老年性心瓣膜钙化的患病情况和易患因素探讨

本文采用前瞻性调查方法,对368例年龄在60岁以上病人进行全面的临床研究,除外风心病14例,二维超声显象检出主动脉瓣钙化和(或)二尖瓣钙化213例(60.2%),且随增龄而增高(P<0.001)。受累瓣膜以主动脉瓣为主,无性别差异(P>0.05);而二尖瓣钙化多见于女性(P<0.001)。Logist回归分析指出高龄和高血压是本病的易患因素。     

吡格列酮对糖尿病大鼠血管钙化的影响及机制

目的研究吡格列酮对糖尿病大鼠血管钙化的影响及其可能机制。方法将36只SD雄性大鼠随机平均分为6组:对照组、糖尿病组、钙化组、糖尿病+钙化组、钙化+吡格列酮组、糖尿病+钙化+吡格列酮组;建立大鼠血管钙化模型(维生素D3+华法林)和糖尿病模型(链尿佐菌素);并对血管组织进行Von Kossa染色、钙含量和碱性磷酸酶活性检测,qRT-PCR检测mRNA表达,免疫组织化学法检测骨保护素蛋白表达。结果钙化组血管平滑肌细胞及其间质内有大量黑色颗粒沉积;糖尿病+钙化组较糖尿病组和钙化组血管组织钙含量、碱性磷酸酶活性分别升高3.63倍、1.35倍和3.69倍、1.30倍(P<0.05),骨保护素mRNA含量及其蛋白表达降低(P<0.05);糖尿病+钙化+吡格列酮组较糖尿病+钙化组钙含量、碱性磷酸酶活性分别下调13.70%、18.04%(P<0.05),骨保护素mRNA含量及其蛋白表达升高(P<0.05)。结论吡格列酮可以减轻血管钙化程度并上调骨保护素mRNA含量及蛋白表达,骨保护素可能是抑制血管钙化主要因素之一。     

左心耳组织中基质金属蛋白酶-2表达与风湿性心脏瓣膜病手术同期行心房颤动射频消融疗效间的相关研究

目的:探讨左心耳组织中基质金属蛋白酶-2(MMP-2)和金属蛋白酶组织抑制因子-2(TIMP-2)的表达对风湿性心脏瓣膜病(风心病)瓣膜手术同期行心房颤动(房颤)射频消融疗效的影响.方法:风心病瓣膜手术同期慢性房颤射频消融术患者共80例,根据术后6个月随访结果分为房颤消除组(n=56)和房颤未消除组(n=24).以逆转录聚合酶链反应法和蛋白质印迹法检测左心耳组织中MMP-2和TIMP-2的信使核糖核酸(mRNA)和蛋白表达,天狼猩红染色偏振光显微镜观察Ⅰ型和Ⅲ型胶原容量分数(CVF-Ⅰ和CVF-Ⅲ).结果:房颤未消除组心房组织MMP-2的mRNA及蛋白表达较房颤消除组明显增加(126.75±47.67 vs.62.43±31.41,P<0.001;140.33±35.17 vs.82.57±29.56,P<0.001),CVF-Ⅰ也较房颤消除组明显增加(18.16±3.22 vs.11.66±3.38,P<0.001).两组之间TIMP-2的mRNA和蛋白表达及CVF-Ⅲ无明显区别.左心耳组织MMP-2的mRNA和蛋白表达与CVF-I呈显著正相关(r=0.575,P<0.001;r=0.637,P<0.001),左心耳组织中MMP-2的mRNA和蛋白表达与左心房直径也呈显著正相关(r=0.465,P=0.003;r=0.571,P<0.001).结论:左心耳组织MMP-2表达与左心房大小和心房纤维化程度相关并影响瓣膜手术同期射频消融治疗房颤的疗效.     

