经右侧颈内静脉行右心室心内膜心肌活检的可行性及安全性探讨

目的探讨经右侧颈内静脉行右心室心内膜心肌活检的可行性和安全性。方法该研究为回顾性描述性研究。以2014年12月至2020年6月在中国医学科学院阜外医院及北京协和医院接受心内膜心肌活检的患者为研究对象,这些患者初步临床诊断为疑诊心肌炎、心肌病、不明原因心力衰竭等,研究排除了冠心病患者。收集入选患者的一般临床资料,包括人口统计学资料(年龄、性别、身高、体重)、纽约心脏协会(NHYA)心功能分级、血N末端B型利钠肽原(NT-proBNP)水平、胸片、超声心动图、血流动力学指标等。所有患者均经右侧颈内静脉在X线透视、双体位引导下行右心室心内膜心肌活检。计算右心室心内膜心肌活检的成功率。观察患者心内膜心肌活检并发症的发生情况,主要并发症包括死亡、需要紧急心脏手术或高级生命支持、心包填塞需心包穿刺引流、永久性房室传导阻滞需安装永久起搏器等;次要并发症包括不需要心包穿刺的心包积液、暂时(持续<24 h)或永久的右束支传导阻滞、一过性莫氏Ⅱ型2∶1房室传导阻滞需要阿托品治疗或需安装临时起搏器、非持续≥10个QRS波的室性心动过速、持续<12 h心房颤动(房颤)或需要转复的房颤;其他并发症包括心内膜心肌活检后新出现的三尖瓣腱索断裂或反流。另外,分别观察操作第1、2和3年的术者操作后患者并发症的发生情况。结果研究共入选272例接受右心室心内膜心肌活检的患者,其中270例成功完成操作,成功率99.3%。入选患者的年龄(42.7±16.9)岁,其中男性164例(60.3%)。21例(7.7%)患者出现并发症,其中2例(0.7%)出现大量心包积液,属于主要并发症,均行心包穿刺引流后缓解;18例(6.6%)出现微量心包积液,1例(0.4%)三尖瓣前叶腱索断裂,均属于次要并发症。无患者出现死亡、需紧急心脏手术抢救或需要永久起搏器置入等严重并发症。术者进行右心室心内膜心肌活检操作后的第1、2、3年并发症发生率分别为9.3%(13/140)、7.8%(7/90)和2.4%(1/42)。结论经右侧颈内静脉入路X线引导下行右心室心内膜心肌活检安全、可行,且随着操作者熟练程度的提高其并发症发生率有降低的趋势。     

致心律失常性右心室心肌病临床诊断探讨

目的探讨致心律失常性右心室心肌病的临床诊断标准.方法将19例致心律失常性右心室心肌病患者常规行超声心动图、心电图、X线胸片、24小时动态心电图、心房调搏及心内电生理检查.结果本组19例患者均有心悸,晕厥发作,心电图多为右束支传导阻滞(78.95%),频发室性早搏(89.5%),右心室源性短阵室性心动过速(78.95%),超声心动图右心室50.80±9.88?mm,右心房48.00±8.79?mm,均增大,右心功能减退,射血分数0.294±0.0812.结论致心律失常性右心室心肌病,可根据发作性晕厥,右束支传导阻滞,频发室性早搏及左束支传导阻滞型室性心动过速,右心室、右心房增大,右心室功能减退,并排除其他各类心脏和胸肺疾病后确诊.     

应用双封堵器封堵治疗复杂膜部瘤型室间隔缺损

目的:探讨应用双封堵器对复杂膜部瘤型室间隔缺损（VSD）进行介入封堵治疗的可行性、有效性和安全性。方法: 12例复杂膜部瘤型VSD患者,左心室造影后常规右股动脉-左心室-VSD-右心室-右股静脉输送轨道,对VSD进行封堵,重复左心室造影,发现存在不能接受的残余分流,遂建立右股动脉-左心室-VSD-右心室-左股静脉输送轨道,应用第2枚封堵器对残余分流进行封堵,左心室、升主动脉造影以及超声心动图检查确认封堵效果良好,释放封堵器。术后1、3、6、12个月复查超声心动图、X线检查和12导联心电图。结果: 12例患者均封堵成功。术毕即刻造影和超声心动图检查示封堵效果良好,无残余分流,各组瓣膜功能良好,无并发症发生。随访期间所有患者杂音消失,超声心动图检查无残余分流,心电图检查均为窦性心律,无房室传导阻滞或束支传导阻滞。结论: 应用双封堵器对复杂膜部瘤型VSD进行封堵治疗是可行的,且具有满意的疗效和安全性。     

