二尖瓣脱垂与感染性心内膜炎38例患者的临床分析

目的分析二尖瓣脱垂患者中感染性心内膜炎的临床和超声心动图特点。方法本院1988年1月至2006年12月住院原发性二尖瓣脱垂(MVP)并发感染性心内膜炎(IE)患者共38例,回顾分析其临床资料。结果MVP并发IE占同期IE发病总数的15.0%,均有发热、心尖部3～4级收缩期杂音。20例(52.6%)有Osler结或肢端皮下出血,15例(39.5%)有大动脉栓塞表现。50%有白细胞增高,平均12.06×109/L;95.7%的病例红细胞沉降率加快,平均48.2 mm/h。11例(28.9%)有不同程度贫血。血培养阳性者20例(52.6%),多为链球菌(80.0%)。二尖瓣前叶脱垂者占78.9%,后叶脱垂者占39.5%,前后叶均脱垂者占18.4%,发现二尖瓣前叶有赘生物者占71.1%,后叶有赘生物者占26.3%;无赘生物者5例,占13.2%,前后叶均有赘生物者5例,占13.2%。1例因脑疝导致死亡。结论MVP是IE的常见病因,其临床特点为起病隐匿,体循环栓塞等并发症的发生率较高。超声心动图检查对于诊断具有重要价值,经食管超声心动图检查对于发现瓣膜赘生物有较高敏感性。     

Evaluation and management of heart murmurs in children

Heart murmurs are common in healthy infants, children, and adolescents. Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease. Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. Physical examination should focus on vital signs; age-appropriate exercise capacity; respiratory or gastrointestinal manifestations of congestive heart failure; and a thorough cardiovascular examination, including features of the murmur, assessment of peripheral perfusion, and auscultation over the heart valves. Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Electrocardiography and chest radiography rarely assist in the diagnosis. Referral to a pediatric cardiologist is recommended for patients with any other abnormal physical examination findings, a history of conditions that increase the likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified by the family physician. Echocardiography provides a definitive diagnosis and is recommended for evaluation of any potentially pathologic murmur, and for evaluation of neonatal heart murmurs because these are more likely to be manifestations of structural heart disease.     

Mitral Valve Prolapse: An Assessment of Clinical Features, Associated Conditions and Prognosis

One hundred and eighty-two patients (100 females, 82 males)with mitral valve prolapse (MVP) confirmed by echocardiographyare described. Their ages range from 12 to 87 years (mean 48years). The symptoms of breathlessness, pain in the chest andpalpitations were analysed. They were associated with left ventricularfailure, co-existing ischaemic heart disease and arrhythmiasin some, but in a proportion the symptoms were thought to bedue to psychoneurosis. Seventy-two patients (40 per cent) werereferred because of complications of MVP. In 67 patients (37per cent) the condition was discovered by chance and in 43 patients(24 per cent) neurotic symptoms had led to referral to hospital.A systolic click was heard in 117 patients (54 per cent); 41patients (23 per cent) had a late systolic murmur and 30 patients(16 per cent) had a pansystolic murmur. The incidence of murmursrose with increasing age, and pansystolic murmurs were morefrequent in males. Thirty-two patients (18 per cent) had neithera click nor a murmur. Twenty-four patients (13 per cent) hadassociated supraventricular tachycardia and 22 (12 per cent)atrial fibrillation. Twelve patients (7 per cent) had severemitral incompetence and eight (4 per cent) developed bacterialendocarditis. Only three patients had symptoms suggesting cerebralischaemia. Twelve patients (7 per cent) had associated aorticincompetence. Twenty-two patients had had an inguinal hernia,the incidence in males over 50 being 26 per cent. Twenty-sixpatients (14 per cent) had non-specific T wave changes in theelectrocardiogram. Echocardiography showed that 112 patients(62 per cent) had mid-systolic buckling of the posterior leafletand 70 patients (38 per cent) had holosystolic prolapse. Inview of the high incidence of complications it is felt thatthe long-term prognosis not as good as has been generally believed.     

