选择性冠状动脉造影诊断左房血栓的价值

目的：评价冠状动脉造影对左房血栓的诊断价值。材料与方法：对１９６例二尖瓣置换术患者进行了选择性冠状动脉造影检查，并与手术结果进行了对照。结果：冠状动脉造影时左房区造影剂染色诊断左房血栓的敏感性为６７．００％，特异性为９４．２０％，阳性预测值为８３．００％，阴性预测值为８７．２０％，准确性为８６．２２％。心房纤颤是左房血栓形成和出现左房区造影剂染色的首要危险因素，二尖瓣关闭不全不利于左房血栓的形成，左房区造影剂染色与左房血栓的大小有一定关系。结论：二尖瓣病变患者行冠状动脉造影时左房区造影剂染色是诊断左房血栓较为可靠的征象。     

Magnetic resonance evaluation of mitral stenosis

In order to study magnetic resonance (MR) abnormalities in mitral stenosis electrocardiogram (ECG)-gated MR imaging was performed with a 2.0 T MR system in 41 patients with mitral stenosis before catheterization. Mean transverse diameter of the left atrium was 8.9±1.4 cm and anteroposterior diameter was 5.1±1.0 cm, indicating significant enlargement. Homogeneous or inhomogeneous flow-related signals in ventricular diastole were detected in the left atrial cavity in 32 cases (78%), and in the atrial appendage in 35 cases (85%). In 21 patients having a mean wedge pulmonary arterial pressure higher than 20 mm Hg, 20 patients (95%) showed flow-related signals in ventricular diastole. Other MR findings were mitral valve doming in diastole, flow-related signal in the pulmonary artery during systole, and left atrial thrombi.     

The missing left atrial appendage

A 34 year old man underwent a transesophageal echocardiogram (TEE) prior to implantation of a biventricular ICD and DC cardioversion, to exclude left atrium and left atrial appendage thrombus. He had a history of repaired tetralogy of Fallot as a child, Stickler syndrome, atrial flutter and was status post recent mitral valve replacement, pulmonary valve replacement and tricuspid valve repair. The left atrial appendage was not visualized on TEE. A cardiac CT clarified that there was a left atrial appendage and provided an explanation as to why it was not visualized on TEE, highlighting the importance of multimodality imaging in patients with complex congenital heart disease.     

Left coronary angiography in the pre-operative diagnosis of thrombosis of the left atrium or its appendage in rheumatic mitral stenosis

We studied the utility of pre-operative selective left coronary angiograms for detecting thrombosis in the left atrium or its appendage in 81 patients with rheumatic mitral stenosis, who subsequently underwent open-heart surgery. Thrombus was predicted by the angiographic demonstration of neovascularity seen as a bunch of small vessels arising from the circumflex branch of the left coronary artery coursing superiorly to the region of the left atrial appendage and terminating in a network of smaller vascular channels with a blush of contrast medium coalescing into small 'lakes'. This pooling of contrast medium was considered essential for positive angiographic diagnosis. Based on these criteria, the angiographic diagnosis of thrombus was made in 27 patients. Thrombus was found in 33 patients at surgery. Selective left coronary angiography had a sensitivity of 72.7%, specificity of 92.7% and predictive value of 88.8% for detecting thrombi in the left atrium or its appendage. Coronary angiography should be performed in all the patients with mitral stenosis who are undergoing cardiac catheterization especially if balloon mitral valvoplasty or closed mitral valvotomy are planned.     

Chest radiographs are unreliable in predicting thrombi in the left atrium or its appendage in rheumatic mitral stenosis

We have assessed the diagnostic accuracy of a flat or concave left mid-cardiac border (the region of the left atrial appendage) on conventional postero-anterior chest radiographs as a predictor of the presence of thrombi in the left atrium or its appendage in 80 patients with rheumatic mitral stenosis who subsequently underwent open-heart surgery. Forty-six patients (Group I) were found to have left atrial thrombus at surgery whereas 34 patients (Group II) showed no evidence of thrombosis. Only 22 of 46 patients in Group I showed a flat or concave left mid-cardiac border (sensitivity, 48%; specificity, 53%; positive predictive value, 58%). Furthermore in Group 1, the thrombus involved the left atrial appendage in 33 patients. In this subgroup only 14 patients showed a flat or concave left mid-cardiac border (sensitivity, 42%; specificity, 49%; positive predictive value, 37%). The presence of flatness or concavity in the left mid-cardiac border on conventional posterior-anterior chest radiographs in patients with rheumatic mitral stenosis is an unreliable indicator of the presence of thrombi in the left atrium or its appendage.     

