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Real-time Three-dimensional Echocardiography (RT-3DE) Application in Evaluation of Left Ventricular Motion in Patients with Rheumatic Mitral Stenosis

ObjectiveTo evaluate myocardial segmental motion function in left ventricular of patients with rheumatic mitral stenosis by using the technology of real-time three-dimensional echocardiography (RT-3DE). MethodsWe retrospectively analyzed the clinical data of 14 patients with rheumatic mitral stenosis between October and November 2014 in our hospital as a trial group. There were 4 males and 10 females with a mean age of 50.9±9.0 years ranging from 34 to 64 years. We chose 11 healthy individuals as a control group. There were 7 males and 4 females with a mean age of 49.5±9.7 years ranging from 32 to 67 years. Both the two groups were subjected to myocardial performance evaluation using two-dimensional echocardiography (2DE) and real-time three-dimensional echocardiography (RT-3DE) to examine the left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), longitudinal strain, circumferential strain, area strain, and lateral strain of each left ventricular myocardial segments. Result RT-3DE detected that the trial group had significantly lower values of LVEF, LVEDV and LVESV than those of the control group (P < 0.05). RT-3DE also revealed that the trial group had a significantly weaker longitudinal strain than the control group (P < 0.05). ConclusionRT-3DE is an accurate technology for assessing myocardial motion and function in patients with rheumatic mitral valve disease.

參附注射液對二尖瓣置換術患者圍術期心肌酶及血流動力學的影響

目的 探討參附注射液對體外循環二尖瓣置換術（MVR）患者圍手術期心肌酶及血流動力學的影響。方法 將40例行MVR的患者隨機分為實驗組（n=20）和對照組（n=20），實驗組于麻醉誘導后手術開始前、術后12、36和60h經靜脈滴注參附注射液（1ml/kg）和250ml生理鹽水；對照組輸入等量的生理鹽水。于術前、術后2、8、24、48和72h取靜脈血檢測兩組血漿肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）含量，并觀察血流動力學指標變化及術中、術后血管活性藥物的用量。結果術后2、8、24、48和72h對照組血漿CK和CK—MB值均高于實驗組（Plt;0.05）。主動脈阻斷前、心臟復跳后30min、手術結束時實驗組平均動脈壓（MAP）均高于對照組（Plt;0.05）。術中和術后住ICU期間實驗組多巴胺和氨力農的用量均低于對照組（Plt;0.05）。結論 參附注射液能減輕心內直視手術患者的心肌損傷，對心功能有一定的保護作用。

Efficacy Analysis of Valvuloplasty for Anterior Leaflet Prolapse

Abstract： Objective To summarize the experiences and analyze the efficacy of mitral valvuloplasty in treating anterior leaflet prolapse. Methods A total of 152 consecutive nonrheumatic heart disease patients including 96 males and 56 females with anterior leaflet prolapse who underwent mitral valvuloplasty from February 1997 to March 2007 were analyzed retrospectively. The age of these patients ranged from 10 to 73 years old (38.54±17.22 years). There were 119 cases of mitral degenerative prolapse or chordae rupture, 24 of ongenital heart disease, 3 of ischemic mitral insufficiency, and 6 of native valve endocarditis. Echocardiography before operation showed the degree of mitral regurgitation was severe in 19, moderate to severe in 63, and moderate in 70 patients. Among the patients, 87 had anterior prolapse and 65 had bilateral prolapse. All patients underwent mitral valve repair under standard cardiopulmonary bypass. Results During the operation, transesophageal echocardiography and saline injection test showed satisfying results in all the patients. No early death occurred after operation. Followup was done to 135 patients for 3 months to 8.5 years with a followup rate of 88.82%. During the follow up, 93 patients were in New Yoke Heart Association（NYHA）class Ⅰ, 35 in Class Ⅱ, 3 in class Ⅲ and 4 in class Ⅳ. The Echocardiography showed that postoperative left atrium diameter (41.09±10.40 mm vs. 45.32±10.07 mm, t=4.186, P=0.000) and left ventricular enddiastolic dimension (52.04±7.74 mm vs. 60.70±7.72 mm,t=9.676, P=0.000) were significantly smaller than that before operation. No or trace mitral regurgitation (MR) was found in 36 patients, mild MR in 45 patients, mild to moderate MR in 38 patients, moderate MR in 9 patients, and moderate to severe MR in 7 patients. Mitral valve replacement was performed in 5 patients after valvuloplasty. Three died during the follow-up. Two of them died of heart failure and one of unknown cause. Conclusion In spite of the complexity, the longterm results of mitral valve repair for anterior leaflet prolapse are satisfactory if the best surgery method is chosen.

