肺动脉压力正常及轻度增高的成年房间隔缺损患者心房水平隐性右向左分流探查

目的:探查正常及轻度肺动脉压力增高的成年房间隔缺损(ASD)患者的右向左分流发生情况。方法:17例中央型ASD患者,男8例,女9例,年龄18~66(47±16)岁,均经胸心脏超声(TTE)检查诊断ASD、心房水平血流分流方向及肺动脉压力。封堵治疗前在静息状态及(或)Valsalva动作时行经颅多普勒超声(TCD)发泡试验联合TTE右心声学造影检查。所有患者在介入封堵治疗前通过右心导管测定肺动脉压力,在封堵治疗后即刻及术后3d、1个月、3个月及6个月再次行TCD发泡试验联合TTE右心声学造影检查。结果:TTE证实房间隔缺损直径5~24mm,所有患者心房水平左向右单向分流。11例患者静息TCD发泡试验联合TTE右心声学造影出现心房水平存在右向左分流,6例静息状态下检查未提示存在右向左分流患者Valsalva动作后均出现右向左分流现象。封堵治疗前经右心导管检查测得肺动脉压力(18~41)/(5~11)mmHg(1mmHg=0.133kPa)。所有患者均成功进行介入封堵治疗。1例患者在封堵治疗术后3d、1个月、3个月存在少量右向左分流,术后6个月17例患者均未见心房水平分流存在。结论:正常及轻度肺动脉高压的ASD患者心房水平存在隐性右向左分流,介入封堵治疗后分流消失。TCD发泡试验联合TTE右心声学造影检查可准确判定心房水平右向左分流。     

右心声学造影在卵圆孔未闭检测中的应用价值

目的 探讨超声右心声学造影（cTTE）在卵圆孔未闭（PFO）检测中的应用价值。方法回顾性分析2017年1月至2020年9月于山西省心血管病医院因怀疑PFO行cTTE的患者354例,均在cTTE前常规行经胸超声心动图（TTE）,其中147例行经食管超声心动图（TEE）。结果 TTE的PFO检出率为60.5%(89/147)低于TEE的70.7%(104/147),差异具有统计学意义（P<0.05）;TEE低于cTTE的76.8%(113/147),差异无统计学差异（P>0.05）。cTTE检测存在心内右向左分流的16例患者中,TEE显示房间隔未见明显异常,3例经皮介入封堵手术后,行cTTE检测右向左分流分级下降至1级及阴性,证实为PFO相关的右向左分流。经皮介入封堵PFO术后1周Valsalva动作后右向左分流检出率为46.3%。结论CTTE检测右向左分流具有独特价值,是TTE和TEE检测PFO中的有益补充。     

军事飞行员房间隔分流诊治的单中心回顾研究

目的 通过超声心动图联合多种影像学方法评估军事飞行员存在的心房水平分流，为飞行员人群的诊治提供依据。方法 回顾性分析2013年1月～2021年6月在空军军医大学空军特色医学中心存在心房水平分流[卵圆孔未闭（patent foramen ovale,PFO）或房间隔缺损（atrial septal defects,ASD）]的军事飞行员的病案资料，包括超声心动图和其他影像学诊断方法及临床处置方案，总结分析此类飞行员影像学资料及临床诊治情况。结果 共21例心房水平分流的军事飞行员纳入研究，包括单纯PFO7例，继发型ASD11例，原发型ASD1例，PFO伴发ASD2例。对15例飞行员行介入封堵治疗，5例PFO进行随访观察，1例原发型ASD的飞行员进行房间隔修补及二尖瓣成形术；所有飞行员于地面观察及复查后均予以鉴定飞行合格。结论 军事飞行员中存在一定比例的心房水平分流，及时通过影像学手段诊断房间隔分流并进行介入封堵是一种有效的治疗手段；但是对于PFO的飞行人员是否需要进行封堵还需进一步深入研究。     