Coronarography in the diagnosis of left atrial thrombosis

Thrombosis of left atrium is frequent in the patients with mitral defect. Systemic embolism that generates by separated thrombus parts is a possible complication during the disease. Echocardiography is routinely used in the diagnosis of left atrial thrombosis. On the basis of angiographic experience, we have set the hypothesis: coronary angiography has a great sensitivity, but small specificity in the diagnosis of left atrial thrombosis. The presence of thrombus in left atrium was analyzed in 60 operated patients with mitral valve disease. During the surgery, thrombus was found in 13, and not found in 47 patients. Coronary angiography was preoperatively performed in all patients. In 9 out of 13 patients with intraoperatively observed left atrial thrombus, thrombus was also found by angiography. In 47 patients thrombus was found neither intraoperatively, and in 45 nor by angiography. The sensitivity of angiography in the diagnosis of left atrial thrombosis is 69%, specificity is 97%, and the accuracy is 90%. Positive index of anticipation is 81%, and negative index of anticipation is 91%.     

左心耳增大及降主动脉左移对风湿性二尖瓣病变的诊断价值(附112例X线平片分析)

本文对112例风心和11例非风心的分析,我们认为:左心耳增大对风湿性二尖瓣病变具有特异的诊断价值;降主动脉左移对判断左心房增大是有帮助的。     

Etiologic significance of enlargement of the left atrial appendage in adults

Fifty-one patients were divided into two groups: 20 patients with proven rheumatic mitral valve disease (RMVD) and 31 patients with left atrial enlargement (LAE) of a nonrheumatic etiology. The latter group included patients with ischemic papillary muscle dysfunction, mitral valve prolapse, and congestive cardiomyopathy. Radiographic studies showed that enlargement of the left atrial appendage (LAAE) was present in 18 of 20 rheumatics but in only one of 31 non-rheumatics. There was no direct relationship between enlargement of the LAA and radiographic or echocardiographic left atrial size, degree of pulmonary venous hypertension (PVH), or presence of atrial fibrillation. It is postulated that rheumatic inflammation of the LAA allows it to dilate out of proportion to the body of the left atrium. In the adult patient with radiographic findings of PVH, LAAE is a valuable and specific radiographic sign of rheumatic mitral valve disease.     

二尖瓣狭窄合并左心房血栓患者的经皮二尖瓣球囊成形术

目的　评价经皮二尖瓣球囊成形术 (PBMV)治疗风湿性二尖瓣狭窄合并左心房血栓的临床疗效和安全性。方法　 2 7例风湿性二尖瓣狭窄合并左心房血栓患者进行PBMV ,19例食管超声心动图 (TEE)有左心房内新鲜血栓者术前经华法令抗凝治疗 3～ 6个月。结果　 2 7例风湿性二尖瓣狭窄合并左心房血栓患者进行PBMV均成功。 19例TEE有左心房内新鲜血栓者 ,PBMV术前经华法令抗凝治疗后 ,TEE复查示 9例左心房血栓消失 ,10例左心房内血栓明显缩小 ,机化为高强回声团块的陈旧性血栓 ;5例经胸心脏超声发现左心房陈旧性血栓 ,未行TEE也未予华法令治疗者 ,术中 1例发生脑栓塞。其余患者均无并发症发生。结论　对风湿性二尖瓣狭窄伴有心房纤维颤动患者 ,PBMV前应常规行TEE检查 ;二尖瓣狭窄伴左心房血栓者经充分抗凝治疗后行PBMV是安全可行的。     

A case of inverted left atrial appendage mimicking a tumor

We report a rare case of an inverted left atrial appendage without prior cardiac surgery. A left atrial mass was incidentally found during routine echocardiography in a 19-year-old man with mitral valve prolapse. Echocardiography revealed a hyperechoic mass in the left atrium, and a neoplastic lesion could not be excluded. On magnetic resonance imaging (MRI), this mass consisted of fat tissue that showed continuation to epicardial fat, indicating an inverted left atrial appendage mimicking a tumor in the left atrium. When a mass in the left atrium is observed on echocardiography, there are several differential diagnoses, including thrombus, vegetation, and intra-atrial neoplasms such as myxomas. Recently, several studies reported cases with inverted left atrial appendages mimicking tumors in patients after cardiac operations. We present a case of inverted left atrial appendage without any prior cardiac surgery. Cardiac MRI was highly useful to obtain the final diagnosis of inverted left atrial appendage.     

