N末端B型利钠肽原对单纯主动脉瓣狭窄心力衰竭患者的诊断价值

目的 评价N末端B型利钠肽原(NT-proBNP)对单纯主动脉瓣狭窄(AS)心力衰竭(心衰)患者的诊断价值.方法 使用酶联免疫的方法对40例AS心衰患者(AS心衰组)和76例正常对照者(正常组)行NT-pmBNP测定,评价其对AS心衰的诊断价值.结果 与正常组相比,AS心衰组NT-proBNP水平显著增高(P<0.01)且在纽约心功能分级(NYHA分级)Ⅱ、Ⅲ和Ⅳ级者呈逐级显著升高(均为P<0.01);其中,临床代偿心衰差异无统计学意义(P>0.05),而临床失代偿心衰升高8倍(P<0.01);在左室舒张期末内径(LVEDD)>50 mm组显著高于LVEDD≤50mm组(P<0.05),左室射血分数(LVEF)≤60%组显著高于LVEF>60%组(P<0.01);在合并心房颤动组显著高于窦性心律组(P<0.05).NT-pmBNP阈值在1360 ng/L时,是诊断心衰(ROC曲线下面积=0.762,P<0.01)及失代偿心衰(ROC曲线下面积=0.997,P<0.01)的最佳阈值;心衰与失代偿心衰诊断的敏感性分别为67.50%和100.00%,特异性均为96.05%,准确性分别为86.21%和95.83%.单因素和多元逐步回归分析一致显示,Log(NT-proBNP)与NYHA分级和LVEF呈显著正、负相关(P<0.05),且呈独立相关.结论 NT-pwBNP对单纯As心衰患者也有重要诊断价值.建议临床采用1360 ng/L作为阈值,诊断单纯AS伴心衰者准确性高达86.21%,尤其对失代偿者准确性高达95.83%.     

Diagnostic value of ultrasound in duodenal stenosis

Radiology and endoscopy are usually used to diagnose stenosis of the duodenum, but the cause of the stenosis may still escape detection. Three pathologic processes--multiple duodenal polyps, duodenal wall cysts, and annular pancreas--are presented to demonstrate how ultrasound, under specific conditions, can provide decisive diagnostic information. The cause of the stenosis may be made accessible to sonographic study through administration of oral fluids and intravenous hyoscin-n-butylbromid (Buscopan).     

Syncope and aortic stenosis: significance of conduction abnormalities.

22 patients with syncope and significant aortic stenosis underwent electrophysiological evaluation in addition to the hemodynamic study. Abnormalities of impulse formation or conduction were present in 12 patients. 6 patients demonstrated HV times greater than or equal to 55 msec. There was no correlation between the aortic valve gradient and the HV interval, between the enddiastolic volume of the ventricle and the HV time and between aortic valve calcification and the HV time. Syncopal attacks were corrected with aortic valve replacement even in patients with prolonged HV times.     

Diagnostic value of multi-slice spiral CT in aortic dissection

Background Aortic dissection occurs at a low incidence, but is associated with high mortality. It is generally acute onset, complicated and is often misdiagnosed; therefore is a macro vascular disease that poses major threat on patients’ lives. Timely diagnosis and management are essential, so we investigated the diagnostic value of multi-slice spiral CT in aortic dissection. Methods clinical data from 21 patients with confirmed aortic dissection were retrospectively analyzed. All patients had undergone plain and contrasted multi-slice spiral CT scans. Results true lumen and pseudo cavity were clearly revealed in all 21 patients, of which 17 showed intimal flap, four showed intimal calcification and inward displacement, while 2 had thrombosis in the pseudo cavity. As for classification among these 21 patients, 9 had type Ⅰ aortic dissection, including two patients with innominate artery involvement, 1 with celiac trunk involvement and 2 with left renal artery involvement; 2 had type Ⅱ aortic dissection, including 1 patient with innominate artery involvement; Another ten patients had type III aortic dissection, including 2 patients with left subclavian artery involvement and 1 with celiac trunk involvement. Nineteen out of 21 patients had clearly revealed initial rupture. Conclusion multi-slice spiral CT is characterized by rapidness, non-invasiveness and accuracy. It provides clear visualization of the location and scope of aortic dissection, location of the rupture as well as the valves, which makes it a first-choice imaging approach for the diagnosis of aortic dissection.     