肺栓塞临床诊断与治疗

目的 :了解肺栓塞 (PE)的病因、症状、体征、诊断及治疗措施。方法 :回顾性分析 2 2例PE患者的年龄、性别、发病原因、临床表现及治疗方法等。结果 :2 2例中接受治疗 2 0例 (90 .9% ) ,其中 2例行导管介入碎栓及溶栓术 ,1例放置下腔静脉滤器 ,1例行肺动脉血栓切除术。治愈或改善 18例 (81.8% ) ,无效 2例 (9.1% ) ,2例未经治疗者死亡。结论 :PE主要由体循环静脉内血栓引起 ,源自下腔静脉系统最常见。PE常因症状无特异性 ,临床易出现误诊、误治。对易感患者应重视预防PE的发生 ,术后或因病卧床的患者早期活动、预防性抗凝治疗等均可有效地降低PE的发病率。对确诊者应立即给予抗凝、溶栓、肺动脉内膜剥脱术或肺动脉介入等相应的治疗。     

TTE联合右心声学造影筛查PFO的价值及介入封堵治疗中期疗效

目的 应用经胸超声心动图（transthoracic-echocardiography,TTE）及经胸右心声学造影（contrast transthoracic-echocardiography,cTTE）筛查隐源性卒中、不明原因晕厥及偏头痛患者中卵圆孔未闭（patent foramen ovale,PFO）的检出率及经皮介入封堵治疗PFO的中期疗效。 方法 选取167例临床诊断为隐源性卒中、不明原因晕厥及偏头痛的患者,均行TTE检查及cTTE检查,根据微气泡右向左分流（the right-to-left shunt,RLS）数量进行量化分级,分为I级、Ⅱ级和Ⅲ级。选取Ⅲ级RLS患者22例,右心选择性造影证实为PFO并根据形态选择合适封堵器行封堵治疗,术后1、3、6个月门诊及电话随访,术后6个月行cTTE复查。 结果 167例患者行cTTE,静息状态下RLS有67例（40.1%）,Valsalva动作后RLS有85例（50.9%）,其中I级分流23例（13.8%）,Ⅱ级分流12例（7.2%）,Ⅲ级分流50例（29.9%）。在3种不同疾病中,隐源性卒中并发PFO检出率为43.5%;不明原因晕厥并发PFO检出率68.0%;偏头痛并发PFO检出率为47.9%;22例行PFO封堵患者,随访6个月,临床症状改善,无并发症,复查cTTE均未见残余分流。 结论 TTE联合cTTE是筛查PFO重要的无创检查手段;两者结合对隐源性卒中、不明原因晕厥及偏头痛并发PFO有较高的检出率。介入封堵治疗PFO能有效预防隐源性卒中、晕厥再发、明显减轻偏头痛症状。     

肺血栓栓塞症的介入治疗

肺动脉血栓栓塞症,简称肺栓塞(pulmonaryembolism,PE)是指血栓堵塞了肺动脉主干或分支所引起的肺循环障碍,其原因多与深静脉血栓形成有关.临床表现复杂,重者猝死.由于PE突发率高、易误诊、漏诊等原因,急性大面积PE死亡率极高[1],我国最新统计资料显示PE占全部死因的第四位. 急性PE主要常用的治疗方法有抗凝、全身静脉溶栓、导管肺动脉局部溶栓、导管碎栓和除栓、外科手术取栓等.如果患者伴发心脏骤停、休克、大面积致死性肺栓塞或存在明确的溶栓、外科手术禁忌证,导管介入治疗是替代治疗方案之一.     

两种不同封堵器对不明原因脑卒中合并大量右向左分流患者卵圆孔未闭的疗效对比

目的:对比两种不同封堵器对不明原因脑卒中(CS)合并大量右向左分流(RLS)患者卵圆孔未闭(PFO)封堵治疗的疗效。方法:2013-05至2016-08期间连续入选CS合并大量RLS的123例PFO患者,应用Cardi-O-fix PFO封堵器(Cardi-O-fix PFO封堵器组,80例)或Amplatzer PFO封堵器(Amplatzer PFO封堵器组,43例)行经皮PFO介入封堵术。所有患者先行影像学检查并经3位经验丰富的神经内科专家明确CS的诊断,然后经胸超声心动图及右心声学造影诊断PFO及大量RLS。回顾患者的基线特征、临床症状、手术及随访数据,观察两种封堵器封堵治疗的疗效。结果:术后两组各有1例发生阵发性心房颤动,Cardi-O-fix PFO封堵器组1例术后出现腹股沟血肿。随访期间两组无复发性脑卒中及死亡事件发生。两组各随访时期残余分流的差异无统计学意义。结论:在预防脑卒中复发方面,PFO介入封堵可为CS伴大量RLS的PFO患者带来获益。Cardi-O-fix PFO封堵器与Amplatzer PFO封堵器在安全性和有效性方面相似。     