Comparison of left coronary and laevo-phase pulmonary angiograms in detecting left atrial thrombi in rheumatic mitral stenosis

We have compared the diagnostic accuracy of left coronary and laevo-phase pulmonary angiograms in detecting left atrial thrombi in 27 consecutive patients with rheumatic mitral stenosis who underwent both these procedures prior to open-heart surgery. In 10 patients, both procedures were 'positive' for thrombus, confirmed at subsequent surgery in all instances (true positive). Both procedures were negative for thrombus in 11 patients, and none of these patients showed thrombi at subsequent surgery (true negative). Left coronary angiography only was positive for thrombus in one patient in whom no thrombus was found at surgery. Laevo-phase pulmonary angiography only was positive for thrombus in five patients, two of whom had thrombus at subsequent surgery. The sensitivity, specificity and predictive accuracy of left coronary angiogram were 83.3% and 93.3% and 90.9% and that of laevo-phase pulmonary angiogram 100%, 80% and 80% respectively. Laevo-phase pulmonary angiograms showed higher sensitivity and left coronary angiograms showed higher specificity for angiographic diagnosis. However, the differences were found to be statistically insignificant. Angiography is a reliable method for detecting left atrial thrombi if both left coronary and pulmonary angiograms are performed and both procedures are positive or negative for thrombus.     

特殊情况的左房室瓣球囊扩张术疗效分析

目的　分析和总结伴有特殊情况的左房室瓣狭窄球囊扩张术(PBMV)的临床疗效和安全性。方法　收集我院自1986年12月至2 0 0 5年1月施行的2 30 0例风湿性心脏病左房室瓣狭窄(MS)病例,其中有特殊情况者6 2 1例。包括非单纯MS(合并左房室瓣关闭不全或主闭)者32 8例;非单纯的MS伴巨大左房者15例;巨大左房者10 6例;左房血栓者5 2例;巨大左房及左房血栓者4例;PBMV或左房室瓣闭式分离术后者79例;PBMV或左房室瓣闭式分离术后非单纯的MS者34例;妊娠大咯血者2例。采用Inoue球囊技术。结果　手术成功率98.5 % ,失败率0 .2 % ;发生严重并发症8例,并发症为1.3% ,其中急性左心衰2例,低心排1例,脑栓塞2例,心脏压塞3例。因急性左心衰、低心排、心脏压塞、脑栓塞造成的死亡各1例。结论　随着操作技巧的不断完善,许多伴有特殊情况的PBMV可安全、有效的接受手术。但术前一定要全面评价瓣膜、心功能、血栓情况     

X-ray appearance and clinical significance of left atrial wall calcification.

Ten patients with calcifications of the left atrium are reported with review of the literature. Calcification of the left atrium is frequently associated with history of rheumatic fever, longstanding congestive heart failure, atrial fibrillation, mural thrombus and embolization. Early recognition of such lesions is essential for the management of the patients, particularly when surgical intervention is contemplated. A practical classification of left atrial calcification is proposed according to the dominant lesion in each group: (a) Calcification of the left atrial appendage alone (Mitral stenosis). (b) cacification of all 3 component lesions of the left atrium, i.e., the left atrial appendage, the free wall, and the mitral valve (Severe mitral stenosis). (c) Calcification of the left atrium in MacCallum's patch alone (Mitral insufficiency).     

Pathophysiology of valvular heart disease: Implications for nuclear imaging

Summary  In general, the echocardiogram has become the mainstay of diagnosis in patients with valvular heart disease. Its strength is that it provides information about valve pathoanatomy and about the severity of stenosis and regurgitation not available by other techniques. However, radionuclide studies offer a more precise gauge of left and right ventricular ejection performance, which is useful in the timing of surgery. Because, at present, most cardiac catheterization procedures in patients with valve disease are performed to evaluate coronary anatomy, a noninvasive technique for detecting coronary disease could obviate the need for invasive studies prior to surgery. The presence of left ventricular hypertrophy especially in aortic stenosis has made myocardial imaging less than perfect in this preoperative evaluation, but clearly this is an area of potential fruitfulness in the use of radionuclide techniques. Additional studies regarding the utility of exercise RNA seem warranted and might be of particular interest in mitral regurgitation, in which little is known about the ability of such studies to help time mitral valve surgery. The addition of estimates of loading during exercise studies is an attractive pathophysiologic adjunct and should be helpful in the interpretation of such studies. The potential role for targeted “hot spot” imaging of ischemia, apoptosis, and necrosis in patients with valvular heart disease remains undefined, although such imaging represents another potential area of investigation that warrants further evaluation.     

