心内膜心肌活检439例次的安全性分析

目的 回顾性分析心内膜心肌活检(EMB)的主要和次要并发症,提供EMB的安全性信息.方法 入选阜外心血管病医院2004年5月至2008年11月的439例次右心室EMB病例.采用Cordis公司改良的长45 cm的Caves-Shulz一次性活检钳,透视下,从右颈内静脉入径行右心室室间隔EMB.操作者共4人,均在有EMB经验人员指导下完成50例后开始独立操作.术中和术后12h进行血压和心电监测,术后作胸片观察有无气胸和血胸,作心电图和超声心动图与术前对照评价有否新出现的传导阻滞、心包积液和瓣膜反流.结果 4.5年间147例患者共进行了439次EMB.其中15例心肌病和1例怀疑心脏肿瘤的患者各进行了1次EMB;131例原位心脏移植的患者共进行423次EMB,平均3.2次/人.未发生心肌穿孔、血性胸腔积液和气胸等主要并发症.次要并发症中持续>24 h的右束支传导阻滞1例(0.23%),暂时(持续<24 h)右束支传导阻滞2例(0.47%),无房室传导阻滞、非持续室性心动过速或心房颤动发生.其他并发症--超声心动图发现4例患者(0.91%)新出现三尖瓣轻至中量关闭不全.所有并发症长期随访均未发现后遗症.结论 熟练的操作者在透视下经右颈内静脉行EMB的并发症非常少见.     

二维超声心动图引导心内膜心肌活检的临床应用(附30例报告)

二维超声心动图(2-DE)引导下,进行30例右心心内膜心肌活检(EMB)。2-DE显示活检钳头段指导取材成功率达96.4%,无严重并发症。心尖四腔心切面引导效果最好,心尖部取材成功率最高。     

心肌活检诊断心肌炎的现状

心肌炎的定义源于组织病理学,即心肌炎是心肌的非缺血性炎症性或免疫性疾病。心内膜心肌活检(EMB)经多年来的实践和不断改进,已成为一种较安全、简便的检查技术,由于 EMB 能从组织病理学上证实心肌炎症的存在,确定其严重程度及监测治疗反应,并可对心肌炎与心肌病之间的关系进行深入的探讨,故不失为诊断和研究对本病的一种新手段.已列为 EMB 的主要适应证之一.(一)EMB 诊断心肌炎后提出的问题1.EMB 心肌炎的检出率。未加选择的病例进行 EMB,急性心肌炎的检出率15-     

经桡动脉左心室心内膜心肌活检在心肌病诊断中的初步应用

目的初步评估经桡动脉左心室心内膜心肌活检(EMB)在心肌病诊断中应用的安全性、有效性及临床意义。方法 2017年12月至2018年2月于北京医院就诊的5例心肌病患者,采集基线资料、安全性及有效性指标。结果 5例患者中,男性3例,女性2例,年龄28~62岁,平均42岁,平均体质指数28.8 kg/m~2,根据临床适应证,行左心室造影、冠状动脉造影及经桡动脉左心室EMB等操作。手术成功率100%,有3例冠状动脉造影及左心室造影后即刻经同一桡动脉途径行EMB,其他2例先行冠状动脉造影,数天后行经桡动脉途径EMB。手术时间34~68 min,中位时间54 min。造影剂用量95.4~150.2 ml,平均123.4 ml。心肌活检组织样本数量4~6块,平均4.4块,质量好,心肌活检组织病理诊断率100%。X线暴露时间10~22 min,平均15.3 min。X线暴露剂量:剂量面积乘积17 323~30 574 cGy·cm~2,中位数为26 433 cGy·cm~2,皮肤总量1 392~3 088 mGy,中位数为2 495 mGy。所有患者术后无需卧床,无手术相关并发症。结论本研究初步显示了经桡动脉左心室EMB的安全性及有效性,为心肌病的诊断提供了一种可能更为安全、有效的全新技术,同时提高患者舒适度,并使手术更加便捷、经济。     

