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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2020, Vol. 17 ›› Issue (06) : 535 -539. doi: 10.3877/cma.j.issn.1672-6448.2020.06.009

所属专题： 文献；

心血管超声影像学

经食管超声心动图在肺移植术中监测吻合血管及右心室功能变化的应用体会
宋艳1, 孙博睿2, 付军科3, 张广健3, 高燕凤2, 白晓芳1, 陈虹1, 董亚玲1, 阮骊韬1,†()   
  1. 1. 710061　西安交通大学第一附属医院超声影像科
    2. 710061　西安交通大学第一附属医院麻醉手术部
    3. 710061　西安交通大学第一附属医院胸外科
  • 收稿日期:2019-08-19 出版日期:2020-06-01
  • 通信作者: 阮骊韬

Application of transesophageal echocardiography in monitoring pulmonary vascular anastomosis and changes of right ventricular function during lung transplantation

Yan Song1, Borui Sun2, Junke Fu3, Guangjian Zhang3, Yanfeng Gao2, Xiaofang Bai1, Hong Chen1, Yaling Dong1, Litao Ruan1,†()   

  1. 1. Department of Ultrasound, the First Affiliated Hospital of Xi’an Jiaotong University, Xi′an, 710061, China
    2. Department of Anesthesia, the First Affiliated Hospital of Xi’an Jiaotong University, Xi′an, 710061, China
    3. Department of Thoracic Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi′an, 710061, China
  • Received:2019-08-19 Published:2020-06-01
  • Corresponding author: Litao Ruan
  • About author:
    Corresponding author: Ruan Litao, Email:
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引用本文：

宋艳, 孙博睿, 付军科, 张广健, 高燕凤, 白晓芳, 陈虹, 董亚玲, 阮骊韬. 经食管超声心动图在肺移植术中监测吻合血管及右心室功能变化的应用体会[J/OL]. 中华医学超声杂志（电子版）, 2020, 17(06): 535-539.

Yan Song, Borui Sun, Junke Fu, Guangjian Zhang, Yanfeng Gao, Xiaofang Bai, Hong Chen, Yaling Dong, Litao Ruan. Application of transesophageal echocardiography in monitoring pulmonary vascular anastomosis and changes of right ventricular function during lung transplantation[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(06): 535-539.

目的

探讨经食管超声心动图（TEE）在同种异体肺移植术中监测吻合血管及右心功能变化的应用价值。

方法

选取2018年9月至2019年7月在西安交通大学第一附属医院就诊，因临床终末期肺疾病行同种异体肺移植手术的患者9例。所有患者均行术中TEE监测，监测指标包括：开胸前及吻合口开放后左上肺静脉流速、左下肺静脉流速、右上肺静脉流速、右下肺静脉流速、左肺动脉流速、右肺动脉流速；开胸前、单肺通气、肺动脉夹闭、吻合口开放后右心室基底段内径及中段内径、三尖瓣环收缩期位移（TAPSE）、右心室面积变化分数（RVFAC）、左心室射血分数（LVEF）。

结果

与术前比较，肺动、静脉吻合开放后血流速度均增快（P均≤0.005），但均未出现显著狭窄。本研究中9例患者右心室基底段内径及右心室中段内径在单肺通气后较开胸前无显著变化；肺动脉夹闭后右心室内径较开胸前显著增大（P均<0.005）；吻合口开放后右心室内径较肺动脉夹闭后显著缩小（P均<0.001），较开胸前也显著缩小（P均<0.05）。本研究中有2例患者TAPSE、RVFAC在术前即低于正常范围，吻合口开放后这2例患者TAPSE及RVFAC无显著改善。本研究9例患者的TAPSE在单肺通气后较开胸前无显著变化，肺动脉夹闭后较开胸前显著降低（P<0.005），但吻合口开放后逐渐恢复至术前水平。本研究9例患者的RVFAC在单肺通气后较开胸前无显著变化，肺动脉夹闭后较开胸前显著降低（P<0.005），吻合口开放后有一定程度增加，但仍低于开胸前水平，差异有统计学意义（P<0.05）。

结论

在同种异体肺移植中，TEE不仅可以评估吻合后肺动、静脉有无吻合口狭窄，还可以在整个肺移植过程中监测右心功能变化情况，对手术进程及术后管理具有指导性意义。

关键词: 超声心动描记术，经食管, 肺移植, 心室功能，右
Objective

To evaluate the value of transesophageal echocardiography (TEE) in monitoring pulmonary vascular anastomosis and changes of right ventricular function in lung transplantation.

