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.     

养血清脑颗粒对慢性脑供血不足患者临床疗效和血流动力学的影响

目的 观察养血清脑颗粒对慢性脑供血不足(CCCI)患者的临床疗效及对血流动力学的影响.方法 90例CCCI患者按就诊时间顺序分为对照组(A组)、养血清脑颗粒组(B组)、联合用药组(C组)各30例.于治疗前后分别检测患者血流动力学指标,同时选取健康志愿者30名为正常时照组,并统计分析.结果 B组、C组总有效率分别为90.00%和93.33%,与A组比较差异有统计学意义(P<0.05).治疗前A组、B组、C组平均血流速度与正常时照组比较有统计学意义(P<0.05).B组、C两组治疗后平均血流速度与治疗前比较差异均有统计学意义(P<0.05),与正常对照组比较差异无统计学意义(P>0.05).A组治疗后平均血流速度与治疗前以及与正常对照组比较个别项目差异有统计学意义.B组、C两组治疗后平均血流速度比较差异无统计学意义(P>0.05).结论 养血清脑颗粒能明显改善患者的血流动力学指标,增加脑供血,改善头晕、头痛等症状,单用齐血清脑颗粒治疗CCCI能达到满意的疗效.     

血流动力学稳定伴右心室功能不全的急性肺血栓栓塞症的临床研究

目的:分析血流动力学稳定伴右心室功能不全(right ventricular dysfunction,RVD)的急性肺血栓栓塞症(简称急性肺栓塞,acute pulmonary embolism,APE)的临床特点、诊断、治疗和预后,以提高对血流动力学稳定伴右心室功能不全的急性肺栓塞的认识.方法:对我院近8年来141例急性肺栓塞患者进行回顾分析,根据超声心动图是否存在右心室功能不全将血流动力学稳定的131例患者分为两组,分别为血流动力学稳定伴RVD(伴RVD组)50例和血流动力学稳定不伴RVD(不伴RVD组)81例,对两组患者的高危因素、临床特点、诊断及治疗等进行分析及比较.结果:血流动力学稳定伴BVD的急性肺栓塞占所有的急性肺栓寒的比率为35.5%.伴RVD组的高危因素主要包括慢性静脉机能不全、陈旧深静脉血栓形成、骨折及手术等.临床表现伴RVD组以呼吸困难最常见(68.0%),与不伴RVD组比较仅晕厥、P2亢进、呼吸频率＞20次/分、心率＞100次/分、低碳酸血症、心电图异常更常见,差异均有统计学意义(P＜0.05).急性肺栓塞患者同时存在晕厥、P2亢进和心电图异常时,对右心室功能不全的阳性预测率可达100%.静脉溶栓治疗伴RVD组(42.0%)明显多于不伴RVD组(9.9%),差异有统计学意义(P＜0.01).结论:血流动力学稳定伴RVD的急性肺栓塞是肺栓塞的重要亚组,对临床上存在晕厥、P2亢进、心电图异常的肺栓塞患者,应尽早行超声心动图检查明确有无RVD,以指导进一步治疗.     

