呼吸对右心衰竭患者三尖瓣反流速度和肺动脉压测定的影响

目的 探讨平静呼吸对右心衰竭患者三尖瓣反流速度和肺动脉收缩压测定的影响.方法 选取32例右心衰竭患者(病例组)和28例右心功能正常而三尖瓣反流患者(对照组)行超声心动图检查.观测三尖瓣反流速度,根据反流法计算肺动脉收缩压,比较两组吸气相与呼气相之间的差异.结果 病例组三尖瓣反流速度、肺动脉收缩压吸气相均小于呼气相(P＜0.001);对照组三尖瓣反流速度、肺动脉收缩压吸气相与呼气相比较差异无统计学意义.结论 使用超声心动图估测肺动脉收缩压时,应注意平静呼吸对右心衰竭患者三尖瓣反流速度和肺动脉收缩压测定的影响,尽量在呼气末或呼气末屏气状态下进行.     

连续多普勒超声评估IPAH患者不同时相肺动脉压与心导管检测的相关性研究蔡燕娟 罗孝勇 陈权

目的：探讨连续多普勒超声对特发性肺动脉高压 (IPAH) 患者不同时相肺动脉压与心导管检测肺动脉压之间的关联。方法：选取2013年6月~2016年3月期间在我院因胸闷、气促等临床可疑IPAH患者113例作为研究对象，利用连续多普勒超声心动图对经心导管确诊的78例IPAH患者主肺动脉内径 (MPA) 、右心房左右径 (RAT) 、左、右心室舒张末期左右径 (LVT 、RVT) 及前后径 (LVD 、RVD) ，计算其右心室与左心室左右径的比值 (RVT/ LVT) 、前后径的比值 (RVD/LVD) ；记录三尖瓣反流最大压差 (收缩压) 、肺动脉瓣舒张早期及末期反流压差 (舒张压) 并计算平均压，将多普勒超声心动图的相关检测指标与心导管测量不同时相肺动脉压力值进行比较。结果：1.超声估测肺动脉高压的灵敏度、特异度、阳性预测值、阴性预测值及准确度分别为87.2%,74.3%,88.3%,72.2%,83.2%.2.本研究中经心导管确诊的78例患者均存在不同程度的三尖瓣反流或肺动脉瓣反流，其中三尖瓣反74例，肺动脉瓣反流62例，两种情况同时存在58例；经多普勒超声心动图检测的IPAH患者的肺动脉收缩压 (PASPe) 、舒张压 (PADPe) 及平均压 (PAMPe) 与右心导管检测的收缩压 (PASPc) 、舒张压(PADPc) 及平均压 (PAMPc) 之间均存在显著相关性 (r=0.667；0.639；0.636，P均<0.05) ；同时，MPA、RAT、RVT/LVT以及RVD/LVD与PASPc之间均存在相关性 (P<0.05) ，RAT、RVT/LVT以及RVD/LVD与PASPc之间相关性最为明显 (P<0.001) 。结论：多普勒超声对IPAH患者不同时相肺动脉压的评估与右心导管测量肺动脉压之间存在显著相关性，利用多普勒超声测量三尖瓣及肺动脉瓣反流对IPAH患者肺动脉压的评估具有较高的准确性，是无创评估肺动脉高压的首选方法。     

超声心动图法测定先天性心脏病肺动脉收缩压的可靠性研究

目的 与有创的导管法对照,评价多普勒超声心动图法测定肺动脉高压患者肺动脉收缩压的可靠性.方法 临床诊断肺动脉高压患者47例,术中对肺动脉收缩压、右心导管法实时监测右房、右室及肺动脉压,术前24 h内进行超声心动图检查,测量三尖瓣最大反流速度,计算右房室压差,并与心导管法测量结果进行相关性分析.注意分析超声心动图法测定中出现的结果并讨论解决办法.结果 多普勒超声心动图法测定的与导管法测定结果差异无统计学意义[(51±5)mm Hg vs(48±5)mm Hg,P>0.05],两种方法测定的△p呈显著正相关r=0.85,P<0.01.结论 多普勒超声心动图测压法可提供可靠的最大三尖瓣跨瓣压,与心导管法所测者相关显著,可为患者临床药物治疗及病情分析提供宝贵的血流动力学资料.     