Methods

This study enrolled nine patients receiving allogeneic lung transplantation because of end stage lung disease at the First Affiliated Hospital of Xi′an Jiaotong University from September 2018 to July 2019. Intraoperative TEE monitoring indicators included the flow velocities of the left upper pulmonary vein, left lower pulmonary vein, right upper pulmonary vein, right lower pulmonary vein, left pulmonary artery, and right pulmonary artery before opening the chest and after opening the anastomosis; and diameters of the right ventricular base and mid-septum, tricuspid annular plane systolic excursion (TAPSE), fractional area change of the right ventricle (RVFAC), and left ventricular total ejection fraction (LVEF) before opening the chest and at single lung ventilation, pulmonary artery clipping, and anastomosis opening.

Results

Compared with the values before opening the chest, the flow velocities of the pulmonary arteries and veins were increased after anastomosis (P≤0.005), but there was no significant stenosis; the diameters of the right ventricular base and mid-septum showed no significant change after single lung ventilation, but were significantly increased after clamping the pulmonary artery (P<0.005). The diameters of the right ventricular base and mid-septum were retracting after opening the anastomosis, and significantly smaller than those at the stage of clamping the pulmonary artery (P<0.001) and before opening the chest (P<0.05). The TAPSE and RVFAC of two patients were lower than the normal range before surgery. After the anastomotic opening, the TAPSE and RVFAC were not improved. Nine patients had no significant change in TAPSE after single-lung ventilation. The TAPSE at the stage of clamping the pulmonary artery was significantly lower than that before opening the chest (P<0.005), but restored to the preoperative level after opening the anastomosis. In this study, 9 patients had no significant change in RVFAC after single-lung ventilation. The RVFAC was significantly decreased after clamping the pulmonary artery (P<0.005), and there was an increase after anastomotic opening, although it was still lower than that before opening the chest (P<0.05).

Conclusion

In allogeneic lung transplantation, TEE can not only assess the anastomotic stenosis of the pulmonary artery and vein after anastomosis, but also monitor the changes of right ventricular function, which is of great significance for monitoring the surgical process and postoperative management.

Key words: Echocardiography, transesophageal, Lung transplantation, Ventricular function, right
表1 肺移植开胸术前与吻合术后肺动、静脉流速参数比较（cm/s，±s）
检测时间 例数 VLUPV VLLPV VRUPV VRLPV VLPA VRPA
开胸前 9 39.83±4.36 38.33±4.50 48.71±5.71 48.00±6.00 66.33±9.89 60.71±10.57
吻合后 9 100.50±17.68 100.50±17.68 99.15±23.14 99.15±23.14 161.67±11.69 167.14±7.56
t值   -10.651 -8.983 -6.278 -5.981 -4.734 -8.411
P值   <0.001 <0.001 0.001 0.001 0.005 <0.001
图1 肺移植患者开胸术前、吻合术后左肺静脉流速变化对比图像。图a为肺移植术前左上肺静脉血流频谱，流速约为38 cm/s；图b为肺移植吻合术后左肺静脉血流频谱，流速约为80 cm/s；图c为患者左肺静脉吻合开放后彩色多普勒血流图像，图像显示为高速血流
表2 肺移植不同手术阶段右心室整体功能及左心室整体收缩功能参数比较（±s）
检测时间 例数 DRVB（mm） DRVM（mm） TAPSE（mm） RVFAC（%） LVEF（%）
开胸前 9 39.11±4.28 36.00±6.28 15.67±2.34 35.56±3.24 67.11±1.69
单肺通气 9 39.22±4.76a 36.89±5.78a 16.45±1.81a 35.67±3.61a 66.22±1.69a
肺动脉夹闭后 9 41.22±4.06b 37.78±5.74b 13.44±2.13b 32.11±4.46b 66.22±0.97b
吻合口开放 9 34.44±3.71c 31.56±2.92c 14.89±3.06c 34.33±3.12c 65.33±2.29c
图2 肺移植患者开胸前、吻合口开放后右心室功能参数变化对比图像。图a为开胸前右心室灰阶图像，右心室基底段内径：45 mm；右心室中段内径：40 mm；右心室面积变化分数：30%；图b为吻合口开放后右心室灰阶图像，右心室基底段内径：40 mm；右心室中段内径：35 mm；右心室面积变化分数：29%
1
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