T电轴正常范围及与心室肥大,束支传导阻滞关系的初步探讨

为探索T电轴的正常范围及其临床意义,分析60例正常人、31例左束支传导阻滞、26例右束支传导阻滞、29例左心室肥大、18例左束文传导阻滞伴左心室肥大、33例右心室肥大和14例右束支传导阻滞伴右心室肥大患者的心电图T电轴.其结果分别为42.9°±21.9°、141.8°±70.7°、48.0°±31.2°、145.2°±58.6°、36.5°±38.0°、41.8°±22.5°和41.1°±22.0°,其中左束支传导阻滞和左束支传导阻滞伴左心室肥大与正常人T电轴范围差异有非常显著意义(P<0.01),而其余各组与正常人T电轴的差异无显著意义(P>0.05).提示60例正常人T电轴范围0°～±86°可作为正常T电轴的参考值,左束支传导阻滞是引起T电轴异常的原因之一.     

小儿先天性心脏病介入治疗302例回顾分析

目的总结先天性心脏病患者介入治疗疗效、并发症情况及预防措施。方法回顾性分析302例行介入治疗的先天性心脏病患儿的临床资料,着重分析治疗疗效及总结并发症的处理经验。本组共302例患儿,男125例,女177例,年龄3个月～14岁,中位年龄4.4岁,体质量(12.8±6.7)kg。其中动脉导管未闭(patent ductus arteriosus,PDA)组183例、房间隔缺损(atrial septal defect,ASD)组69例、室间隔缺损(ventricular septal defect,VSD)组50例,分别行PDA、ASD、VSD堵闭术,术后半年内每个月随访心电图及超声心动图检查1次,半年后每6～12个月复查心电图及超声心动图检查1次。结果 PDA组、ASD组、VSD组的成功封堵率分别为99.4%(182/183),100%(69/69),98%(49/50)。各组术后并发症发生率(术后72h内)分别为2.2%(4/183),4.3%(3/69),10%(5/50)。PDA组183例患儿3例存在残余分流,1例出现溶血;ASD组69例患儿2例存在少量残余分流,1例出现暂时性Ⅱ度房室传导阻滞;VSD组50例患儿1例存在残余分流,1例出现Ⅲ度房室传导阻滞,3例出现完全性右束支传导阻滞。在6个月～3年的随访中,PDA组仅1例有微量残余分流,2例心脏扩大;ASD组无残余分流,Ⅱ度房室传导阻滞转为Ⅰ度房室传导阻滞;VSD组1例有少量残余分流,1例持续存在完全性左束支传导阻滞。结论 PDA及ASD封堵技术成熟,手术效果好,并发症发生率低。VSD封堵术后早期心律失常(术后5d左右)发生率较高,术后持续监测患者心电图的变化非常重要。     

经导管主动脉瓣置换术围手术期心电图表现及临床意义

目的 探讨经导管主动脉瓣置换术围手术期心电图表现及临床意义.方法 选择我院自2018年1月-2018年12月收治的50例行经导管主动脉瓣置换术治疗的患者作为研究对象,按照患者病情的不同分别采用Venus-A瓣膜、J-Valve瓣膜对其行手术治疗,观察患者术前及术后24 h心电图表现,并统计其术后并发症发生情况.结果 采用Venus-A瓣膜行经导管主动脉瓣置换术治疗患者,围手术期有3例患者发生新发左束支传导阻滞,1例患者发生新发右束支传导阻滞,1例患者发生新发III度房室传导阻滞.采用J-Valve瓣膜行经导管主动脉瓣置换术治疗患者,围手术期有3例患者发生新发左束支传导阻滞,2例患者发生新发多源室性心动过速及室性早搏,1例患者发生新发右束支传导阻滞.经对症治疗后,所有患者传导功能均于术后7-12 d恢复正常.结论 经导管主动脉瓣置换术围手术期对患者行心电图监测,能有效检出其异常传导情况,从而能指导临床尽早采取有效方案对患者进行干预,进而能保障其术后安全.     