心力衰竭患者氨基端脑钠素原与有创血流动力学监测的相关研究

目的:评价心力衰竭患者血浆氨基端脑钠素原(NT-proBNP)与有创血流动力学监测指标的相关性.方法:选择心力衰竭患者纽约心功能分级(NYHA)Ⅱ-Ⅳ级89例,在入院12 h内行漂浮导管监测,同时采用酶联免疫吸附(ELISA)方法检测血浆NT-proBNP.比较有创血流动力学指标在不同血浆NT-proBNP水平时的变化,比较血浆NT-proBNP、左心室舒张末内径和左心室射血分数在不同肺动脉楔压水平时的变化,同时探讨血浆NT-proBNP与肺动脉楔压的相关性.结果:89例患者有创血流动力学指标在不同血浆NT-proBNP水平的变化比较:血浆NT-proBNP水平＞600者与≤600者比较,右心房压、右心室压、肺动脉压、肺动脉楔压、肺循环阻力均明显升高,差异均有统计学意义(P＜0.05～0.01).89例患者不同血浆NT-proBNP水平问肺动脉楔压、左心室舒张末内径和左心室射血分数比较:肺动脉楔压:与血浆NT-proBNP水平≤600者比较,其它血浆NT-proBNP水平者均显著增高,差异均有统计学意义(P均＜0.01).左心室舒张末内径:仅3600≥NT-proBNP＞2601者较≤600者明显升高,差异有统计学意义(P＜0.05).左心室射血分数:仅血浆NT-proBNP＞3601者较≤600者明显降低,差异有统计学意义(P＜0.05).89例患者不同肺动脉楔压等级间血浆NT-proBNP水平、左心室舒张末内径和左心室射血分数的比较:血浆NT-proBNP水平:与肺动脉楔压＜18者比较,其它等级肺动脉楔压者均明显升高,差异均有统计学意义(P均＜0.01);左心室舒张末内径:与肺动脉楔压＜18者比较仅38＞肺动脉楔压≥28者明显升高,差异有统计学意义(P＜0.01);左心室射血分数:与肺动脉楔压＜18者比较,肺动脉楔压≥18者、38＞肺动脉楔压≥28者、肺动脉楔压≥38者均明显降低,差异均有统计学意义(P＜0.05～0.01).在校正了各种影响因素后,肺动脉楔压与NT-proBNP显著相关;多元线性回归分析也表明NT-proBNP与肺动脉楔压独立相关.结论:心力衰竭患者血浆NT-proBNP与有创血流动力学监测指标有很好的相关性.     

慢性阻塞性肺疾病与肺动脉高压自然病程的探讨

目的 探讨慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)并发肺动脉高压(pulmonary arterial hypertension,PAH)的发生和发展.方法 对88例[COPD肺动脉平均压(meanpulmonary arterial pressure,MPAP)≤20 mm Hg(1 mm Hg=0.133 kPa)]进行肺功能、心电图、血气及右心漂浮导管检测血流动力学,每5年一次共随访20年.结果 ①88例COPD随访至终点(20年或死亡),36例并发PAH(A组)死亡24例(66.7%);其余52例未并发PAH(B组)死亡18例(34.6%).MPAP平均每年上升0.51 mm Hg.②COPD急性加重次数>3次/年A组为22例(66.1%),B组为12例(23.1%),两组差异有统计学意义(P<0.05).③COPD急性加重时MPAP、肺血管阻力、内皮素1、血栓素B2均高于稳定期(P<0.05).动脉血氧分压、氧输送量、一氧化氮、6-前列素Fia、均低于稳定期(P<0.05).结论 PAH是COPD自然病程中一种常见的并发症,它的出现可以增加病死率;COPD急性加重频繁发作是诱发COPD并发PAH的重要因素之一.     

超声二维斑点追踪技术评价肺动脉高压右心功能及血流动力学的临床研究

目的探讨超声二维斑点追踪技术评价肺动脉高压右心功能及血流动力学的临床效果。方法选取48例为研究对象,根据患者肺动脉收缩压指标分为A组20例(轻度)、B组16例(中度)、C组12例(重度),选取同期健康体检者20例为对照组,采用超声二维斑点追踪技术评价肺动脉高压右心功能及血流动力学的相关性表现。结果 A、B、C组右心室游离壁低段、中间段、心尖段纵向收缩期峰值应变率显著低于对照组(P0.05),且A、B、C组间同阶段纵向收缩期峰值应变率呈依次递减表现,但无统计学意义(P0.05)。结论超声二维斑点追踪技术评价肺动脉高压右心功能及血流动力学的临床效果显著,可通过右心室纵向应变率提示患者功能减低情况,反应患者血流动力学变化,具有临床推广及应用价值。     

