Left ventricular end-systolic wall stress to volume relationship before and after surgical closure of ventricular septal defect

Summary Left ventricular function was examined angiographically in 64 patients with ventricular septal defect and 13 postoperative patients with a preoperatively large shunt (postoperative group). The unoperated 64 patients were divided into three groups; small (left-to-right shunt ratio <35%), moderate (35%–50%), and large (>50%). The control group consisted of 27 patients with Kawasaki disease. For assessing left ventricular function, left ventricular shape and the end-systolic wall stress to end-systolic volume index ratio, as well as left ventricular ejection fraction were examined. Left ventricular ejection fraction was higher in the small-shunt group (p<0.05) than in the control group, but normal in the other groups. Left ventricular end-diastolic shape was normal only in the small-shunt group and more spherical in the other groups. The large-shunt group alone manifested more spherical left ventricular end-systolic shape and lower end-systolic wall stress to end-systolic volume index (p<0.001). These findings suggest that the left ventricular dysfunction is present in patients with a left-to-right shunt larger than 50%, but this change was reversible in patients who underwent early repair of ventricular septal defect.     

室间隔缺损并二尖瓣返流的病因及预后分析

目的：探讨小儿室间隔缺损（VSD）并二尖瓣返流（MR）的病因及预后。方法：应用HP－500或2000型超声心动图常规探查，明确有无VSD。确诊后应用二维超声、脉冲多普勒叠加彩色血液多切面探查二尖瓣口有无异常返流信号。结果：1787例单纯VSD患儿中233例并MR，其中82．0％有以复呼吸道感染，且感染次数越多，MR程度越重；9．9％VSD患儿二尖瓣存在先天性发育异常；SVD越大，重度MR者越多；手术者MR消失率（78．3％）较非手术者（37．4％）明显提高（P＜0．001）。结论：反复感染、瓣膜先天性病变、大的左向右分流与VSD和并发MR密切相关；适时关闭VSD或修补瓣膜可改善患儿预后。     

儿童室间隔缺损封堵术后早期完全性左束支传导阻滞心电图相关指标的变化

目的观察单纯室间隔缺损(VSD)患儿介入封堵术后早期发生完全性左束支传导阻滞(CLBBB)患儿的心电图变化。方法纳入21例行膜周部VSD介入封堵且术后早期出现CLBBB的患儿,同时以性别、年龄及封堵器大小进行1:1配对,纳入同时期术后未合并任何心律失常的单纯膜周部VSD的患儿21例作为对照组。比较两组患儿组间及组内术前、术后1 d、术后3 d、术后5 d、术后30 d心电图左室电压、QT间期、心率校正的QT间期(QTc)、QT离散度(QTd)、心率校正的QT离散度(QTcd)、JT离散度(JTd)和心率校正的JT离散度(JTcd)的变化。结果两组患儿左室电压、JTcd随手术时间的变化而变化(P0.05);左室电压及QTd变化存在时间因素与分组因素的交互效应(P0.05);CLBBB组与对照组的JTcd比较差异有统计学意义(P0.05);CLBBB组与对照组的左室电压在术后3 d和术后5 d组间比较差异有统计学意义(P0.05)。结论 VSD患儿介入封堵术后有无CLBBB者早期心电图指标左室电压和JTcd有差异,其中JTcd可能对预测术后早期CLBBB的发生有参考作用。     

Biventricular diastolic function assessed by Doppler echocardiogram in children vertically infected with human immunodeficiency virus

Objectiveto determine, by Doppler-echocardiography, the frequency of cardiac diastolic dysfunction in asymptomatic and clinically stable pediatric patients with vertical infection by the human immunodeficiency virus (HIV), from the cardiovascular viewpoint.Methodsthis was an observational, prospective, and cross-sectional study, performed at a regional referral clinic for patients with HIV, in a convenience sample of 94 individuals, assessing biventricular diastolic function by Doppler-echocardiography, and weight, blood hemoglobin, and percentage of lymphocytes T-CD4⁺.Resultsfifty patients had diastolic dysfunction. Left ventricular dysfunction occurred in 38.7%, and the predominant type of dysfunction was decreased myocardial compliance. Right ventricular dysfunction was observed in 29.4% of the sample, and abnormal relaxation was the most prevalent type. Simultaneous biventricular dysfunction occurred in 14.1% of the individuals. There was no association between dysfunction and the immune status.Conclusionsdiastolic dysfunction occurred, individually or simultaneously, with no association with immune status; decreased myocardial compliance was predominant in the left ventricle, and abnormal relaxation in the right ventricle.     

