Echocardiographic predictors of pulmonary hypertension in patients with severe aortic stenosis.

BACKGROUND: Pulmonary hypertension complicating severe aortic stenosis increases morbidity and mortality. Causes and mechanisms of this are unclear. METHODS: This is a retrospective observational study of 626 patients with severe aortic stenosis who had measurable pulmonary arterial pressure by Doppler echocardiography. Clinical, echocardiographic and pharmacological data were related to the presence of pulmonary hypertension. RESULTS: Of the 626 patients, 119 (19%) had severe pulmonary hypertension defined as pulmonary artery systolic pressure > or =60 mmHg. Patients with severe pulmonary hypertension had a smaller aortic valve area (P < 0.0001), a lower left ventricular ejection fraction (P < 0.0001), a higher mitral E/A velocity ratio (P < 0.0001) indicating a higher filling pressure and a higher prevalence of 3 or 4+ mitral regurgitation (P < 0.001). They were less likely to be on a beta blocker (P = 0.05) or a statin (P = 0.02). Smaller aortic valve area, left ventricular dysfunction, mitral regurgitation and lack of statin use were independent predictors of severe pulmonary hypertension. CONCLUSIONS: Severity of aortic stenosis, left ventricular dysfunction, and mitral regurgitation are risk factors for the genesis of pulmonary hypertension and statins may potentially be protective in patients with severe aortic stenosis.     

心脏超声估测肺动脉压对于评估肺栓塞预后的作用

目的 探讨多普勒超声估测肺动脉压力对于评估肺栓塞预后的作用.方法 对66例肺动脉栓塞住院患者进行回顾性分析.根据2008年欧洲心脏病协会颁布的急性肺栓塞诊治指南对肺栓塞患者进行危险分层,根据心脏多普勒超声检查,对于存在三尖瓣反流的患者估测肺动脉收缩压,＞40 mm Hg为肺动脉高压组,≤40 mm Hg为肺动脉压正常组.比较两组间临床指标和危险分层的差异.结果 肺动脉收缩压与肺栓塞患者的危险度分层关系密切(P＜0.05),肺动脉高压组的氨基端前脑钠肽值较肺动脉压正常组明显增高(P＜0.01),但其肌钙蛋白T值与肺动脉压正常组相比差异无统计学意义(P＞0.05).结论 多普勒超声估测肺动脉压力对于肺栓塞预后有一定的评估意义.     

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

Background

Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR.

Methods

From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS < 35 mmHg, N = 224), mild–moderate (35 ≤ sPAP < 50 mmHg, N = 159) and severe (sPAP ≥ 50 mmHg, N = 39).

Results

Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild–moderate and severe PH (p = 0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1–15.3, p = 0.04) and New York Heart Association class III–IV (OR 14.9, 95% CI 1.8–117.8, p = 0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6–4.9, p < 0.0001), severe PH (HR 2.4, 95%CI 1.2–4.6 p = 0.01), NHYA III–IV class (HR 2.3, 95% CI 1.3–4, p = 0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6–3.1,p < 0.0001) and age (HR 1.08, 95%CI 1.03 - 1.13, p = 0.01). Five-year survival was 86% ± 3% with normal sPAP, 81% ± 4% with mild–moderate PH and 63 ± 10% with severe PH (p < 0.001).

Conclusions

In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival     

超声心动图在球囊肺动脉瓣成型术的应用探讨

目的　探讨超声心动图（ＥＣＨＯ） 在球囊肺动脉瓣成型术（ＰＢＰＶ） 中的应用。方法　收集从１９９５ 年１ 月至１９９８ 年７ 月共９０ 例肺动脉瓣狭窄（ＰＳ）的患儿,其中男６１ 例,女２９ 例,年龄１～１４ 岁,平均（６－３±３－９）岁,体重９ ～４５ ｋｇ,平均（２０－５±１５－８） ｋｇ,１８ 例合并卵圆孔未闭,１２ 例合并右室流出道狭窄。ＰＢＰＶ 术前后均作ＥＣＨＯ 及心导管检查,测量肺动脉瓣环（ＰＶＡＤ）,肺动脉瓣（ＰＶ） 开放口径,ＰＶ 最大血流速度Ｖｍａｘ 及压力阶差ΔＰ,右室流出道（ＲＶＯＴ） 血流速度,并作对照分析。结果　ＰＢＰＶ术前ＥＣＨＯ与心导管检查所测ＰＶＡＤ、ＰＶ开放口径、ＰＶΔＰ无显著性差异（ Ｐ＞０－０５） ,ｔ＝ ２－５６,显示有密切相关;ＰＢＰＶ 术前后心导管及ＥＣＨＯ 所测ＰＶ 开放口径、ＰＶΔＰ均有显著性差异（Ｐ＜０－０１）。术后２４ 小时ＥＣＨＯ检查,有１９ 例ＲＶＯＴ血流增快,经服β－ 受体阻滞剂（ 心得安１～２ ｍｇ·ｋｇ１·ｄ１） ,３～６ 月后恢复正常。结论　超声心动图为ＰＢＰＶ术前选择球囊及扩张方法提供可靠资料,并能评价ＰＢＰＶ的扩张效果及长期随访,且对是否服用β－ 受体阻滞剂提供依据。ＥＣ     

