• 【2型糖尿病患者的心肌脂肪变性和双心室应变及应变率成像。】 复制标题 收藏 收藏
    DOI:10.1161/CIRCULATIONAHA.110.955542 复制DOI
    作者列表:Ng AC,Delgado V,Bertini M,van der Meer RW,Rijzewijk LJ,Hooi Ewe S,Siebelink HM,Smit JW,Diamant M,Romijn JA,de Roos A,Leung DY,Lamb HJ,Bax JJ
    BACKGROUND & AIMS: BACKGROUND:Magnetic resonance spectroscopy can quantify myocardial triglyceride content in type 2 diabetic patients. Its relation to alterations in left (LV) and right (RV) ventricular myocardial functions is unknown. METHODS AND RESULTS:A total of 42 men with type 2 diabetes mellitus were recruited. Exclusion criteria included hemoglobin A(1c) >8.5, known cardiovascular disease, diabetes-related complications, or blood pressure >150/85 mm Hg. Myocardial ischemia was excluded by a negative dobutamine stress test. LV and RV volumes and ejection fraction were quantified by magnetic resonance imaging. LV global longitudinal and RV free wall longitudinal strain, systolic strain rate, and diastolic strain rate were quantified by echocardiographic speckle tracking analyses. Myocardial triglyceride content was quantified by magnetic resonance spectroscopy and dichotomized on the basis of the median value of 0.76. The median age was 59 years (25th and 75th percentiles, 54 and 62 years). Median diabetes diagnosis duration was 4 years, and median glycohemoglobin level was 6.2 (25th and 75th percentiles, 5.9 and 6.8). There were no differences in LV and RV end-diastolic and end-systolic volume indexes and ejection fraction between patients with high (≥0.76) and those with low (<0.76) myocardial triglyceride content. However, patients with high myocardial triglyceride content had greater impairment of LV and RV myocardial strain and strain rate. The myocardial triglyceride content was an independent correlate of LV and RV longitudinal strain, systolic strain rate, and diastolic strain rate. CONCLUSIONS:High myocardial triglyceride content is associated with more pronounced impairment of LV and RV functions in men with uncomplicated type 2 diabetes mellitus.
    背景与目标: 背景:磁共振波谱技术可以量化2型糖尿病患者的心肌甘油三酯含量。它与左心室(LV)和右心室(RV)心肌功能改变的关系尚不清楚。
    方法与结果:总共招募了42名2型糖尿病男性。排除标准包括血红蛋白A(1c)> 8.5,已知的心血管疾病,糖尿病相关并发症或血压> 150/85 mm Hg。多巴酚丁胺负荷试验阴性排除了心肌缺血。左室和右室体积和射血分数通过磁共振成像定量。通过超声心动图斑点跟踪分析定量左室总纵和右室游离壁的纵向应变,收缩应变率和舒张应变率。心肌甘油三酯含量通过磁共振波谱法定量,并在0.76的中值的基础上二分。中位年龄为59岁(第25和75个百分位数,54和62岁)。糖尿病的中位诊断持续时间为4年,中位糖化血红蛋白水平为6.2(第25和第75个百分位数,分别为5.9和6.8)。高(≥0.76)和低(<0.76)心肌甘油三酯患者之间的LV和RV舒张末期和收缩末期容积指数和射血分数无差异。然而,高甘油三酸酯含量的患者对LV和RV心肌应变和应变率的损害更大。心肌甘油三酯含量与LV和RV纵向应变,收缩压应变率和舒张压应变率有独立的相关性。
    结论:高甘油三酸酯含量与2型糖尿病患者并发LV和RV功能明显受损有关。
  • 【经导管肺动脉瓣穿孔后肺闭锁完整的室间隔中度发育不良的右心室患者实现双室循环。】 复制标题 收藏 收藏
    DOI:10.1111/chd.12658 复制DOI
    作者列表:Chen RHS,K T Chau A,Chow PC,Yung TC,Cheung YF,Lun KS
    BACKGROUND & AIMS: OBJECTIVE:Transcatheter valve perforation for pulmonary atresia intact ventricular septum is the standard of care for patients with mild right ventricular hypoplasia. However, its role in moderate right ventricular hypoplasia has been less well defined. We sought to report the long-term outcome of patients with moderate hypoplastic right ventricle who had undergone the procedure. DESIGN, SETTINGS, AND PATIENTS:We performed a retrospective analysis on patients who had undergone transcatheter pulmonary valve perforation from January 1996 to January 2015 at our institution. The procedures would be carried out irrespective of the right ventricular size, as long as there were no absolute contraindications. INTERVENTION AND OUTCOME MEASURES:Demographic and procedural data were correlated with outcome measures. Outcomes analyzed included procedural success, reintervention rates, final circulation type, and functional class. Multivariate analysis and receiver operator curve were used to identify for parameters in predicting biventricular circulation. RESULTS:The procedural success rate was 92% (33 out of 36) in this group with moderate right ventricular hypoplasia (tricuspid valve z score -4.2 ± 3.0, 69.4% of patients with z score <-2.5). Early reintervention rate was 39%, mostly being insertion of modified Blalock-Taussig shunt. Overall reintervention-free survival was 53%, 30%, and 19% at 1, 6, and 12 months postintervention. Despite no significant catch-up right ventricular growth, majority of survivors (84%) enjoyed a biventricular circulation with good functional status. A tricuspid to mitral valve ratio >0.79 was a good predictor of biventricular outcome. (specificity of 100%, positive predictive value 100%) CONCLUSION: Encouraging long-term results with biventricular circulation and functional status were demonstrated with transcatheter pulmonary valve perforation in patients even with moderate hypoplastic right ventricle, which is comparable to that with mild right ventricular hypertrophy. The baseline tricuspid to mitral valve ratio was identified as a potentially useful tool in predicting biventricular circulation.