血清C反应蛋白水平对急性肺栓塞患者病情严重程度和预后的评估价值

目的探究血清C反应蛋白(CRP)水平对急性肺栓塞患者病情严重程度和预后的评估价值。方法选取内蒙古自治区人民医院呼吸内科2012年1月—2015年1月收治的急性肺栓塞患者58例,根据血清CRP水平分为A组26例(CRP≥10 mg/L)和B组32例(CRP10 mg/L)。回顾性分析两组患者的生命体征(包括收缩压、舒张压、心率和呼吸频率)、疾病危险程度分层(分为低危、中危和高危)、并发症发生情况〔包括右心室功能不全、低血压、动脉血氧分压(Pa O2)60 mm Hg、心肌损伤和心源性休克〕和预后(包括入住ICU和住院期间死亡)。结果A组患者收缩压和舒张压低于B组,心率和呼吸频率高于B组(P0.05)。A组患者疾病危险程度分层劣于B组(u=3.024,P=0.003)。A组患者右心室功能不全、低血压、心肌损伤发生率高于B组(P0.05);两组患者Pa O260mm Hg发生率及心源性休克发生率比较,差异无统计学意义(P0.05)。A组患者入住ICU率高于B组(P0.05);两组患者住院期间病死率比较,差异无统计学意义(P0.05)。结论血清CRP水平能有效评估急性肺栓塞患者病情严重程度和预后,血清CRP≥10 mg/L常提示急性肺栓塞患者心功能损伤严重、微循环血流灌注不足,且会增加入住ICU的概率。     

血流动力学对肺栓塞患者的预后评估

正静脉血栓栓塞症(VTE)是第三个最常见的心血管疾病,包括急性肺栓塞和深静脉血栓形成,其年发病率为100~200/100000[1],而急性肺栓塞是静脉血栓栓塞症最严重的临床表现。肺栓塞是以各种栓子堵塞肺动脉或其分支为其发病原因的一组疾病或临床综合征,根据急性肺栓塞患者的血流动力学(休克和/或低血压:收缩压90 mm Hg或血压降低40 mm Hg达15 min以上,除外新出现的心律失     

肺小动脉楔入造影对先天性心脏病患儿肺动脉高压的评估价值

目的通过对肺小动脉行肺小动脉楔入造影(PWA),分析PWA对先天性心脏病(CHD)相关肺动脉高压(PAH)的评估价值。方法对50例CHD患儿进行心导管及PWA检查,根据肺动脉压力分为肺动脉压力、阻力正常组[A组,15例,肺平均动脉压(m PAP)≤25 mm Hg(1 mm Hg=0.133 k Pa)、全肺阻力(PVR)300 dyne·s·cm~5],肺动脉压力升高、阻力正常组(B组,24例,m PAP25 mm Hg、PVR300 dyne·s·cm~5),肺动脉压力、阻力均升高组(C组,11例,m PAP25 mm Hg、PVR≥300 dyne·s·cm5)。观察肺小动脉逐渐变细速率(ROT)、肺循环时间(PCT)、肺毛细血管充盈度(BH)与血流动力学指标的相关性。结果 C组肺小动脉ROT显著小于A组[(8.16±2.14)mm比(18.70±2.25)mm]、B组[(8.16±2.14)mm比(13.83±3.45)mm],差异均有统计学意义(P=0.000);B组和C组的ROT与m PAP无相关性,C组ROT与PVR负相关(相关系数r=-0.606,P0.05)。C组PCT指数显著大于A组[(1.50±0.37)s/m~2比(1.08±0.23)s/m~2]、B组[(1.50±0.37)s/m~2比(1.22±0.32)s/m~2],差异均有统计学意义(P0.05);B组和C组PCT指数与m PAP无相关性,C组PCT指数与PVR正相关(相关系数r=0.783,P=0.01)。三组患者毛细血管充盈度比较,差异均有统计学意义(F=23.697,P=0.000),其中B组、C组与A组相比毛细血管充盈度显著减少(P0.05)。结论 PWA能定量评估CHD相关PAH患者的肺血管床。     