儿童室间隔缺损自然闭合影响因素探讨

目的探讨影响儿童室间隔缺损(VSD)自然闭合的因素。方法于1993-01—2006-01采用彩色二维多普勒超声心动图仪或实时三维心脏彩色多普勒超声仪对潍坊市人民医院儿科诊治的372例单纯VSD患儿进行多切面观察,充分显示VSD部位、游离缘,测量缺损大小、穿隔血流宽度、肺动脉收缩压(Pp)和双室内径等,并查X线胸片及体检。每3～6个月随访1次,最长随访时间8年。结果75例VSD自然闭合,确诊年龄(11.7±5.1)个月,闭合年龄(26.2±11.6)个月。6个月至3岁组闭合率最高(72.0%),后依次为<6个月组(13.3%),～6岁组(12.1%),～7岁组(2.7%);闭合组62例收缩期杂音消失,13例变为Ⅰ或Ⅱ级局限的收缩期杂音;闭合组均为小中型VSD,大型VSD无一例闭合,两组差异有显著性(P<0.01)。闭合组和未闭合组VSD直径分别为(8.7±3.6)mm、(13.7±4.8)mm,差异有统计学意义(P<0.01);单发VSD闭合率高于多发VSD(P<0.01);膜周部VSD闭合62例,肌部VSD闭合13例,干下型无闭合病例,差异有显著性意义(P<0.01)。肌部VSD闭合率高于膜周部(P<0.01);超声心动图(UCG)显示VSD游离缘不规整回声弱者闭合率显著高于游离缘规整回声强者(P<0.01);闭合组和未闭合组Pp分别为(27.2±11.7)mmHg(1mmHg=0.133kPa)、(39.2±12.6)mmHg,差异有统计学意义。Pp越高,自然闭合率越低,>50mmHg无闭合病例;闭合组左室舒张末径(LVEDD)、右室舒张末径(RVEDD)、心胸比率(C/T值)显著低于未闭合组(P均<0.01)。结论VSD患儿年龄,缺损大小、类型、数目、形态,Pp,心室大小是影响VSD自然闭合的因素。VSD游离缘回声弱且不规整形态可作为缺损有自然闭合趋势的重要标志。Pp监测对判定漏诊的多发VSD有一定价值。     

Validity of electrocardiographic criteria for left ventricular hypertrophy in children with pressure- or volume-loaded ventricles: Comparison with echocardiographic left ventricular muscle mass

To determine the correlation between electrocardiographic (ECG) findings and anatomy utilizing echocardiography in children with pressure- or volume-loaded left ventricles, we analyzed the preoperative ECG tracings of 19 patients who underwent surgery for significant aortic stenosis and 12 patients who underwent cardiac catheterization or surgery for clinically significant ventricular septal defects. We then compared them with a group of 21 normal controls. The left ventricular muscle mass in these patients was calculated from echocardiograms using the simplified cubed formula. Posterior and septal wall thickness and cavity size were significantly greater in the aortic stenosis group than in the normal group. Only cavity size was significantly greater in the ventricular septal defect group than in the normal group. Eighteen aortic stenosis patients (95%) and ten ventricular septal defect patients (83%) had a left ventricular muscle mass greater than 2 standard deviations above the mean for the normal group. Significant differences were found in the voltages of SV1+RV6 and in the voltage of RV6 alone between normals, aortic stenosis patients, and ventricular septal defect patientsregardless of age. Using conventional ECG criteria for left ventricular hypertrophy, the highest sensitivity in aortic stenosis patients (67%) and ventricular septal defect patients (60%) was modest. The likelihood ratio for a positive test in either group was the best for SV1+RV6 >98^th centile for age; RV6>98^th centile for age was the best single measurement. No correlation was found between voltage and any measurable hemodynamic or anatomic data. Conventional pediatric ECG criteria for left ventricular hypertrophy have only modest sensitivity regardless of whether the heart is under pressure or volume load. Because left ventricular muscle mass can be precisely determined by echocardiography, these ECG criteria should be applied cautiously.     

室间隔缺损手术中减少手术输血的安全性研究

目的探讨室间隔缺损手术中减少手术输血对患儿输血量、安全性和并发症的影响。方法选择新乡市中心医院2018年1月至2019年6月行室间隔缺损修补手术的患儿72例,男38例,女34例;年龄4~10岁。采用随机数字表法分为减少输血组和对照组,每组各36例。减少输血组:(1)麻醉后根据血压情况经中心静脉缓慢放血5 mL/kg,储存入专用枸橼酸抗凝储血袋置4℃恒温冰箱中保存;(2)从切皮开始严密止血,锯开胸骨止血后,全身肝素化,回收创面出血,使用自体血回收装置;(3)尽量缩短体外循环管路,术中红细胞比容(Hct)在0.18~0.20以上不输注红细胞,停体外循环后,回输膜肺及管道余血;(4)术中足量使用抗纤溶药物,鱼精蛋白中和后使用自体血回收装置回收血液;(5)应用止血药物和止血材料;(6)术后入住重症监护室(ICU)后控制血压在适当水平,避免血压过高引起出血,避免盲目补液,减少不必要的血液稀释;(7)术后早期鼓励患儿下床活动,改善患儿胃肠道活动,以达增强营养的目的。对照组:(1)不常规术前预备自体血;(2)主动脉插管前全身肝素化;(3)常规体外循环装置;(4)ICU常规治疗。对2组患儿一般情况、红细胞输注率、平均红细胞用量、术中失血量、术后引流量、手术时间、脱离呼吸机时间、ICU停留时间、住院时间、住院费用、肺部感染率、二次气管插管率、二次手术率、转中胶体渗透压(COP)及转中、术前、术后、出院时血红蛋白量、Hct等进行比较。结果72例患儿均顺利康复出院,减少输血组红细胞输注率为22.22%(8/36例),对照组红细胞输注率为83.33%(30/36例),2组比较差异有统计学意义(χ2=93.12,P<0.05)。减少输血组红细胞用量为(1.56±0.68)U,对照组红细胞用量为(4.26±1.12)U,2组比较差异有统计学意义(t=1.18,P<0.05)。减少输血组术后失血量、术后引流量、术后住院时间、住院费用少于对照组,2组比较差异均有统计学意义(t=1.38、2.35、2.22,均P<0.05)。2组手术时间、ICU停留时间、脱离呼吸机时间、出院时血红蛋白量、出院时Hct比较差异均无统计学意义(t=0.25、0.85、0.85、0.72,均P>0.05)。2组肺部感染率、二次气管插管率、二次手术率比较差异均无统计学意义(χ2=56.36、55.33、55.33,均P>0.05)。结论室间隔缺损患儿手术中采用减少手术输血安全可行,且有助于减少室间隔缺损患儿围术期血液用品数量,节约住院费用,减少输血并发症。     