    背景与目标: 目的:经导管瓣膜穿孔治疗肺动脉闭锁完整的室间隔是轻度右室发育不全患者的标准治疗方法。但是,其在中度右心室发育不全中的作用尚未明确。我们试图报告接受该手术的中度发育不良右心室患者的长期预后。
    设计,地点和患者:我们对1996年1月至2015年1月间在本机构行经导管肺动脉瓣穿孔的患者进行了回顾性分析。只要没有绝对的禁忌症,就可以进行手术,而与右心室的大小无关。
    干预措施和结果指标:人口统计学和程序数据与结果指标相关。分析的结果包括手术成功率,再干预率,最终循环类型和功能类别。多变量分析和接收机操作员曲线用于确定预测双心室循环的参数。
    结果:该组中度右心室发育不全(三尖瓣z评分-4.2±3.0,z评分<-2.5的患者中有69.4%)的手术成功率为92%(36分之33)。早期再干预率为39%,主要是插入改良的Blalock-Taussig分流器。干预后1、6和12个月的无干预总生存率为53%,30%和19%。尽管右心室没有明显的追赶性增长,但大多数幸存者(84%)的双心室循环功能状态良好。三尖瓣对二尖瓣的比率> 0.79是双室结局的良好预测指标。 (特异性为100%,阳性预测值为100%)结论:即使是中度右室发育不良的患者,经导管肺动脉穿孔也证明了双室循环和功能状态的长期结果令人鼓舞。肥大。基线三尖瓣对二尖瓣比被确定为预测双心室循环的潜在有用工具。
  • 【连续右室起搏对急性右心室压力超负荷的影响。】 复制标题 收藏 收藏
    DOI:10.1152/ajpheart.00446.2006 复制DOI
    作者列表:Quinn TA,Berberian G,Cabreriza SE,Maskin LJ,Weinberg AD,Holmes JW,Spotnitz HM
    BACKGROUND & AIMS: :Temporary sequential biventricular pacing (BiVP) is a promising treatment for postoperative cardiac dysfunction, but the mechanism for improvement in right ventricular (RV) dysfunction is not understood. In the present study, cardiac output (CO) was optimized by sequential BiVP in six anesthetized, open-chest pigs during control and acute RV pressure overload (RVPO). Ventricular contractility was assessed by the maximum rate of increase of ventricular pressure (dP/dt(max)). Mechanical interventricular synchrony was measured by the area of the normalized RV-left ventricular (LV) pressure diagram (A(PP)). Positive A(PP) indicates RV pressure preceding LV pressure, whereas zero indicates complete synchrony. In the control state, CO was maximized with nearly simultaneous stimulation of the RV and LV, which increased RV (P = 0.006) and LV dP/dt(max) (P = 0.002). During RVPO, CO was maximized with RV-first pacing, which increased RV dP/dt(max) (P = 0.007), but did not affect LV dP/dt(max), and decreased the left-to-right, end-diastolic pressure gradient (P = 0.023). Percent increase of RV dP/dt(max) was greater than LV dP/dt(max) (P = 0.014). There were no increases in end-diastolic pressure to account for increases in dP/dt(max). In control and RVPO, RV dP/dt(max) was linearly related to A(PP) (r = 0.779, P < 0.001). The relation of CO to A(PP) was curvilinear, with a peak in CO with positive A(PP) in the control state (P = 0.004) and with A(PP) approaching zero during RVPO (P = 0.001). These observations imply that, in our model, BiVP optimization improves CO by augmenting RV contractility. This is mediated by changes in mechanical interventricular synchrony. Afterload increases during RVPO exaggerate this effect, making CO critically dependent on simultaneous pressure generation in the RV and LV, with support of RV contractility by transmission of LV pressure across the interventricular septum.