血液透析影响血清碱性磷酸酶、骨硬化蛋白与骨代谢的机制

目的研究血液透析影响血清碱性磷酸酶(ALP)、骨硬化蛋白与骨代谢的机制。方法将163例受试者分为两组:血液透析组(血液透析患者,n=79),健康对照组(医院健康体检参与者,n=84);通过标准实验室方法测定血清和尿液中的肌酐水平;通过Western印迹检测骨硬化蛋白和血清ALP蛋白的表达;通过试剂盒检测骨代谢标志物含量;通过实时荧光定量-聚合酶链式反应(RT-qRCR)检测炎症因子mRNA的表达量。结果两组性别、年龄、体重、身高和体重指数比较差异无统计学意义(P>0.05);血液透析后,血液透析组肌酐和尿素氮水平明显低于血液透析前,差异有统计学意义(P<0.05);血液透析后血液透析组骨硬化蛋白和血清ALP蛋白表达量明显低于血液透析前,但仍明显高于健康对照组,差异均有统计学意义(均P<0.05);血清抗酒石酸酸性磷酸酶(TRAP)5b和血清甲状旁腺激素(PTH)呈正相关,血液透析后,血液透析组骨代谢标志物ALP、TRAP 5b、血清Ⅰ型胶原C端肽(CTX)和PTH含量、肿瘤坏死因子(TNF)-αmRNA、白细胞介素(IL)-6 mRNA表达量均明显低于血液透析前,但仍明显高于健康对照组,差异均有统计学意义(均P<0.05)。结论血液透析通过调节IL-6和TNF-α,增加尿素氮清除率,影响血清ALP、骨硬化蛋白与骨代谢标志物含量。     

二尖瓣退行性变瓣膜组织中Sox9表达的研究

目的:探讨Sox9在二尖瓣退行性变(DMVD)与正常二尖瓣瓣膜组织中的表达差异。方法:收集11例DMVD患者(DMVD组)二尖瓣瓣膜与3例因其他疾病死亡患者(对照组)的正常二尖瓣瓣膜,行免疫组织化学染色,根据Sox9阳性细胞比例及阳性细胞染色强度,采用二次记分法判读,0~3分为Sox9低表达,4~9分为Sox9高表达,对两组Sox9表达情况进行统计学分析。结果:Sox9表达定位于细胞核,在对照组二尖瓣瓣膜内皮细胞、海绵层间质细胞内散在表达;Sox9在DMVD组二尖瓣瓣膜主要表达于间质细胞,各层均有分布,在海绵层呈团簇状分布。对照组二尖瓣瓣膜Sox9阳性细胞比例及染色强度均较低,其中Sox9低表达3例,高表达0例,综合评分1~3分;DMVD组二尖瓣瓣膜内Sox9低表达2例,高表达9例,综合评分3~9分;Sox9在DMVD组和对照组二尖瓣瓣膜中的表达差异有统计学意义(P=0.027)。结论:Sox9在DMVD二尖瓣瓣膜中高表达,可能参与二尖瓣瓣膜退行性变病变过程。     

MMP-9/TIMP-1在风心病射频消融术后房颤复发中的表达及意义

目的改良迷宫术是外科治疗房颤的有效方法,但对于瓣膜病特别是风湿性心脏病所合并房颤的患者,早期的手术效果并不理想。本研究目的是观察基质金属蛋白酶-9(MMP-9)和金属蛋白酶组织抑制剂1(TIMP-1)在风心病患者房颤射频消融术后左房组织中的表达,探讨其与疗效的相关性。方法从80例行瓣膜置换同期行射频消融的风心病合并持续性房颤患者中获取组织标本。根据随访术后6个月心律的情况,结果分为房颤未消除组(24例)及窦性心律组(56例)。应用半定量逆转录-聚合酶连反应技术(RT-PCR)及免疫印迹方法 (Western blotting)检测心房组织中基质金属蛋白酶9的m RNA及蛋白的表达水平。结果与窦性心律组相比,房颤组MMP-9的m RNA、蛋白的表达及胶原容量分数(Collagen Volume Fraction,CVF)显著增高。(P=0.001;P=0.01;P=0.003),同时TIMP-1的m RNA及蛋白的表达两组无显著差别。关联分析显示心房组织中MMP-9的m RNA及蛋白的表达及CVF(r=0.625,P<0.01 VS r=0.567,P<0.01)与左房的直径成正相关。结论 MMP-9与左心耳的胶原容量分数(CVF)成正相关,与在风心病射频消融术后房颤复发有相关性。     