超声心动图对特发性肺动脉高压的评估

目的探讨超声心动图对特发性肺动脉高压(IPAH)的评估价值。方法 2013年8月至2014年8月在我院经右心导管检查确诊的58例IPAH患者,应用超声心动图诊断仪测量右心房左右径(RAT)、主肺动脉内径(MPA),右、左心室舒张末期前后径(RVD、LVD)及左右径(RVT、LVT),计算右、左心室前后径及左右径的比值(RVD/LVD、RVT/LVT);运用多普勒超声测量三尖瓣反流最大压差、肺动脉瓣舒张早期反流压差、肺动脉瓣舒张末期反流压差,将超声心动图的检测指标与心导管测值进行相关性分析。结果 58例患者均存在不同程度三尖瓣反流或肺动脉瓣反流,其中存在三尖瓣反流患者56例,肺动脉瓣反流患者48例,同时存在肺动脉瓣反流和三尖瓣反流患者46例;超声心动图估测肺动脉收缩压(PASPe)与右心导管检测肺动脉收缩压(PASPc)呈显著正相关(r=0.668,P<0.001),超声心动图估测肺动脉平均压(PAMPe)、肺动脉舒张压(PADPe)与右心导管检测肺动脉平均压PAMPc、舒张压PADPc相关性良好(r=0.637,P<0.001;r=0.640,P<0.001),RVD/LVD、RAT、RVT/LVT与PASPc呈明显相关(r值分别为0.598、0.47、0.491,均P<0.001),MPA与PASPc相关性较差(r=0.281、P<0.05)。结论超声心动图与右心导管测量的PASP、PAMP、PADP具有高度相关性,超声心动图通过三尖瓣反流及肺动脉瓣反流来评估特发性肺动脉压是临床上首选、无创准确测量肺动脉压力的方法之一。     

超声心动图在心脏移植术后动态观察右室结构及三尖瓣反流中的应用

目的:了解超声心动图在心脏移植术后动态观察右室结构改变及三尖瓣反流的临床意义。方法:患者心脏移植术后,每天1次,连续7d,第2周起每周1次,利用超声心动图仪动态观察右室内径,于心尖四腔心切面观察测量三尖瓣反流面积、三尖瓣反流速度,由此估测肺动脉收缩压。结果:心脏移植后右室增大,并且持续约1周时间,1周后逐渐缩小;三尖瓣反流面积逐渐增大,术后第5天达最大面积后逐渐减小;肺动脉收缩压估测值术后第1、2天低于正常值(以30mmHg为标准),第3天起逐渐增高,第2、3周内呈持续增高后逐渐稳定。结论:超声心动图能够方便、快速、较准确地观察评价心脏移植术后右心室改变,了解三尖瓣反流及肺动脉高压估测值的动态变化及临床意义,具有动态、方便、无创的优点,为临床在心脏移植术后的后续治疗护理提供大量参考信息,有重大的临床意义。     

连续多普勒超声心动图测定三尖瓣闭锁不全时的肺动脉压

作者对51例各种心脏病患者进行多普勒超声心动图及右心导管检查,脉冲多普勒超声发现三尖瓣闭锁不全并可供分析者30例。应用连续多普勒超声测定三尖瓣最大返流速度(Vmax),根据简化Bernoulli方程计算收缩期右室-右房压差(△4V_(max)~2)。多普勒超声测得压差与导管测值密切相关(r=0.71);将临床估测的肺动脉收缩压,后者与导管测值亦密切相关(r=0.70)。由于肺动脉压增高患者其三尖瓣闭锁不全发生率高(89％),故本法有实用价值,是一种准确的,可供广泛采用的无创性检查方法。     