    背景与目标: :暂时性双心室起搏(BiVP)是一种有前景的术后心脏功能障碍的治疗方法,但改善右心室(RV)功能障碍的机制尚不清楚。在本研究中,在控制和急性RV压力超负荷(RVPO)期间,通过连续BiVP对六只麻醉的开胸猪进行了心输出量(CO)的优化。通过最大心室压力增加率(dP / dt(max))评估心室收缩力。机械室间同步性是通过标准化RV左心室(LV)压力图(A(PP))的面积来测量的。正A(PP)表示RV压力先于LV压力,而零表示完全同步。在对照状态下,CO在几乎同时刺激RV和LV的情况下最大化,从而增加RV(P = 0.006)和LV dP / dt(max)(P = 0.002)。在RVPO期间,通过RV优先起搏可使CO最大化,从而增加RV dP / dt(max)(P = 0.007),但不影响LV dP / dt(max),并降低从左到右的末端舒张压梯度(P = 0.023)。 RV dP / dt(max)的增加百分比大于LV dP / dt(max)(P = 0.014)。舒张末期压力没有增加以说明dP / dt(max)的增加。在对照组和RVPO中,RV dP / dt(max)与A(PP)呈线性相关(r = 0.779,P <0.001)。 CO与A(PP)的关系呈曲线关系,在RVPO期间,CO的峰值在控制状态下为正A(PP)(P = 0.004),而A(PP)接近零(P = 0.001)。这些观察结果表明,在我们的模型中,BiVP优化可通过增加RV收缩力来改善CO。这是由机械心室同步性的改变所介导的。在RVPO期间后负荷增加会加剧这种效应,使CO严重依赖于RV和LV中同时产生的压力,并通过LV压力跨室间隔的传递来支持RV收缩力。
  • 【双侧心律除颤器植入术中对侧入路结合静脉去闭塞术的意义】 复制标题 收藏 收藏
    DOI: 复制DOI
    作者列表:Jacon P,Benhalima A,Thony F,Defaye P
    BACKGROUND & AIMS: :The authors report the case of a patient in whom a biventricular defibrillator was successfully implanted from the right, following a failed approach from the left. The patient had chronic thrombosis of the subclavian vein, and this procedure was only possible after venous deocclusion and the positioning of an endoprosthesis. The authors underline the significance of the contralateral approach in case of difficulties in inserting pacing devices, as well as the complementary benefits of interventional radiological procedures in order to allow vascular access in cases of chronic venous thrombosis.
    背景与目标: :作者报告了一个患者的情况,该患者从左侧失败的方法成功地从右侧植入了双心室除颤器。该患者患有锁骨下静脉的慢性血栓形成,只有在静脉脱塞并放置了内置假体后才可以进行此操作。作者强调了对侧入路在难以插入起搏装置的情况下的重要性,以及在慢性静脉血栓形成的情况下为了允许血管通路而进行介入放射学治疗的补充益处。
  • 【临时性双室支持和体外膜氧合:一种适用于多器官功能衰竭的心源性休克的可行治疗方法。】 复制标题 收藏 收藏
    DOI:10.1007/s10047-017-0966-5 复制DOI
    作者列表:Seguchi O,Fujita T,Watanabe T,Kuroda K,Hisamatsu E,Nakajima S,Sato T,Sunami H,Yanase M,Hata H,Kobayashi J,Nakatani T,Fukushima N
    BACKGROUND & AIMS: :Various strategies using a ventricular assist device (VAD) are applied to rescue Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (Profile-1) patients. However, the optimal use of VAD in Profile-1 patients has not been completely elucidated. We retrospectively reviewed 23 Profile-1 patients [mean age 36.9 ± 16.6 years, 14 males; 11 with non-ischemic cardiomyopathy (NICM), 9 with fulminant myocarditis (FM), 2 with ischemic cardiomyopathy (ICM), and 1 with peripartum cardiomyopathy (PPCM); 18 with pre-operative percutaneous extracorporeal membrane oxygenation (p-ECMO) support] who underwent VAD implantation from 2011 to 2015 at our institution. Nine initially received left VAD (LVAD) alone (NICM in 9, ICM in 2 with ICM, and FM in 1), one with NICM received biventricular VAD (BiVAD; n = 1), and 10 received LVAD combined with right ventricular support using an ECMO circuit (BiVAD-ECMO) (FM in 8, NICM in 1, and PPCM in 1). Paracorporeal VAD was used in all patients. ECMO was used for the patients with severe pulmonary edema, inflammation, anemia, and thrombopenia. The BiVAD patient died 1.4 months after VAD implantation. The overall survival was comparable between patients with BiVAD-ECMO and LVAD (2-year survival, 80.0 and 75.0%, respectively). Three VAD strategies were initially applied in Profile-1 patients. Among them, the BiVAD-ECMO strategy is a promising therapeutic option to rescue Profile-1 patients with multiple organ failure.
    背景与目标: :使用心室辅助设备(VAD)的各种策略可用于挽救机械辅助循环支持配置文件1(Profile-1)患者的机构间注册表。但是,尚未完全阐明Profile-1患者中VAD的最佳用法。我们回顾性地回顾了23例Profile-1患者[平均年龄36.9±16.6岁,14例男性;非缺血性心肌病(NICM)11例,暴发性心肌炎(FM)9例,缺血性心肌病(ICM)2例,围产期心肌病(PPCM)1例; 18例术前经皮体外膜氧合作用(p-ECMO)支持,他们于2011年至2015年在我们机构接受了VAD植入。最初有9个单独接受左VAD(LVAD)(NICM为9个,ICM为2个,ICM为FM,1个为FM),一个NICM则接受双心室VAD(BiVAD; n = 1),另外10个接受LVAD联合右心室支持ECMO电路(BiVAD-ECMO)(FM输入为8,NICM输入为1,PPCM输入为1)。所有患者均使用了体外VAD。 ECMO用于严重肺水肿,炎症,贫血和血小板减少症的患者。 BiVAD患者在VAD植入后1.4个月死亡。 BiVAD-ECMO和LVAD患者的总体生存率相当(2年生存率分别为80.0和75.0%)。最初在Profile-1患者中应用了三种VAD策略。其中,BiVAD-ECMO策略是挽救多器官功能衰竭的Profile-1患者的有前途的治疗选择。
  • 【双室辅助设备的微创植入。】 复制标题 收藏 收藏
    DOI:10.1055/s-0034-1367736 复制DOI
    作者列表:Deuse T,Reichenspurner H
    BACKGROUND & AIMS: :As minimally invasive left ventricular assist device implantation is being advocated and more widely performed, bailout strategies for postoperative right ventricular failure (RVF) become necessary. We describe our surgical technique for additional right ventricular assist device implantation through a third mini-thoracotomy incision. This new technique allows avoidance of sternotomy even if RVF occurs.