Mitral annulus calcification and sudden death

Mitral valve annulus calcification is a degenerative cardiac condition often found at autopsy in the elderly. While usually considered incidental to the cause of death, we report two cases where mitral valve annulus calcification with valve stenosis was associated with sudden death. Case 1: a 61-year-old female who had underlying atherosclerosis and hypertension collapsed at home. At autopsy there was marked mitral valve annulus calcification with valve stenosis and cardiomegaly. Case 2: a previously well 74-year-old female collapsed in a toilet. At autopsy there was marked calcification of the mitral valve annulus with valve stenosis. In both cases death was attributed to the effects of the calcified mitral valve annulus. Although such calcification may be unrelated to the terminal lethal mechanism, the association with left atrial enlargement, atrial fibrillation, mitral regurgitation, mitral stenosis, bacterial endocarditis, ischaemic and thromboembolic stroke, myocardial infarction, and arrhythmias, means that it should not be overlooked in the differential diagnosis in cases of sudden and unexpected death.     

二尖瓣脱垂的CT表现

目的了解二尖瓣脱垂的CT表现并探讨CT诊断二尖瓣脱垂的可行性。方法对25例经手术或心脏超声证实的二尖瓣脱垂患者的64层CT心脏图像进行分析。结果所有25例患者均可见收缩期二尖瓣叶突人左心房,并超过瓣环平面2mm。其他CT表现包括瓣叶增厚超过2mm（14例）和腱索断裂（3例）。结论二尖瓣脱垂具有特殊的CT表现,CT能够可靠地诊断二尖瓣脱垂。     

左心房粘液瘤320层CT影像分析

目的:评价320层CT诊断左心房粘液瘤的临床应用价值。方法:分析45例超声心动图检查诊断为左心房粘液瘤的患者,男28例,女17例,年龄49~79岁,平均59.2岁。应用320层CT心功能扫描模式,获得粘液瘤形态学影像,同时显示冠状动脉各分支图像,观察瓣膜开闭功能。结果:45例患者CT显示左心房内不规则肿块样充盈缺损,29例呈均匀软组织密度,16例伴有不规则高密度钙化。其中6例患者诊断为左心房粘液瘤合并冠心病,8例患者诊断为左心房粘液瘤伴二尖瓣关闭不全。结论:应用320层CT心功能扫描模式,不但可以显示左房粘液瘤心态特点,还可同时观察冠状动脉及二尖瓣的情况,为患者术前提供综合全面的影像学信息。减短患者术前检查时间,可使患者获得全面、有效的治疗。     

Assessment of right ventricular afterload in mitral valve diseases with radionuclide angiography

Right ventricular function at rest and during exercise was studied in 33 patients with mitral valve disease by equilibrium gated radionuclide angiography using 99mTc in vivo labeled red blood cells. Radionuclide measurements of right ventricular ejection fraction (RVEF) were correlated with mean pulmonary arterial pressure (mPAP). RVEF decreased significantly with exercise. There was no significant correlation between RVEF at rest and mPAP. However, mPAP showed significant negative correlation with RVEF during exercise and with the changes of RVEF from rest to exercise. It is concluded that RVEF during exercise in mitral valve disease is affected by right ventricular afterload, and the measurements of RVEF at rest and during exercise by equilibrium gated radionuclide angiography is useful to assess right ventricular afterload.     

Two-dimensional echocardiography in the diagnosis of intracardiac masses: A prospective study with anatomic validation

The accuracy of two-dimensional echocardiography in the detection of intracardiac masses was verified in 334 patients who underwent cardiac catheterization in our laboratory over 21 consecutive months. A complete two-dimensional echocardiographic (2DE) examination was performed a day before catheterization. The presence or absence of a mass was verified at surgery in 77 patients who successively underwent mitral or aortic valve replacement (51), left ventricular aneurysmectomy with or without myocardial revascularization (25), and resection of atrial myxoma (2). In 32 patients 2DE revealed the presence of a mass-left or right atrial thrombi in 12, left atrial myxoma in 2, left ventricular thrombi in 16, and endocardial vegetations in 2. The other 45 patients were free of intracardiac masses on 2DE. Anatomic verification at surgery revealed the presence of an intracardiac mass in 34 patients. In 30 (true positives) of these, 2DE revealed the mass as well, and in 4 (false negatives) the presence of a mass had not been identified by 2DE. In 2 patients (false positives) the predicted mass was not found at surgery. Absence of a mass was correctly predicted by 2DE in 41 patients (true negatives). Thus 2DE detected intracardiac masses with sensitivity of 88.2% and a specificity of 95.3%. We recommend that 2DE be performed in all patients prior to hemodynamic study and/or cardiac surgery to enable safer management of patients with intracardiac masses during cardiac catheterization and/or cardiac surgery.     

Angiographic demonstration of tumor vascularity in left atrial myxoma: A case report

We describe a 63-year-old woman with a large sessile left atrial myxoma and coexisting mitral valve stenosis and regurgitation. The diagnosis of a left atrial tumor was confirmed by echocardiography and coronary angiography. This case reveals the rare finding of tumor vascularity originating from both the right coronary artery and left circumflex artery.