依据血流动力学特征指导高血压治疗用药的可行性探索

目的探索依据血流动力学表型指导降压药物选择的可行性。方法采用前瞻性单中心随机单盲对照研究方法,纳入102例初发未治疗或经治疗血压未达标(≥140/90 mm Hg)的高血压患者。采用阻抗心动图(ICG)检查采集血流动力学指标,并分为依据血流动力学治疗组(A组,51例)和常规经验治疗组(B组,51例),治疗4～12周,主要疗效指标为两组的诊室血压下降幅度。结果与B组比较,A组收缩压[(19.9±10.7)mm Hg比(12.0±11.8)mm Hg]和舒张压[(11.3±6.2)mm Hg比(4.9±9.9)mm Hg]较基线降幅更大,A组达标率更高(66.7%比41.2%)(均为P0.05)。男性、年龄50岁、经治、基线收缩压160 mm Hg、基线舒张压≥90 mm Hg亚组中,A组血压达标率均高于B组(均为P0.05)。A组患者中,β受体阻滞剂用药后的心排指数较基线显著下降(P=0.044),利尿剂用药后胸腔血容量饱和度显著降低(P=0.001),钙通道拮抗剂使用后大动脉硬化指数(P=0.003)和系统血管阻力指数(P=0.003)均较基线明显降低,而肾素血管紧张素系统抑制剂类药物使用后系统血管阻力指数显著降低(P0.001)。结论使用血流动力学检查协助判断未控制的高血压患者可能的血压升高机制,并以此为依据选择降压药物可能更有效地降低血压,并提高降压达标率。     

Hemodynamics and gas exchange in acute lung embolism

The main hemodynamic consequence of pulmonary embolism is the acute mechanical reduction of the pulmonary vascular cross-sectional area. This results in a sudden increase of the pulmonary vascular resistance, and if the cardiac output is to be maintained, in an increase in pulmonary artery pressure and right ventricular work. The extent of hemodynamic changes in pulmonary embolism are determined primarily by the size of the emboli and whether or not the patient has underlying cardiopulmonary disease. Although humoral factors and neural reflexes play a role in determining the severity of hemodynamic responses to pulmonary embolism in experimental animals, their role in patients is uncertain. In patients free of preembolic cardiopulmonary disease, the extent of embolic obstruction can be related directly to the mean pulmonary artery pressure. Accordingly, either the extent of obstruction or the mean pulmonary artery pressure may be used as a measure of right ventricular afterload. Obstruction of 25 to 40% leads to an increase in mean pulmonary artery pressure of 20 to 30 mm Hg, massive obstruction over 75% to a pressure of 40 to 45 mm Hg. Continuous hemodynamic monitoring helps to estimate the speed of the resolution of emboli and to a certain extent the adequacy of treatment. Right arterial pressure is consistently elevated by a mean pulmonary artery pressure over 30 mm Hg and provides also a rough estimate of the degree of pulmonary vascular obstruction. A previously normal right ventricle will dilate at a mean pulmonary artery pressure of 40 to 45 mm Hg. which may result in acute tricuspid insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)     

Novel percutaneous catheter thrombectomy in acute massive pulmonary embolism: rotational bidirectional thrombectomy (ROBOT).