护骨胶囊联合鲑鱼降钙素治疗老年骨质疏松的效果

目的探讨护骨胶囊联合鲑鱼降钙素治疗老年骨质疏松的效果。方法收集240例老年骨质疏松患者临床资料,依据治疗方案的不同,将采用鲑鱼降钙素+钙尔奇D治疗的120例患者临床资料纳入对照组;将采用护骨胶囊+鲑鱼降钙素+钙尔奇D治疗的120例患者临床资料纳入观察组,两组均治疗3个月。比较治疗前及治疗3个月后的骨代谢标志物〔骨保护素(OPG)、Ⅰ型胶原氨基端延长肽(PINP)、骨形态发生蛋白(BMP)-2、骨密度〔髋部骨密度、腰椎骨密度、骨痛情况,并比较治疗期间两组不良反应发生率。结果治疗3个月结束时,两组OPG、PINP、BMP-2水平均高于治疗前,且观察组高于对照组,差异有统计学意义(P<0.05);治疗3个月结束时,两组髋部和腰椎的骨密度均高于治疗前,且观察组高于对照组,差异有统计学意义(P<0.05);治疗3个月结束时,两组视觉模拟评分法(VAS)评分均低于治疗前,且观察组低于对照组,差异有统计学意义(P<0.05);治疗期间,观察组不良反应发生率与对照组相比,差异无统计学意义(P>0.05)。结论护骨胶囊联合鲑鱼降钙素治疗可改善老年骨质疏松患者骨代谢情况,提升骨密度,降低患者骨痛程度,且不会增加药物不良反应。     

二尖瓣环大小和运动幅度对球囊扩张术疗效的影响

前瞻性观察二尖瓣环大小及运动幅度对经皮二尖瓣球囊扩张术（ＰＢＭＶ）疗效的影响,结果：风心病二尖瓣狭窄组的二尖瓣环直径较正常对照组明显增大,瓣环在心动周期中的变化值,变化率及位移较正常对照组明显减少,风心病二尖瓣狭窄患者瓣膜超声评分〉８分组≤８分线比较,瓣环较小,瓣环的变化值,变化率及位移明显降低,术后疗效满意组的二尖瓣环大小及运动幅度均大于非满组,１９个相关因素多元逐步回归分析表明,二尖瓣环直径和     

高血压患者血清骨保护素水平的变化及与动态动脉硬化指数的相关性

目的探讨原发性高血压(EH)患者血清骨保护素水平和动态动脉硬化指数(AASI)的关系与意义。方法选取2018年5-12月心血管内科收治的轻中度EH患者272例为观察组,正常血压者114人为对照组。观察两组受试者血脂、血糖、尿酸、骨保护素、糖化血红蛋白(HbA1c)、高敏C反应蛋白(hsCRP)水平的差异和AASI的变化。根据AASI测定结果将观察组患者进一步分为A组(AASI≤0.40,n=52)、B组(AASI 0.41～0.50,n=140)、C组(AASI≥0.51,n=80),分析各个指标的组间差异及相互关系。结果与对照组比较,观察组患者AASI(0.76±0.12比0.42±0.10)、血清骨保护素[(1528.6±185.7)比(1196.2±165.5)ng/L]及hsCRP[(7.42±1.64)比(1.12±0.63)mg/L]水平升高(均P0.05)。与A组比较,B、C组患者hsCRP、骨保护素水平升高,与B组相比,C组进一步升高(均P0.05)。AASI与血清骨保护素呈正相关(r=0.486,P0.05)。多元线性回归分析显示,血清骨保护素是AASI的影响因素(B=0.112,P0.05)。结论 EH患者血清骨保护素与AASI密切相关。     