心脏核磁共振在心肌淀粉样变中的诊断价值

目的 研究心内膜心肌活检(EMB)确诊心肌淀粉样变性(CA)患者的临床和心脏核磁共振(CMR)特点,明确CMR在CA中的诊断价值.方法 回顾性分析2006年9月至2010年12月期间EMB确诊CA并行CMR检查患者的临床表现、心电图、心脏超声及CMR结果.结果 共18例患者通过EMB确诊为CA,其中5例进行了CMR检查.5例患者均有心力衰竭的临床表现以及心电图改变,心脏超声示左心室向心性肥厚,心肌回声增强、颗粒样回声,左心房扩大,限制性舒张功能不全.CMR主要表现为左心室壁增厚,室间隔增厚明显,双房均增大,心室收缩功能正常或减低,舒张功能均不同程度受限,部分伴有心包及胸腔积液,延迟钆显像(LGE)呈不同程度的延迟强化,位于左心室心内膜下或心肌弥漫性延迟强化,部分患者强化可为线样、颗粒样或斑片状.随病程延长,心肌LGE程度及范围有更严重的趋势,与心电图改变一致.结论 CMR有助于CA诊断及病情判断,为CA重要的无创检查方法之一.临床怀疑CA患者可早期进行CMR检查,特别是在没有开展EMB检查的医院.     

泰国南方地区的抗结核药物受损及管理系统问题

地点：泰国南方的三家研究所,11家医院及38家社区医院.目的：评估泰国南方结核病医疗机构使用的抗结核药物质量及其管理系统.设计：利用访视、查阅文件、观察药物储存、检查药物并行异烟肼（IINH）、利福平（RMP）、吡嗪酰胺（PZA）及乙胺丁醇（EMB）样品的实验室分析.结果：任何级别单位均未发现有抗结核药物的脱销.13家医院/研究所（25%）撤去了EMB糖衣片的箔包装.11家医院/研究所（21%）将EMB糖衣片一分为二,作为200mg片分发.观察发现,在44%医院/研究所肉眼发现有变质受损的EMB.除了14%的EMB外,全部药物样品均通过了含量测定.INH与EMB均通过了溶解试验评价,但有62%的RMP及26%的PZA样本未通过.结论：在结核病控制方面,不达标的变质受损抗结核药物是一个严重问题.研究地区的抗结核药物管理也存在问题.关于抗结核药物包装、储存的培训及建立分发、清单管理,质量保证和督查的完整体系是主要的控制措施.     

乙胺丁醇引起高尿酸血症

Postlethwaire等(1972)观察到乙胺丁醇(EMB)可引起血清尿酸水平增加,Self等(1977)、Khanna(1980)先后报导了BMB引起痛风性关节炎,本文作者进一步研究了EMB对血清尿酸水平的影响。报告:12例健康人和70例结核病人无关节炎和痛风,肝、肾功能正常。病人随机分4组: A组,12名健康人;B组,18例用SM+INH治疗;C组,21例用INH+EMB治疗,D组,31例用SM+INH+EMB治疗。C组和D组病人按15、20、25ml/kg应用     

结核分枝杆菌耐乙胺丁醇分离株emb B基因突变研究

目的探讨结核分枝杆菌对乙胺丁醇（EMB）产生耐药的分子机制,建立直接快速检测结核分枝杆菌EMB药物敏感性的实验方法。方法采用聚合酶链反应（PCR）扩增技术对临床耐乙胺丁醇结核分枝杆菌进行PCR扩增,扩增产物经纯化后,直接进行DNA测序分析。结果 54例临床分离株中,19例为EMB敏感株,35例为EMB耐药株。35例耐药株中13例（37.1%）发生基因突变。13例基因突变皆为错义突变,且有1例同时发生310位和313位突变。结论 embB306位氨基酸Met被置换是结核分枝杆菌对乙胺丁醇产生耐药性的重要机制,测序分析可以确认耐药基因的突变位点,是快速检测耐乙胺丁醇结核分枝杆菌的快速、有效的方法。     

心内膜心肌活检在心肌疾病诊断中的应用

本文就37例经静脉心内膜心肌活体组织检查(EMB)资料进行回顾性分析,显示其在不明原因的心律失常病例中,对心肌炎的检出较高(66.7％),EMB的序列随访对指导心肌炎的治疗及探讨其自然病程有重要意义。分析表明心肌炎有可能发展为心肌病,但诊断原发性心肌病时,必须结合临床资料。     