Three‐dimensional critical care transesophageal echocardiography: A bedside tool in the diagnosis and management of shock

Critical care echocardiography has become fundamental in diagnosis, management, and monitoring of patients in shock. Transesophageal echocardiography has gained importance, particularly in critically ill patients under mechanical ventilation. We describe echocardiographic findings concerning a patient admitted with confusion, pulmonary edema, hypotension, and systolic murmur at apex.     

Current management of mitral valve prolapse

Mitral valve prolapse is a pathologic anatomic and physiologic abnormality of the mitral valve apparatus affecting mitral leaflet motion. "Mitral valve prolapse syndrome" is a term often used to describe a constellation of mitral valve prolapse and associated symptoms or other physical abnormalities such as autonomic dysfunction, palpitations and pectus excavatum. The importance of recognizing that mitral valve prolapse may occur as an isolated disorder or with other coincident findings has led to the use of both terms. Mitral valve prolapse syndrome, which occurs in 3 to 6 percent of Americans, is caused by a systolic billowing of one or both mitral leaflets into the left atrium, with or without mitral regurgitation. It is often discovered during routine cardiac auscultation or when echocardiography is performed for another reason. Most patients with mitral valve prolapse are asymptomatic. Those who have symptoms commonly report chest discomfort, anxiety, fatigue and dyspnea, but whether these are actually due to mitral valve prolapse is not certain. The principal physical finding is a midsystolic click, which frequently is followed by a late systolic murmur. Although echocardiography is the most useful mode for identifying mitral valve prolapse, it is not recommended as a screening tool for mitral valve prolapse in patients who have no systolic click or murmur on careful auscultation. Mitral valve prolapse has a benign prognosis and a complication rate of 2 percent per year. The progression of mitral regurgitation may cause dilation of the left-sided heart chambers. Infective endocarditis is a potential complication. Patients with mitral valve prolapse syndrome who have murmurs and/or thickened redundant leaflets seen on echocardiography should receive antibiotic prophylaxis against endocarditis.     

Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologists

It is not exactly known how ED physicians perform in evaluating cardiac systolic murmurs. In 203 consecutive medical ED patients with systolic murmur, we compared the initial clinical evaluation, including auscultation, with transthoracic echocardiography. Of the 203 patients, 132 (65%) had innocent murmurs and 71 patients (35%) had valvular heart disease. Sensitivity and specificity of the initial clinical routine evaluation in diagnosing echocardiographic valvular heart disease were 82% (70%-86%) and 69% (60%-76%), respectively. Independent significant positive predictors of valvular heart disease were grade >2/6 systolic murmur (odds ratio [OR], 8.3; confidence interval [CI], 3.5-19.7, P<.001) and pathologic electrocardiogram (ECG) (OR, 8.4; CI, 3.2-22, P<.001. Patients younger than 50 years with a systolic murmur graded < or =2/6 had innocent murmurs in 98%. The initial clinical evaluation, including auscultation, by experienced ED physicians in internal medicine distinguishes well between innocent murmurs and valvular heart disease in medical patients with cardiac systolic murmurs.     

The impact of echocardiographic results on treatment decisions for patients suspected of mitral valve prolapse

Although echocardiography is frequently ordered in ambulatory settings for patients suspected of mitral valve prolapse (MVP), its impact on their subsequent management is unknown. We studied the relationship between the results of echocardiography for outpatients suspected of MVP, and two frequent medical decisions: treatment with beta blockers and the recommendation of antibiotic prophylaxis to prevent bacterial endocarditis. A medical record audit was performed on 274 outpatients referred to a university medical center echocardiography laboratory to rule out MVP. Although echocardiographic evidence for MVP significantly influenced the decision to recommend antibiotic prophylaxis (P less than 0.001), symptoms were more likely to be used as indications for beta-blocker therapy in patients suspected of the condition. We conclude that echocardiographic results are used for recommending antibiotic prophylaxis to outpatients suspected of MVP, but not for beta-blocker therapy.     

Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service.

OBJECTIVE: We sought to determine whether physicians with training in echocardiography could successfully use a small echocardiographic device to detect occult cardiovascular disease in patients admitted to a general medical service. METHODS: In all, 103 consecutive patients had a physician-performed bedside echocardiographic examination with a small portable ultrasound device. RESULTS: Of patients, 70% did not have a clinical indication for echocardiography and of these patients, 39% had an abnormal study with the portable ultrasound device. There was a high rate of false-positive examinations, but approximately 17% of patients without a clinical indication for echocardiography had an important cardiac abnormality detected, including 10% with unsuspected left ventricular systolic dysfunction. CONCLUSIONS: Many patients on a general medical hospital ward have unsuspected, clinically important cardiac findings such as left ventricular dysfunction that can be screened for by physicians with training in echocardiography using small portable ultrasound devices.     

Mitral valve prolapse: physical assessment complications and management

This article presents the fundamental knowledge nurse practitioners need when managing the care of a client with mitral valve prolapse (MVP). The assessment discussion includes information on where and how to perform cardiac auscultation, and it also includes a discussion of the particular mid-to-late systolic click with murmur that is typical of MVP. Client preparation for diagnostic tests (echocardiogram and ECG) is also presented. Potential complications of endocarditis, mitral regurgitation, ventricular dysrhythmia, chest pain, systemic emboli and sudden death are discussed. Particular emphasis is given to the nursing management and client teaching that are required for clients with MVP. Nursing management includes teaching the client 1) the need and schedule for chemoprophylaxis of endocarditis, 2) how to maintain left ventricular volume, 3) the possible relationship between chest pain and hypovolemia and 4) the advantages of regular exercise. Changes in the click-murmur that may occur with pregnancy and the impact of MVP on contraception and childbearing decisions are discussed. Specific nursing diagnoses that may arise with the client with MVP are listed. Outcome criteria that may be used for evaluation of nursing care are provided.     

Aortic dissection with fistula to left atrium: diagnosis by transesophageal echocardiography with successful repair.

The aorta-atria fistula is an infrequent complication of aortic dissection, and it is rarely diagnosed before death. A 41-year-old man who 8 years previously had undergone prosthetic aortic valve replacement had an aortic dissection complicated by aorta-left atrial fistula. This patient had acute left heart failure associated with a systolic and diastolic murmur at the lower left sternal border suggesting an aortic prosthetic malfunction. The cardiac diagnosis was made with transesophageal echocardiography and Doppler color flow imaging; it was notable that the cardiac lesions were not detected by transthoracic echocardiography. On the basis of the echocardiographic findings, the patient underwent successful emergency replacement of the dissecting ascending aorta with closure of the aorta-left atrial fistula. Transesophageal echocardiography is the procedure of choice for defining this abnormality. In this case a prompt surgical repair consisting of replacement of the affected segment of the aorta with the prosthesis and closure of the fistula provided optimum resolution of the clinical situation.     

心脏黏液瘤的临床及超声特点探讨

目的探讨心脏黏液瘤的临床及超声特点。方法选取11例心脏黏液瘤患者,男5例、女6例,行多普勒超声检查,均经手术和病理证实,分析患者的临床特点及超声特点。结果 11例患者的临床表现包括胸闷、心悸、发热、晕厥、脑梗死、心律失常等,体征包括舒张期杂音、双期杂音、肿瘤扑落音等。11例患者均为单发,左房多见,超声表现为心房内稍高回声团块,边界清晰,部分呈分叶状,大部分内部回声较均匀,多数瘤体有蒂附着于房间隔上,随心动周期规律摆动,同时并发心房增大,下腔静脉增宽等。结论心脏黏液瘤临床表现个体差异极大,但超声表现较为典型,可以作为该病的首选检查方式。     