白细胞介素17促进主动脉瓣膜间质细胞向成骨样细胞转化

目的研究白细胞介素17(IL-17)是否促进主动脉瓣膜钙化形成及其可能机制。方法利用体外主动脉瓣膜间质细胞培养技术,瓣膜间质细胞培养传代3⁵次后,采用简单随机抽样法分为两组:(1)对照组,细胞培养基中添加2 ml RPMI-1640完全培养液;(2)实验组,细胞培养基中添加2 ml RPMI-1640完全培养液和IL-17(50 ng/ml)。继续孵育48 h后,用细胞茜素红钙染色检测两组瓣膜间质细胞钙化情况,用Western blot和RT-PCR检测两组瓣膜间质细胞碱性磷酸酶(ALP)及骨形态蛋白2(BMP-2)的表达情况。结果实验组细胞中明显钙结节形成,对照组细胞中少量钙结节形成;与对照组比较,实验组细胞ALP和BMP-2蛋白(0.741±0.063比0.184±0.032;0.900±0.060比0.396±0.030,均为P<0.01)与基因(0.236±0.004比0.106±0.003;0.523±0.052比0.194±0.047,均为P<0.01)表达量均明显升高。结论 IL-17可促进主动脉瓣膜间质细胞向成骨样细胞转化。     

Surgical pathology of mitral valves--the Indian scene

Of the 75 cardiac valves excised at surgery over a 2 year period, 54 were mitral valves. Using simple morphological criteria along with clinical data, the valves were assigned to 2 major groups, rheumatic and non-rheumatic. The group with rheumatic disease accounted for 90% of cases. Mitral stenosis, incompetence and combined stenosis with incompetence were encountered with equal frequency (38, 38 and 24%). Mitral insufficiency of rheumatic etiology, no longer considered to be a major problem in the west, continues to be frequent in India. An increased incidence of mitral regurgitation in young females is an important feature noticed in this series.     

Effects of isosorbide dinitrate on rheumatic and non-rheumatic mitral regurgitation

Isosorbide dinitrate was given to seven patients with isolated mitral regurgitation (three cases of rheumatic origin, four non-rheumatic) to assess its hemodynamic effects. The pulmonary capillary pressure, left ventricular end-diastolic pressure, left ventricular end-diastolic volume index, and the aortic pressure were all significantly reduced. The heart rate was significantly increased, while the systemic vascular resistance and the left ventricular contractility index were unchanged. The regurgitant flow increased by an average of 72.2% in the rheumatic group, but decreased by an average of 4.8% in the non-rheumatic group (p < 0.05). The forward cardiac output decreased slightly in both groups, but the difference was not significant (NS). It appears that isosorbide dinitrate has a more detrimental effect on cases of mitral regurgitation of rheumatic origin than on those of non-rheumatic origin. We suggest the difference in the responses is a consequence of the dynamic nature of the regurgitant orifice in the non-rheumatic group and the static nature of the orifice in the rheumatic group.     

In-hospital and Readmission Outcomes With Percutaneous Balloon Mitral Valvuloplasty

Percutaneous balloon mitral valvuloplasty (PBMV) is primarily performed for rheumatic mitral stenosis (MS). Therefore, limited data exist on PBMV in countries with a low incidence of rheumatic disease. Using the Nationwide Readmission Database, we examined trends in in-hospital mortality and 30-day readmission among patients who received PBMV for rheumatic and non-rheumatic MS. We also examined the change in 90-day hospitalization rate before vs after PBMV. Between 2016 and 2019, there were 1109 hospitalizations in which patients received PBMV for rheumatic (n = 955, 86.1%) vs non-rheumatic MS (n = 154, 13.9%). The all-cause in-hospital mortality for rheumatic and non-rheumatic MS did not change over time (0.9% → 2.0%, P = 0.94, and 5.9% → 9.5%, P = 0.09 respectively). Similarly, the 30-day readmission for patients with rheumatic and non-rheumatic MS did not change over time (12.4% → 9.9%, P = 0.26, and 4.4% → 10.5%, P = 0.30, respectively). The 90-day all-cause hospitalization rate remained the same before vs after PBMV for rheumatic and non-rheumatic MS (25.5% → 21.8%; P = 0.14, and 24.0% → 33.7%; P = 0.19, respectively). Although no statistically significant change was noted over time for trends in in-hospital mortality, 30-day readmission, or even in the change in 90-day all-cause hospitalizations before and after PBMV for both types of MS, among those with non-rheumatic MS, there was a signal of an increase in the in-hospital mortality, and 30-day readmission, even more, there was 29% relative increase in 90-day hospitalizations after PBMV. Future studies are needed to examine the role of PBMV in patients with non-rheumatic MS.     