经胸超声心动图右心声学造影在“反常栓塞”卵圆孔未闭封堵治疗中的临床应用

目的 探讨经胸超声心动图右心声学造影(c TTE)在“反常栓塞”卵圆孔未闭(PFO患者封堵治疗中的临床应用。方法 收集2017年12月至2019年11月于新疆维吾尔自治区人民医院心血管内科收治的10例行PFO封堵术患者资料。所有患者均因反复发作的不明原因缺血性脑卒中于神经内科就诊,排除血管性及神经性原因,经由cTTE诊断为PFO合并反常栓塞。分析c TTE结果、PFO封堵术成功率及术中并发症发生情况。采用头痛影响测验-6(HIT-6)对偏头痛患者进行评价,观察治疗效果。结果 cTTE共检出右向左分流(RLS)Ⅰ级1例,Ⅱ级4例,Ⅲ级5例。10例患者均成功行PFO封堵术,共发生并发症2例,分别为急性血栓及心包积液各1例,经积极处理均治愈。在术后3 d及术后1个月、术后3个月分别行cTTE检查,仅1例患者在术后3个月的c TTE显示仍有残余RLS分流;所有患者均未再发缺血性脑卒中,亦无短暂性脑缺血发作、心肌梗死等情况发生。术前合并偏头痛的6例患者,在术后1个月偏头痛症状明显改善,HIT-6评分术后1个月较术前、术后3个月较术后1个月均明显降低,差异有统计学意义(t=6.158、5.357,P 0.01)。结论 cTTE可有效诊断PFO-RLS及其分流情况,为PFO封堵术的成功实施提供了良好的条件。     

卵圆孔未闭并发不明原因脑卒中患者封堵治疗的疗效和安全性

目的:探讨封堵治疗卵圆孔未闭(patent foramen ovale,PFO)并发不明原因缺血性脑卒中患者的临床疗效及安全性。方法:26例缺血性脑卒中患者,均经头颅CT或磁共振成像(MRI)证实有脑梗死病灶,排除其他脑梗死原因,如主动脉和脑血管病变,及左心系统疾病等。经颅多普勒超声(TCD)声学造影判断有右向左分流,经胸超声心动图(TTE)和(或)经食管超声心动图(TEE)证实为PFO或PFO并发房间隔瘤。所有患者均行PFO封堵治疗。结果:26例患者,静息超声测量PFO大小为1.0~4.6(2.8±1.2)mm,其中5例PFO并发房间隔瘤。TCD声学造影分流量Ⅰ级6例,Ⅱ级9例,Ⅲ级以上11例。24例封堵成功,技术成功率为92%,所用封堵器18 mm 6个、25 mm7个、30 mm 8个及35 mm 3个。未成功病例2例,主要原因为导丝无法到达左房。术后随访6个月~1年,TTE检查未见封堵器移位及心房水平残余分流,TCD声学造影检查均无右向左分流,所有患者无再发缺血性脑梗死。结论:经导管封堵PFO是一种安全有效的治疗方法,可有效减少缺血性脑卒中的再发生。     

反常栓塞与不明原因脑卒中研究的当前问题

卵圆孔是心脏房间隔上胚胎时期遗留下来的一个通道,存在于胎儿期和近1/4的成人,是一个潜在的血栓由自体静脉系统至脑及外周动脉栓塞的途径。正常情况下,卵圆孔未闭（patent foramen ovale,PFO）不引起任何临床症状,但当右心房压力一过性或持续性增高时,可引起心房间右向左分流,身体其他部位的栓子或原位血栓就有可能脱落,造成反常栓塞（paradoxical embolism,PDE）。PDE可引起一系列临床综合征,包括不明原因脑卒中（cryptogenic stroke,CS）、偏头痛、斜卧呼吸-直立型低氧血症、睡眠呼吸暂停综合征、冠脉正常的心肌梗死、脑白质病变及神经减压病所造成的动脉气体栓塞等［1］。但由于主动脉弓的特殊解剖及大脑较其他器官对缺血更敏感,故临床上大部分PDE都表现为短暂性脑缺血发作（transient ischemic attack,TIA）或CS。尽管已有许多令人信服的证据涉及PFO与CS,但其确切发病机制尚未完全明确。本文重点介绍了目前PFO所致PDE并发CS的当前研究现状,尤其是几个随机对照试验（randomized controlled trials,RCT）的结果,以期对我国今后PFO并发CS的治疗提出新的观点。     

