目的总结左胸骨旁小切口微创封堵分流方向偏向流出道的室间隔缺损（VSD）的初步经验。 方法2014年2～8月广州医科大学附属第一医院对15例分流方向偏向流出道的VSD患者施行左胸骨旁小切口微创封堵手术，其中男7例，女8例；年龄10个月～19岁（4.5±4.6）岁；体重5.5～54.0（14.6±14.1）kg；其中干下型6例，嵴内型6例，膜周部型3例；缺损直径2.5～6.5（4.0±1.2）mm，距主动脉瓣环距离≤1 mm 9例，≤2 mm4例，>2 mm 2例；合并主动脉瓣右冠瓣轻度脱垂5例；采用左胸骨旁第2或第3肋间1.5～2.5 cm切口，在经食管超声心动图（TEE）监视下在右心室流出道表面选择适当的穿刺点，建立VSD输送轨道并置入封堵器，观察有无残余分流、主动脉瓣反流；术后3个月复查经胸超声心动图。 结果15例均成功封堵，无中转开胸，无残余分流和心律失常，新发主动脉瓣轻微反流2例，围手术期输血1例；手术时间30～120（58±28）min，术中出血量5～200（26±50）ml；术后住院时间3～13（4.3±2.6）d，无二次开胸止血、Ⅲ°房室传导阻滞、主动脉瓣反流加重、溶血、切口感染等并发症；术后3个月返院复查经胸超声心动图13例，无新发主动脉瓣反流和封堵器脱落；2例术中新发主动脉瓣反流加重，其中1例出现残余分流。 结论左胸骨旁小切口封堵分流方向偏向流出道VSD 手术安全、切口小、操作简单，近期效果尚满意；对合并主动脉瓣轻度脱垂VSD 需慎重施行外科微创封堵手术。
【摘要】 目的 采用多柔比星（doxorubicin，DOX）制备心肌损伤动物模型，评价各种检测心功能变化方法的意义。 方法 14只新西兰大白兔，DOX耳缘静脉注射，每周3 mg/kg，共10周。分别于给药前、第4周末及实验结束时测定血清肌钙蛋白Ⅰ（cTnI）和脑钠肽（BNP）水平，彩色多普勒超声心动图检测心功能变化，并观察心肌组织病理形态学改变及心肌细胞凋亡情况。 结果 使用DOX前后对比，血清cTnI和BNP浓度升高（Plt;0.05）；左室射血分数（LVEF）和左室短轴缩短率（LVFS）下降（Plt;0.05）；心肌组织病理显示心肌细胞出现不同程度的空泡变性与水肿，细胞间隙明显增宽，大量炎性细胞浸润。心肌细胞凋亡明显增加。 结论 结合心脏超声检查和血清cTnI、BNP指标检测可判断心肌损伤程度。【Abstract】 Objective To observe the changes of heart function caused by doxorubicin in rabbits. Methods A total of 14 New-Zealand white rabbits were intravenous-injected with doxorubicin with a dosage of 3 mg/kg intravenously once a week, and the accumulative dose was 30 mg/kg. Before the medication and at the 4th and 10th weekend after the medication, the serum levels of cardiac troponin I (cTnI) and brain natriuretic peptide (BNP) were measured; left ventricular ejection function (LVEF) and left ventricular fractional shortening (LVFS) were performed on the rabbits respectively. At the 10th weekend, the pathological changes of cardiac tissue and the apoptosis of myocardial cell were detected. Results The levels of cTnI and BNP significantly increased (Plt;0.05), and the LVEF and LVFS markedly decreased (Plt;0.05) after the administration of doxorubicin. Uneven vacuolar degeneration and edema of cardiocytes could be observed with a wide cell spaces and inflammatory cell infiltration in the histopathological slices. Conclusion The combined application of heart sonography with the detection of the serum levels of cTnI and BNP can evaluate the degree of myocardial damage of the rabbits models very well.