    背景与目标: 随着微创左室辅助装置的植入和广泛应用,术后右心衰竭(RVF)的救助策略变得十分必要。我们描述了我们的外科手术技术,通过第三次迷你开胸切口进一步植入了右心室辅助装置。即使发生RVF,这种新技术也可以避免胸骨切开术。
  • 【心衰双室起搏后左心室和右心室节段功能早期变化的评估:组织多普勒成像研究。】 复制标题 收藏 收藏
    DOI:10.1177/0003319706291173 复制DOI
    作者列表:Bilge AK,Ozben B,Ozyigit T,Acar D,Hunerel D,Adalet K,Nisanci Y
    BACKGROUND & AIMS: :Tissue Doppler imaging allows assessment of systolic and diastolic regional ventricular function. The aim of this study was to assess early changes in regional systolic and diastolic functions and differences in transition time to contraction between the ventricles after cardiac resynchronization therapy. Fourteen patients were included, who underwent echocardiography before and 1 month after resynchronization. The difference between transition time to contraction of left and right ventricles decreased to 24.4 +/- 10.7 milliseconds from 65.3 +/- 18.2 milliseconds after resynchronization therapy (P = .001). There was a significant relation between the decrease in difference between transition time and increase in ejection fraction (r = 0.80, P = .002). Early or late diastolic myocardial motion increased in 7 segments of left and 2 segments of right ventricles. Systolic myocardial motion increased in 7 segments of left and in all segments of right ventricles. Resynchronization therapy improved systolic and diastolic functions in both ventricles. The difference between transition time to contraction of ventricles might be helpful in estimating optimal resynchronization.
    背景与目标: :组织多普勒成像可评估收缩和舒张区域心室功能。这项研究的目的是评估心脏再同步治疗后区域收缩和舒张功能的早期变化以及心室之间收缩过渡时间的差异。包括十四名患者,他们在再同步之前和之后1个月接受了超声心动图检查。左心室和右心室收缩之间的过渡时间之间的差异从再同步治疗后的65.3 /-18.2毫秒降低到24.4 /-10.7毫秒(P = .001)。过渡时间之间的差异减少与射血分数增加之间存在显着关系(r = 0.80,P = .002)。舒张早期或晚期心肌运动在左心室的7个部分和右心室的2个部分中增加。在左心室的7个节段和右心室的所有节段中,收缩期心肌运动均增加。重新同步治疗改善了两个心室的收缩和舒张功能。过渡时间到心室收缩之间的差异可能有助于估计最佳的再同步。
  • 【通过完整的静脉通路放置双心室Impella。】 复制标题 收藏 收藏
    DOI:10.1002/ccd.27103 复制DOI
    作者列表:Kamioka N,Patel A,Burke MA,Greenbaum A,Babaliaros V
    BACKGROUND & AIMS: :Impella (Abiomed, Danvers, MA) is an effective option for emergent treatment of critical refractory cardiogenic shock. However, in patients who have inadequate peripheral arterial access, Impella for left ventricular support sometimes requires surgical access, leading to disadvantages for emergent procedures or invasiveness for very sick patients. In addition, Impella for right ventricular support was recently reported to contribute to the management of severe biventricular dysfunction. In this report, we describe a case of refractory cardiogenic shock in a patient with inadequate vascular access who was treated with biventricular Impella via venous and caval-aortic access under conscious sedation. This technique can be used as a bridge to surgical ventricular assist device or heart transplantation. © 2017 Wiley Periodicals, Inc.
    背景与目标: :Impella(Abiomed,Danvers,MA)是紧急治疗严重难治性心源性休克的有效选择。但是,在外周动脉通路不足的患者中,用于左心室支持的Impella有时需要进行手术通路,这对重病患者的紧急手术或侵入性造成不利影响。此外,最近报道了用于右心室支持的Impella有助于严重的双室功能障碍的治疗。在本报告中,我们描述了在血管通路不足的患者中发生难治性心源性休克的情况,该患者在有意识的镇静作用下经静脉和腔-主动脉通路接受了双室Impella的治疗。该技术可以用作通向手术室辅助设备或心脏移植的桥梁。分级为4 +©2017 Wiley Periodicals,Inc.