心电图呈右束支传导阻滞图形患者的最适起搏方式探索

右束支传导阻滞是常见的心电图表现,在有起搏指征的患者中,对合并右束支传导阻滞图形的患者最适的起搏方式一直在探索。常规右心室起搏和双心室起搏对起搏依赖的右束支传导阻滞患者不能很好地保持心脏电机械同步性,而近年来的经希浦系统的生理性起搏可能是该类患者新的治疗选择。现对右束支传导阻滞的发生机制、病理生理影响和起搏方式探索进行综述,为未来起搏方式的选择提供参考。     

国产封堵器治疗膜部室间隔缺损并发心律失常的分析及两种防治措施对心律失常转归的影响

目的:探讨国产封堵器治疗膜部室间隔缺损(VSD)并发心律失常的原因及2种防治措施对心律失常转归的影响。方法:入选先天性心脏病膜部VSD并行介入治疗的患者260例,年龄(16.3±12.5)岁,经胸超声检查VSD大小为(6.0±3.2)mm,随机分成两组:A组(130例)介入术后常规静脉滴注地塞米松3~10mg,或后续口服强的松3~7d;B组(130例)介入术后根据是否并发心律失常情况再静脉滴注地塞米松3~10mg或后续口服强的松3~7d。统计分析所有患者术中及术后并发的各种心律失常,并对其处理,随访3~6个月,观察其转归。结果:260例膜部VSD患者介入术中或术后共并发心律失常55例,平均年龄(13.8±11.6)岁;出现时间(3.6±1.4)d。其中A组10例(发生率7.7%):完全性左束支阻滞1例,完全性右束支阻滞3例,不完全性右束支阻滞2例,加速性交界性心动过速伴干扰性房室脱节2例,左前分支阻滞2例;B组45例(发生率34.6%):一过性Ⅲ度房室传导阻滞1例,高度房室传导阻滞1例,完全性左束支阻滞4例,间歇性左右束支传导阻滞3例,完全性右束支阻滞10例,不完全性右束支阻滞11例,左前分支阻滞6例,加速性交界性心动过速伴干扰性房室脱节9例;两组术后心律失常发生率比较,差异有统计学意义(P0.01);经激素治疗后,B组中1例一过性Ⅲ度房室传导阻滞转为Ⅱ度Ⅰ型房室传导阻滞,随访3~6个月。B组中2例完全性右束支阻滞、2例不完全性右束支阻滞和3例左前分支传导阻滞未恢复,治愈率84.4%;而A组中只有1例完全性右束支阻滞治疗后未完全恢复,转为不完全性右束支阻滞,治愈率90%,两组术后心律失常治愈率比较差异有统计学意义(P0.05)。结论:应用国产封堵器介入治疗VSD比较安全有效,严重并发症极少,主要并发症为各种心律失常,如果及时发现,并给予激素治疗,约90%可以恢复,术后常规给予激素治疗,可减少并发症,加快恢复。     

完全性左束支传导阻滞62例分析

完全性左束支传导阻滞(CLBBB)远较完全性右束支传导阻滞少见。多数学者认为,心脏发生CLBBB,表示有严重心肌损害,大多数病例预后较差。我院自1963～1987年共检查心电图256584例,     

肥厚型梗阻性心肌病围术期心律失常特点及治疗策略

目的:分析外科手术矫治肥厚型梗阻性心肌病(HOCM)患者围术期心律失常特点及治疗策略.方法:1996-10至2009-12,76例患者因HOCM经常规主动脉切口行室间隔心肌切除术.术前主要心律失常类型:偶发室性早搏(6例)、完全右束支传导阻滞(5例)、阵发性房性心动过速(4例)、心房颤动(3例)、短阵室性心动过速(3例).结果:全组手术死亡4例(5.3%,4/76),主要死因:顽固性心律失常、严重低心排血量综合征及急性肾功能衰竭.与术前比较,生存患者术后左心房内径及左心室内径均减小、左心室流出道压差下降、室间隔厚度变薄,差异均有统计学意义(P<0.01-0.05).术后主要心电图异常表现:完全左束支传导阻滞(40例)、室内传导阻滞(8例)、Ⅲ度房室传导阻滞(7例)、心房颤动(7例)、偶发室性早搏(7例)、左前分支传导阻滞(6例)、I度房室传导阻滞(5例).结论:HOCM患者术后心电图主要异常表现为传导束传导异常和心房颤动.如术前合并完全右束支传导阻滞,术后极易合并Ⅲ度房室传导阻滞,需引起重视.     