Incidence of extracerebral paradoxical embolisms in patients with intracardiac shunts

BACKGROUND: Although extracerebral embolism accounts for 5-10% of all paradoxical embolisms, it still remains a ghostlike entity in cardiovascular pathophysiology. The aim of this brief report was to analyze the profile of patients with paradoxical extracerebral embolism and intracardiac shunts, and the role of shunt closure on the recurrence of extracerebral paradoxical embolism (EPE) in a population of patients evaluated for patent foramen ovale (PFO)/atrial septal defect (ASD) transcatheter closure. METHODS: From July 2003 to December 2006, 150 patients (mean age 51.4+/-15.1 years, range13-78 years, M/F=49/101) were planned for transcatheter closure of PFO/ASD at our institutional program of Adult Congenital Heart Disease Management. Clinical history and medical records of all patients were reviewed searching for association of PFO/ASD, stroke, and presumptive EPE. RESULTS: Association of PFO with presumptive EPE was found in nine patients (6%, mean age 40.1+/-14 years, M/F=3/6). Five patients had ST-elevation myocardial infarction (mean value of troponin was 15.3+/-2.1 ng/ml), while four patients had inferior limb acute ischemia. In patients with coronary embolism, coronary angiography was performed immediately after chest pain onset revealing normal coronary artery and only a mild hypokinesia. In patients with peripheral acute ischemia, early (>4 h from symptoms onset) angiography demonstrated normal main peripheral vessel and an embolic closure of popliteal artery (one patient), distal tibial artery (two patients), or peroneal artery (one patient) that normalized with heparin therapy in a few hours except in one patient. Migraine with aura was present in seven of nine patients. Cerebral MRI revealed previous ischemic areas in four of nine patients. Coagulation disorders were detected in six of nine patients. Echocardiography demonstrated a large to medium PFO in seven patients and a cribrosus ASD in two patients. CONCLUSION: Although a large study is required to assess optimal diagnosis and clinical implications of EPE, the clinical profile emerging from our study may help to identify some easy criteria of diagnosis in order to improve diagnosis and decrease the recurrence of such probably underestimated manifestations of PFO/ASD.     

Characteristics of adult patients with atrial septal defects presenting with paradoxical embolism

Background : The association between patent foramen ovale (PFO), atrial septal aneurysm, and cryptogenic stroke due to paradoxical embolism has been established. The correlation between atrial septal defect (ASD) in adults and paradoxical embolism is less well defined. Methods : We examined our single center experience with 329 adult patients undergoing percutaneous device closure of interatrial communication defects to identify clinical and morphologic differences among adult patients with ASDs who presented with or without paradoxical embolism. Comparison was made with patients with PFO. Results : Although a significant left‐to‐right shunt was the predominant indication for ASD closure, 20 patients (14%) presented with a paradoxical embolism. These patients tended to be younger and had smaller defects (both by size and shunt ratio) than ASD patients without paradoxical embolism, and were more likely to be female than PFO patients. Conclusions : The incidence of adult patients with ASD who presented with paradoxical embolism is higher than expected and suggests that this diagnosis should be considered in patients with cryptogenic stroke. © 2009 Wiley‐Liss, Inc.     

Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience

BACKGROUND: Patients with a patent foramen ovale (PFO) after cerebral, coronary, or systemic embolic events of presumed paradoxical origin are at risk for recurrent thromboembolism. We report our single-center experience of interventional closure of interatrial communications for secondary prevention of presumed paradoxical embolism. Methods and Results- Since 1997, percutaneous closure of interatrial communications was performed at our institution in 66 patients (mean age 47.8+/-12.7 years; 31 males) with a PFO or an atrial septal defect and at least 1 documented presumed paradoxical thromboembolic event. Fifty-eight patients had cerebral embolism, 10 had coronary embolism, and 3 had peripheral embolism. Several patients experienced multilocal arterial embolism. Fifty-four patients had a PFO, 33 of them with an atrial septal aneurysm, and 12 had an atrial septal defect. The implantation procedure was successful and without complication in all patients. After 3 months, only 2 patients showed a residual shunt, which disappeared in both cases after 12 months. In 112.2 patient-years of follow-up (range, 5 weeks to 3.5 years), we have not seen any recurrent thromboembolic event. CONCLUSIONS: Interventional closure of interatrial communications is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. To further evaluate this strategy, randomized trials comparing interventional closure with anticoagulation have been initiated by us and others.     

Encerramento percutâneo de defeitos do septo interauricular guiado por ecocardiograma intracardíaco − A experiência de um centro

IntroductionDevice closure of interatrial communications has become a well-established technique to treat left-to-right shunt associated with atrial septal defect (ASD) and to prevent paradoxical embolism in patients with patent foramen ovale (PFO). Guidance by transesophageal echocardiography (TEE) is the standard practice but intracardiac echocardiography (ICE) is a feasible and safe alternative for monitoring these procedures.ObjectivesTo report our experience in the percutaneous closure of ASD and PFO guided by ICE.MethodsWe retrospectively reviewed all patients with ASD or PFO who underwent percutaneous closure guided exclusively by ICE between January 2008 and December 2010. All patients were followed clinically with regular echocardiographic evaluation (at discharge, one month, three, six and twelve months) to exclude residual shunt and device malposition.ResultsA total of 127 patients (mean age 46.6±12.2 years; 71% female) underwent transcatheter device closure of ASD or PFO during the study period. Device deployment with ICE monitoring was 100% successful, with a low rate of complications and eliminating the need for additional imaging techniques.ConclusionsICE provides anatomical detail of ASD/PFO and cardiac structures, facilitating congenital cardiac interventional procedures. It eliminates the major drawbacks associated with TEE and enables the interventional cardiologist to control all aspects of the procedure without relying on additional echocardiographic support.     

Exclusion of patients with arteriosclerosis reduces long-term recurrence rate of presumed arterial embolism after PFO closure

BACKGROUND: Percutaneous transcatheter closure of patent interatrial communications after presumed paradoxical embolism is used as an alternative to surgery or long-term anticoagulation for the treatment of patients who are at risk for recurrent thromboembolism. To avoid atherosclerotic events to be judged as recurrent paradoxical embolism, we prospectively excluded all patients with detectable arteriosclerosis from our series and investigated long-term results. METHODS AND RESULTS: We report the outcome of 180 patients who underwent percutaneous transcatheter closure of patent foramen ovale (PFO), PFO like atrial septal defect (ASD), or an ASD because of paradoxical embolism. One hundred four patients had cerebral embolism, 57 had transient ischemic attacks, 16 coronary embolism, and 3 had peripheral embolism. Twenty-three patients experienced multilocal arterial embolism. One hundred twenty-five patients had a PFO, 63 of them with an atrial septal aneurysm (ASA), 24 a PFO-like ASD (7 of them with an ASA), and 31 had an ASD. After 18 months, only 5 patients (2.8%) showed a trivial residual shunt. At a mean follow-up of 40 months (range 4 to 88), resulting in 602 observed patient-years, only 1 patient experienced a presumed paradoxical (coronary) embolism (calculated annual risk to suffer a recurrent thromboembolic event: 0.16%). CONCLUSIONS: Percutaneous transcatheter closure of PFO/ASD is a safe and effective therapeutic option for the secondary prevention of presumed paradoxical embolism. It is associated with a high success rate, low incidence of hospital complications, and very low frequency of recurrent systemic embolic events.     

Rare case of pulmonary arteriovenous fistula simulating residual defect after transcatheter closure of patent foramen ovale for recurrent paradoxical embolism.

