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大动脉转位并伴有Mustard或Senning术后baffle并发症患者的导管消融术
Catheter ablation in transposition of the great arteries with Mustard or Senning baffles
Khairy P, Van Hare GF  2009/5/31 18:19:25 
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Heart Rhythm, 2009,
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Complete transposition of the great arteries (D-TGA) accounts for 5% to 7% of congenital heart defects. Although the arterial switch procedure has now replaced atrial redirection as the surgical procedure of choice, most adults today with D-TGA have had Mustard or Senning baffles. These surgeries involve extensive atrial reconstruction and predispose to sinus node dysfunction and atrial tachyarrhythmias. By 20 years after surgery, the prevalence of atrial tachyarrhythmias is approximately 25%, continues to increase with time, and is similar among patients with Mustard or Senning baffles. In our experience, intra-atrial reentrant tachycardia (IART) is the most common arrhythmia substrate, followed by nonautomatic focal atrial tachycardia (NAFAT) and atrioventricular (AV) nodal reentrant tachycardia. Accessory-pathway-mediated tachyarrhythmias and atrial fibrillation occur less frequently. Table 1 summarizes the arrhythmias encountered in D-TGA.

Sudden cardiac death is the most common cause of death in patients with D-TGA and Mustard or Senning baffles, with a risk that exceeds that of tetralogy of Fallot. Importantly, observational studies have linked atrial arrhythmias to increased risk of sudden death, and a multicenter study of implantable cardioverter-defibrillator recipients suggests that supraventricular arrhythmias may trigger ventricular arrhythmias. In IART, atrial tachycardia rates tend to be slower than with typical atrial flutter, leading to 1:1 conduction, which in turn may result in hemodynamic instability. This phenomenon is potentially compounded by ineffective atrial transport, subendocardial ischemia of the systemic right ventricle, and systemic ventricular dysfunction. Therefore, an aggressive management strategy to prevent rapidly conducting atrial tachyarrhythmias is generally advisable. Catheter ablation is often considered the definitive treatment of choice.
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上腹痛20余天——上海中山病例

上海复旦大学附属中山医院消化科  刘黎黎  高虹

 

患者，男性，19岁，因“上腹痛20余天”于2005年12月15日入院。患者22天前开始出现中上腹持续剧烈疼痛，伴大便次数增多，3～4次/天，不成形，黑色，后出现呕吐，呕吐物为黄绿色胆汁样物质，有时低热，诊断性腹穿抽出少量淡血性液体，外院腹部平片示：小肠梗阻。查血见白细胞18.0×109/L，N 88.4%，尿蛋白(＋)，于12天前行剖腹探查术，术中见腹腔内有淡血性液体200 ml，见小肠节段性病变，未见肠坏死及穿孔，行腹腔冲洗引流术，术后予地塞米松、制酸、生长抑素、营养补液、抗感染治疗后，未见好转而转入我院。

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