超声心动图在心脏移植术后动态观察右室结构及三尖瓣反流中的应用

目的：了解超声心动图在心脏移植术后动态观察右室结构改变及三尖瓣反流的临床意义。方法：患者心脏移植术后，每天1次，连续7d，第2周起每周1次，利用超声心动图仪动态观察右室内径，于心尖四腔心切面观察测量三尖瓣反流面积、三尖瓣反流速度，由此估测肺动脉收缩压。结果：心脏移植后右室增大，并且持续约1周时间，1周后逐渐缩小；三尖瓣反流面积逐渐增大，术后第5天达最大面积后逐渐减小；肺动脉收缩压估测值术后第1、2天低于正常值（以30mmHg为标准），第3天起逐渐增高，第2、3周内呈持续增高后逐渐稳定。结论：超声心动图能够方便、快速、较准确地观察评价心脏移植术后右心室改变，了解三尖瓣反流及肺动脉高压估测值的动态变化及临床意义，具有动态、方便、无创的优点，为临床在心脏移植术后的后续治疗护理提供大量参考信息，有重大的临床意义     

超声多普勒方法估测肺动脉平均压的效果比较

目的评价四种超声多普勒指标估测肺动脉平均压(PAMP)的效果。方法收集预行先心病封堵术的患者80例,以右心导管测量的PAMP为诊断标准,与肺动脉反流峰值速度(PRV)、三尖瓣反流峰值速度(TRV)、肺动脉频谱加速时间(AT)、右室射血前期时间与AT比值(PEP/AT)估测的PAMP进行比较。结果四种方法估测的结果与导管值具有相关性(r=0.739、0.798、0.430、0.481,P0.001)。ROC曲线显示PRV、TRV、PEP/AT的诊断价值较高,AT的诊断价值中等。Kappa值提示PRV的诊断一致性较高,TRV、PEP/AT中度,AT较差。结论应用超声多普勒估算先心病患者PAMP时,首先推荐使用肺动脉瓣反流和三尖瓣反流峰值速度,当不存在瓣膜反流时,可以使用肺动脉频谱指标作为补充。     

彩色多普勒超声心动图评价婴幼儿急性肺炎的肺动脉压力

目的 应用彩色多普勒超声心动图(CDE)评价婴幼儿急性肺炎的肺动脉压力变化.方法 病例选择急性肺炎婴幼儿60例,其中轻症、重症各30例,为1、2两组,无心肺病史的正常婴幼儿30例为对照组.CDE测量三尖瓣反流速度、肺动脉瓣血流加速时间、右室射血时间及右室流出道时间速度积分评价婴幼儿急性肺炎的肺动脉压力和肺血管阻力.结果 60例急性肺炎患儿,检出三尖瓣反流者53例,其中32例肺动脉压力增高,其余21例肺动脉压力正常.重症肺炎肺动脉压力升高者有30例,轻症2例.对照组20例测得三尖瓣反流,肺动脉压力均正常.结论 急性肺炎患儿的肺动脉压力可能升高.重症肺炎患儿的肺动脉压力升高较明显,同时伴肺血管阻力升高.     

产前超声诊断胎儿三尖瓣下移畸形的应用价值

目的 探讨产前超声诊断胎儿三尖瓣下移畸形的临床价值。方法 回顾性分析6例经胎儿超声心动图诊断为三尖瓣下移畸形的超声诊断资料与随诊结果，总结其异常声像图特点。结果6例胎儿均经尸体解剖证实为三尖瓣下移畸形，其中三尖瓣隔叶下移2例，隔叶及后叶下移3例，隔叶、后叶及前叶下移1例。6例三尖瓣下移畸形中4例伴有功能右室缩小，合并房间隔缺损1例，肺动脉狭窄1例；4例伴有胸、腹腔及心包积液。胎儿三尖瓣下移畸形主要声像图表现为右心扩大，三尖瓣叶附着点下移，心尖到二尖瓣前叶附着点的距离与到三尖瓣隔叶附着点的距离比值≥1．8，形成典型房化右室特征；彩色血流显示三尖瓣重度反流，其反流起源点低，反流面积大，但反流速度低，平均反流速度217．0cm／s。结论 胎儿三尖瓣下移畸形具有特征性声像图表现，产前超声诊断胎儿三尖瓣下移畸形具有重要临床价值。     

Comparison of several noninvasive methods for estimation of pulmonary artery pressure

