磁共振相位对比法对慢性高原病患者主肺动脉改变初步研究

目的 探讨利用磁共振相位对比法(phase contrast MR imaging,PCMRI)评价慢性高原病(chronic mountain sickness,CMS)患者主肺动脉(main pulmonary artery,MPA)结构、血流动力学及平均压(mean pulmonary artery pressure,MPAP)的应用价值。材料与方法 收集经我院临床诊断的22例成年男性CMS患者(CMS组)和20名来自同一海拔高度的健康成人志愿者(对照组)进行对比研究。利用Philips Achiva 1.5 T磁共振扫描仪对主肺动脉进行2D/QF序列扫描,获得其横截面积(cross-sectional area,CSA)、正向峰值流速(peak positive velocity,PPV)、反向峰值流速(peak negative velocity,PNV)、右心室搏出量(right ventricular stroke volume,RVSV)和反流分数(regurgitant fraction,RF),然后计算MPA相对扩张度(relative dilatation degree,RDD)和MPAP。结果 (1)结构参数:CMS组CSA及RDD分别为(7.52±0.71)cm2和(36.11±11.27)%;对照组CSA及RDD分别为(6.34±1.12)cm2和(52.08±7.54)%。其中CSA较对照组增大(P0.01);RDD较对照组减小(P0.01)。(2)血流动力学参数:CMS组PPV、PNV、RVSV和RF分别为(72.19±9.41)cm/s、(28.61±4.16)、(64.43±21.48)ml和(7.11±0.93)%;对照组PPV、PNV、RVSV和RF分别为(80.32±11.15)cm/s、(22.64±6.14)、(59.12±19.34)ml和(4.31±0.48)%。其中PPV较对照组减小(P=0.015),PNV较对照组增大(P0.01),RVSV较对照组增大(P=0.411),RF较对照组增大(P=0.004)。(3)CMS组MPAP[(36.71±12.36)mmHg]较对照组MPAP[(15.77±6.69)mmHg]明显增大(P0.01)。结论 CMS患者长期低压缺氧环境导致MPA横截面积扩张和弹性降低,血流速度改变,反流分数及MPAP均有不同程度增加,最终导致肺动脉高压。PC-MRI能无创、准确地提供CMS患者主肺动脉结构、血流动力学及压力的信息,从而达到初步评估主肺动脉改变特点的目的。     

慢性阻塞性肺疾病患者肺动脉扩张与肺功能的相关性分析

目的探讨慢性阻塞性肺疾病患者(COPD)肺动脉扩张与肺功能的关系。方法随机选择2016年11月至2018年11月广州市胸科医院收治的104例慢性阻塞性肺疾病肺动脉扩张患者作为研究组。另选取同期我院收治的慢性阻塞性肺疾病肺动脉正常患者104例作为对照组,两组均接受肺功能检查,指定同一名高年资、高职称医务人员按照仪器设备相关延期完成两组肺功能检测,具体项目包括呼气峰流速(PEF)、第一秒用力呼气容积(FEV1)/用力肺活量(FVC)、FEV1、每分钟最大通气量(MVV)、MVV/预计值%等。结果研究组PEF、MVV、FEV1/FVC、FEV1等各项肺功能指标检测值均显著低于对照组,差异有统计学意义(P 0. 05)。结论慢性阻塞性肺疾病患者肺动脉扩张与肺功能具有显著相关性,即肺动脉扩张患者肺功能相关指标检测值较低。     

双源CT对慢性肺动脉栓塞的诊断价值分析

目的:探讨双源CT肺动脉造影对慢性肺动脉栓塞的诊断价值。材料与方法:对16例患者行双源CT血管造影检查,采用多平面重建(MPR)、最大密度投影(MIP)、容积再现(VR)多种图像后处理技术,并结合轴位图像进行综合分析。结果:16例均能显示肺动脉栓塞的部位、范围、局部管腔狭窄程度,慢性肺动脉栓塞主要表现为肺动脉分支减少或者管腔阻塞、中断,肺动脉管腔内偏心性、附壁性的充盈缺损及肺动脉增粗等。结论:双源CT血管造影是诊断慢性肺动脉栓塞无创性检查方法之一,具有较高的诊断准确率。     