肺栓塞的超声心动图诊断

目的探讨经胸彩色多普勒超声心动图肺栓塞的诊断价值。方法利用二维超声(2DE)、脉冲多普勒(PW)和彩色多普勒血流显像(CDFI)检测肺动脉、心脏和下腔静脉等。结果超声心动图肺栓塞的直接征象可做诊断,间接征象可做提示。结论超声心动图简便易行、费用低,可筛检、重复检测肺动脉压。     

Late death from aneurysm rupture following balloon angioplasty for branch pulmonary artery stenosis

We report on a child with Williams syndrome who died from aneurysm rupture 2 weeks following balloon angioplasty for branch pulmonary artery stenosis. © 1996 Wiley-Liss, Inc.     

综合超声与磁共振成像对照评价主动脉夹层前瞻性研究

目的：通过与磁共振成像对照研究，评价经胸超声心动图（ＴＴＥ）和经食管超声心动图（ＴＥＥ）在主动脉夹层的应用价值。方法：３９例经手术确诊或经磁共振成像、数字减影血管造影术及ＴＥＥ２种检查方法证实的３９例主动脉夹层患者。结果：ＴＴＥ、ＴＥＥ和磁共振成像诊断主动脉夹层，敏感性分别为９０％、１００％和９７％；特异性分别为９３％、９７％和１００％。ＴＴＥ主要不足在于对降主动脉夹层、原发破口和假腔血栓检出率偏低。ＴＥＥ在夹层破口、假腔血栓、主动脉瓣反流和冠状动脉的检查方面优于磁共振成像。而磁共振成像在头臂动脉及腹主动脉分支的检查方面优于ＴＥＥ。本研究显示主动脉夹层破口血流在收缩期从真腔进入假腔，舒张期又返回真腔。结论：①综合超声心动图和磁共振成像均是理想的主动脉夹层诊断方法；ＴＴＥ适合于筛选检查，ＴＥＥ有确诊价值。②主动脉夹层破口血流方向与真假腔压力变化有关，而与破口部位无关。     

肺动脉肉瘤误诊为肺血栓栓塞症三例原因分析

目的　提高对肺动脉肉瘤的认识及正确诊断率。方法　结合 3例肺动脉肉瘤患者的临床资料和有关文献对肺动脉肉瘤及肺血栓栓塞症 (PTE)的临床特点进行对比分析。结果　肺动脉肉瘤与肺血栓栓塞症临床表现相似 ,但肺动脉肉瘤患者发病隐匿 ,多有发热、体重减轻 ,无下肢深静脉血栓形成病史 ,影像学显示单侧肺动脉扩张 ,主肺动脉及左、右肺动脉内大量肿块 ,临床上经溶栓和抗凝治疗后病情仍恶化 ,确诊需手术。结论　肺动脉肉瘤易误诊为PTE ,需引起临床注意     

双侧肾动脉狭窄致难治性高血压2例并文献复习

难治性高血压的发病机制及病因复杂,其心血管风险及预后不良的概率增加,因此对难治性高血压的诊断及治疗十分重要.本文通过两个病例,并结合相关文献,对难治性高血压的诊断及治疗进展进行了简要的梳理.     

Combined unilateral pulmonary artery agenesis and contralateral peripheral pulmonary artery stenosis

Unilateral absence of a pulmonary artery is a rare congenital malformation. This report details the finding in two cases of this anomaly associated with peripheral stenosis of the contralateral pulmonary artery.     

