部(RVA)起搏改变了正常的心室激动顺序,是血流动力表现最差的起搏部位,而右室流出道(RVOT)间隔部起搏可以实现接近生理状态的心室激动顺序和双心室同步,改善血流动力学。开展RVOT间隔部起搏是今后生理性起搏发展趋势。     

右室流出道室性早搏的射频消融治疗

目的探讨射频消融治疗右室流出道室性早搏的方法和疗效。方法选择52例右室流出道室性早搏患者进行射频消融法治疗,男28例,女24例,年龄15~67岁,平均45.1岁;病史3~14年,平均6.8年均有明显症状,但无器质性心脏病的证据。多种抗心律药物治疗无效,心电图显示室性早搏均呈左束支阻滞图形,Ⅱ、Ⅲ、AVF导联为高大的R波。采用起搏标测。结果即刻成功率94%(49/52)。术前与术后1周24h动态心电图检查室性早搏为(11250~37460)次/24h和(0~1120)次/24h,两者间差异(P<0.01)。随访2~32个月,无复发。结论无器质性心脏病顽固性右室流出道室早的导管射频消融是一种安全可靠的方法。     

The bovine jugular vein: a totally integrated valved conduit to repair the right ventricular outflow

BACKGROUND AND AIMS OF THE STUDY: Current techniques to correct valvular anomalies of the right ventricular outflow tract (RVOT) include repair and replacement of the pulmonary valve. However, the performance of currently used conduits has been less than ideal because of unfavorable hemodynamics and mid- to long-term complications. An early experience with a totally integrated Contegra valved conduit derived from a bovine jugular vein is reported; this conduit has the advantage that there is no discontinuity between its lumen and the valve it incorporates. METHODS: Between October 1999 and October 2001, a total of 22 Contegra valved conduits (12-22 mm) was implanted in 21 children aged <5 years, and in one patient aged 21 years. Diagnosis included tetralogy of Fallot (n = 13), pulmonary atresia (n = 3), double outlet right ventricle with pulmonary stenosis (PS) (n = 3), transposition of the great arteries, ventricular septal defect and PS (n = 2) and truncus arteriosus (n = 1). In 15 of these patients, distal and proximal anastomoses were performed on the beating heart. RESULTS: There was no mortality and no valved-conduit-related early morbidity. Intraoperative invasive assessment demonstrated excellent hemodynamic characteristics: mean peak pressure increase was 8.5+/-6.3 mmHg (varying between 4 mmHg in the 20-mm conduit and 18 mmHg in the 14-mm conduit). These values were confirmed by pre-discharge transthoracic pulsed-wave Doppler echocardiography. Because of endocarditis, one conduit was explanted after 11 months and replaced with a pulmonary homograft. Two patients required reintervention. CONCLUSION: The Contegra valved conduit is an excellent immediate substitute in the treatment of RVOT lesion when a pulmonary valve has to be inserted. Both systolic and diastolic valve functions are promising. Further data are required to confirm the favorable hemodynamics, as well as the durability and efficacy of this conduit in the long term.     

Composite pericardial monocusp patch for the reconstruction of right ventricular outflow tract. Clinical application in 7 patients

Right ventricular outflow tract (RVOT) reconstruction with a new composite pericardial monocusp patch incorporating a sinus of Valsalva was performed in 7 patients. There was one hospital death. Follow-up ranged from 20 to 52 months (mean 25.4 months, cumulatively 206 patient months). Four patients have been recatheterized at an average of 6.5 months (1 to 12 months) after surgery. The average RVOT gradient was 9 +/- 2 mmHg, and mean right ventricular end-diastolic pressure was 10 +/- 5.5 mmHg. All except one have a competent pulmonary valve with normally functioning monocusp, and no thrombosis, calcification or aneurysmal dilatation.     

Late results of right ventricular outflow tract reconstruction with Bj?rk-Shiley valved conduits

Between 1971 and December 1976, 27 children with congenital heart disease underwent right ventricular outflow tract reconstruction with conduits incorporating a Bj?rk-Shiley valve. The conditions corrected were pulmonary atresia with ventricular septal defect (14 patients), truncus arteriosus (6 patients), and complex disease (7 patients). At operation the children were aged from 12 days to 16 years (five patients were less than one year old). Overall mortality for the group was high (52%). There were nine early deaths and five late ones. Actuarial survival till death or reoperation was 55% at four years, 35% at eight years, and 28% at 12 years. Ten children subsequently underwent reoperation for conduit stenosis caused by neointimal proliferation and valve obstruction. The new conduits incorporated a biological valve. Mortality was highest in patients aged less than one year, and in those with truncus arteriosus, severe pulmonary hypertension, or complex heart disease. Mechanical valves should be avoided in conduit reconstruction of the right ventricular outflow tract for congenital heart disease.     

