多平面经食管超声心动图观察主动脉瓣病变

本文对３１例主动脉瓣病变患者进行了多平面经食道超声心动图（ＭＴＥＥ）的研究，其中主动脉瓣狭窄１２例（主动脉瓣二瓣化７例，风湿性３例，退行性病变２例），主动脉瓣关闭不全１９例（风湿性１０例，升主动脉夹层动脉瘤４例，赘生物３例，单纯脱垂２例）。主要从食管中上段的一系列切面观察主动脉瓣的形态结构。ＭＴＥＥ在确定主动脉瓣病变的病因方面明显优于ＴＴＥ。在判断主动脉瓣狭窄和主动脉瓣返流的程度方面ＭＴＥＥ具有重     

Surgical pathology of pure aortic stenosis: a study of 374 cases

The gross surgical pathologic features of the aortic valve were reviewed in 374 patients who had had clinically pure aortic stenosis and aortic valve replacement at our institution during the years 1965, 1970, 1975, and 1980. The most common cause of aortic stenosis, accounting for 46% of our cases, was calcification of a congenitally bicuspid valve. In the remainder, stenosis was produced by postinflammatory fibrocalcific disease (including rheumatic disease) in 35%, by degenerative calcification of an aging valve in 10%, and by calcification of a congenitally unicommissural valve in 6%. The cause of aortic stenosis was indeterminate in 4%. Valvular lesions included various degrees of dystrophic calcification, commissural fusion, and cuspid fibrosis. Calcification tended to occur more extensively and at a younger age in men than in women. Furthermore, it tended to produce stenosis and to necessitate valve replacement earliest in patients with unicommissural valves (mean age, 48 years), later in those with bicuspid or postinflammatory valves (mean age, 59 and 60 years, respectively), and latest in those with degenerative stenosis (mean age, 72 years). In our study, the relative incidence of postinflammatory aortic stenosis remained unchanged from 1965 to 1980, despite the steadily decreasing incidence of acute rheumatic fever reported in western countries. Our data suggest that (1) the incidence of chronic rheumatic heart disease has not yet begun to decrease appreciably, (2) many episodes of acute rheumatic fever may be subclinical, or (3) some forms of nonrheumatic aortic valve disease may produce gross alterations indistinguishable from those of classic chronic rheumatic valvulitis.     

孤立性主动脉瓣狭窄病因的超声分析

为明确超声心动图检查中，孤立性主动脉瓣狭窄（ＡＳ）的病因及相应的影像特点，对１９９０年以来在我院超声心动图室发现的６６例孤立性ＡＳ（４４例合并关闭不全）进行分析。结果为先天性二瓣畸形（４８．５％），退行性病变（２１％），风湿病变（１５．２％）是ＡＳ的主要病因。但老年组（年龄＞６５岁），以退行性病变为主（６６．６％）。它导致主动脉瓣狭窄最晚，平均６７岁，先天性二叶瓣畸形，平均４９岁，风湿病变，平均４３岁。先天性二瓣畸形及退行性病变引起的瓣膜狭窄与瓣叶的增厚、钙化及固定有关，无或仅有轻微的连合处融合，风湿病变以连合处的融合为特点。研究表明：年龄对孤立性主动脉瓣狭窄的病因诊断有重要的影响；不同病因导致的主动脉瓣狭窄有不同的超声影像特点。     

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm(2) is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.     

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm² is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.     

风湿性心脏病并发左心房血栓的危险因素探讨

目的　探讨风湿性心脏病并发左心房血栓的发生率及危险因素。方法　采用非条件Logistic回归模型分析二尖瓣狭窄患者并发左心房血栓的危险因素。结果　风湿性心脏病并发左心房血栓的发生率为 10 .77% ;二尖瓣狭窄、二尖瓣关闭不全、主动脉瓣病变和联合瓣膜病的发生率分别为 15 .6 3%、1.2 5 %、0和 2 .11%。二尖瓣狭窄并发左心房血栓的预测因子是左房自发性超声对比现象 (leftatrialspontaneousechocontrast ,LASEC) (相对危险比3.0 9,P<0 .0 0 0 0 )和房颤 (相对危险比 1.74 ,P =0 .0 0 2 3)。结论　风湿性心脏病二尖瓣狭窄患者最易发生左心房血栓 ;LASEC和房颤是决定二尖瓣狭窄发生左心房血栓的危险因素。二尖瓣狭窄伴房颤、LASEC的患者应积极抗凝治疗     

Clinical insights of non‐obstructive general angioscopy for assessing atherosclerotic pathology of aortic valve in vivo

Non-obstructive general angioscopy (NOGA) images of severe aortic valve stenosis (AS) and atherosclerotic aorta were documented. Atheromatous embolization is known as an important complication of endovascular therapy for severe AS. However, it is hard to detect atherosclerotic changes of the aortic valve and atheromatous aorta related to them in the in-vivo setting. NOGA, which is a novel imaging modality for the aorta and aortic valves, can visualize atherosclerosis of aortic intima vividly. NOGA may play a role in risk stratification for atheromatous embolism with endovascular therapy. We reported a case of severe AS and atheromatous aorta to evaluate before an operation with NOGA.