慢性肺动脉栓塞的外科治疗

为探讨手术治疗慢性肺动脉栓塞的疗效,对9例临床诊断为慢性肺动脉栓塞患者在全麻及体外循环下行血栓清除及肺动脉内膜剥脱术。结果:9例患者术后恢复顺利,随访9～72个月,远期效果良好。认为对慢性肺动脉栓塞患者采用外科血栓清除及肺动脉内膜剥脱术是行之有效的治疗方法。     

影响经皮二尖瓣球囊成形术术后肺动脉压力正常化的相关因素研究

目的　探讨继发性肺小动脉病变对经皮二尖瓣球囊成形术 (PBMV)术后肺动脉高压正常化的影响。方法　对 5 2 3例二尖瓣狭窄合并肺动脉高压的患者 ,PBMV术前、后测定其肺动脉收缩压 (PASP)、左房收缩压 (LASP)等血流动力学指标 ,运用多因素logistic回归分析影响术后肺动脉压正常化的因素 ,并将患者分为重度肺动脉高压组 (A组 )和非重度肺动脉高压组 (B组 )进行比较分析。结果　A组患者的PASP由术前的 (89 6 9± 16 2 7)mmHg(1mmHg =0 133kPa)下降为术后的 (5 3 0 4±16 5 2 )mmHg ,B组患者的PASP值由术前的 (48 2 3± 11 4 7)mmHg降至术后的 (33 6 4± 9 0 1)mmHg。logistic回归表明 ,术前PASP水平高是影响术后肺动脉压正常化的显著因素。A组中术后肺动脉压力下降至正常的患者比例 (4 5 % )明显低于B组 (42 5 % ) ;与B组比较 ,A组患者无论在术前、术后LASP与PASP均缺乏良好的线性关系。结论　由于继发性肺小血管改变引起的“二级狭窄”是造成PBMV术后肺动脉压力不能恢复至正常的主要原因。     

Spontaneous coronary artery dissection in mitral stenosis

Spontaneous coronary artery dissection is a rare disease thatoccurs most commonly in young people, especially in peripartumor postpartum women. It has rarely been diagnosed during lifeand has never before been observed associated with any othernon-ischaemic heart disease. We report a case associated withmitral stenosis, in which successful valvular and coronary surgerywere carried out. We speculate whether rheumatic coronary arteritiswas a cause of the dissection.     

Reconstruction of bilateral branch pulmonary artery stenosis caused by Takayasu's aortitis.

A 63 year-old female presented with dyspnea on exertion. Her chest X-ray showed cardiomegaly, and right ventricular overload and tricuspid regurgitation were detected. Her pulmonary ventilation and blood flow scintigraphy findings were suspicious of pulmonary vascular disease; the diagnosis was pulmonary hypertension and bilateral branch pulmonary artery stenosis. After the inflammation settled, the stenotic bilateral branch pulmonary artery was reconstructed with a prosthetic vessel and the pulmonary pressure normalized immediately. A resected specimen revealed that the stenotic changes were from Takayasu's disease. The patient's postoperative course was uneventful, and pulmonary ventilation and blood scintigraphy returned to an almost normal range. At follow-up 5 years and 6 months after the operation, there was no evidence of pulmonary artery disease (eg, stenosis and/or ischemia) or of any change in the central vessels of the retina, the so-called Takayasu's retinopathy.     

Accurate assessment of aortic stenosis with intravenous contrast.

We came across an interesting case of calcific aortic stenosis in which severity was inaccurately assessed on two-dimensional and Doppler echocardiogram resulting in catheterization. Use of intravenous transpulmonary contrast agent enhanced the Doppler signal enabling better quantification of the transvalvular gradient. Use of contrast in such difficult to image patients is very useful in establishing a correct diagnosis.     

肾动脉狭窄所致的一过性肺水肿与左室舒张功能不全的鉴别

目的:探讨肾动脉狭窄导致一过性肺水肿的临床特点,分析其与左室舒张功能不全的鉴别要点。方法:回顾分析2002年5月~2004年5月住院的难治性高血压并发夜间阵发性呼吸困难的患者12例,造影显示单侧或双侧肾动脉狭窄超过50%,肾动脉球囊扩张及支架置入后随访6个月观察临床症状、血压、肾功能的变化。结果:单侧及双侧肾动脉狭窄各6例,7例患者伴有肾功能不全,5例肾功能正常但肌酐清除率<80ml/min。5例患者伴有低血钾(<3.5mmol/L),夜间阵发性呼吸困难发作突然,利尿剂治疗效果好。肾动脉支架置入后3个月血压较治疗前明显降低(P<0·05),7例肾功能不全患者血肌酐降低[(121·5±28·4)μmol/L∶(166.4±46.3)μmol/L(P<0·05)],血钾恢复正常,所有患者夜间阵发性呼吸困难消失。结论:难治性高血压突发夜间阵发性呼吸困难,同时并发肾功能不全、低血钾、利尿剂治疗效果佳,应高度提示肾动脉狭窄导致的肺水肿,而非单纯左室舒张功能不全。     