Objective To investigate long-term echocardiography characteristics and their clinical significance of patients after mitral valve replacement （MVR）. Methods We retrospectively analyzed clinical data of 204 patients who underwent prosthetic MVR and finished echocardiography examination at least 5 years after surgery in West China Hospital of Sichuan University. There were 44 male patients and 160 female patients with their age of 23 to 73 （50.9±10.6）years. Postoperatively， all the patients were followed up for 5-15 （7.9±2.3）years and regularly received echocardiography examination at the outpatient department. Analysis variables included left atrium （LA） dimension， left ventricle （LV） dimension，right atrium （RA） dimension， right ventricle （RV） dimension， left ventricular ejection fraction （LVEF） and effective orificearea （EOA） of the mitral valve. Results Long-term echocardiography showed that LA and LV dimensions were signifi-cantly smaller than preoperative dimensions （P＜0.05）， while RA and RV dimensions were not statistically different from preoperative dimensions （P＞0.05）. Long-term LVEF was significantly higher than preoperative value （P＜0.05）. Long-term EOA was 1.1-4.8 （2.3±0.5）cm2， including EOA of 1.1-1.4 cm2 in 7 patients （3.4%，7/204），and 1.6-1.9 cm2in 42 patients （20.6%，42/204）. During long-term follow-up， 7 patients underwent their second heart surgery， including2 patients with prosthetic valve dysfunction， 1 patient with prosthetic perivalvular leak and severe hemolytic anemia，3 patients with severe tricuspid regurgitation which were not improved after medication treatment， and 1 patient with moderateaortic valve stenosis and regurgitation. Two patients had left atrial thrombosis during follow-up， including 1 patient who died of endocarditis 7 years after surgery， and another patient who was still receiving conservative therapy and further follow-up. Conclusion Concomitant tricuspid or aortic valve disease should be actively treated during MVR， and postoperative patients need better follow-up. Many patients after MVR need long-term cardiovascular medication treatment during follow-up in order to improve their heart function and long-term survival rate.
Objective To conduct a systematic review to evaluate preoperative and postoperative changes of echocardiography indexes which reflect left ventricular morphology and contractile function after heart valve replacement of patients with valvular heart disease with giant left ventricle. Methods We electronically searched CBMdisc， VIP database，Wanfang database， CNKI database， PubMed and ScienceDirect from time of establishment of each database to June 2012 to identify literatures addressing heart valve replacement for patients with valvular heart disease and giant left ventricle. Quality of included literatures was evaluated， and relevant data were extracted to conduct meta-analysis. Preoperative and postoperative changes of echocardiography indexes of patients undergoing heart valve replacement were compared. R2.15.2 software was used for statistical analysis. Results Twelve retrospective cohort studies were included in this study involving 833 patients. The quality of included literature was relatively high. Meta-analysis showed that left ventricular end-diastolic diameter （LVEDD） at 2 weeks， 6 months， 1 year， 2 to 3 years postoperatively were reduced by 11.72 mm［95% CI （9.52，13.92）， P＜0.001］， 20.02 mm ［95% CI （18.28， 21.76）， P＜0.001］， 22.48 mm ［95% CI （19.55， 25.40）， P＜0.001］ and 24.69 mm ［95% CI （22.21， 27.18）， P＜0.001］ respectively compared with preoperative value. Left ventricularend-systolic diameter （LVESD） at 2 weeks， 6 months， 1 year， 2 to 3 years postoperatively were reduced by 7.74 mm ［95% CI （3.76， 11.72）， P＜0.001］， 15.54 mm ［95% CI （12.55， 18.54）， P＜0.001］， 18.84 mm ［95% CI （15.54， 21.14），P＜0.001］ and 21.02 mm［95% CI （17.67， 24.37）， P＜0.001］ respectively compared with preoperative value. Compared with preoperative value， left ventricular ejection fraction （LVEF） decreased by 7% at 2 weeks postoperatively ［95% CI （1%， 12%）， P=0.013］， increased by 9% at 6 months postoperatively ［95% CI （-14%， -3%）， P=0.002］， increased by 11% at 1 year postoperatively ［95% CI （-22%， 0%）， P=0.041］， and increased by 13% at 2-3 years postoperatively ［95% CI （4%， 21%）， P=0.004］. Compared with preoperative value， left ventricular fraction shortening （LVFS） decreased by 0.05 at 2 weeks postoperatively ［95% CI （0.03， 0.07）， P＜0.001］， increased by 0.02 at 6 months postoperatively ［95% CI （0.00， 0.04）， P=0.055］， increased by 0.03 at 1 year postoperatively ［95% CI （0.00， 0.06）， P=0.035］， and increased by 6% at 2-3 years postoperatively ［95% CI （0.02， 0.11）， P=0.008］. Conclusions LVEED and LVESD of patients with valvular heart disease and giant left ventricle continuously decrease after heart valve replacement， especially in the first 6 months postoperatively， and return to normal in 2 to 3 years. LVEF and LVFS decrease in the first 2 weeks postoperatively， then start to increase， are higher than preoperative values at 6 months， and return to normal in 2 to 3 years. Heart valve replacement is conducive for the recovery of left ventricular morphology and systolic function of patients with valvular heart disease and giant left ventricle.
