心房颤动治疗的未来发展方向——混合消融

心房颤动是临床常见的心律失常,已有研究证明其与严重不良心脑血管事件(心力衰竭、脑卒中和心肌梗死)有关,目前全球心房颤动的患病人数超过了3 300万,预计未来40年内其患病率将增加1倍以上。多年来,医学相关人员在探究心房颤动的病理生理机制及开创改进其治疗方法等方面付出了大量努力。目前心房颤动的治疗管理仍是临床医学上的一个难题,尽管心房颤动治疗的手术消融和导管消融技术已逐渐趋于成熟,但对于心房颤动最佳的治疗方式、消融能量的选择尚无统一定论。导管消融通常需要多次手术且成功率低,而手术消融术后不良事件发生率较高。近年来,鉴于心脏外科医生和电生理学家之间的密切合作,结合导管及微创手术消融诞生了一种治疗心房颤动的新型策略——混合消融模式。混合消融克服了导管消融和微创手术消融的缺点,减少了不良结局,在治疗持续性心房颤动,尤其是长期持续性心房颤动上取得了可观的成效。本文主要通过回顾心房颤动消融的研究进展,对比分析目前混合消融模式治疗心房颤动的现有研究成果,归纳总结这种新型心房颤动治疗策略的优势与挑战,以期为临床心房颤动的治疗提供更多选择。     

Asbestos exposure and tuberculous pleurisy as developmental causes of progressive unilateral upper-lung field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis

BackgroundUnilateral upper-lung field pulmonary fibrosis (upper-PF), which is radiologically consistent with pleuroparenchymal fibroelastosis, develops after thoracic surgery. In most patients with unilateral upper-PF, aberrant intra-/extra thoracic air commonly emerges and an autopsy shows chronic pleuritis, which indicates that pleural involvement is associated with upper-PF development. If so, there may be patients with unilateral upper-PF who have a history of pleural involvement, including tuberculous pleurisy (TP) or asbestos exposure (AE). This study aimed to examine this supposition.MethodsWe examined the radiological reports of all consecutive patients from 2012 to 2018 to investigate whether there were patients having unilateral upper-PF and a history of TP or AE.ResultsEight patients were included in the study. Five patients had a history of TP, and the remaining three had that of AE. All patients were men and had respiratory symptoms, and seven patients presented with restrictive ventilatory impairment. The interval between TP or last AE and upper-PF development was long, with a median of over 20 years. The upper-PF lesion was commonly located in the right lung, and aberrant intrathoracic air was observed in five patients during their clinical course. Additionally, the upper-PF lesion transformed into a cystic lesion in six patients, which resulted in Aspergillus infection in two patients. The prognosis was poor, with a median overall survival of 38 months.ConclusionsUnilateral upper-PF developed even in patients with a history of pleural involvement. Our results indicate that pleural involvement plays an important role in the development of unilateral upper-PF.     

Spectrum of Restrictive and Infiltrative Cardiomyopathies: Part 2 of a 2-Part Series

Restrictive cardiomyopathies are the least common form of heart muscle disease. They are characterized as infiltrative and noninfiltrative, storage diseases, and endomyocardial disorders. Genetic diseases commonly present during childhood or adolescence. However, a growing percentage of elderly patients with heart failure with preserved ejection fraction are being recognized as having forms of restrictive cardiomyopathy, particularly cardiac amyloidosis. Noninvasive evaluation has replaced endomyocardial biopsy in the diagnostic evaluation of most suspected etiologies. The detection of infiltrative cardiomyopathies, particularly primary and secondary forms of iron overload, as well as inflammatory diseases such as sarcoidosis has slowly led to improved outcomes via disease-specific therapies.     

Simultaneous epicardial–endocardial mapping of the sinus node in humans with structural heart disease: Impact of overdrive suppression on sinoatrial exits

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心内膜垫缺损超声心动图与X线检查的对照分析

本文报道了２５例心内膜垫缺损的Ｘ线、心血管造影及超声心动图的对照分析，总结了３种方法各自的优缺点，并与手术结果进行了对照。     

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.     

预激综合征旁道的心电图、心脏标测定位(附六例报告)

对6例预激综合征旁道进行心电图、电生理检查及心外膜标测定位和比较,结果提示综合二种心电图δ波极性作旁道定位的方法有较高的准确性。电生理检查对确定左或右旁道的存在有帮助,而作心内膜标测确定旁道位置较困难。认为显性预激综合征者,旁道切割术前不必强调作电生理检查,除非为隐匿性预激。用手指压迫预计的旁道部位,使δ波消失和/或阵发性室上性心动过速终止可能是心外膜标测的一种简便的方法。