Noninvasive estimation of pulmonary artery pressure is an important component of cardiac ultrasound studies. A number of methods are available for estimation of pulmonary pressure, each with varying degrees of reported accuracy. To assess feasibility and accuracy, noninvasive pulmonary artery pressure estimates were performed in infants and children at the time of catheterization. Patients were examined prospectively until there were 50 patients, in whom each of six methods for estimation of pulmonary pressure had been accomplished. All patients had tricuspid and pulmonary regurgitation of less than severe degree and no structural, flow, or electrocardiographic abnormality known to compromise the six methods. Systolic pressure was estimated by the Burstin method and also from peak tricuspid regurgitation velocity. Mean pressure was estimated by acceleration time divided by ejection time from waveforms obtained from the right ventricular outflow tract and main pulmonary artery. Diastolic pressure was estimated by systolic time intervals and from end-diastolic pulmonary regurgitation velocity. Noninvasive estimates were compared with simultaneous or nearly simultaneous catheterization measurements. For systolic pressure Burstin estimates were accomplished in 89% with high accuracy (r = 0.97). Tricuspid regurgitation velocities were recorded in 82%, also with high accuracy (r = 0.96). Waveforms for mean pressure estimation were recorded in 98% to 100% of patients. Those from the right ventricular outflow tract corresponded well with catheterization pressures (r = 0.94), whereas those recorded from the main pulmonary artery offered poor prediction of pulmonary pressure (r = 0.63). Systolic time interval measurements were accomplished in only 65% and did not correlate highly with catheterization (r = 0.84). Diastolic pressure estimates based on pulmonary regurgitation velocity were recorded in 98% of subjects with high accuracy (r = 0.96). Each method had advantages and disadvantages. The Burstin method was accurate but technically demanding and is reported to be limited by heart rate and significant right-sided regurgitation. Peak tricuspid velocities proved unexpectedly difficult to record in some patients but when successful, provided excellent prediction of pressure. Recording of waveforms for ratios of acceleration time to ejection time proved easy, but accuracy was high only for outflow tract waveforms. Peculiarities of main pulmonary artery flow may have led to poor accuracy for ratios measured from that site. For diastolic pressure estimation, systolic time interval records were the most difficult to obtain and did not provide useful accuracy. In contrast, pulmonary regurgitation velocities were easily obtained and provided high accuracy results. This is a selected pediatric series, evaluating methods in nearly ideal circumstances.(ABSTRACT TRUNCATED AT 400 WORDS)     

The Doppler echocardiographic method of determining right ventricular pressure in patients with congenital heart defects in the early postoperative period

A comparative analysis of the results of invasive and noninvasive measurement of right ventricular pressure showed a high correlation for systolic (r = 0.97, P less than 0.05, n = 41) and diastolic (r = 0.89, p less than 0.05, n = 41) pressures. The noninvasive technique is applicable only in the presence of tricuspid regurgitation or that of ventricular septal defect ejection. Moreover, in slight or minimal tricuspid regurgitation when the peak of systolic regurgitation is poorly seen, there is a difference between the results of these measurements (7-10 mm Hg). It has been concluded that Doppler echocardiography is an informative noninvasive tool for measuring pressure in the right ventricle and pulmonary artery and offers an opportunity of determining pulmonary hypertension quantitatively before and after surgery.     

二维及多普勒超声心动图诊断原发性肺动脉高压

应用二维及多普勒超声心动图首诊８例原发性肺动脉高压（ＰＰＨ）患者，并经心导管等检查证实，ＰＰＨ超声表现为右房、右室扩大，右室壁肥厚，肺动脉扩张，室间隔形态异常，心内间隔连续性好，肺动脉血流频谱形态及收缩时间间期变化、肺动脉瓣返流及高速三尖瓣返流等征象。认为室间隔形态异常和通过三尖瓣返流压差法来间接估计肺动脉压是一种简便可行的方法。虽然ＰＰＨ缺乏特异性超声表现，但结合临床分析，超声检查可以提出ＰＰＨ     

Doppler-determined peak systolic tricuspid pressure gradient in persons with normal pulmonary function and tricuspid regurgitation.