     

老年性心脏瓣膜病变的超声心动图表现及分析

运用二维超声心动图对530例,年龄在50岁以上的老年受检者进行检查,共检查出老年性心脏瓣膜病变78例,占受检总数的14.7%.结果表明:老年性心脏瓣膜病变,以主动脉瓣环钙化和主动脉瓣、二尖瓣钙化为多.但老年性风湿性心脏瓣膜病变应引起警惕,它常表现为“原因不明”的心房纤颤和/或哑型二尖瓣狭窄.钙化性瓣膜病变较少有血流动力学紊乱,不引起明显临床症状,其确切临床意义应引起重视,有待进一步研究.     

Percutaneous balloon valvuloplasty in adult patients with valvular heart disease

Percutaneous balloon valvuloplasty is a new, nonsurgical technique for treatment of acquired mitral or aortic valvular stenosis. The procedure is still investigational and performed following approved research protocols. Although technically more difficult and at times impossible to perform, percutaneous BV of the mitral valve has been shown to be both safe and effective for increasing the mitral valve orifice area and for relief of symptoms associated with severe rheumatic mitral stenosis. Because of the relative infancy of the procedure, long-term data are available for only 1 to 2 years following BV. Thus far, however results obtained with mitral BV are similar to those obtained using surgical commissurotomy. From a long-term perspective, results of aortic BV in the elderly population are less impressive. The procedure appears to be only palliative and is associated with high rates of restenosis occurring fairly soon after the procedure. However, in the very elderly patient who is a nonsurgical candidate, aortic BV can provide improvement in aortic valve orifice size and in relief of debilitating symptoms associated with severe aortic stenosis. As with surgical aortic valve replacement, aortic BV also provides improvement over the natural course of the disease. More data are needed to aid in better definition and selection of patients who are suitable candidates for this procedure.     

风湿性心脏病合并急性心肌梗死临床病例分析

目的分析风湿性心脏瓣膜病患者合并急性心肌梗死的临床特点及造影表现。方法回顾性分析5例风湿性心脏瓣膜病合并急性心肌梗死患者的临床资料。结果5例患者均为二尖瓣病变,其中4例合并心房纤颤。心电图显示前壁心肌梗死3例,下壁心肌梗死2例。合并其他部位栓塞者1(脑栓塞)。4例患者进行了冠状动脉造影检查,其中1例提示为冠脉栓塞,3例提示为粥样硬化性冠脉病变。结论风湿性心脏病合并急性心肌梗死的病因可为冠状动脉粥样硬化性心脏病,也可为血栓栓塞。血栓栓塞导致急性心肌梗死者常有心房纤颤等血栓好发因素,急性期造影常表现为冠脉闭塞,有时可见栓塞征象。冠心病急性心肌梗死造影则多显示多支病变。     

Acquired aortic stenosis

Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.     

Plasma osteopontin as a predictor of coronary artery disease: association with echocardiographic characteristics of atherosclerosis

Osteopontin (OPN), a bone‐related protein, is present within the atherosclerotic plaques, most strikingly in calcified plaques. Valvular calcifications are accepted as a part of the spectrum of atherosclerosis and are associated with atherosclerotic calcification in the coronary arteries. The study aimed to evaluate the association of plasma OPN with the presence and extent of coronary stenosis, mitral annular calcification (MAC), and aortic valve sclerosis in stable angina patients. We studied 120 subjects who underwent coronary angiography because of ischemic chest pain. Coronary artery disease (CAD) was defined as ≥50% stenosis in ≥1 coronary artery. MAC and aortic valve sclerosis were detected by echocardiography. Lipid profile, high sensitive C‐reactiveprotein (hsCRP), and OPN were measured in all studied subjects. Patients with CAD had increased plasma OPN when compared with those without CAD (P<0.001). Plasma OPN levels were significantly positively correlated with atherogenic lipid profile, hsCRP, MAC grading, aortic valve sclerosis grading, and the number of stenosed coronary vessels in CAD patients. In multivariate analysis, OPN was an independent predictor of CAD (P=0.01), MAC (P=0.01), and aortic valve sclerosis (P=0.04). In conclusion, OPN is an independent predictor of MAC and aortic valve sclerosis. Plasma OPN levels reflect the extent of coronary stenosis and can be used as a biomarker to identify patients with coronary atherosclerosis. J. Clin. Lab. Anal. 24:201–206, 2010. © 2010 Wiley‐Liss, Inc.     