Diagnostic value of CT angiography in coronary arteries stenosis detection

BACKGROUND: Noninvasive imaging of coronary arteries is very important. CT angiography (multislice computed tomography and electron beam computed tomography -- MSCT and EBT) is most reliable method for noninvasive coronary visualization. PURPOSE: The aim of our study was to evaluate the diagnostic value of CT angiography in coronary arteries stenoses detection in patients with coronary arteries disease (CAD). MATERIALS AND METHODS: 140 patients with CAD who underwent EBT (n=97) or 4-slice CT (n=43) coronary angiography and conventional coronary angiography as a gold standard were included in the study. RESULTS: Sensitivity and specificity of CT angiography in coronary stenoses detection (proximal and mid segments) were 86% and 97%, respectively. Positive and negative predictive values were 90% and 96%, respectively. Overall accuracy was 95%. 6.2% of coronary segments were excluded from the study because of unsatisfactory image quality. CONCLUSIONS: CT angiography is noninvasive method for coronary stenoses detection with high sensitivity and specificity. Nevertheless EBT and 4-slice CT angiography can not replace conventional coronary angiography because of lower temporal and spatial resolution, artifacts in patients with arrhythmias and huge coronary calcification.     

Prognostic value of aortic valve area index in asymptomatic patients with severe aortic stenosis

Recently, an aortic valve area (AVA) index (AVAI) <0.6 cm(2)/m(2) was proposed as an indicator of severe aortic stenosis. The purpose of the present study was to clarify the prognostic value of the AVAI. We identified 103 consecutive asymptomatic patients (mean age 72 ± 11 years) with severe aortic stenosis, defined by an AVA of <1.0 cm(2), who had not undergone aortic valve replacement on initial evaluation. During follow-up (median 36 ± 27 months), 31 aortic valve replacements and 20 cardiac deaths occurred. Multivariate analysis revealed that an AVAI <0.6 cm(2)/m(2) (hazard ratio 2.6, 95% confidence interval 1.1 to 6.3; p = 0.03) and peak aortic jet velocity (Vp) >4.0 m/s (hazard ratio 2.6, 95% confidence interval 1.2 to 5.8; p = 0.02) were associated with cardiac events but that an AVA <0.75 cm(2) was not. The event-free survival of patients with an AVAI of ≥0.6 cm(2)/m(2) was better than that for those with an AVAI <0.6 cm(2)/m(2) (86% vs 41% at 3 years, p <0.01). Furthermore, patients with an AVAI of ≥0.6 cm(2)/m(2) and Vp of ≤4.0 m/s showed an excellent prognosis, but those without these findings had poorer outcomes. In conclusion, AVAI is a powerful predictor of adverse events in asymptomatic patients with severe aortic stenosis. Furthermore, the combination of AVAI and Vp provides additional prognostic information. Watchful observations are required for timely aortic valve replacement in patients with an AVAI of <0.6 cm(2)/m(2) or a Vp >4.0 m/s.     

Diagnostic accuracy of continuous wave Doppler echocardiography in severe aortic stenosis in the elderly

Forty-four male patients (mean age 63.6 years) with aortic stenosis (AS) were evaluated by conventional hemodynamic methods and continuous wave (CW) Doppler echocardiography. The relationship between Doppler mean gradients and direct mean pressure gradients in all patients was significant, with an r value of 0.88. Sixteen of 17 patients with a mean Doppler gradient greater than or equal to 40 mmHg had severe AS (AVA less than or equal to 1.0 cm2). Twenty-seven patients had a Doppler gradient less than 40 mmHg, and 8 of these patients had severe AS (AVA less than or equal to 1.0 cm2). The sensitivity and specificity of a Doppler gradient greater than or equal to 40 mmHg in detecting severe AS were, therefore, 67% and 95%, respectively. Thirty-three percent (8/24) of patients with severe AS and low Doppler gradients (less than 40 mmHg) had evidence of poor left ventricular function, evidenced by a lower cardiac output, a higher heart rate and an abnormal PEP/LVET ratio compared to the other patients. Thus, the presence of a low stroke volume less than or equal to 60 ml/beat and PEP/LVET x HR greater than 26 is of value in identifying patients where the Doppler is likely to significantly underestimate the degree of aortic stenosis.     