The Doppler-estimated peak systolic tricuspid pressure gradient is the most reliable noninvasive method for the evaluation of pulmonary artery systolic pressure in patients with tricuspid regurgitation. Our goal was to evaluate the range of this gradient in healthy persons and determine a normal upper limit. We studied 53 healthy persons (34 women, 19 men; aged 14 to 55 years, mean 38.9 +/- 12.7 years) who did not smoke and who had an adequate Doppler signal of tricuspid regurgitation. The presence of pulmonary or cardiac disorders was excluded by a review of the subject's medical history in addition to physical examination, spirometry, arterial blood gasses determination, electrocardiography, chest x-ray examination, and rest echocardiography. Tricuspid gradient ranged from 12.6 to 29. 3 mm Hg (mean 19.3 +/- 4.0); 35.8% of patients had values higher than 20 mm Hg. In conclusion, a tricuspid gradient of 30 mm Hg may be considered as the upper normal limit. The different approaches for estimating mean right atrial pressure are also discussed.     

Superiority of 10% air-10% blood-saline mixture for measuring the velocity of tricuspid regurgitation in patients with severe emphysema.

BACKGROUND: Severe emphysema frequently is associated with elevated pulmonary artery systolic pressure. However, it is often difficult to obtain adequate tricuspid regurgitation (TR) signals for measurement of pulmonary artery systolic pressure in patients with severe emphysema. PURPOSE: This study was conducted to evaluate the usefulness of air-blood-saline mixture in measuring TR velocity in severe emphysema. METHODS: We studied 82 patients with severe emphysema (67.7 +/- 9.2 years, 57 males) who had no or mild TR on color Doppler. Contrast echocardiography studies were performed with agitated 10% air-90% saline and 10% air-10% blood-80% saline mixtures. Tracing quality and peak velocity were assessed on baseline continuous wave signals and contrast continuous wave signals with the 2 mixtures. RESULTS: With the injection of an air-saline mixture, the quality of TR tracing improved in 45 patients (P <.0001) and a higher peak TR velocity was obtained (2.46 +/- 0.37 m/s vs 2.95 +/- 0.40 m/s, P <.0001) compared with baseline echocardiography. Compared with air-saline mixture, the air-blood-saline mixture further enhanced TR tracing quality in 17 patients (P <.0001) and the peak TR velocity increased to 3.13 +/- 0.42 m/s (P <.0001). CONCLUSIONS: In patients with severe emphysema, an air-blood-saline mixture improves the quantifiable TR signals for more accurate estimation of pulmonary artery systolic pressure, even when there is minimal valve TR.     

Association between myocardial right ventricular relaxation time and pulmonary arterial pressure in chronic obstructive lung disease: analysis by pulsed Doppler tissue imaging.

This study assessed right ventricular function in chronic obstructive lung disease and pulmonary hypertension by Doppler tissue imaging. Doppler echocardiography of the right ventricle and Doppler tissue imaging of the tricuspid annulus were performed in 63 subjects: 20 healthy controls, 20 with lung disease, and 23 with both lung disease and pulmonary hypertension. Two-dimensional tricuspid systolic plane excursion was lower in patients with pulmonary hypertension than in the other 2 groups. Doppler tricuspid inflow measurements distinguished patients in both of the diseased groups from the control subjects, but they did not differentiate patients with pulmonary hypertension from those without it. The ratio of peak E-wave to peak A-wave velocities derived by Doppler tissue imaging was significantly lower and the myocardial acceleration time longer in both groups of lung disease than in the control group. Only myocardial relaxation time distinguished the 3 groups (all P <.01); a gradual increase in time occurred, with the shortest time seen in controls, a longer time in patients with chronic obstructive lung disease without pulmonary hypertension, and the longest time in patients with lung disease and pulmonary hypertension. In the overall population including subjects with at least minimal tricuspid regurgitation, myocardial relaxation time was positively related to pulmonary systolic pressure. In conclusion, Doppler tissue imaging distinguishes subsets of patients affected by lung disease with or without pulmonary hypertension and identifies patients with different levels of pulmonary artery systolic pressure.     