肺动脉高压的诊断

肺动脉高压是一种慢性,持续性肺动脉压力升高的疾病。患者并不伴有明显的左心衰竭。肺动脉高压的准确诊断非常复杂,需应用一些有创和无创的辅助检查来完成。有创和无创检查均有其局限性,所以在应用这些检查时,医生应慎重考虑。本文综述了肺动脉高压的基本检查方法和诊断标准。     

69例急性、慢性肺血栓栓塞的临床分析

目的对69例急性、慢性肺动脉血栓栓塞患者的临床特点进行分析,以提高肺动脉栓塞诊断的正确率,减少误诊和漏诊率。方法对69例肺动脉血栓栓塞的患者的临床资料进行分析。结果通过对69例患者的症状、体征、实验室检查以及其他辅助检查资料进行分析,为正确诊断、及时治疗提供帮助。结论提高对肺动脉血栓栓塞的认识,早期发现,正确诊断和及时治疗,降低患者的死亡率。     

CT肺动脉成像及心脏超声对慢性肺动脉高压肺血管形态及压力改变监测研究

目的评价CT肺动脉成像及心脏超声对慢性肺动脉高压(PAH)患者的肺血管形态及压力改变监测价值。方法将不同病因的34例中、重度PAH患者进行CT肺动脉成像及心脏超声检查,分别计算肺动脉收缩压(sPAP)、肺动脉平均压(mPAP)、肺动脉舒张压(RADP)、肺动脉内径宽度客观指标变化情况。并结合临床症状判断其心脏功能与肺血管结构和压力变化情况。结果 mPAP、sPAP、RADP在4周、12周呈持续下降趋势;mPAP在12周末较4周时有较大下降,差异有显著性(P0.05);RADP在12周末较4周时有明显下降,差异有显著性(P0.05)。心脏B超测量肺动脉内径变化与胸部CT组间无统计学差异(P0.05)。随着肺动脉压力的降低,影像学测量肺动脉主干及右肺动脉内径测量值均呈现下降趋势,间接表示肺动脉压力下降,组间比较显示统计学差异(P0.05)。结论 PAH是目前临床诊治的难点,心脏超声及CT肺动脉成像检查具有患者易于接受、临床可操作性强等优点。但诸如肺血管结构变化与压力改变的对应的计算或者测量方法等问题仍有待临床进一步研究。     

呼吸科肺动脉高压患者病因构成与临床特点

目的总结呼吸科住院肺动脉高压患者的病因构成及临床特点,提高呼吸科医生对肺动脉高压的认识水平。方法收集2014年1月至2015年8月山西医科大学第一医院呼吸科住院的189例肺动脉高压患者的临床资料,肺动脉高压均为超声心动图诊断。按最新肺动脉高压病因分类法分类,采用回顾性分析的研究方法探讨其病因构成与临床特征。结果 189例肺动脉高压患者占同期呼吸科住院患者的6.31%,其中动脉性肺动脉高压12例(6.35%);左心疾病相关肺动脉高压20例(10.58%);肺部疾病和(或)低氧相关肺动脉高压127例(67.20%);慢性血栓栓塞性肺动脉高压22例(11.64%);未明多因素机制相关肺动脉高压8例(4.23%)。亚类病因中慢性阻塞性肺疾病最常见,为102例(53.97%)。肺动脉压力以中、重度为主,为137例(72.49%)。结论肺动脉高压是综合医院呼吸科的常见疾病,肺部疾病和(或)低氧相关肺动脉高压是最常见的类型,其次为慢性血栓栓塞性肺动脉高压与左心疾病相关肺动脉高压。     

连续多普勒超声评估特发性肺动脉高压患者不同时相肺动脉压与心导管检测的相关性研究

目的探讨连续多普勒超声(CW)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。方法选取我院因胸闷、气促等临床可疑IPAH患者113例,以经心导管确诊为诊断金标准,计算CW对IPAH患者的诊断效能;分析CW检测肺动脉压指标与心导管检测肺动脉压指标,以及常规超声指标[主肺动脉内径(MPA)、右房左右径(RAT)、右、左心室舒张末期左右径(RVT、LVT)、前后径(RVD、LVD)、右、左心室左右径比值(RVT/LVT)及前后径比值(RVD/LVD)]与心导管所测肺动脉压的关系。结果 113例疑似IPAH患者中,心导管确诊78例,其中超声准确诊断68例,漏诊10例,误诊9例。CW估测肺动脉高压的敏感性、特异性、阳性预测值、阴性预测值及准确率分别为87.2%、74.3%、88.3%、72.2%及83.2%。经CW检测IPAH患者的肺动脉收缩压(PASPe)、舒张压(PADPe)及平均压(PAMPe)与心导管检测的收缩压(PASPc)、舒张压(PADPc)及平均压(PAMPc)均呈正相关(r=0.667、0.639、0.636,均P<0.05);且MPA、RAT、RVT、RVD、RVT/LVT及RVD/LVD与PASPc均呈正相关(r=0.283、0.471、0.551、0.442、0.593、0.489,均P<0.05)。结论 CW对IPAH患者不同时相肺动脉压的评估与心导管检测肺动脉压之间存在显著相关性;应用CW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。     