PCR-SSCP检测耐乙胺丁醇结核杆菌embB基因突变的价值

目的探讨应用聚合酶链反应-单链构象多态性(PCR-SSCP)技术检测结核分支杆菌耐乙胺丁醇(EMB)分离株embB基因突变情况,研究其应用价值。方法2000-06~2002-08对河南省结核病耐药监测项目收集的菌株及河南省各地市结核防治所收集的68株结核分支杆菌菌株采用PCR-SSCP分析68例结核菌株embB。结果以H37Rv标准株为对照,30株药物敏感株的embB基因SSCP泳动均正常,38株耐EMB分离株中25株embB基因SSCP泳动异常,异常检出率占66%。结论部分分支结核杆菌耐EMB是由于其embB基因突变引起,PCR-SSCP可成为检测部分结核杆菌耐EMB耐药基因的有效方法。     

Endomyocardial biopsy: experience with 156 patients

Transcatheter endomyocardial biopsy (EMB) is a well known technique but its clinical value is still controversial. Our experience in the first 156 patients studied, in whom 182 EMB were performed, is reported and particular attention is given to the clinical value of the biopsy. Complications were observed in 7 patients and left ventricular EMB appeared to be more complicated (2/23) than right ventricular EMB (5/159). The clinical value of EMB was well documented (63.5%) in patients with congestive heart failure and a dilated heart (group 1) in whom a fairly high presence of myocarditis (17.5%), in different stages, was observed (13/74 patients). In patients with congestive failure and a restrictive/constrictive physiology (group 2), with angina and normal coronary arteries (group 3) and with acute advanced atrio-ventricular block and young age (group 5) the clinical value of EMB was good (85.7%, 58.3% and 60.6% respectively). The clinical value of EMB was on the contrary poor in patients with idiopathic ventricular arrhythmias (group 4) and in an heterogeneous group of patients (group 7), where EMB was mainly performed to exclude myocarditis. EMB had no clinical value in patients with aortic or mitral incompetence (group 6) studied according to a research protocol. EMB is a safe procedure which provides useful clinical informations in more than 50% of patients studied. The fairly high incidence of myocarditis (25 out of 156 patients studied) and the protean clinical presentations of the disease are stressed.     

The role of right ventricular endomyocardial biopsy for idiopathic giant cell myocarditis

BACKGROUND: Idiopathic giant cell myocarditis (GCM) is an uncommon cause of cardiac failure distinguished clinically from lymphocytic myocarditis by rapidly progressive heart failure, arrhythmias, and heart block. Unlike fulminant lymphocytic myocarditis, patients with fulminant cardiac failure caused by GCM may respond to certain immunosuppressive agents; however, right ventricular endomyocardial biopsy (EMB) is infrequently used to establish the diagnosis partly because the sensitivity of EMB for GCM is unknown. The purpose of this study was to estimate the sensitivity of right ventricular EMB for GCM in a referral population. METHODS AND RESULTS: Twenty subjects (of 63 total) in the Multicenter Giant Cell Myocarditis Registry underwent both right ventricular EMB and heart pathology (HRTP) evaluation from apical wedge, explantation, or autopsy. The false-negative rate of right ventricular EMB was defined as the ratio of negative EMB to positive HRTP results. Ten of the 20 subjects were women. The mean age was 38 years (range, 16-53 years). Twelve (60%) subjects had a positive EMB and positive HRTP confirming GCM. Three (15%) had a negative EMB and positive HRTP for GCM. Five had a positive EMB and negative HRTP evaluation for GCM. The resulting sensitivity of EMB for GCM was 80% (12/15) with a positive predictive value of 71%. Assuming the 5 subjects with a positive EMB and negative HRTP are true positives, the sensitivity improves to 85% (17/20). Predictors of negative HRTP after positive EMB were time from symptom onset to HRTP (P.006) and time from EMB to HRTP (P.03). CONCLUSIONS: The sensitivity of right ventricular EMB is high in patients with GCM who have early disease presentation and a fulminant clinical course. Although these results may not apply to individuals with less aggressive disease, EMB may be used selectively to distinguish fulminant heart failure caused by GCM from other causes in which the prognosis may differ.     