經導管二尖瓣緣對緣修復術救治急性心肌梗死并發二尖瓣乳頭肌斷裂一例

Surgical Treatment of Partial Atrioventricular Canal Defect in 66 Cases

Objective To summarize the experiences of surgical treatment for partial atrioventricular canal defect. Methods The data of 66 patients of surgical treatment for partial atrioventricular canal defect from January 1984 to December 2007 were analyzed retrospectively. The cleft of mitral valve presented in all of those patients. There were 52 cases with direct suture on cleft, 8 cases with direct suture with commissurroplasty, 1 case with posterior leaflet plasty, 3 cases with direct suture St.Jude ring and 2 cases mitral valve replacement. The ostium primum atrial septal defects were repaired with patches of Dacron in 12 cases and autologous pericardium in 54 cases. Coronary sinus was situated on the left atrium in 5 and ostium primum atrial septal defects were repaired in Kirklin’s way; the others in MeGoon’way. Meanwhile other heart abnormalities were done. Results There were two early deaths (3.03%), one patient died of heart arrhythmia and one patient died of respiratory failure. Complications of total A-V block was in 2 cases. Both of them were replanted with pace makers.52 cases were followed up, followup time was 5 months to 22 years(mean follow-up 15 years). All patients had better life. Four patients have been re -operated for different reasons post primary operation. One had good result after re-mitral valve replacement. One case died of acute renal failure and the other two died of low cardiac output syndrome. Conclusions Early operation is definitely recommended when the diagnosis is confirmed. Because the structure or function of mitral valve is saved, pulmonary hypertension is avoided and the mortality is lower in the future. The key points of operation are to rectify the mitral insufficiency, repair ostium primum atrial septal defects and avoid atrioventricular block. The patients of mild regurgitation of mitral valve have good results. Provided in those have more than middle regurgitation of mitral valve then their longterm results are poor.

右胸前外側切口行二尖瓣置換術

目的總結經右胸前外側切口徑路行二尖瓣置換術的臨床經驗。方法125例二尖瓣病變患者經右胸前外側切口徑路在體外循環下行二尖瓣置換術,首次行二尖瓣置換術45例,再次行二尖瓣置換術80例。手術切口位于右乳房下方,長約15～18cm,切口內側緣在胸骨右緣。結果術中升主動脈阻斷時間37.95±15.06min,體外循環時間72.36±17.40min。術后早期死亡4例,死亡率3.2%。術后并發室性心律失常5例,右肺不張2例。結論采用右胸前外側切口徑路行二尖瓣置換術具有顯露好、操作方便、損傷小、術后輸血少和美觀等優點,尤其適合再次心臟手術患者和女性患者。

保留后瓣及瓣下結構的二尖瓣置換術

目的 總結保留后瓣及瓣下結構的二尖瓣置換術（MVR）的臨床經驗，并觀察其與常規MVR比較的臨床效果。方法 風濕性心瓣膜病患者54例，其中行保留后瓣及瓣下結構的MVR24例（保留二尖瓣后瓣組），行常規MVR30例（常規手術組），觀察兩組患者術前、術后3個月的左心室舒張期末內徑（LVEDD）、左心室射血分數（LVEF）、左心室短軸縮短率（LVFS）等指標。結果 保留二尖瓣后瓣組無死亡患者，常規手術組死亡1例；保留二尖瓣后瓣組術后血管活性藥物的用量、種類和呼吸機使用時間較常規手術組減少；術后3個月保留二尖瓣后瓣組LVEDD較常規手術組減小，LVEF較常規手術組增大（P〈0．05）。結論 保留后瓣及瓣下結構的MVR手術操作不復雜，不增加心內手術時間，有可能減少左心室破裂的危險，術中操作仔細可以避免卡瓣，術后心功能恢復較好，更適用于心功能較差、左心室較大的以二尖瓣關閉不全為主的患者。

Clinical Application of Homemade Flexible Annuloplasty Ring in Mitral Valve Repair