CTPA在诊断肺动脉血栓栓塞症中的临床价值研究

目的 探讨螺旋CT肺动脉造影(Computed tomography pulmonary angiography,CTPA)在诊断肺动脉血栓栓塞症(PTE)中的临床应用价值.方法 回顾性分析2006年7月至2008年10月经CTPA诊断的8例肺动脉血栓栓塞患者的CT征像.结果 8例经CTPA确诊的PIE病例,共累及86支肺动脉(51.1%).受累肺动脉位于右肺56支(65.1%),肺段动脉受累58支(67.4%).栓子形态包括完全充盈缺损16支,中心充盈缺损18支,偏心性部分充盈缺损39支,附壁充盈缺损13支.PE的间接征象主要包括肺动脉高压、肺梗死灶形成、胸腔积液和支气管动脉扩张等.结论 螺旋CT进行CTPA检查具有快捷、无创、安全等特点,是诊断肺动脉血栓栓塞症(FIE)的首选检查.     

超声心动图诊断肺动脉栓塞的价值

目的:探讨超声心动图对肺动脉栓塞的诊断价值。方法:回顾性分析13例经临床综合诊断确诊肺动脉栓塞患者的经胸超声心动图资料。结果:13例患者超声心动图检查均显示右心室内径扩大,肺动脉内径增宽,三尖瓣反流。7例患者左、右肺动脉内径增宽,检出肺动脉内附壁栓子7个,栓子附着处彩色多普勒均可见充盈缺损。6例合并下肢静脉血栓,1例风湿性心脏病二尖瓣狭窄并肺动脉狭窄,1例合并卵圆孔重新开放。结论:超声心动图可通过对肺动脉栓子的检出直接诊断肺动脉栓塞,也可通过右心室扩大、肺动脉扩张、肺动脉高压等超声表现结合临床资料间接诊断。     

Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

BACKGROUND: There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study. METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis. RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively). CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.     

Aorta Larger Than Pulmonary Artery in the Fetal 3‐Vessel View

Objective. Fetal great artery asymmetry may accompany congenital heart disease. The fetal echocardiographic 3‐vessel view (3VV) allows assessment of the superior vena cava, ascending aorta (AA), and main pulmonary artery (MPA). Our aim was to determine the association of congenital heart disease in fetuses with an AA/MPA ratio of greater than 1. Methods. We electronically searched our fetal echocardiographic database for studies performed between March 2002 and January 2008 that showed 3VVs with AA/MPA ratios of greater than 1 and correlated the findings with the presence of congenital heart disease. Results. In 2797 fetal echocardiograms, we identified 31 fetuses with normal 4‐chamber views showing AA/MPA ratios of greater than 1 in the 3VV. Of 31 fetuses, 25 (81%) had tetralogy of Fallot (ToF) or a ToF variant, and 6 (19%) had an aortic valve abnormality or isolated dilatation of the AA. Conclusions. Screening obstetric fetal sonography showing a 3VV AA/MPA ratio of greater than 1 suggests congenital heart disease and indicates the need for comprehensive fetal echocardiography.     

Timing of pulmonary valve replacement after tetralogy of Fallot repair

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. If left untreated, it carries a 33% mortality in the first year of life and a 50% mortality in the first 3 years of life. Since the introduction of the first open-heart repair by Lillehei and Varco in 1954, surgical management of TOF has evolved to be the primary repair during infancy in the majority of patients. Surgical management of TOF results in anatomic and functional abnormalities in the majority of patients, such as chronic pulmonary valve regurgitation and right ventricular (RV) dysfunction. Long-standing chronic pulmonary valve regurgitation can result in RV dilatation and failure, increasing tricuspid regurgitation, impaired exercise performance and supraventricular or ventricular arrhythmias. A timely reoperation may prevent these consequences, with a complete RV-function recovery. This article provides insight into the questions of when to perform a pulmonary valve implantation and in whom.     