Assessment of colour flow imaging in the grading of valvular regurgitation

To assess the accuracy of colour flow imaging in the gradingof valvular regurgitation, we studied 100 consecutive patientswith angiographic mitral regurgitation (55), aortic regurgitation(35) or both (10). The etiology of valve regurgitation was rheumaticin 42 and non-rheumatic in 58 patients. For comparison, 28 subjectswith no structural cardiac disease were studied. Mitral valveregurgitation was assessed with colour flow imaging by measuringthe maximal regurgitant jet area and the maximal jet area normalizedto left atrial area; aortic valve regurgitation was assessedfrom jet area and jet width normalized to ventricular outflowtract width. The best correlation between colour flow imagingand angiography was obtained with normalized measurements forboth mitral (r = 0.82, P<0.0001) and aortic regurgitation(r = 0.94, P<0.0001). A proportion of patients and controlswithout angiographic regurgitation showed evidence of mild mitral(31% and 32%) and aortic (14% and 11%) regurgitation on colourflow imaging. There was a large overlap in the normalized colourflow measurements between angiographically mild and moderatemitral regurgitation: (43%); the overlap was greater when regurgitationwas rheumatic in origin (45% ) rather than non-rheumatic (10%)(P<0.001). There was also overlap in the normalized colourflow findings in patients with angiographic aortic regurgitation,which was greater in rheumatic vs non-rheumatic disease. Knowledgeof the etiology significantly improved the separation of allangiographic grades of aortic regurgitation using colour flowmeasurements (P = 0.006). These findings confirm the high sensitivityof colour flow imaging in the detection of valvular regurgitationand indicate that its accuracy is higher in patients with non-rheumaticthan rheumatic heart disease.     

Echocardiographic diagnosis of mitral valve insufficiency

Seventy-two persons with various forms of mitral insufficiency of rheumatic and non-rheumatic etiology and 17 healthy individuals (control group) were examined. The results of echocardiography in 35 patients were compared with operative (mitral commissurotomy, valve plastics) findings. Several typical variants of a mitral echogram in patients with "pure", predominant and concomitant mitral insufficiency were distinguished. The predominantly "valvular" mechanism of mitral insufficiency in patients with rheumatic disease and the predominant role of "subvalvular" pathology in nonrheumatic insufficiency were revealed. The diagnostic value of determining the indices of cardiac activity and the size of the left parts of the heart by means of echocardiography is confirmed.     

Changes in the etiology of valvular heart disease in the rapidly aging Korean population

Background

The aim of this study is to assess the changes in the causes of valvular heart disease between 2006 and 2011 in Korea.

Methods

Data were collected from the Korean National Health Insurance Service from 2006 through 2011. These data consisted of primary diagnoses related to valvular heart disease regardless of other conditions. Valvular heart disease included non-rheumatic mitral valve disorders, non-rheumatic aortic valve disorders, rheumatic mitral valve disorders, and rheumatic aortic valve disorders.

Results

Overall, the age-standardized cumulative prevalence of non-rheumatic valvular heart disease was 70.6 per 100,000 persons in 2006 and 110.3 in 2011. This represented an increase from 42.2 to 65.2 in women and from 28.4 to 45.1 in men. In particular, there was a greater increase in prevalence in patients aged 65 years or older compared with groups aged 20–44 years or 45–64 years for both genders. The age-standardized cumulative prevalence of rheumatic valve disease did not change dramatically between 2006 and 2011.

Conclusions

The overall age-standardized cumulative prevalence of non-rheumatic valvular heart diseases increased between 2006 and 2011, especially in individuals older than 65 years. These changes should be considered in future designs of cardiovascular healthcare services in countries with a rapidly aging population.     