Complications of endomyocardial biopsy in children

OBJECTIVES

To evaluate the incidence of, and risk factors for, complications of endomyocardial biopsy in children.

BACKGROUND

Endomyocardial biopsy (EMB) is a low risk procedure in adults, but there is a paucity of data with regard to performing this procedure in children.

METHODS

Retrospective review of the morbidity and mortality of 1,000 consecutive EMB procedures.

RESULTS

One thousand EMB procedures (right ventricle 986, left ventricle 14) were performed on 194 patients from July 1987 through March 1996. Indications for EMB included heart transplant rejection surveillance (846) and the evaluation of cardiomyopathy or arrhythmia for possible myocarditis (154). Thirty-seven (4%) procedures were performed on patients receiving intravenous inotropic support. There was one biopsy related death, secondary to cardiac perforation, in a two-week-old infant with dilated cardiomyopathy. There were nine perforations of the right ventricle, eight occurring in patients with dilated cardiomyopathy and one in a transplant recipient. The transplant patient did not require immediate intervention; two patients required pericardiocentesis alone, and six underwent pericardiocentesis and surgical intervention. All nine perforations were from the femoral venous approach (p < 0.01). Multivariate analysis demonstrated that the greatest risk of perforation occurred in children being evaluated for possible myocarditis (p = 0.01) and in those requiring inotropic support (p < 0.01). Other complications included arrhythmia (5) and single cases of coronary-cardiac fistula, flail tricuspid leaflet, pneumothorax, hemothorax, endocardial stripping and seizure.

CONCLUSIONS

Risk of endomyocardial biopsy is highest in sick children with suspected myocarditis on inotropic support. However, EMB can be performed safely with very low morbidity in pediatric heart transplant recipients.     

Endomyocardial biopsy in heterotopic heart transplant recipients via the femoral vein

The results of endomyocardial biopsy (EMB) via the femoral vein in heterotopic heart transplant recipients were retrospectively analyzed and compared with those obtained using the right internal jugular vein approach. A total of 139 EMB were performed in 8 patients using the femoral (35) or the jugular (104) approach. Twenty three (64.7%) of the procedures performed via the femoral vein were part of the yearly hemodynamic and coronary artery study, and 12 (35.3%) constituted a routine postoperative evaluation of the myocardium rejection state in patients with imperviousness of the right internal jugular vein. Comparing the results obtained with the femoral approach, we observed a higher overall success rate (94.3 vs 88.5%, NS) and obtained more samples that were useful for histologic evaluation (95.5 vs 85.9%, NS); with the jugular procedure, the fragments were significatively larger in diameter (1.28 ± 0.55 vs 1.61 ± 0.85 mm, mean ± SD) and in area (1.49 ± 1.16 vs 2.28 ± 2.24 mm², mean ± SD). No cardiac or local complications were noted when the femoral approach was used, while two attempts to perform biopsy via the jugular vein resulted in obstruction of this vessel. Our data suggest that the femoral venous approach for endomyocardial biopsy in heterotopic heart transplant recipients is a valid alternative to the more commonly used routes.     

New instrument for transvenous cardiac biopsy

A new forceps is described for obtaining serial endomyocardial biopsy specimens from the human heart. The instrument is introduced percutaneously into the right internal jugular vein and used to obtain tissue from the apex of the right ventricle. Eighty-five biopsy procedures have been performed in 19 patients after cardiac transplantation. The tchnique used was 100 percent successful in obtaining endomyocardial biopsy specimens, and there were no significant complications. A biopsy procedure may be performed within 5 minutes. Serial percutneous transvenous endomyocardial biopsies are now routinely performed with this instrument in new heart transplant recipients and in patients with primary cardiomyopathy.     