Comparison of Intrapulmonary and Systemic Pharmacokinetics of Colistin Methanesulfonate (CMS) and Colistin after Aerosol Delivery and Intravenous Administration of CMS in Critically Ill Patients

Colistin is an old antibiotic that has recently gained a considerable renewal of interest for the treatment of pulmonary infections due to multidrug-resistant Gram-negative bacteria. Nebulization seems to be a promising form of administration, but colistin is administered as an inactive prodrug, colistin methanesulfonate (CMS); however, differences between the intrapulmonary concentrations of the active moiety as a function of the route of administration in critically ill patients have not been precisely documented. In this study, CMS and colistin concentrations were measured on two separate occasions within the plasma and epithelial lining fluid (ELF) of critically ill patients (n = 12) who had received 2 million international units (MIU) of CMS by aerosol delivery and then intravenous administration. The pharmacokinetic analysis was conducted using a population approach and completed by pharmacokinetic-pharmacodynamic (PK-PD) modeling and simulations. The ELF colistin concentrations varied considerably (9.53 to 1,137 mg/liter), but they were much higher than those in plasma (0.15 to 0.73 mg/liter) after aerosol delivery but not after intravenous administration of CMS. Following CMS aerosol delivery, typically, 9% of the CMS dose reached the ELF, and only 1.4% was presystemically converted into colistin. PK-PD analysis concluded that there was much higher antimicrobial efficacy after CMS aerosol delivery than after intravenous administration. These new data seem to support the use of aerosol delivery of CMS for the treatment of pulmonary infections in critical care patients.     

CT肺动脉造影检测肺栓塞:采用容积螺旋穿梭技术捕捉最佳成像时相

目的探讨采用容积螺旋穿梭(VHS)技术进行肺动脉血管造影成像(CTPA)的临床应用价值。方法对研究组30例疑诊肺栓塞患者采用VHS进行CTPA成像,于开始注药后10s启动扫描,连续扫描4次(path)。回顾性分析对照组15例疑诊肺栓塞患者的64排CT常规CTPA资料,于注射对比剂后13～16s进行扫描。测量肺动脉主干、各段肺动脉的强化程度及主肺动脉的噪声,由2名医师按照5点评分法评价图像质量。结果研究组全部病例均成功配合完成检查,最佳path在第Ⅰ～Ⅳ个时相占比例分别为30.00%(9/30)、36.67%(11/30)、26.67%(8/30)、6.67%(2/30)。研究组平均MPA的CT值为(286±39)HU,对照组为(278±71)HU,差异无统计学意义(P=0.631)。研究组MPA最低强化值为240HU,对照组3例低于200HU。研究组肺段动脉可评价率平均为(88±14)%,高于对照组的(72±33)%(P=0.192)。对研究组图像质量及肺动脉强化两研究者一致性的Kappa值分别0.366、0.714,86.67%病例图像质量及90.00%肺动脉强化良好,均优于对照组(P均<0.05)。对图像噪声及运动伪影的主观评价两组间差异均无统计学意义。结论采用VHS技术有利于捕捉最佳肺动脉强化时相,是简单、实用的肺动脉血管造影方法。     

显微镜下型多血管炎患者的护理

总结5例显微镜下型多血管炎(MPA)患者的护理,以探讨显微镜下型多血管炎患者的护理方法。认为做好对MPA患者的临床症状和身体评估是非常必要的,同时也要做好发热、咯血、急慢性肾功能不全、关节肌肉疼痛、贫血及其他相应的对症护理,以便提高MPA患者的护理质量。     