Echocardiographic findings in patients with Wegener granulomatosis

OBJECTIVE: To describe the spectrum and clinical implications of echocardiographic findings associated with Wegener granulomatosis. PATIENTS AND METHODS: We retrospectively reviewed the clinical records and echocardiographic data of consecutive patients with confirmed Wegener granulomatosis referred to the echocardiography laboratory during the 21-year period from 1976 through 1997. RESULTS: Of the 85 patients Identified as having confirmed Wegener granulomatosis, 73 (86%) were found to have echocardiographic abnormalities. In 26 (36%) of these 73 patients, lesions appeared directly related to Wegener granulomatosis. We found regional wall motion abnormalities in 17 (65%) of these 26 patients. Left ventricular systolic dysfunction with decreased ejection fraction was found in 13 patients (50%) and pericardial effusion in 5 patients (19%). Other findings Included valvulitis, left ventricular aneurysm, and a large intracardlac mass. A significantly increased mortality rate was observed among patients who had cardiac involvement of Wegener granulomatosis found by echocardiography. CONCLUSIONS: We found a high frequency of echocardiographic abnormalities that appear to be related to Wegener granulomatosis and associated with Increased mortality. Because cardiac involvement in Wegener granulomatosis often is silent and associated with Increased morbidity and worse prognosis, echocardlographic screening of patients with active Wegener granulomatosis may be of clinical value.     

实时三维经胸超声心动图评价二尖瓣脱垂

目的 探讨实时三维经胸超声心动图(RT3D TTE)评价二尖瓣脱垂的可行性。方法 采集36例二尖瓣脱垂患者的RT3D TTE图像,经过旋转及切割,明确瓣膜脱垂区域,并与手术结果对照。结果 RT3D TTE平均检查时间为(7.1±2.3)min,33例(91.67%)成像质量较好。RT3D TTE评价二尖瓣脱垂的敏感度、特异度、阳性似然比、阴性似然比分别为97.10%(67/69)、96.12%(124/129)、25.05、0.03,与手术结果的相关性较好(r=0.933,P<0.05),观察者间的一致性较好(Kappa＝0.97)。结论 RT3D TTE可快速、准确评价二尖瓣脱垂。     

Tricuspid valve prolapse: A common occurrence in the click-murmur syndrome

Isolated mitral valve prolapse (MVP) may represent one end of a spectrum of disease involving dysfunction of multiple cardiac valves. Eighty-nine consecutive patients with MVP diagnosed by two-dimensional echocardiography (2-D echo) were prospectively studied specifically to determine the incidence of tricuspid valve prolapse (TVP) and its clinical correlations. Criteria for prolapse of the atrioventricular (A-V) valves by 2-D echo included extension of the valve leaflets behind an imaginary line defining the valve annulus. Forty-one of 82 patients with MVP had associated TVP. No significant differences existed between patients with isolated MVP and combined A-V valve prolapse with regard to sex, clinical history, symptoms, or physical examination. The parasternal long axis view was more sensitive than the apical four chamber view in diagnosing prolapse of either mitral or tricuspid valves. Thus, TVP is a frequent concomitant of MVP and occurs with equal frequency in both young and old patients.     

The hemodynamic support of physical loading in patients with mitral valve prolapse]

Bicycle ergometry and echocardiographic studies were carried out in 29 patients aged 17-29 years with first revealed mitral valve prolapse (MVP) without any signs of mitral regurgitation. According to bicycle ergometry, the patients manifested changes in hemodynamics pointing to dysfunction of the cardiovascular system. Echocardiography discovered a reduction of the mass and a rise of the rate of contraction of the circular fibers of the left ventricle, evidence of the myocardial genesis of the hemodynamic changes. Comparison of the findings of bicycle ergometry and echocardiography allowed a conclusion about the necessity of the follow-up of patients with MVP in spite of the high level of threshold load and the lack of the clinical signs of heart failure.     