Relative efficiency and risk of endomyocardial biopsy: comparisons in heart transplant and nontransplant patients

Right ventricular endomyocardial biopsy remains the gold standard for the diagnosis of acute rejection of the cardiac allograft. Among 704 consecutive procedures performed in 39 transplant recipients (2,842 myocardial samples), endomyocardial biopsy by either the right internal jugular (n = 661) or the femoral venous (n = 43) approach was compared with 243 consecutive procedures performed in nontransplant patients (n = 149 and n = 94, internal jugular and femoral approach, respectively). The internal jugular vein could not be located in only 0.61% (4/661) of heart transplant versus 5% (7/149) of nontransplant procedures (P less than 0.001). Vascular access plus sufficient myocardial sampling was obtained in all but 0.61% (4/661) internal jugular procedures performed in heart transplant patients and in all but 7% (11/149) of those performed in nontransplant patients (P less than 0.0001). (Vascular access was achieved in all femoral venous procedures performed in both transplant and nontransplant patients; sampling was successful after vascular access in all heart transplant recipients and all but two [2.1%] nontransplant procedures.) Cardiac complications occurred in nontransplant patients after one internal jugular procedure (cardiac perforation with tamponade) and after one femoral venous procedure (pericardial effusion). No cardiac complications occurred in transplant recipients, but 2 other complications were observed: One local abscess and one superior vena caval perforation with hemothorax associated with hypotension, both after an internal jugular approach. The overall efficiency (no safety problem; vascular access and adequate sample) was higher among transplant than nontransplant procedures (99% vs 93%, respectively, P less than 0.0001). These observations continue to support routine application of endomyocardial biopsy for monitoring rejection in cardiac transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications of transvenous right ventricular endomyocardial biopsy in adult patients with cardiomyopathy: a seven-year survey of 546 consecutive diagnostic procedures in a tertiary referral center.

To determine the incidence, nature and subsequent management of complications occurring during right ventricular endomyocardial biopsy in patients with cardiomyopathy, all events occurring during 546 procedures in 464 consecutive patients were prospectively recorded. The internal jugular vein was the primary site of introduction in 96% of cases. A total of 33 complications (6%) occurred: 15 (2.7%) during catheter insertion including 12 arterial punctures (2%), 2 vasovagal reactions (0.4%) and 1 episode of prolonged bleeding (0.2%), all without sequelae; 18 (3.3%) during biopsy included 6 arrhythmias (1.1%), 5 conduction abnormalities (1%), 4 possible perforations (0.7%) and 3 definite perforations (0.5%) (pericardial fluid). Two (0.4%) of the three patients with a perforation died. There was no secular trend in the complication rate, nor were complications associated with specific clinical or hemodynamic characteristics. It is concluded that the overall rate of endomyocardial biopsy complications (6%) is low, but mortality may occur.     

Endomyocardial biopsy in heart transplantation: the experience of the Naples Center]

From January 1988 through August 1992, 38 cardiac transplants were performed. 385 endomyocardial biopsies (EMBs) from 32 cardiac allograft recipients were investigated. In 21 (5.45%) EMBs the specimens were inadequate for the diagnosis. In the remaining 364 EMBs the grades of acute rejection were: minimal in 213 (58.51%) EMBs, mild in 132 (36.26%), mild/moderate in 12 (3.3%) and moderate in 7 (1.93%). The most reliable histologic feature of acute rejection was the myocyte necrosis or damage in presence of pironinophilic mononuclear cell infiltrate, so our therapeutic protocol requires myocyte damage to perform an additional treatment, which was performed in 7 cases (1.93%). An intermediate grade mild/moderate, was introduced to classify the EMBs in which the myocyte necrosis was scant or not clear. In these patients another EMB was performed after 3 or 5 days. One patient died of chronic rejection 17 months after the transplant. Changes not related to acute rejection were: ischemic early or late necrosis; changes related to previous biopsy site; subendocardial infiltrate of mononuclear cells (Quilty's alteration); focal, diffuse or perimyocytic fibrosis and artefacts as contraction bands; nuclear or cytoplasmic vacuolar alterations. Some of these changes occasionally made the diagnosis hard or the specimens inadequate for the diagnosis. In spite of these diagnostic difficulties, the EMB is a safe and reliable invasive investigation which plays an important role in the management of rejection in cardiac allograft recipients.     