Abstract: Objective To summarize the clinical results of homemade flexible annuloplasty ring in mitral valve repair, in order to discuss the appropriate ring size. Methods Sixtysix patients (55 males,and 11 females with a mean age of 44.62±15.94 years) with mitral insufficiency underwent mitral valve repair with homemade flexible annuloplasty ring from April 2002 to November 2009 in Fu Wai Hospital. In order to choose the ring with an appropriate size, we made and kept to the following principles: if the intercommissural distance was bigger than size 30, we chose a ring 2size smaller; if the measured distance was smaller than size 30, 1size smaller ring would be chosen. Patients were followed by echocardiography to observe the mitral valve function. Results All patients were cured and discharged from the hospital. The results of echocardiography showed mild to moderate regurgitation in 1 patient, mild regurgitation in 11 patients, and normal mitral function or trace regurgitation in the rest 54 patients. Mitral valve forward velocity was 1.40±0.30 m/s with no mitral stenosis or systolic anterior motion (SAM) of the anterior mitral leaflet. Fiftyone patients were followed up from 2 months to 7 years(24.60±25.90 months). The results of echocardiography on 38 patients showed that 1 patient had moderate regurgitation, 5 patients had mild to moderate regurgitation, 9 patients had mild regurgitation and others had normal mitral function or trace regurgitation. For these 38 patients included in the followup study, mitral valve forward velocity was 1.50±0.40 m/s with no mitral stenosis, SAM or left ventricular outlet tract obstruction. During the followup, the left atrium size (43.19±10.48 mm vs. 48.59±9.40 mm, t=4.524, P=0.000) and left ventricular end diastolic diameter (52.64±7.35 mm vs. 6269±8.77 mm, t=7.607, P=0.000) decreased significantly than the preoperative size and diameter respectively.  The application of restrictive homemade flexible annuloplasty ring in mitral valve annuloplasty had satisfactory, durable and stable clinical results.

Clinical Outcomes and Predictive Factor Analysis of Mild-to-moderate or Moderate Functional Mitral Regurgitationafter Aortic Valve Replacement in Patients with Severe Aortic Stenosis

Objective To evaluate clinical outcomes of mild-to-moderate or moderate functional mitral regurgitation（FMR）after aortic valve replacement （AVR） in patients with severe aortic stenosis （AS），and analyze prognostic factors of these patients with mild-to-moderate or moderate FMR （2＋to 3＋）. Methods From September 2008 to December　2011，a total of 156 patients with severe AS （peak aortic gradient （PAG）≥50 mm Hg） as well as FMR （2＋to 3＋） underwent　surgical treatment in Zhongshan Hospital. There were 95 male and 61 female patients with their average age of 59.2±10.5 years. Detailed perioperative clinical data were collected，and postoperative patients were followed up. The ratio of FMRpreoperative/FMR postoperative was calculated. Patient age，gender，body weight，history of hypertension，ventricular arrhythmia，atrial fibrillation （AF），left ventricular ejection fraction （LVEF），left ventricular end-diastolic diameter （LVEDD），left atrial diameter （LAD），pulmonary artery hypertension （PAH），PAG were assessed by logistic multivariate　regression analysis. Results Six patients died postoperatively，including 4 patients with low cardiac output syndrome and 2 patients with refractory ventricular arrhythmia. Perioperative mortality was 3.8%. The average follow-up time was 20.3±8.5 months and follow-up rate was 85.3% （133/156）. Eight patients died during follow-up，including 3 patients with heart failure，2 patients with ventricular arrhythmia，and 3 patients with anticoagulation-related cerebrovascular accident. Multivariate regression analysis showed that FMR preoperative/FMR postoperative ratio was not correlated with age≥55 years，male gender，body weight≥80 kg，LVEDD≥55 mm，LVEF≤50%，history of hypertension or ventricular　arrhythmia. However，LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF were negatively　correlated with postoperative FMR improvement. Conclusions Risk factors including LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF are negatively correlated with postoperative improvement of FMR （2＋to 3＋）. Patients with severe AS and above risk factors should receive concomitant surgical treatment for their FMR during AVR，since preoperative FMR（2＋to 3＋）usually does not improve or even aggravate after AVR.

Observation of left atrial hydrodynamic change in patients with rheumatic mitral stenosis

Objective To investigate the correlation between the left atrial hydrodynamic change and atrial fibrillation (AF) in the patients with rheumatic mitral stenosis. Methods According to cardiac rhythm before operation, 49 patients with rheumatic mitral stenosis accompanying chronic AF were divided into two groups,group A: AF, 25 cases; group B: sinus rhythm, 24 cases. Control group : 29 healthy volunteers were examined. By using echocardiography, left atrial hydrodynamics were tested, and repeated 6-8 months after the operation. Results Left atrial stress (LAS), left atriala area (LAA) and left atrial volume(LAV) in group A after operation was much lower than before operation, LAS after operation in group B was also lower than before operation(Plt;0.01). Before operation, LAS in group A was significantly lower than that in group B, LAA and LAVwere larger. After operation, LAA and LAV in group A were significantly larger than those in group B(Plt;0.01). LAS, LAA and LAV in group A and group B before and after operation were higher than those in control group. Conclusion Left atrial hydrodynamic enviroment in patients with mitral stenosis has not reached normal even after valve replacement, LAS may be an important factor of causing AF.