Abstract： Right ventricular dysfunction or right heart failure is a complex clinical syndrome and often leads to a poor prognosis and high mortality. In order to detect right ventricular dysfunction at an early stage, provide a therapy guidance and evaluate treatment outcomes， right ventricular function evaluation has aroused more and more concern in clinical physicians. With the advantages of being non-invasive， accuracy and repetitiveness， echocardiography is used extensively in the assessment of heart function. In this review， we focus on how to use echocardiography to evaluate right ventricular function easily, efficiently， accurately and sensitively， and provide a good foundation for its further clinical application.
Transesophageal echocardiogram (TEE) can promote the quality of cardiac surgery and reduce peri-operative complications, and thus has been gradually accepted by cardiac surgeons. Through an esophageal probe, TEE can clearly visualize the internal structure of the heart without interrupting surgical procedure. As a newly developed technology which breaks the limitations tied to the traditional two-dimensional TEE, the realtime threedimensional transesophageal echocardiogram (RT3D-TEE) has the advantages of showing threedimensional structure of the heart and providing full range of anatomical information of the heart. Furthermore, it can precisely analyze the anatomical structure of the abnormal heart valves and provide assessment of the change of heart volume. Relying on its unique imaging property, it can largely facilitate preoperative decision-making and provide realtime intraoperative guidance as well as accurate postoperative evaluation. It has now been successfully applied in various types of cardiac surgical procedures including valve repair surgery, congenital heart defect intervention, cardiac mass removal as well as heart function evaluation. In this article, we will review the applications of RT3D-TEE in cardiac surgery, and try to form a basis for its further clinical application.
Abstract: Objective To introduce a new technique: transthoracic closure of perimembranous ventricular septal defect (VSD) without cardiopulmonary bypass (CPB) under transesophageal echocardiography (TEE）guidance, and summarize the clinical experiences and midterm followup results. Methods A total of 136 patients with perimembranous VSD, 3 months to 15 years averaging 1.8 years, underwent transthoracic device closure. The weight of these patients ranged from 4.0 to 26.0 kg with an average weight of 12.7 kg. The diameter of their VSD ranged from 3 to 12 mm averaging 5.1 mm. A small transthoracic incision (34 cm incision by inferior sternotomy or 23 cm transverse incision in the third intercostal space) was made and the best location for right ventricular puncture was chosen and the delivery pathway was established under TEE guidance. Proper devices were delivered and then deployed to close the defect. Patients were followed up closely with a standard protocol, arranged for echocardiography, electrocardiogram and chest Xray film. Results In all the cases, 131 cases of VSD (96.3%) were successfully closed. The procedure time was less than 90 minutes and the implanting time was 5.42 minutes (16.3±5.7 min). Symmetrical devices were implanted into 89(67.9%) of the 131 patients and the other 42 patients (32.1%) were closed with asymmetrical ones. The result of TEE soon after operation showed that 3 patients had tiny residual shunt, 4 had new trivial and mild tricuspid regurgitation (TR). However, no TR worsening, aortic regurgitation (AR), complete atrioventricular heart block, or left or right outflow tract obstruction was detected in all patients. One patient 〖CM(159mm〗with transient atrioventricular block restored to sinus rhythm after 3 days of medical treatment. Five cases (3.7%) were converted to conventional open heart repair during the operation. Followup was done to all the patients for a period ranged from 6 months to 30 months (18.3±6.6 months). Tiny residual shunt in the 3 cases mentioned above vanished during the followup period. No new TR, AR, hemolysis, thrombosis, dislocation of the devices, or outflow stenosis was detected postoperatively. The tiny incision caused less psychologic depression. Conclusion Minimally invasive transthoracic device closure of VSD without CPB is a simple, effective and safe intervention under guidance of TEE for most of perimembranous VSD patients. The short and midterm clinical outcomes are promising. Longterm followup is indispensable.