Cardiac catheterization through the internal jugular vein in pediatric patients. An alternative to the usual femoral vein access.

The percutaneous femoral vein approach is used routinely for cardiac catheterization in the pediatric age but in some children, it may be impossible as in the case of iliac vein or inferior vena cava thrombosis due to previous cardiac catheterization, or inconvenient as for right ventricular endomyocardial biopsies. In the period between 1982 and 1990, 160 cardiac catheterizations or right ventricular endomyocardial biopsies were performed in 102 children. Patients ranged in age between 2 months and 17 years (mean, 3.8 years) and in weight from 3.2 to 57.3 kg (mean, 14.4 kg). Indications for the internal jugular vein approach were as follows: (1) thrombosis of the inferior vena cava due to previous cardiac catheterization in 42 patients (41 percent); (2) right ventricular endomyocardial biopsy after cardiac transplant in 19 patients (19 percent); (3) control catheterization of the pulmonary arteries following classic or bidirectional cavopulmonary anastomosis in 16 patients (16 percent); (4) superior vena cava obstruction following Mustard's procedure in 14 patients (14 percent); (5) failed percutaneous femoral venous approach in six patients (6 percent); and (6) absence of the hepatic segment of the inferior vena cava in four patients (4 percent). The right or left internal jugular vein could be entered in all but three procedures (98 percent). Seventeen patients had more than one procedure through the same internal jugular vein and the vein was found patent in all. A complete right heart cardiac catheterization was performed using this route. Right ventricular endomyocardial biopsy and interventional procedure were performed through this route. Two major complications occurred. A patient developed a central transient ischemic attack and another patient developed a persistent Horner syndrome. Accidental carotid puncture occurred in five patients without consequences. Our data indicate that cardiac catheterization in infants and children can be performed safely through the internal jugular vein, with a high success rate and a low incidence of major complications.     

Endomyocardial biopsy in heart transplantation]

From October 1984 to June 1991, 1,549 endomyocardial biopsies (EMB) were performed on 122 patients submitted to a Cardiac Transplant procedure (CT) at the Hospital Puerta de Hierro in Madrid. All biopsies were performed with the long sheath technique and the King bioptome. A total of 8,707 specimens were obtained, of which 7,311 (83.97%) were considered adequate for pathological examination. We did not find significant differences between the internal jugular (83.21%) and the femoral vein (84.82%) approaches. About 20% of the samples were not adequate for pathological evaluation after the fifth procedure performed on the same patient. There has been no deaths in our group. One patient (0.06%) had right ventricular perforation with tamponade that required surgical treatment. Two patients (2.98%) presented coronary fistulae related to EMB. The percent of other minor complications was less than 0.5%. EMB is mandatory for the control of rejection in the first year after cardiac transplantation, and has shown to be a reliable and safe method in experienced hands.     

肥厚梗阻型心肌病经导管化学消融术中心律失常并发症及处理

目的探讨肥厚梗阻型心肌病（ＨＯＣＭ）经导管化学消融（室间隔）术中心律失常发生类型、程度、持续时间及处理措施。方法经β受体阻滞剂、钙拮抗剂治疗效果不佳的ＨＯＣＭ患者１５例（男性９例,女性６例,年龄２６～６０岁）接受导管化学消融治疗。术中严密监测心电图,记录经导管向间隔支动脉推注无水乙醇后,心律失常的发生过程及处理后的转归。结果１３例（８６．７％）患者发生心律失常并发症,７例发生两种以上类型心律失常。其中三度房室阻滞８例,完全性右束支阻滞６例,窦性心动过缓３例,频发室性早搏６例,非持续性室性心动过速２例。除１例窦性心动过缓及５例完全右束支阻滞持续时间较久外,其余的心律失常均在暂停注射无水乙醇或采取其它相应措施后数秒至２０ｍｉｎ内消失。结论导管化学消融室间隔术中心律失常发生率虽然较高,但大多持续时间短暂、程度较轻,多为可逆性,未影响患者术后疗效。