  • 【优化双室起搏中房室和室间隔延迟的不同方法的比较。】 复制标题 收藏 收藏
    DOI:10.1093/europace/eum287 复制DOI
    作者列表:Zuber M,Toggweiler S,Roos M,Kobza R,Jamshidi P,Erne P
    BACKGROUND & AIMS: AIMS:It has been shown that optimizing atrioventricular (AV) and interventricular (VV) delay improves cardiac performance in patients with biventricular pacemakers. However, there is no standard method for optimization available yet. The aim of this study was to compare echocardiographic parameters-displacement imaging, A wave duration, and aortic velocity time integral (VTI)-and acoustic cardiography derived electromechanical activation time (EMAT) using different approaches of AV and VV delay optimization. We tested whether the initial optimization of the AV interval followed by VV optimization at that optimal AV interval or initial optimization of the VV interval followed by AV optimization at the determined optimal VV interval was accurate and consistent, and how this compared to testing every conceivable combination of AV and VV intervals available. METHODS AND RESULTS:A group of 20 patients with biventricular pacemakers was included. Displacement imaging, A wave duration, and aortic VTI were determined at different combinations of AV (100, 150, 200, 250 ms) and VV (RV40, 0, LV40 ms) intervals. If AV duration was determined first, displacement imaging identified the best setting in 8/20, aortic VTI in 10/20, A duration in 13/20, and EMAT in 18/20 patients. With VV duration determined first, the best setting was more difficult to identify regardless of the method used. There was a poor agreement in optimal AV and VV delays of the different methods, and there was no single patient in whom all four methods yielded the same delay combination. CONCLUSION:It is advisable to measure a full grid of AV and VV delays to identify optimal settings rather than optimizing one of the two delays first. Different techniques for delay optimization resulted in different optimal delay combinations.
    背景与目标: 目的:研究表明,优化房室(AV)和心室间(VV)延迟可改善双室起搏器患者的心脏性能。但是,尚无标准的优化方法可用。这项研究的目的是比较使用不同的AV和VV延迟优化方法的超声心动图参数-位移成像,A波持续时间和主动脉速度时间积分(VTI)和心电图得出的机电激活时间(EMAT)。我们测试了AV间隔的初始优化,随后在该最佳AV间隔处的VV优化或VV间隔的初始优化,然后在确定的最佳VV间隔处进行AV优化的准确性和一致性,以及与测试每种可能的组合进行比较可用的AV和VV间隔。
    方法与结果:纳入20例双室起搏器。在AV(100、150、200、250 ms)和VV(RV40、0,LV40 ms)间隔的不同组合下确定位移成像,A波持续时间和主动脉VTI。如果首先确定AV持续时间,则置换成像可确定8/20的最佳设置,10/20的主动脉VTI,13/20的A持续时间和18/20的患者的EMAT。首先确定VV持续时间,无论采用哪种方法,都很难确定最佳设置。不同方法在最佳AV和VV延迟方面的一致性差,并且没有一个患者的所有四种方法产生相同的延迟组合。
    结论:建议测量AV和VV延迟的完整网格以识别最佳设置,而不是首先优化两个延迟之一。用于延迟优化的不同技术导致了不同的最佳延迟组合。
  • 【一级房室传导阻滞患者的常规和双室起搏。】 复制标题 收藏 收藏
    DOI:10.1093/europace/eus089 复制DOI
    作者列表:Barold SS,Herweg B
    BACKGROUND & AIMS: :Recent reports suggest that first-degree atrioventricular block is not benign. However, there is no evidence that shortening of the PR interval can improve outcome except for symptomatic patients with a very long PR interval ≥0.3 s. Because these patients require continual forced pacing, biventricular pacing should be used according to accepted guidelines for third-degree AV block. Functional atrial undersensing may occur in patients with conventional dual-chamber pacing and first-degree AV block because the sinus P-wave tends to be displaced into the post-ventricular atrial refractory period (PVARP) an arrangement that may cause a pacemaker syndrome. Prevention requires programming a shorter AV and PVARP that is feasible because retrograde conduction is rare in first-degree AV block patients. A relatively new pacing mode to minimize right ventricular stimulation has been designed by eliminating the traditional AV interval but with dual-chamber backup. This pacing mode permits the establishment of very long AV intervals that may cause pacemaker syndrome. About 50% of patients undergoing cardiac resynchronization therapy (CRT) have a PR interval ≥200 ms. The CRT patients with first-degree AV block are prone to develop electrical desynchronization more easily than those with a normal PR interval. The duration of desynchronization after exceeding the upper rate on exercise is also more pronounced. AV junctional ablation is rarely necessary in patients with first-degree AV block but should be considered for symptomatic functional atrial undersensing or when the disturbances caused by first-degree AV block during CRT cannot be managed by programming.