膜部室间隔缺损封堵术后完全性左束支传导阻滞治疗效果分析

目的探讨儿童膜部室间隔缺损(VSD)封堵术后完全性左束支传导阻滞(CLBBB)的治疗及预后。方法回顾分析2009年2月至2019年6月就诊的18例VSD封堵术后CLBBB患儿的临床资料。结果 18例接受VSD封堵术并经心电图检测确诊CLBBB患儿的平均年龄为5.69±2.33岁(3岁2个月～10岁5个月),男性11例、女性7例,随访时间中位数5年(3个月～10年)。14例无心力衰竭患儿中4例经糖皮质激素治疗CLBBB即恢复,随访3～6个月各项指标均无异常;8例随访5～10年,无不适,心电图无变化,心功能、左室射血分数、心房利钠肽均无异常,但左室舒张末期内径(LVDD)增大;2例接受封堵器取出及VSD修补术,1例术后出现完全性右束支传导阻滞,余无异常,另1例术后出现完全性房室传导阻滞,植入起搏器,随访1年QRS波时限较术前缩短,心功能无异常,LVDD增大。4例合并心力衰竭患儿中3例行心脏再同步化治疗(CRT)植入术,1例行左室起搏,术后QRS波均150 ms;1例行CRT术后3天因急性心力衰竭死亡,另3例随访1～2年心功能明显改善。结论对于VSD封堵术后早期出现CLBBB患儿,糖皮质激素可能有效,若无效,可选择手术取出封堵器,但有发生完全性房室传导阻滞的风险。若合并心力衰竭,CRT或左室起搏治疗可能有一定效果。     

多普勒超声心动图对先天性心脏病合并肺动脉高压儿童左室形态与功能的评价

目的：探讨多普勒超声心动图对先天性心脏病（CHD）儿童肺动脉高压（PAH）的诊断价值及PAH对左室重塑和舒张功能（LVDF）的影响。方法：对彩色多普勒超声心动图证实的45例继发肺动脉高压的先天性心脏病患儿的超声心动图和多普勒血流资料与22例无PAH的先天性心脏病患儿（对照组）对比分析。结果：PAH组及对照组的左室舒张末内径分别为18.24±1.71 mm vs 16.28±0.52 mm、右室内径 12.23±2.14 mm vs 8.14±0.73 mm、肺动脉内径 11.20±1.35 mm vs 7.92±0.21 mm。两组比较差异有显著性（P<0.05）；VTR 流速增快（2.56±0.46）m/s及PASP压力（40.23±4.56）mmHg升高 ，与对照组相比差异亦有显著性（P<0.05）；室间隔增厚与对照组相比差异不明显。对照组、PAH组的二尖瓣口血流多普勒频谱A峰流速分别为94.56±31.45 m/s vs 51.17±26.67 m/s、A峰流速速度时间积分为10.89±2.73 s vs 4.94±1.85 s及AV/EV为1.79±0.32 vs 0.59±0.19、AVTI/EVTI为1.61±0.49 vs 0.45±0.21 两组比较差异有显著性(P<0.01)。左室等容舒张时间分别为119. 86±54.62 s vs 52.31±28.06 s。PAH组明显延长(P<0.05)。E峰流速、E峰流速速度时间积分及E峰减速时间两组无明显改变(P>0.05)。而增高的肺动脉压与二尖瓣口血流频谱AV/EV比值呈正相关,相关系数 r=0.4 456， P<0.01。结论：多普勒超声心动图不仅是先天性心脏病儿童合并肺动脉高压最重要的诊断方法之一，还可提供肺动脉高压对左室重塑和舒张功能受损的指标，对临床判断病情轻重及预后有重要价值。［中国当代儿科杂志，2007，9（5）：422-424］