Temporal changes in the causes of aortic stenosis: a surgical pathologic study of 646 cases

Among 646 patients with pure aortic stenosis who underwent valve replacement at our institution between 1981 and 1985, the three most frequent causes were calcification of congenitally bicuspid aortic valves (38%), degenerative (senile) calcification of tricuspid aortic valves (33%), and postinflammatory (presumably rheumatic) calcification and fibrosis (24%). Among the 324 patients younger than 70 years of age, calcified bicuspid valves were observed in 50%. In contrast, among 322 patients 70 years of age or older, degenerative calcification accounted for 48% of the stenotic aortic valves. During the 5 years of the study, the relative frequency of postinflammatory disease decreased from 30% to 18%, and that of bicuspid valves decreased from 37% to 33%. In contrast, the relative frequency of degenerative calcification increased from 30% to 46%. Consequently, degenerative (senile) calcification is currently the most common cause of aortic stenosis among patients undergoing valve replacement at our institution. This finding may be related to changes in life expectancy in the general population, alterations in patient referral practices, and an increased willingness of surgeons to operate on older patients. Regardless of cause, the observed temporal changes in etiologic factors for aortic stenosis may indicate a potential source of increasing health-care costs among the elderly population.     

Models of aortic valve calcification.

Aortic valve stenosis is a complex inflammatory process, akin to arterial atherosclerosis, involving lymphocytic infiltrates, macrophages, foam cells, endothelial activation and dysfunction, increased cellularity and extracellular matrix deposition, and lipoprotein accumulation. A clonal population of aortic valve myofibroblasts spontaneously undergoes phenotypic transdifferentiation into osteoblast-like cells and forms calcific nodules in cell culture. Animal models complement these cell culture models by providing in vivo systems in which to study the complex molecular and cellular interactions that cause aortic valve disease in the native hemodynamic and biochemical environment. Whereas some species, such as swine, can develop spontaneous vascular and valvular atherosclerotic lesions, others, such as rabbits and mice, have not been shown to develop lesions naturally and require an inciting factor, such as hypercholesterolemia. In this article, we review the published cell culture and animal models available to study calcific aortic valve disease.     

Surgical pathology of combined aortic stenosis and insufficiency: a study of 213 cases

The gross surgical pathologic features of the aortic valve were reviewed in 213 patients who had had clinically combined aortic stenosis and insufficiency and aortic valve replacement at our institution during the years 1965, 1970, 1975, and 1980. The three most common causes were postinflammatory disease (69%) and calcification of congenitally bicuspid (19%) and unicommissural (6%) aortic valves. Other causes included infective endocarditis (2%) and congenitally quadricuspid or malformed tricuspid aortic valves (1% each); the cause was indeterminate in 1%. In the postinflammatory and bicuspid states, calcification tended to be more extensive in men than in women. The relative incidence of postinflammatory disease in our study did not change appreciably from 1965 to 1980, despite the steadily decreasing incidence of acute rheumatic fever reported in western countries.     

Aortic Stenosis

Patients with aortic stenosis (AS) have an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular disease and an increased incidence of coronary events and death. Statins may reduce the progression of AS. Angina pectoris, syncope or near syncope, and heart failure are the three classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the presence and severity of AS. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these four risk factors should be treated with aspirin 75-100 mg daily.     

Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis

Calcification of normal tricuspid and congenital bicuspid valves is the most common cause of aortic stenosis in industrialized countries. There is compelling evidence that thickening and calcification in aortic valve disease is a complex inflammatory process and not simply age-related degeneration. Both aortic sclerosis and stenosis represent phenotypic expressions of one disease continuum. Patients with symptomatic severe aortic stenosis benefit from aortic valve replacement. However, management in the absence of symptoms remains challenging. While a delay of aortic valve replacement due to lack of symptom recognition may result in a dismal outcome, unselected premature aortic valve replacement may be associated with unbalanced risks of cardiac surgery. Echocardiography is the standard for evaluating the severity of aortic stenosis; however, most of the current echocardiographic parameters have limitations in predicting the onset of symptoms. This review summarizes the current guidelines and the emerging application of echocardiographic techniques in the management of asymptomatic severe aortic stenosis.     

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers–Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.     

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.     

Optimum management of elderly patients with calcified aortic stenosis

Increased life-expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on the pathogenesis of calcific aortic stenosis, diagnosis and possible ways to halt the progression to severe symptomatic aortic stenosis, methods of assessing symptoms and severity, and modalities and timing of aortic valve replacement. At present the treatment of aortic stenosis for the majority of patients is surgical, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement. This article also discusses the role of emerging techniques of closed heart valve implantation either transfemoral or transapical, and which patients might be candidates for these new approaches to the treatment of aortic stenosis in the elderly population.