    背景与目标: :最近的报告表明,一级房室传导阻滞不是良性的。但是,没有证据表明缩短PR间隔可以改善预后,除非有很长PR间隔≥0.3 s的有症状患者。由于这些患者需要持续的强制起搏,因此应根据公认的三度房室传导阻滞指南使用双心室起搏。具有常规双腔起搏和一级房室传导阻滞的患者可能会发生功能性心房感觉减退,因为窦性P波倾向于移入心室后不应期(PVARP),这可能会导致起搏器综合症。预防需要编程较短的AV和PVARP,这是可行的,因为在一级AV阻滞患者中逆行传导很少见。通过消除传统的AV间隔但具有双腔室备用功能,设计了一种相对较新的起搏模式,以最大程度地减少对右心室的刺激。这种起搏模式允许建立很长的AV间隔,这可能会导致起搏器综合症。接受心脏再同步治疗(CRT)的患者中约有50%的PR间隔≥200 ms。与具有正常PR间隔的患者相比,具有一级AV阻滞的CRT患者更容易发生电气失同步。在超过运动的上限速率之后,失步的持续时间也更加明显。具有一级房室传导阻滞的患者很少需要进行房室结消融,但应考虑到有症状的心房功能减退或当无法通过编程处理CRT期间一级房室传导阻滞引起的干扰时。
  • 【使用四极左心室导线进行多部位和双心室起搏的急性血流动力学比较。】 复制标题 收藏 收藏
    DOI:10.1093/europace/eus435 复制DOI
    作者列表:Thibault B,Dubuc M,Khairy P,Guerra PG,Macle L,Rivard L,Roy D,Talajic M,Karst E,Ryu K,Paiement P,Farazi TG
    BACKGROUND & AIMS: AIMS:Pacing from multiple sites in the left ventricle (LV) may bring about further resynchronization of the diseased heart compared with biventricular (BiV) pacing. We compared acute haemodynamic response (LV dP/dtmax) of multisite and BiV pacing using a quadripolar LV lead. METHODS AND RESULTS:In 21 patients receiving cardiac resynchronization therapy, a quadripolar LV lead and conventional right atrial and ventricular leads were connected to an external pacing system. A guidewire pressure sensor was placed in the LV for continuous dP/dt measurement. Four multisite pacing configurations were tested three times each and compared with BiV pacing using the distal LV electrode. Nineteen patients had useable haemodynamic data. Median increase in LV dP/dtmax with BiV vs. atrial-only pacing was 8.2% (interquartile range 2.3%, 15.7%). With multisite pacing using distal and proximal LV electrodes, median increase in LV dP/dtmax was 10.2% compared with atrial-only pacing (interquartile range 6.1%, 25.6%). In 16 of 19 patients (84%), two or more of the four multisite pacing configurations increased LV dP/dtmax compared with BiV pacing. Overall, 72% of all tested configurations of multisite pacing produced greater LV dP/dtmax than obtained with BiV pacing. Pacing from most distal and proximal electrodes was the most common optimal configuration, superior to BiV pacing in 74% of patients. CONCLUSION:In the majority of patients, multisite pacing improved acute systolic function further compared with BiV pacing. Pacing with the most distal and proximal electrodes of the quadripolar LV lead most commonly yielded greatest LV dP/dtmax.
    背景与目标: 目的:与双心室(BiV)起搏相比,从左心室(LV)多个部位起搏可能使患病心脏进一步再同步。我们比较了使用四极LV导线的多部位和BiV起搏的急性血液动力学反应(LV dP / dtmax)。
    方法和结果:在21例接受心脏再同步治疗的患者中,将四极LV导线和常规的右心房和心室导线连接到外部起搏系统。将导丝压力传感器放置在LV中,以进行连续dP / dt测量。四种多部位起搏配置各进行了3次测试,并与使用远端LV电极的BiV起搏进行了比较。 19名患者有可用的血液动力学数据。 BiV与仅心房起搏相比,LV dP / dtmax的中位数增加为8.2%(四分位间距为2.3%,15.7%)。与仅使用心房起搏(四分位间距为6.1%,25.6%)相比,使用远端和近端LV电极进行多部位起搏时,LV dP / dtmax的中位数增加为10.2%。在19位患者中的16位(占84%)中,与BiV起搏相比,四种多位起搏配置中有两种或两种以上增加了LV dP / dtmax。总体而言,在所有多点起搏测试配置中,有72%的LV dP / dtmax高于BiV起搏。最远端和近端电极起搏是最常见的最佳配置,在74%的患者中优于BiV起搏。
    结论:在大多数患者中,与BiV起搏相比,多部位起搏可进一步改善急性收缩功能。用四极LV导线的最远端和最远端电极起搏最通常产生最大的LV dP / dtmax。
  • 【家族性右室发育异常伴双心室受累和炎性浸润。心脏肌肉疾病研究小组。】 复制标题 收藏 收藏
    DOI:10.1136/hrt.76.1.66 复制DOI
    作者列表:Pinamonti B,Miani D,Sinagra G,Bussani R,Silvestri F,Camerini F
    BACKGROUND & AIMS: The aetiology of right ventricular dysplasia/cardiomyopathy is presently unknown. A genetic background has been suggested, but myocarditis may play a part in its pathogenesis. Two familial cases of right ventricular dysplasia, one of whom had also a diagnosis of myocarditis, are reported. Both patients presented with ventricular arrhythmias. The father subsequently had a "flu-like" syndrome, heart failure, and biventricular dysfunction; "active" myocarditis was found at endomyocardial biopsy. Then the patient died suddenly. The daughter developed progressive biventricular dysfunction; then she was resuscitated from a cardiac arrest, and subsequently died suddenly. In both patients necropsy showed severe right ventricular atrophy and fibro-adipose substitution, associated with biventricular fibrosis. Inflammatory infiltration was also present in the first patient. This study shows the association of right ventricular dysplasia and myocarditis in the same family. These cases may represent a link between inherited and acquired ("inflammatory") forms of the disease.