We report on a patient suffering from recurrent cerebrovascular events despite previous transcatheter closure of persistent foramen ovale (PFO) with a Helex occluder. There was evidence of persistent left-to-right atrial shunt shown by transesophageal contrast echocardiography and the patient was admitted to our institution for interventional closure of the supposed residual defect. However, the PFO was completely closed by the device and left pulmonary artery injections showed a pulmonary arteriovenous fistula in the left lower lobe. This rare malformation may well explain the recurrent paradoxical embolism. Transcatheter fistula closure with coils was performed successfully. This case underlines that the existence of an isolated pulmonary arteriovenous fistula as a right-to-left shunt in patients with cryptogenic stroke should not be overlooked, even if a PFO is present and pulmonary arteriovenous fistula is not suggested by the initial physical findings or chest X-ray.     

622例急性肺栓塞患者的临床特点分析

目的:分析急性肺栓塞(Acute pulmonary embolism,APE)患者的临床特征、危险因素、心电图和实验室检查等特点,提高对这种常见的致死性疾病的诊断意识。方法:连续入选2007年1月至2013年12月,在我院经影像学方法诊断的急性肺栓塞患者622例,记录临床特征、危险因素、影像学及实验室检查结果。结果:患者平均年龄(66.4±17.4)岁,女性占54.0%。常见症状是呼吸困难、胸痛和咳嗽,分别占75.4%、37.5%、13.5%和96.1%的PE患者存在三种最常见的症状。常见呼吸急促、心动过速和深静脉血栓形成(DVT)的体征,分别占16.4%、16.1%和15.9%。常见的危险因素是既往深静脉血栓史[肺栓塞(PE)和/或DVT]、恶性肿瘤、外科手术和制动,分别占21.0%、11.3%、13.8%和14.0%。心电图异常的患者占42.9%,包括窦性心动过速、心房颤动、SIQIIITIII、右束支传导阻滞和胸前导联T波明显倒置,分别为15.1%、6.2%、14.3%、4.7%和22.2%。患者入院科室为呼吸科47.9%,心内科40.4%,血管外科5.1%,其他外科3.9%。21.2%的患者接受静脉溶栓,介入溶栓和外科取栓手术患者占10.3%;71.9%单纯抗凝治疗。患者院内死亡21例(3.4%)。结论:PE症状缺乏特异性,很容易与其他疾病误诊,尤其是心内科疾病。危险因素的识别、心电图和超声心动图的表现以及实验室检查结果有助于PE的诊断。     

Association of interatrial shunts and migraine headaches: impact of transcatheter closure

OBJECTIVES: To examine the relationship between patent foramen ovale (PFO) or atrial septal defect (ASD) with the incidence of migraine headache (MHA) and assess whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. BACKGROUND: Migraine headache is present in 12% of adults and has been associated with interatrial communications. This study examined the relationship between PFO or ASD with the incidence of MHA and assessed whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA. METHODS: A sample of 89 (66 PFO/23 ASD) adult patients underwent transcatheter closure of an interatrial communication using the CardioSEAL (n = 22), Amplatzer PFO (n = 43), or the Amplatzer ASD (n = 24) device. RESULTS: Before the procedure, MHA was present in 42% of patients (45% of patients with PFO and 30% of patients with ASD). At three months after the procedure, MHA disappeared completely in 75% of patients with MHA and aura and in 31% of patients with MHA without aura. Of the remaining patients, 40% had significant improvement (>or=2 grades by the Migraine Disability Assessment Questionnaire) of MHA. CONCLUSIONS: Transcatheter closure of PFO or ASD results in complete resolution of MHA in 60% of patients (75% of patients with migraine and aura) and improvement in symptoms in 40% of the remaining patients. Interatrial communications may play a role in the etiology of MHA either through paradoxic embolism or humoral factors that escape degradation in bypassing the pulmonary circulation. A randomized trial is needed to determine whether transcatheter closure of interatrial shunts is an effective treatment for MHA.     

Impending paradoxical embolism. When and how to treat?

Impending paradoxical embolism (IPDE) is the presence of an entrapped thrombus through the patent foramen ovale (PFO). Usually IPDE are diagnosed by echocardiography or thoracic CT-scan performed during the evaluation of patient presenting with a suspicion of pulmonary embolism (PE). We report the case of a 73-year-old patient presenting with a very large IPDE successfully treated with cardiac surgery and we focus our discussion on the treatment modalities of this rare entity (anticoagulation alone, fibrinolytic regimens, cardiac surgery, percutaneous thrombectomy) and on PFO management after IPDE.