Clinical value of Doppler echocardiography in the assessment of adults with aortic stenosis

Continuous wave Doppler echocardiography was used to study 41 adults with clinically suspected aortic stenosis undergoing cardiac catheterisation. Non-invasive assessment of the severity of stenosis was made before catheterisation using electrocardiograms, chest radiographs, and cross sectional echocardiography in addition to clinical examination and assessment modified, where appropriate, by the result of the Doppler examination. Catheterisation gradients were obtained in 33 patients and correlated well with those obtained by Doppler examination particularly when simultaneous recordings were obtained. All patients with surgically significant stenoses were identified by non-invasive assessment including Doppler examination and overestimation was not found in any patient with a less than significant stenosis. Thus surgery can be recommended in patients with aortic stenosis without the need for previous cardiac catheterisation.     

Doppler echocardiography in adults with symptomatic aortic stenosis. Diagnostic utility and cost-effectiveness

To evaluate the diagnostic utility and cost-effectiveness of Doppler echocardiography in adults with symptomatic aortic stenosis, we performed a prospective study in which the need for aortic valve replacement (AVR) was the outcome event. The total sample consisted of 103 adults (mean age, 69 years) undergoing cardiac catheterization for suspected aortic stenosis. Twenty-six patients (25%) were used as a training set to develop a clinical prediction rule. (1) If maximum aortic jet velocity (Vmax) was more than 4.0 m/s, AVR was recommended. (2) If Vmax was less than 3.0 m/s, AVR was not needed. (3) If Vmax was 3.0 to 4.0 m/s and (a) Doppler aortic valve area (AVA) was 1.0 cm2 or less, AVR was recommended, while (b) if Doppler AVA was 1.7 cm2 or greater, AVR was not needed, and (c) if Doppler AVA was 1.1 to 1.6 cm2, consideration of the degree of coexisting aortic insufficiency was necessary. When this rule was applied to the test set (n = 77), the sensitivity was 98%, with a specificity of 89% and a total error rate of 3.9%. The approach could have resulted in cost savings between 24% and 34% compared with an invasive diagnostic approach.     

Prognostic value of aortic stenosis in patients after acute coronary syndrome

With the aim to assess prevalence of aortic stenosis (AS) and prognostic value of its detection among survivors of acute coronary syndrome (ACS) we examined 851 patients included into multicenter prospective study of risk factors of serious vascular events and death after acute coronary syndrome. The patients were enrolled into the study in stable condition on 10th day after onset of myocardial infarction (MI) or unstable angina (UA). Examination involved medical history, laboratory tests and echocardiography. Afterwards all cases of death and serious vascular events were registered. Severity of AS was specified by maximal aortic flow rate: 1st degree > 2.5, 2nd degree 3.0-4.0, 3rd degree > 4.0 m/s. AS was detected in 16 patients (1.9%). AS severity was 1st, 2nd and 3rd degree in 9, 4 and 3 patients, respectively. Patients with AS were significantly older (77.4 vs. 61.3 years, p < 0.001), more often had history of chronic heart failure (CHF) (81.3 vs. 53.2%, p = 0.021) and lowered renal function (66.7 vs. 34.0%, p < 0.041). At multifactorial analysis independent prognostic value in relation to development of serious events showed age > 75 years (OR 1,395 [1.023-1.902], p = 0.036), history of CHF (1.319 [1.015-1.713], p = 0.038), history of MI (1.692 [1.320-2.170], p < 0.001), left ventricular diastolic dimention (1.023 [1.005-1.041], p = 0.012), left atrial diameter (1.024 [1.001-1.047], p = 0.037) and presence of AS (3.211 [1.742-.,916], p < 0.001). Prevalence of preexisting AS among patients who have had MI/UA is 1.9% what is similar to data of European Heart Survey ACS-II (1.8%). Presence of AS of any severity in a survivor of ACS worsens prognosis independently of other known risk factors.     