Dynamics of cardiovascular system functional state indices in patients with idiopathic mitral valve prolapse against the background of magnerot and alprazolam therapy

144 patients with idiopathic mitral valve prolapse (MVP) were examined. They were divided into groups of treatment with magnerot, and placebo (control group). Decrease of echocardiography indices of MVP was noticed in the patients who received magnerot. After therapy with alprazolam only tendency to decrease of prolapse depth was registered. Significant decrease of maximal systolic and diastolic pressure, mean diastolic pressure, hypertonic load with diastolic pressure and increased variability of systolic and diastolic pressure occurred after therapy with magnerot. Decrease of systolic and diastolic pressure was noticed after therapy with alprazolam. At Halter monitoring of patients with MVP were noticed that magnerot had greater effect than alprazolam to decrease of number of tachycardia (paroxysmal supraventricual and nonparoxysmal) episodes. Significant decrease of number of patients with sympathicotonia and, at the same time, increase of number of person with equal tonus of both vegetative nervous systems were registered after therapy with magnerot (by 9 times) and with alprazolam (by 4.5 times).     

Anatomic three-dimensional echocardiographic correlation of bicuspid aortic valve.

This study was undertaken to verify the echocardiographic characteristics of bicuspid aortic valve (AV) using 3-dimensional transesophageal echocardiography by comparing the findings with anatomic examination of autopsy specimens from carriers of this condition. Three-dimensional reconstructions of transesophageal echocardiograms were performed on 14 patients with bicuspid AV, and 20 autopsy specimens of bicuspid AVs were analyzed. Echocardiographic images and autopsy material were correlated. Two variants of bicuspid aorta were identified. In group I the AV had 2 leaflets. This group included 9 (9/14) 3-dimensional echocardiographic studies and 13 (13/20) necropsies. In group II 3 sigmoid leaflets had originally developed and 2 underwent dysplastic fusion, resulting in functionally bicuspid valves. Five (5/14) echocardiographic studies and 7 (7/20) anatomic specimens fell into this category. There was a clear correspondence between anatomic and echocardiographic findings, which leads to the conclusion that 3-dimensional echocardiography is a technique that reliably defines the morphological details of bicuspid AV with the precision of anatomopathologic examination.     

Assessing diagnosis in heart failure: which features are any use?

We assessed the value of symptoms, past history, medications and signs in the evaluation of patients who might have heart failure secondary to left ventricular systolic dysfunction. An open-access echocardiography service was set up to help identify patients with left ventricular systolic dysfunction who might benefit from treatment with an angiotensin-converting-enzyme inhibitor. History and examination were recorded for each of these patients. The patients were divided into groups according to whether left ventricular systolic function was preserved or not and whether various clinical features were present or not. Of 259 consecutive patients studied, 41 had impairment of left ventricular systolic function as assessed by echocardiography. Past history of myocardial infarction and displaced apex beat were the best single predictors of left ventricular systolic dysfunction as assessed by echocardiography. The combination of past history of myocardial infarction and displaced apex had the best positive predictive value of all. Patients with such clinical features or combinations of clinical features may not need echocardiography, and where access to this resource is limited, it could be reserved for patients without such diagnostic features.      

Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure

Right ventricular size and contractility were evaluated using two-dimensional echocardiography during the first days of respiratory support in 23 patients requiring mechanical ventilation for acute respiratory failure. Nine patients had normal echocardiographic right ventricular function, and nine other patients had a slightly enlarged right ventricle with normal systolic function. The remaining five patients had a severely enlarged right ventricle with abnormal contractile pattern. In these five patients, two-dimensional echocardiography also showed a reduction in left ventricular size suggesting detrimental ventricular interdependence. All 23 patients had normal left ventricular systolic function by two-dimensional echocardiography.