Pathology of mitral valve stenosis and pure mitral regurgitation—Part II

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. in Part I, conditions producing mitral valve stenosis were reviewed. in over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. in Part II, conditions producing pure mitral regurgitation are discussed. in contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.     

Surgical pathology of the mitral valve: gross and histological study of 1288 surgically excised valves.

A consecutive series of 1288 mitral valves surgically excised from 1981 through 1989 were studied macroscopically and histologically. The explanted valves were affected by: chronic rheumatic disease (1179, 91.5%), floppy mitral valve (84, 6.5%), bacterial endocarditis (19, 1.5%), and post-ischemic mitral incompetence (6, 0.5%). Among 1179 post-rheumatic cases, mixed mitral stenosis and incompetence was the most frequent malfunction (747, 58%). Isolated mitral incompetence was diagnosed in 72 (6.11%) cases only, and isolated stenosis in 360 cases. In 52 valves, excised because of chronic rheumatic disease, the histology showed unexpected signs of acute rheumatism of the leaflets and the papillary muscles. In these patients clinical symptoms and blood tests were negative for rheumatic disease. Mitral incompetence, possibly due to papillary muscle dysfunction, was the prevalent lesion (61.5%). A total of 181 patients (14.05%) with pure mitral incompetence underwent surgery. In 84 patients (46.4%), the floppy mitral valve was the most frequent cause of valve dysfunction, 72 (39.8%) had rheumatic disease, 19 (10.5%) infective endocarditis, and 6 (3.4%) ischemic heart disease. In the group with floppy mitral valve, males were more prevalent than females (51:33). The mean age of the 4 patients with Marfan's syndrome and non-Marfan patients was noticeably different (17 vs 49 yr). Moreover leaflet deformation, tendinous cord elongation and annulus dilatation were the most common causes of valve incompetence. Floppy mitral valve and infective endocarditis were the cause of cordal rupture in 43.5% of the cases. This was a severe complication which always required emergency surgery.     

A comparison of sleep in rheumatic and non-rheumatic patients

The St. Mary's Hospital Sleep Questionnaire was used to investigate sleep in 439 hospitalized rheumatic and non-rheumatic patients. This questionnaire enabled an evaluation of both the level of sleep disturbance and the causes of such disturbance. The findings from this study indicated that there was little difference in the level of sleep disturbance between rheumatic and non-rheumatic patients. The sleep problem most frequently cited by rheumatic patients was pain. Noise appeared to be the worst environmental sleep problem in these patients. The only significant difference in the sleep problems reported by rheumatic and non-rheumatic patients, was that pain was cited more frequently in the rheumatic group. In order to determine whether sleep varied according to type of rheumatic disease, the rheumatic patients were divided into four diagnostic groups (rheumatoid arthritis; seronegative spondarthritis; osteoarthritis; other conditions). There were no significant differences between these groups in sleep disturbance or reported sleep problems.     

The relative incidence of rheumatic valve disease in New York and Costa Rica and its bearing on the rheumatic origin of calcareous aortic stenosis

The incidence of rheumatic endocarditis of the mitral valve alone, and of the mitral and aortic valves together, in three independent series of autopsies is compared. Differences in the total incidence of valvular lesions were noted in each of the three series. These differences cannot be attributed to racial or geographical factors alone, since two of the series represent cases from essentially the same types of population in the New York area. However, the relative incidence of each type of valve lesion is constant in the three series. Mitral stenosis is more common in women than in men in each series. The incidence of calcareous deforming lesions, limited to the aortic valve, is also determined in the three autopsy series and is found to vary constantly with the incidence of rheumatic lesions in each of the three series. In males, lesions of the mitral valve alone, together with lesions of both mitral and aortic valves, are about two and one-half to three times as common in each series as are calcareous deforming lesions limited to the aortic valve. Lesions of the aortic valve only are more common in males and involve an older age group than do the other types of rheumatic lesions. The incidence of lesions of the aortic valve only, in the groups surviving longer than 50 years in each series, is relatively the same as for the entire age group in each series, however.