8例心内膜心肌纤维化的诊疗经验

目的总结8例心内膜心肌纤维化(EMF)的诊断和治疗经验。方法对有不明原因的心力衰竭并考虑为EMF的8例患者施行超声心动图(UCG)、核磁共振成象(MRI)、心内膜心肌活检(EMB)等检查,4例予内科治疗,4例行外科手术。结果UCG、MRI及EMB获得EMF诊断的例数分别为3/8,4/4及3/4,同时行以上3种检查诊断的例数为3/3。4例经内科治疗,2周至6个月内全部死亡。2例施行右心室心内膜切除加三尖瓣成形术,术后恢复良好,随访6～9年,心功能2级,能从事轻度工作。2例行右心室心内膜切除加三尖瓣置换术,手术死亡1例,1例存活6年,死于心力衰竭。结论综合应用UCG、MRI及EMB可提高EMF的诊断率,对病变较轻的EMF患者行心内膜切除加瓣膜成形或置换术可获得良好的效果,对病变重的病例应行心脏移植。     

心脏淀粉样变患者的心电图和心脏超声特点

目的 总结心内膜心肌活检(EMB)证实原发型心脏淀粉样变(CA)患者的心电图和心脏超声特点,为临床医师能够早期识别和诊断CA提供帮助.方法 自2006年9月至2009年10月收治临床怀疑CA患者共20例(其中男性7例),平均年龄(50±12)岁,进行EMB检查.11例(55%)患者诊断为CA,血清和(或)尿检查示游离单克隆轻链(λ)明显升高,确诊为原发型CA.分析该11例心电图和心脏超声的特点.结果 心电图分析发现,11例患者的6个肢导联电压均较低,均值为0.33～0.51 mV,其中肢导联低电压和假性梗死波形发生率均为45%.心脏超声检查结果分析发现,11例患者室壁呈向心性增厚和左心室腔容积正常,绝大多数患者可见左心房扩大(10例,91%)、心肌内可见颗粒样强回声(9例,82%)、中至大量心包积液(7例,64%)以及左心室收缩功能受损(8例,73%).结论 对于临床原因不明的心力衰竭,心脏超声示向心性肥厚且左心室腔容积不大,伴心肌内颗粒样强回声或心包积液,而心电图示肢导联低电压或假性梗死波形者,高度疑似原发型CA的可能性,应进一步行EMB和血清(尿)生化检查,以便早期明确诊断和及时治疗.     

经右侧颈内静脉行右心室心内膜心肌活检的可行性及安全性探讨

目的探讨经右侧颈内静脉行右心室心内膜心肌活检的可行性和安全性。方法该研究为回顾性描述性研究。以2014年12月至2020年6月在中国医学科学院阜外医院及北京协和医院接受心内膜心肌活检的患者为研究对象,这些患者初步临床诊断为疑诊心肌炎、心肌病、不明原因心力衰竭等,研究排除了冠心病患者。收集入选患者的一般临床资料,包括人口统计学资料(年龄、性别、身高、体重)、纽约心脏协会(NHYA)心功能分级、血N末端B型利钠肽原(NT-proBNP)水平、胸片、超声心动图、血流动力学指标等。所有患者均经右侧颈内静脉在X线透视、双体位引导下行右心室心内膜心肌活检。计算右心室心内膜心肌活检的成功率。观察患者心内膜心肌活检并发症的发生情况,主要并发症包括死亡、需要紧急心脏手术或高级生命支持、心包填塞需心包穿刺引流、永久性房室传导阻滞需安装永久起搏器等;次要并发症包括不需要心包穿刺的心包积液、暂时(持续<24 h)或永久的右束支传导阻滞、一过性莫氏Ⅱ型2∶1房室传导阻滞需要阿托品治疗或需安装临时起搏器、非持续≥10个QRS波的室性心动过速、持续<12 h心房颤动(房颤)或需要转复的房颤;其他并发症包括心内膜心肌活检后新出现的三尖瓣腱索断裂或反流。另外,分别观察操作第1、2和3年的术者操作后患者并发症的发生情况。结果研究共入选272例接受右心室心内膜心肌活检的患者,其中270例成功完成操作,成功率99.3%。入选患者的年龄(42.7±16.9)岁,其中男性164例(60.3%)。21例(7.7%)患者出现并发症,其中2例(0.7%)出现大量心包积液,属于主要并发症,均行心包穿刺引流后缓解;18例(6.6%)出现微量心包积液,1例(0.4%)三尖瓣前叶腱索断裂,均属于次要并发症。无患者出现死亡、需紧急心脏手术抢救或需要永久起搏器置入等严重并发症。术者进行右心室心内膜心肌活检操作后的第1、2、3年并发症发生率分别为9.3%(13/140)、7.8%(7/90)和2.4%(1/42)。结论经右侧颈内静脉入路X线引导下行右心室心内膜心肌活检安全、可行,且随着操作者熟练程度的提高其并发症发生率有降低的趋势。     