    背景与目标: 右心室发育不良/心肌病的病因目前未知。已经提出了遗传背景,但是心肌炎可能在其发病机理中起作用。据报告,有2例家族性右室发育异常,其中1例也被诊断出心肌炎。两名患者均出现室性心律失常。父亲随后患有“流感样”综合征,心力衰竭和双心室功能障碍。在心肌内膜活检中发现“活动性”心肌炎。然后病人突然死亡。女儿发展为进行性双室功能不全;然后她因心脏骤停而复活,随后突然死亡。两名患者的尸检均显示严重的右心室萎缩和纤维脂肪替代,并伴有双心室纤维化。第一名患者中也存在炎症浸润。这项研究显示了同一家庭中右心室发育不良与心肌炎的关系。这些病例可能代表了疾病的遗传形式和获得性(“炎症”)形式之间的联系。

  • 【叶轮全心双室辅助期间实验猪的血液学变化。】 复制标题 收藏 收藏
    DOI:10.1016/1350-4533(96)81930-8 复制DOI
    作者列表:Qian KX,Wang SS,Chu SH
    BACKGROUND & AIMS: :The impeller total heart was developed and published several years ago but its in-vivo evaluations could only be made recently. Originally, the device was designed for long-term implantation. As the first step, however, it was used this time in acute biventricular assistance, to demonstrate the blood compatibility of the pumps, and to demonstrate the feasibility of an impeller type centrifugal total heart. The haematological measurements made during the experiments indicated that no remarkable blood damage occurred and that all the biochemical datums remained relatively unchanged. Because the centrifugal pump has been considered, until now, to be able only to produce a nonpulsatile flow, its applications have been limited mainly to assist the heart. This first assessment of an impeller total heart reported here will open the application area of centrifugal pumps to include cardiovascular surgery.
    背景与目标: :叶轮全心是几年前开发和发布的,但其体内评估只能在最近进行。最初,该设备是为长期植入而设计的。但是,作为第一步,这一次它是在急性双心室辅助中使用的,以证明泵的血液相容性,并证明叶轮式离心全心脏的可行性。实验期间进行的血液学测量表明,没有发生明显的血液损伤,并且所有生化数据均保持相对不变。因为迄今为止,离心泵一直被认为只能产生非脉动流,所以其应用主要局限于辅助心脏。本文报道的对叶轮总心脏的首次评估将打开离心泵的应用领域,以包括心血管外科手术。
  • 【右心室压力超负荷且正在接受双心室修复的患者在手术台上拔管†。】 复制标题 收藏 收藏
    DOI:10.1093/ejcts/ezz139 复制DOI
    作者列表:Nawrocki P,Wisniewski K,Schmidt C,Bruenen A,Debus V,Malec E,Januszewska K
    BACKGROUND & AIMS: OBJECTIVES:Right ventricular pressure overload, which can result in restrictive right ventricular physiology, predicts slow recovery after biventricular repair of congenital heart defects. The goal of the study was to assess how extubation in the operating room influences the postoperative course in these patients. METHODS:Between January 2013 and June 2017, a total of 65 children [median age 0.96 (0.13-9.47) years; median weight 8 (3.05-25.8) kg] with right ventricular pressure overload underwent an intracardiac correction. The most common malformations were tetralogy of Fallot (n = 34) and double outlet right ventricle with pulmonary stenosis (n = 11). The patients were divided into 2 groups: the first (n = 36) comprised late extubated (LE) and the second (n = 29), early extubated (EE) children, immediately after chest closure in the operating room. Preoperative, perioperative and postoperative records were analysed retrospectively. RESULTS:Children who had EE had a lower heart rate (EE 124.2 vs LE 133.6 bpm; P = 0.03), higher arterial blood pressure (systolic: EE 87.9 ± 9.35 vs LE 81.4 ± 12.0 mmHg; P = 0.029; diastolic: EE 51.1 ± 6.5 vs LE 45.9 ± 6.64 mmHg; P = 0.003), lower central venous pressure (EE 8.6 ± 1.89 mmHg vs LE 9.9 ± 2.42 mmHg; P = 0.03), fewer pleural effusions in the first 6 postoperative days (EE 1.38 ml/kg/day vs LE 5.98 ml/kg/day; P = 0.009), shorter time of dopamine support ≥3 μg/kg (EE 7.29 ± 12.26 h vs LE 34.78 ± 38.05 h, P < 0.001), shorter stays in the intensive care unit (EE 2.7 ± 2.67 vs LE 5.0 ± 4.77 days, P = 0.001) and hospital (EE 11.8 ± 4.79 vs LE 15.5 ± 7.8 days; P = 0.022). CONCLUSIONS:Extubation in the operating room of children with right ventricular pressure overload undergoing biventricular correction is feasible and safe and has a beneficial effect on the postoperative course.