慢性高原病患者骨髓造血细胞凋亡及caspase-8和caspase-9表达研究

目的 探讨慢性高原病( CMS)患者骨髓造血细胞凋亡指数及caspase-8和caspase-9mRNA表达变化的意义.方法 选取18例CMS患者,采用末端脱氧核苷酸转移酶介导的dUTP缺口标记(TUNEL)技术定量研究骨髓单个核细胞(BMMNC)凋亡指数,同时采用RT-PCR半定量方法检测BMMNC caspase-8和caspase-9 mRNA的表达.以16例骨科单纯骨折患者为对照.结果 ①CMS患者BMMNC凋亡指数[(8.51±3.35)％]明显低于对照组[(16.00±4.28)％](P＜0.01).②CMS患者caspase-8和caspase-9 mRNA的相对表达水平分别为0.28 ±0.07和0.23±0.08,对照组分别为0.45±0.09和0.41±0.09,CMS组均明显低于对照组(P值均＜0.01).③CMS患者caspase-8和caspase-9mRNA表达水平与血红蛋白浓度呈负相关(r值分别为-0.520及-0.610,P值均＜0.05),与凋亡指数均未发现明显相关性(P值均＞0.05),CMS患者凋亡指数与血红蛋白浓度呈负相关(r=-0.890,P＜0.01).结论 CMS患者BMMNC凋亡指数及caspase-8和caspase-9表达水平均降低,提示CMS患者骨髓造血细胞凋亡减少,caspase-8和caspase-9均参与CMS骨髓造血细胞凋亡异常机制.     

Pulmonary artery diameters in healthy fetuses from 19 to 40 weeks' gestation.

OBJECTIVE: The purpose of this study was to construct nomograms for diameters of the fetal main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA) according to gestational age (GA) and estimated fetal weight (EFW). METHODS: Between May 2005 and February 2006, MPA and branch artery diameters were prospectively estimated with ultrasonography in 220 healthy fetuses from 19 to 40 weeks' gestation and correlated with GA and EFW. RESULTS: Mean MPA, RPA, and LPA diameters ranged from 2.93, 1.71, and 1.66 mm, respectively, at 19 weeks to 9.23, 5.49, and 5.65 mm at 40 weeks. Linear regression yielded the following formulas for the expected diameters according to GA: MPA=-2.77 + 0.30 x GA; RPA=-1.71 + 0.18 x GA; and LPA=-1.95 + 0.19 x GA. The following formulas were obtained by logarithm distribution for the expected diameters according to EFW: MPA=-1.165 + 0.247 x log of estimated fetal weight (lnFW); RPA=-0.651 + 0.141 x lnFW; and LPA=-0.718 + 0.150 x lnFW. CONCLUSIONS: Nomograms of MPA and branch pulmonary artery diameters according to GA and EFW have been described, generating reference values.     

二维斑点追踪技术评价慢性阻塞性肺疾病患者右心室收缩功能

目的 探讨二维斑点追踪成像(2D-STI)技术评价慢性阻塞性肺疾病(COPD)患者右心室收缩功能的临床价值。方法 将58例COPD患者按肺动脉收缩压分为轻度肺动脉高压(MPAH)组和无肺动脉高压(NPAH)组,另选取30名健康志愿者为正常对照组。应用二维应变软件于剑下四腔心切面测量右心室游离壁基底段和中间段的纵向收缩期峰值速度(Vs)、收缩期峰值应变(S)及收缩期峰值应变率(SRs)。对比各组间常规超声参数及二维应变参数的差异。结果 常规超声参数:与正常对照组比较,MPAH组及NPAH组右心室前壁厚度(RVAW)和舒张末期右心室中间段内径均明显增大,MPAH组收缩末期主肺动脉内径(MPA)增大(P均<0.05);与NPAH组比较,MPAH组RVAW和MPA均明显增大(P均<0.05)。二维应变参数:与正常对照组比较,MPAH组和NPAH组右心室游离壁基底段及中间段Vs、S、SRs均显著减低(P均<0.05);与NPAH组比较,MPAH组右心室游离壁基底段及中间段S及Vs均显著减低(P均<0.05)。结论 2D-STI技术是一种早期、客观评价COPD患者右心室收缩功能的新方法。     

超声评价新生儿暂时性肺动脉分支狭窄

目的 应用超声评价正常新生儿肺动脉分支狭窄。方法 应用二维超声脉冲和持续多普勒及彩色多普勒血流显象对39例正常新生儿肺总动脉及分支的内径、血流速度和压力阶差进行估测，并进行统计学分析。结果 39例新生儿的肺部动脉与其分支间的血流速度和压力阶差有极显差异（P＜0．01）；右肺动脉的血流速度和压力阶差）左肺动脉，并有显性差异（P＜0．05）。男女性别间并无显性差异（P＞0．05）。经过2周－6月的随访，上述差异均消失。结论 部分正常新生儿肺总动脉与其分支间可存在血流速度和压力阶差的显性差异，与性别无关，经3－6月后可消失，为一种暂时性现象。多普勒超声为诊断和随访的敏感而便捷的方法。