Prediction of recovery after abstinence in alcoholic cardiomyopathy: Role of hemodynamic and morphometric parameters

The aim of the study is to describe the hemodynamic and morphometric characteristics of patients with alcoholic cardiomyopathy (ACM) and to evaluate whether these parameters can identify the subgroup of patients in whom recovery of cardiac function after abstinence will occur. Nineteen male patients (mean age 52.4 years, range 39–64 years) with symptomatic left ventricular dysfunction (LVD) [ejection fraction (EF) < 50%] and a history of chronic heavy alcohol intake were submitted to a full invasive work-up including right ventricular endomyocardial biopsy (EMB). Counseling aimed at obtaining abstention and clinical follow-up were regularly performed in all patients. The two requisites necessary to define recovery were (1) an increase in left ventricular EF, and (2) improvement of symptoms. The former was defined as a gain in left ventricular EF > 15% from baseline; the latter, as a gain of at least one New York Heart Association (NYHA) functional class. Using these criteria, 9 alcoholic patients (48%) (Group A) improved significantly, while 10 (52%) (Group B) either stabilized or deteriorated at 2 years' follow-up. Group A patients had significantly lower pulmonary artery mean pressure (27.8 mmHg ± 13.3 vs. 40.3 mmHg ± 12.4; p < 0.05) and pulmonary capillary wedge pressure (18.4 mmHg ±8.9 vs. 26.5 mmHg ± 7.7; p < 0.05) compared with Group B. All other hemodynamic data did not show statistically significant differences in the two groups. Quantitative evaluation of myocardial hypertrophy and interstitial fibrosis performed on EMB tissue samples using the morphometric approach was not predictive of recovery. Improvement in cardiac performance and functional class was detected in about one-half of patients with ACM who abstained from alcohol, and occurred even in cases presenting with severe LVD. Recovery is associated with significantly lower pulmonary artery and pulmonary wedge pressures. The morphometric evaluation of EMB does not provide adjunctive prognostic information in these patients.     

限制型心肌病的临床和病理评价

目的 探讨限制型心肌病患者的临床和心内膜心肌活检的组织学病理特点.方法 对25例临床诊断为限制型心肌病的患者进行心内膜心肌活检,并作临床、实验室检查、右心导管以及心肌病理检查,对其结果进行分析.结果 25例患者均有心功能不全的表现,血浆脑钠肽水平有中度升高.右心导管显示右心房压、右心室舒张末压和肺动脉楔压均有明显升高,心排血量有轻度减低.心内膜心肌活检病理检查显示16例有淀粉样物质沉积,2例有嗜酸性粒细胞性心肌炎.其他7例患者的心肌病理显示有心肌病变,结合临床资料和其他组织病理,其中3例诊断为特发性限制型心肌病,2例为淀粉样变性,其余2例病因不明确.最终21/25的限制型心肌病患者通过心内膜心肌活检明确病因.结论 限制型心肌病病因包括有淀粉样变性、嗜酸性粒细胞浸润和特发性心肌病等.心内膜心肌活检在限制型心肌病的病因诊断中具有重要价值.     

Endomyocardial biopsy in heart transplantation]

From October 1984 to June 1991, 1,549 endomyocardial biopsies (EMB) were performed on 122 patients submitted to a Cardiac Transplant procedure (CT) at the Hospital Puerta de Hierro in Madrid. All biopsies were performed with the long sheath technique and the King bioptome. A total of 8,707 specimens were obtained, of which 7,311 (83.97%) were considered adequate for pathological examination. We did not find significant differences between the internal jugular (83.21%) and the femoral vein (84.82%) approaches. About 20% of the samples were not adequate for pathological evaluation after the fifth procedure performed on the same patient. There has been no deaths in our group. One patient (0.06%) had right ventricular perforation with tamponade that required surgical treatment. Two patients (2.98%) presented coronary fistulae related to EMB. The percent of other minor complications was less than 0.5%. EMB is mandatory for the control of rejection in the first year after cardiac transplantation, and has shown to be a reliable and safe method in experienced hands.