    背景与目标: 目的:右心室压力超负荷可导致右心室生理受限,预测先天性心脏缺陷的双心室修复后恢复缓慢。该研究的目的是评估手术室中的拔管如何影响这些患者的术后病程。
    方法:2013年1月至2017年6月,共有65名儿童[中位数为0.96(0.13-9.47)岁;右心室压力超负荷的平均体重8(3.05-25.8)kg]进行了心脏内矫正。最常见的畸形是法洛氏四联症(n = 34)和右心室双出口伴肺动脉狭窄(n = 11)。将患者分为两组:第一组(n = 36)为晚期拔管(LE),第二组(n = 29)为早期拔管(EE)儿童,在手术室关闭胸腔后立即进行。回顾性分析术前,围手术期和术后的记录。
    结果:患有EE的儿童心率较低(EE 124.2 vs LE 133.6 bpm; P = 0.03),较高的动脉血压(收缩压:EE 87.9±±9.35 vs LE 81.4±±12.0 mmHg; P = 0.029;舒张压:EE 51.1 ±6.5 vs LE 45.9±6.64 mmHg; P = 0.003),较低的中心静脉压(EE 8.6±1.89 mmHg vs LE 9.9±2.42 mmHg; P = 0.03),术后前6天胸膜积液较少(EE 1.38 ml /公斤/天vs LE 5.98 ml / kg / day; P = 0.009),多巴胺支持时间短于≥3μg/ kg(EE 7.29±12.26 h vs LE 34.78±38.05 h,P <0.001),在强化集中的时间更短护理单位(EE 2.7±2.67 vs LE 5.0±4.77天,P = 0.001)和医院(EE 11.8±4.79 vs LE 15.5±7.8天; P = 0.022)。
    结论:右心室压力超负荷患儿接受双心室矫正术在手术室拔管是可行,安全的,对术后病程有益。
  • 【非阻塞性肥厚型心肌病患者的双心室力学和功能储备下降:对运动能力的影响。】 复制标题 收藏 收藏
    DOI:10.1007/s10554-019-01530-y 复制DOI
    作者列表:Wu XP,Li YD,Wang YD,Zhang M,Zhu WW,Cai QZ,Jiang W,Sun LL,Ding XY,Ye XG,Qin YY,Jiang Z,Guo DC,Lu XZ
    BACKGROUND & AIMS: :The present study investigated the changes of biventricular mechanics at rest and during exercise and examined the association between exercise capacity and biventricular mechanics and functional reserve in nonobstructive hypertrophic cardiomyopathy (NHCM) patients. A total of 50 NHCM patients and 25 controls were consecutively recruited for this study. Using echocardiography and two-dimensional speckle-tracking imaging, an experienced echocardiographer determined the following indices: RV free wall longitudinal strain (RVFWLS), LV global longitudinal strain (LVGLS), strain rate (SR), and functional reserve of strain values. We also investigated the relationships between biventricular mechanics and exercise capacity using metabolic equivalents (METs). NHCM patients had lower RVFWLS, LVGLS, systolic SR, early diastolic SR, and systolic and diastolic reserve during exercise compared to controls. An association of biventricular mechanics (LVGLS, RVFWLS) with exercise capacity at rest and during exercise was established. Multivariable logistic regression revealed that RVFWLS and LVE/e' during exercise (RVFWLS-exe, E/e'-exe) were independent predictors of exercise intolerance. Receiver operating characteristic curve analysis indicated that LVE/e'-exe had a higher area under the curve for predicting exercise intolerance in NHCM patients. In hierarchical analysis, RVFWLS-exe provided an incremental predictive value of exercise intolerance over LVGLS during exercise (LVGLS-exe) and LVE/e'-exe. LVE/e'-exe also changed incrementally compared to LVGLS-exe and RVFWLS-exe. NHCM patients have decreased biventricular mechanics at rest and during exercise and impaired biventricular functional reserve, and biventricular mechanics are associated with functional capacity. We propose that simultaneous evaluation of biventricular function should provide incremental predictive value for exercise intolerance.
    背景与目标: :本研究调查了非阻塞性肥厚型心肌病(NHCM)患者在休息和运动过程中双心室力学的变化,并研究了运动能力与双心室力学与功能储备之间的关系。连续招募了总共50名NHCM患者和25名对照。经验丰富的超声心动图医师使用超声心动图和二维斑点跟踪成像技术确定以下指标:RV无壁纵向应变(RVFWLS),LV整体纵向应变(LVGLS),应变率(SR)和应变值的功能储备。我们还使用代谢当量(METs)研究了双心室力学与运动能力之间的关系。与对照组相比,NHCM患者运动期间的RVFWLS,LVGLS,收缩期SR,早期舒张期SR以及收缩期和舒张期储备较低。建立了双心室力学(LVGLS,RVFWLS)与静止和运动期间的运动能力的关联。多变量logistic回归显示运动期间的RVFWLS和LVE / e'(RVFWLS-exe,E / e'-exe)是运动耐量的独立预测因子。受试者工作特征曲线分析表明,LVE / e'-exe在曲线下具有较高的面积,可预测NHCM患者的运动耐量。在分级分析中,RVFWLS-exe提供了运动耐力优于运动期间LVGLS(LVGLS-exe)和LVE / e'-exe的递增预测值。与LVGLS-exe和RVFWLS-exe相比,LVE / e'-exe也发生了增量变化。 NHCM患者在休息和运动期间双心室力学下降,双心室功能储备受损,并且双心室力学与功能能力相关。我们建议同时评估双心室功能应为运动不耐症提供递增的预测价值。

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