切换至 "中华医学电子期刊资源库"
高级检索
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:
全文 ( ) 下载PDF ( ) 导出引用
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]. 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]. 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
Chambers DC, Cherikh WS, Goldfarb SB, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-fifth Adult Heart Transplantation Report: 2018 Focus Theme: Multiorgan Transplantation [J]. J Heart Lung Transplant, 2018, 37(10): 1169-1183.
2
Hahn RT, Abraham T, Adams MS, et al. Guidelines for performaing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anethesiologists [J]. J Am Soc Echocardiogr, 2013, 26(9): 921-964.
3
Tan Z, Roscoe A, Rubino A. Transesophageal Echocardiography in Heart and Lung Transplantation [J]. J Cardiothorac Vasc Anesth, 2019, 33(6): 1548-1558.
4
李一丹，吴雅峰，侯生才, 等. 经食管超声心动图在同种异体肺移植术中监测的应用体会 [J]. 中华超声影像学杂志, 2018, 27(3): 196-199.
5
Sellers D, Cassar-Demajo W, Keshavjee S, et al. The evolution of anesthesia for lung transplantation [J]. J Cardiothorac Vasc Anesth, 2017, 31(3): 1071-1079.
6
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging [J]. Eur Heart J Cardiovasc Imaging, 2015, 16(3): 233-270.
7
Essandoh M, Bhatt A, Flores A, et al. Transesophageal echocardiography monitoring during lung transplantation [J]. J Cardiothorac Vasc Anesth, 2017, 31(6): e98-e99.
8
Cartwright BL, Jackson A, Cooper J. Intraoperative pulmonary vein examination by transesophageal echocardiography: An anatomic update and review of ulitity [J]. J Cardiothorac Vasc Anesth, 2013, 27(1): 111-120.
9
Stein PD, Denier JE, Goodman LR, et al. Pulmonary vein thrombosis in patients with medical risk factors [J]. Radiol Case Rep, 2018, 13(6): 1170-1173.
10
Denton EJ, Rischin A, McGiffin D, et al. Refractory pulmonary edema caused by late pulmonary vein thrombosis after lung transplantation: a rare adverse event [J] . Ann Thorac Surg, 2016, 102(3): e197-e199.
[1] 张贺彬, 高枫, 郑哲岚, 王晓嫚, 陈丽, 杨寸芯, 胡佩佩. 二维斑点追踪超声心动图对业余马拉松运动员右心室收缩功能的评估[J]. 中华医学超声杂志（电子版）, 2022, 19(10): 1091-1097.
[2] 张红梅, 李春梅, 王胰, 张清凤, 丁戈琦, 邓燕, 林薿, 李文华, 尹立雪. 经胸右心声学造影不同右心房增压方式评估卵圆孔未闭隐匿性右向左分流的价值[J]. 中华医学超声杂志（电子版）, 2022, 19(06): 508-513.
[3] 夏娟, 马小静, 谢姝瑞, 何亚峰, 程冠, 吴梅. 实时三维经食管超声心动图对二尖瓣脱垂的诊断价值[J]. 中华医学超声杂志（电子版）, 2021, 18(10): 941-947.
[4] 轩晨昊, 许红阳. 降钙素原对双肺移植患者术后痰培养阳性的预测价值研究[J]. 中华危重症医学杂志(电子版), 2023, 16(03): 211-214.
[5] 中华医学会器官移植学分会肺移植学组, 国家肺移植质控中心. 新型冠状病毒感染肺移植受者选择中国专家建议[J]. 中华移植杂志(电子版), 2023, 17(01): 13-16.
[6] 惠姣洁, 梁锋鸣, 王逸峰, 王大鹏, 陈静瑜, 许红阳. 肺移植术后体外膜肺氧合流量不足处理经验[J]. 中华移植杂志(电子版), 2022, 16(04): 238-240.
[7] 吴婷, 孙燕燕, 郑媛媛, 韩威力. 支气管扩张合并强直性脊柱炎单肺移植一例[J]. 中华移植杂志(电子版), 2022, 16(04): 235-237.
[8] 郭强, 童松, 吴创炎, 陈重瑞, 吴特, 王思桦. 肺移植缺血再灌注损伤差异表达基因的生物信息学分析[J]. 中华移植杂志(电子版), 2021, 15(06): 353-358.
[9] 顾思超, 李敏, 童润, 詹庆元. 肺移植供受者术中及术后48小时内肺部病原菌分布特点及预防性抗菌药物应用策略[J]. 中华移植杂志(电子版), 2021, 15(05): 282-285.
[10] 夏维, 许红阳, 毛文君, 陈静瑜. 体外膜肺氧合在肺移植围手术期的应用[J]. 中华移植杂志(电子版), 2021, 15(04): 199-204.
[11] 王桂龙, 顾正峰, 吴金波, 胡春晓, 秦钟, 张昕, 陈静瑜. 双肺移植手术室内拔管二例[J]. 中华肺部疾病杂志(电子版), 2023, 16(01): 138-140.
[12] 夏金根, 胡诗雨. 体外二氧化碳清除技术的重症应用场景[J]. 中华重症医学电子杂志, 2023, 09(01): 40-45.
[13] 李宁, 刘言, 林慧庆. 肺移植供肺缺血再灌注损伤的机制及预防[J]. 中华胸部外科电子杂志, 2023, 10(04): 247-256.
[14] 方文涛. 从技术精进到理念超越——《中华胸部外科电子杂志》2022年第一期导读[J]. 中华胸部外科电子杂志, 2022, 09(02): 109-110.
[15] 李春光, 李志刚. 肺移植供肺维护策略研究进展[J]. 中华胸部外科电子杂志, 2022, 09(02): 75-79.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号