Mitral valvular abnormalities associated with supravalvular aortic stenosis. Observations in 3 cases

In 3 of 5 specimens of heart from patients with supravalvular aortic stenosis, lesions of the mitral valve were observed. In the youngest patient, an infant, the changes consisted of collagenous thickening of leaflets and mild degrees of protrusion of segments of the leaflets toward the left atrium (hooding). In the 2 older subjects, aged 7 and 38 years, respectively, the processes of hooding and valvular thickening were pronounced. In addition, each of the latter 2 patients had endocardial fibrous lesions of the left ventricular endocardium related to thick chordae attaching to the posterior leaflets. In the oldest subject, chordae were adherent to the related left ventricular endocardium.     

超声测量心外膜脂肪组织厚度对冠心病的诊断预测价值

目的评价经超声测量的心外膜脂肪组织厚度(visceral adipose thickness,EAT)对冠状动脉狭窄程度的预测价值。方法共有147例接受冠状动脉造影患者入选本研究,根据造影结果,分为冠状动脉粥样硬化性心脏病(冠心病)(coronary artery disease,CAD)组101例和非CAD组46例。对所有患者采集病史,体检并进行实验室检查,超声测量EAT。对各组之间的EAT值进行比较,将患者的冠状动脉病变积分(coronary artery core,CAS)值与EAT进行相关性分析。结果 CAD组的EAT显著高于非CAD组,差异有统计学意义[(7.41±1.63)mm vs.(4.41±1.60)mm,P0.01]。严重冠状动脉病变组EAT较轻度冠状动脉病变组EAT明显升高[(8.53±1.00)mm vs.(7.16±1.73)mm,P0.01]。相关分析显示,CAS与EAT呈正相关(r=0.71,P0.001)。以EAT值≥5.35mm诊断CAD,诊断敏感性87.13%,特异性80.43%,ROC曲线下面积为89%(95%可信区间0.84～0.95;P=0.01)。结论由超声测量的EAT可作为评价冠状动脉病变程度简便、可靠和实用的评价指标,和CAD关系密切,可作为CAD患者无创的协同诊断方法之一,用于对CAD患者的筛查。     

Doppler left ventricular diastolic filling abnormalities in aortic stenosis and their relation to hemodynamic parameters

Doppler mitral flow indexes and their relation to invasively measured hemodynamic diastolic indexes were assessed in 13 patients with isolated aortic stenosis (AS), and compared to Doppler indexes in 10 normal subjects matched for age, heart rate, left ventricular (LV) ejection fraction and LV load. Patients with AS showed no difference in Doppler early filling (E) indexes, but demonstrated greater Doppler atrial filling (A) indexes in comparison to normal subjects: atrial velocity (89 +/- 31 vs 56 +/- 7 cm/s), atrial integral (11.4 +/- 4.8 vs 5.7 +/- 1.6 cm), A/E velocity (1.69 +/- 0.89 vs 1.06 +/- 0.26) and A/E integral (3.53 +/- 6.64 vs 0.81 +/- 0.27) (all p less than 0.05). Doppler indexes in patients with AS did not correlate with hemodynamic indexes of LV relaxation or chamber stiffness. Significant correlations were observed between Doppler and angiographic peak filling rates (r = 0.70) and between Doppler atrial filling velocity and LV end-diastolic volume (r = -0.66), LV end-diastolic pressure (r = -0.48) and LV ejection fraction (r = 0.53) (all p less than 0.05). These data indicate that, compared to matched normal subjects, most patients with AS have an increased atrial contribution to LV filling. However, in patients with decreased LV function, atrial function may also be depressed, as indicated by a decreased atrial contribution to LV filling, resulting in "normalization" of the Doppler mitral flow pattern.