目前在国外较具规模的心脏中心,经皮主动脉瓣球囊成形术已成为新生儿极重型主动脉瓣狭窄的有效治疗方式,在极低体重早产儿中的成功报道也越来越多[1-3].但在国内迄今尚未见到类似报道.我们尝试经颈动脉途径运用经皮球囊扩张术成功治疗了一名1 900 g极低体重早产儿的极重型主动脉瓣狭窄,现报道如下.

目的评价经胸超声心动图(TTE)和经食管超声心动图(TEE)在应用Amplatzer封堵器关闭儿童房间隔缺损(ASD)中的应用价值.方法对12例拟诊为继发孔型ASD的儿童(年龄2～13岁),应用Amplatzer封堵器经导管关闭ASD.通过TTE和(或)TEE在术前显示ASD大小及其边缘的解剖特点,术中指导封堵器的放置,术后评价疗效.结果(1)12例中,TEE排除ASD诊断1例,诊断为下腔型ASD和显示缺损前上缘薄弱者各1例,这3例未实施封堵术.(2)TEE测量ASD大小(5～26mm,平均13.6mm),与ASD伸展径(7～30mm,平均16.6mm)具有高度相关性(r=0.994,P<0.01);与术前TTE测量ASD大小很接近(5～21mm,平均14.3mm),后者与ASD伸展径亦具有高度相关性(r=0.932,P<0.01).(3)9例实施封堵术者,有8例封堵成功;1例在封堵器释放后15min发生脱落,改为外科修补.(4)8例成功实施封堵术者经TTE随访1～22个月,无残余分流征象.结论应用Amplatzer封堵器经导管关闭ASD可取得良好效果;超声心动图在经导管关闭ASD过程中具有重要价值,TTE和TEE各具优点,TTE适用于病例的初步筛选和术后随访;而TEE则在决定是否进行封堵术和指导封堵器的正确放置等方面发挥重要的作用.

经食管超声心动图(TEE)是70年代发展起来的一种超声技术，本文就TEE的方法，及其在先心围术期中的应用适应症和并发症等方面作一综述。

目的:探讨循环血管紧张素Ⅱ(AngⅡ)是否加重先天性心脏病体外循环手术中心脏的缺血再灌注损伤.方法:从1999年10月26日至2000年1月25日接受体外循环手术的先心病患儿46例,年龄6～166个月,平均(52.79±20.56)个月,体重6～42千克,平均(19.23±10.00)千克.分别测定术中主动脉开放时血AngⅡ和四个心脏缺血再灌注损伤观察指标:(1)超声心动图估测术后心脏射血分数(EF);(2)术后24h内正性肌力药物的使用情况;(3)主动脉开放后6h血清肌酸激酶同工酶(CK-MB)浓度;(4)术后24h内严重心律失常的发生情况,比较两方面的关系.结果:术后正性肌力药物使用组和未用药组,严重心律失常发生组和未发生组的AngⅡ有显著性差异.AngⅡ与主动脉开放后6h血CK-MB显著相关.术后EF＜0.5和≥0.5患者AngⅡ无显著性差异.结论:循环AngⅡ加重了先天性心脏病体外循环手术中心脏的缺血再灌注损伤.

目的探讨体表面积纠正的冠状动脉内径在川崎病随访中的意义.方法 58例川崎病患者发作期和随访期分别进行超声心动图检查,测量其左右冠状动脉内径,比较体表面积纠正的冠状动脉内径及冠状动脉内径绝对值的变化.结果按传统标准全组发作期无冠状动脉扩张,与发作期相比随访期平均冠状动脉内径无显著变化.随访期平均体表面积纠正的左右冠状动脉内径显著缩小,(sLCA:4.73±1.40) mm/m2 vs (3.88±1.28) mm/m2,P<0.01;sRCA:(4.51±1.28) mm/m2 vs (3.71±1.10) mm/m2,P<0.01),缩小率与随访时间和发病年龄显著相关.结论体表面积纠正的冠状动脉内径是反映川崎病发作期后冠状动脉内径动态变化的敏感指标.

心脏缺血再灌注损伤的研究成果可以影响到冠心病心肌梗死的治疗、心脏直视手术中的心肌保护等多个领域,故一直是广大基础和临床医学工作者热门的话题.近年来肾素-血管紧张素系统(RAS)尤其是血管紧张素Ⅱ(Ang Ⅱ)与心脏缺血再灌注损伤关系得到越来越多的重视,Ang Ⅱ特别是心脏缺血后局部激活的RAS被认为可以加重心脏缺血再灌注损伤,伤由此一些新的治疗手段开始运用于临床,本文就这一领域的最新进展作一综述.