Reconstruction of the right ventricular outflow tract with bovine pericardial monocusp patch

From November 1980 to May 1982, 19 patients underwent surgery in this institution for right ventricular outflow tract obstruction. Surgery was performed by placing a bovine pericardial monocusp patch across the pulmonary annulus. There was one hospital death (5.3%), and one late death. The follow-up ranged from 24 to 42 months (mean 32.5 +/- 5.3 months; total, 552 patient months). The condition of the remaining 17 patients is good. Repeat cardiac catheterization was performed in 11 patients and revealed that the right ventricular/pulmonary artery systolic gradient was reduced to 13.7 +/- 9.7 mm Hg postoperatively. Angiography showed a freely mobile, thin valve cusp. No calcification, aneurysmal dilatation, or shrinkage of the monocusp patch was observed. Our experience suggests that right ventricular outflow tract reconstruction with bovine pericardial monocusp patches can be safely performed with good hemodynamic results.     

Early results of balloon dilatation of the stenotic bovine jugular vein graft in the right ventricular outflow tract in children

The aim of this study was to evaluate the early results of interventional balloon dilatation of stenotic bovine jugular vein (BJV) grafts implanted for reconstruction of the right ventricular outflow tract (RVOT) in children. METHODS: From May 2001 to December 2005, 153 BJV grafts were implanted in children in our institution. An average of 16.9 (7.6-41.1) months after implantation, 17 balloon dilatations in a significant stenosis proximal (n = 1), distal anastomosis (n = 8), BJV valve (n = 3), or at multiple sites (n = 5) were performed in 15 children (male:female = 9:6) with a mean age of 3.9 (0.8-13.0) years. Balloon diameter was 75-133.3% (mean 100.3) of the original BJV size. Mean follow-up was 8.8 (2 days to 22.8 months) months. RESULTS: In 10 interventions (58.8%) the instantaneous peak gradient was reduced below 50 mmHg. A balloon diameter > or =100% of the original BJV size correlated significantly with a successful intervention. No major complications, two minor (nonobstructive floating membranes at the dilatation site and one septicemia) occurred afterward. Freedom from reintervention after 6 months was 58.2% for all, 77.8% for dilatations of the proximal anastomosis and mixed stenotic lesions, and 33.3% for the distal anastomosis. CONCLUSION: Balloon dilatation of stenotic BJV grafts is safe and can significantly reduce the pressure gradient in two-thirds of interventions. Balloon diameters above the original graft size should be aimed for. The most frequent stenosis of the distal anastomosis tends to renarrow early after dilatation. Nevertheless, balloon dilatation should be considered in nearly every stenotic graft to gain time until a surgical or interventional graft exchange.     

Late results of right ventricular outflow tract reconstruction with Bj?rk-Shiley valved conduits.

Between 1971 and December 1976, 27 children with congenital heart disease underwent right ventricular outflow tract reconstruction with conduits incorporating a Björk-Shiley valve. The conditions corrected were pulmonary atresia with ventricular septal defect (14 patients), truncus arteriosus (6 patients), and complex disease (7 patients). At operation the children were aged from 12 days to 16 years (five patients were less than one year old). Overall mortality for the group was high (52%). There were nine early deaths and five late ones. Actuarial survival till death or reoperation was 55% at four years, 35% at eight years, and 28% at 12 years. Ten children subsequently underwent reoperation for conduit stenosis caused by neointimal proliferation and valve obstruction. The new conduits incorporated a biological valve. Mortality was highest in patients aged less than one year, and in those with truncus arteriosus, severe pulmonary hypertension, or complex heart disease. Mechanical valves should be avoided in conduit reconstruction of the right ventricular outflow tract for congenital heart disease.     

右心室流出道起搏的临床应用

近年来人们认识到右心室流出道间隔部位起搏与右心室心尖部起搏相比 ,心室激动顺序比较接近正常。现报道59例右心室流出道永久起搏的结果。资料和方法　 2 0 0 1年 1月～ 2 0 0 3年 1月我院共给 59例患者植入永久右心室流出道起搏的起搏器 ,男性 38例 ,女性 2 1例 ,年龄 33～ 82 (68± 1 8)岁。病态窦房结综合征2 9例 ;三度房室阻滞 30例 ,其中 5例为心房颤动伴三度房室阻滞。所有患者均采用美国ST .Jude公司生产的起搏器。 48例患者植入双腔起搏器 ,1 1例植入VVI起搏器。右心室流出道起搏导线均为激素释放电极双极导线。植入时首先将导…