超声检查在肺动脉高压诊疗中可靠性的Meta-分析

目的:综合评价超声检查在肺动脉高压(PAH)诊疗过程中的可靠性。方法:在数据库PubMed(1966年1月至2006年5月),Embase(1980年至2006年),中国期刊网(1978年1月至2006年5月)中,检索以PAH为研究对象,应用超声检查和右心导管检查,评价患者的血流动力学状态,对二种方法所测得的肺动脉收缩压进行比较的临床研究,对超声检查在PAH诊疗过程中的可靠性进行Meta-分析。结果:1.共有8项研究进行了超声检查结果与右心导管检查结果相关性分析,入选PAH患者256例。二者具有良好的相关性,合并后的R值为0.679,95%可信区间为0.623～0.735。2.共有6项研究对超声检查和右心导管检查进行了肺动脉收缩压测量值的比较,超声检查的结果明显低估了右心导管的结果;对其中48h内完成二种检查的2项研究进行综合比较,发现超声检查的结果仍低于右心导管检查结果,但二者差异的显著性降低。结论:在PAH的诊疗过程中超声检查的结果低估了肺动脉收缩压但可以反映其变化趋势。     

肺栓塞合并肾动脉反常栓塞一例报道

1 病例资料 患者女性,58 岁,因"晕厥一次,腹痛4 天"就诊.患者静息状态下无明显诱因突然意识丧失,无四肢抽搐、无口吐白沫,约10 min 自行转醒,即感持续性腹痛,无胸闷、胸痛、恶心、呕吐、腹泻、血便及黑便、呕血和肉眼血尿,晕厥时由旁边家人扶助,没有跌倒及撞击情况.门诊检查除外主动脉夹层,因心电图异常及心肌损伤标记物升高,以"急性冠脉综合征"收住院.既往否认高血压、糖尿病,身体健康,无不良嗜好,否认家族遗传病史.20 d 前双下肢外伤骨裂,草药包敷卧床至今.     

Bladed balloon angioplasty for peripheral pulmonary artery stenosis.

Treatment for peripheral pulmonary artery stenosis is challenging, and conventional balloon angioplasty has not proved to be universally effective. Evaluated was the efficacy of bladed balloon (BB) dilation to address vessels resistant to conventional high-pressure (10-15 atm) balloon angioplasty (BA). Thirty-one procedures were performed on 14 children with age range 1 month to 15 years. The diameter of the BB ranged from 3 to 8 mm. After BB dilation, all children had subsequent conventional BA (balloon size range, 3-10 mm). The minimal lumen diameter (MLD) before and after the procedure, whether there was a waist at initial BA, and BB diameter-to-MLD ratio before the procedure were measured. A > 50% increase in MLD was considered successful. Four children had Williams syndrome, two children Alagille syndrome, five children Fallot's tetralogy, and three miscellaneous lesions. The resistant stenosis was located in the right central pulmonary artery in 6, right branch pulmonary artery in 7, left central pulmonary artery in 6, and left branch pulmonary artery in 12 lesions. Median BB diameter was 253% (117-440%) of the MLD and increased from 2.0 +/- 0.7 to 3.2 +/- 0.8 mm (P < 0.0001), with a mean increase of 73% +/- 62%. There was an inverse relationship between the MLD before and increase after the procedure (r = 0.75; P < 0.001). The BB diameter-to-MLD ratio before procedure was significantly associated with the increase in MLD (r = 0.70; P < 0.001). After the procedure, 18 of the 31 procedures were considered successful. In all successful procedures, the BB diameter was greater than twice the MLD before the procedure. Comparing children with Williams and Alagille syndrome with the remaining eight children, there were no significant differences in the increase in MLD. A small aneurysm and thrombus were noticed in two and three children, respectively, but no fatal complications were reported. BB angioplasty is effective for resistant peripheral pulmonary artery stenosis when conventional BA fails. The diameter of the BB should be larger than twice the minimal luminal diameter of the stenotic lesion.