To evaluate the midterm and long term results of surgical repair for tetralogy of Fallot by echocardiography. Methods :From January 1994 to February 2000,109 postoperative cases with tetralogy of Fallot were investigated. There were 81 male and 28 female with age 5～158 months and weight 6～43kg. One-staged repair was done in 105 cases and the remained 4 underwent two-staged repair in which only a transannular patch was given in the initial stage. Right ventricular outflow tract reconstruction contained transannular patch in 79,right ventricular outflow patch in 28 and artificial conduit in 2. The follow-up time by echocardiography was 1～72 months. Results:The Postoperative residual shunt occurred in 20(18. 3 % ). Although the diameter of the residual VSD was 0. 1 ～0. 2cm in 70% and had no left-sided heart dilation,there was bacterial endocarditis occurred in one case. Residual obstruction occurred in 2 (1.8 % ). Pulmonary regurgitation occurred in 85 (77.9 % ) of which the occurrence of right ventricular dilation was significantly higher than those without pulmonary regurgitation (92.9 % vs 20. 8 %, P＜0. 001). In follow-up period ,pulmonary hypertension occurred in three of the four cases after the initial procedure. Conclusions:The midterm and long term results of surgical repair of tetralogy of Fallot are generally satisfied. Relative high occurrence of pulmonary regurgitation deserves to be further investigated. Intensive surveillance is advocated in cases with residual shunt or having undergone palliative procedures.

目的:分析和探讨左心发育不良综合征(HLHS)的临床及超声心动图特点及其对临床早期干预的意义.方法:对1989年4月～2000年8月间我院收治10例HLHS病例进行回顾性分析.年龄为生后2h～36d,男性4例,女性6例.临床表现青紫5例,呼吸窘迫5例,心力衰竭8例,代谢性酸中毒8例.超声心动图检查示Ⅰ型3例,Ⅱ型1例,Ⅲ型1例,Ⅳ型5例.平均左室舒张末期内径10.1±2.1mm,平均主动脉根部内径6.1±1.7mm.结果:死亡6例,放弃治疗及病情好转出院各2例.结论:HLHS的临床及心超特点明显,超声心动图有很高诊断价值,临床早期诊断对预后有重要影响.

Objective To observe the changes of Calcitonin gene-related peptide (CGRP) in perioperative peri-od of cardiopulmonary bypass (CPB). Methods A pig model of myocardial ischemia-reperfusion injury was establishedduring CPB. Plasma concentration of C GRP of coronary vein was measured by radioimmunoassay on six consecutive pe-riods before, during and after CPB. Heart rate, blood pressure, systolic and diastolic left ventricular pressure were de-tected simultaneously. Plasma CGRP concentration of coronary vein in 36 patients with congential heart diseases under-gone open-heart surgery was also determined on seven consecutive periods perioperatively. Results Plasma CGRP lev-el during CPB before cardiac arrest was of no statistieal difference compared with that before CPB, while it wasmarkediy increased when the heart was reperfused. It continued to elevate and remained at a high level 4 to 24 hourspostoperatively. The elevated level of GGRP appeared earlier than the improvement of hemodynamic parameters. Con-clusion The elevated CGRP has a protective effect on the reperfusional myocardium associated with CPB. (ShanghaiMed J, 2000,23:451-453. )

目的探讨婴幼儿先心术后呼吸道管理.方法收治婴幼儿先心术后病例96例,平均年龄16±7.8个月,平均体重10±5.2千克. 其中93例接受Ⅰ期根治术,3例接受姑息性手术.术后呼吸机通气采用定容或西门子300的压力调节定容模式(PRVC).部分病例术后接受吸入一氧化氮(NO)和外源性肺表面活性物质(PS)治疗.结果术后呼吸机辅助时间3.5～84小时,平均8.6小时.ICU 期间呼吸道感染率8.2%(8/96),肺不张发生率7.2%(7/96).术后近期死亡率6.2%(6/9 6),死亡原因低心排综合征3例、严重感染2例、出血1例.结论婴幼儿先心术后呼吸道管理有其自身特点,抓住这些特点就可以使手术的死亡率、并发症的发生率进一步下降,从而获满意的疗效.