Echocardiographic contrast increases the yield for right ventricular pressure measurement by Doppler echocardiography

Doppler ultrasound has become accepted as a measurement of right ventricular systolic pressure in patients who have a quantifiable signal from tricuspid regurgitation. This study evaluated the use of intravenous injection of saline solution for echo contrast to increase the percentage of quantifiable tricuspid regurgitant signals in patients who have any detectable tricuspid regurgitation at baseline. Patients underwent a standard Doppler evaluation, followed by a contrast study with the injection of 4 to 6 ml of agitated saline solution into a brachial vein. Baseline and contrast tricuspid regurgitant signals were assessed for quality, quantifiability, and reproducibility of the derived pressures by three observers on two occasions. The average absolute pairwise deviation among the three observers was low: 1.6 mm Hg (standard deviation, 1.4 mm Hg). The intraobserver mean discrepancy was low: 0.03 mm Hg (standard deviation, 2.33 mm Hg). Patients who did not have tricuspid regurgitation (n = 10) failed to develop such regurgitation during contrast injection. Only eight of 40 patients (20%) who had trace or mild tricuspid regurgitation had quantifiable baseline signals, but 34 patients (85%) had quantifiable signals with contrast injection. All patients who had mild to moderate, moderate, or severe tricuspid regurgitation (n = 10) had quantifiable signals before contrast injection. Of all patients who had any tricuspid regurgitation, 88% had quantifiable signals with contrast injection. Echo contrast was shown to improve the yield of quantifiable signals in patients who had trace and mild tricuspid.     

超声心动图研究正压通气对犬心功能的影响及其机制

目的观察正压通气时心内瓣口血流速度和左、右心功能的变化,研究正压通气影响血流动力学机制的新理论。方法11条杂种犬,用超声心动图测定正压通气时心内各瓣口的血流速度,右室、左室每搏量,左室容积和射血分数的变化。结果三尖瓣和肺动脉瓣口血流速度正压吸气相减低,呼气相增加;二尖瓣和主动脉瓣口血流速度变化与之相反(P<0.05)。与自主呼吸相比,正压吸气时,右室每搏量减少,左室舒张末和收缩末容积减小,射血分数降低(P<0.05)。结论正压通气使室间隔趋于右移,同时,肺血管床回心血量增加,但与自主呼吸时相比,腔静脉回心血量相对减少,故心功能降低。     

Continuous-wave Doppler determination of the pressure gradient across pulmonary artery bands: hemodynamic correlation in 20 patients

The feasibility and accuracy of continuous-wave Doppler echocardiography in measuring pressure gradients across the pulmonary artery band were assessed. Simultaneous continuous-wave Doppler and catheter pressure measurements were prospectively performed in 20 patients with complex congenital heart disease and prior pulmonary artery banding. In two other patients, adequate Doppler signals could not be obtained. Doppler velocity was converted to pressure gradient by using the modified Bernoulli equation. Simultaneous continuous-wave Doppler spectral envelopes and catheter pressure wave forms were digitized at 10-ms intervals to obtain maximal instantaneous, mean, and peak-to-peak pressure gradients. The maximal Doppler gradient ranged from 23 to 154 mm Hg, and the simultaneous maximal catheter pressure gradient ranged from 34 to 168 mm Hg. The correlation (r) between these two measurements had a coefficient of 0.98 and a standard error of the estimate (SEE) of 7 mm Hg. The peak-to-peak systolic gradient ranged from 17 to 156 mm Hg and correlated with the maximal Doppler gradient (r = 0.95; SEE = 11 mm Hg). The mean Doppler and mean catheter pressure gradients also were correlated (r = 0.93; SEE = 9 mm Hg). As Doppler echocardiography measures instantaneous velocity and therefore instantaneous pressure gradient, the more precise correlation was between Doppler gradient and maximal instantaneous catheter gradient rather than peak-to-peak systolic gradient. Continuous-wave Doppler echocardiography is an accurate noninvasive technique for measurement of pressure gradients across pulmonary artery bands. In combination with clinical evaluation and two-dimensional echocardiography, it should substantially aid clinical decision making.