BACKGROUND: Although thrombolysis is a standard therapy in cases of pulmonary embolism (PE), fatal outcome is often observed. We designed and investigated the efficacy of a novel percutaneous catheter therapy, rotational bidirectional thrombectomy (ROBOT), for PE. METHODS AND RESULTS: Eighteen patients with acute massive PE (Miller score > or = 20) were included in this study. We separated them into two groups [group A (n = 10), thrombolysis; group B (n = 8): thrombolysis and ROBOT or ROBOT alone]. There was no difference in the hemodynamic indices between the groups at diagnosis. ROBOT was designed to fragment emboli by rotating a regular pigtail catheter. Three deaths occurred in group A because of hemodynamic impairment, but there was no death in group B. One day after treatment, systolic pulmonary artery pressure had decreased from 53 +/- 8 to 30 +/- 8 mm Hg (P < 0.05) in group B and from 54 +/- 5 to 42 +/- 19 mm Hg (NS) in group A. The hospitalization period in group B was shorter than that in group A (17 +/- 6 vs. 27 +/- 10 days, P < 0.05). CONCLUSION: ROBOT therapy results in a significant, rapid improvement in the hemodynamic situation and in a better outcome than conventional therapy in patients with acute massive pulmonary embolism.     

二尖瓣形态对经皮球囊二尖瓣成形术近远期疗效的影响

目的 观察不同瓣膜形态的二尖瓣狭窄患者行经皮球囊二尖瓣成形术的近远期疗效.方法 根据Wilkins超声二尖瓣形态学积分,将385例二尖瓣狭窄患者分为＞8分组(125例)和≤8分组(260例).均采用改良Inoue法对患者行经皮球囊二尖瓣成形术.术后进行随访,并比较两组患者的临床疗效.结果 经皮球囊二尖瓣成形术成功370例,＞8分组经皮球囊二尖瓣成形术的成功率低于≤8分组(92.8％比97.7％,P＜0.05).术后6个月,两组患者各项超声心动图检查指标均较术前显著改善(均P＜0.05);与≤8分组(254例)比较,＞8分组(116例)经皮球囊二尖瓣成形术后左心房平均压、肺动脉收缩压、跨瓣压差及二尖瓣瓣口面积的改变值均较小[分别为(14.22±5.02)mm Hg(1 mm Hg=0.133 kPa)比(15.44±5.19) mm Hg、(26.13±9.27) mm Hg比(31.93±9.98)mm Hg、(9.21±4.11)mm Hg比(10.16 ±4.21)mm Hg和(1.02±0.15)cm2比(1.20±0.22)cm2,均P＜0.05].经皮球囊二尖瓣成形术成功且完成远期随访[(78±20)个月]的患者共353例,两组患者各项超声心动图检查指标均较术前显著改善(均P＜0.05);与≤8分组(245例)比较,＞8分组(108例)左心房平均压、肺动脉收缩压、跨瓣压差及二尖瓣瓣口面积的改变值均较小[分别为(13.28±5.06) mm Hg比(14.77±5.17)mm Hg、(21.19±9.17) mm Hg比(28.92±9.91) mm Hg、(7.30±4.40)mm Hg比(9.16±4.28)mm Hg和(0.92±0.17)cm2比(1.07±0.20)cm2,均P＜0.05],且再狭窄发生率较高(20.4％比8.2％,P＜0.05).结论 二尖瓣瓣膜形态是决定经皮球囊二尖瓣成形术疗效的关键因素之一.对于超声二尖瓣形态学积分低的患者,经皮球囊二尖瓣成形术成功率较高,术后近期及远期随访疗效较好,再狭窄发生率较低,治疗方案可优先选择经皮球囊二尖瓣成形术.     

Hybrid方法建立肺血减少型先天性心脏病幼猪动物模型

目的 研究肺血减少型先天性心脏病(先心病)肺血管发育的病理生理过程及其相关调节机制,探讨肺血减少型先心病幼猪动物模型构建的可行性方法.方法 采用出生1～2个月的幼猪共20只,按照购入时的编号顺序(1～20),随机分为3组:(1)对照组(C组,n=6),右胸前外侧切口造成一过性肺血减少;(2)轻中度狭窄组(T1组,n=7),右胸前外侧切口经右心房表面送入球囊扩张器行人工房间隔造口+肺动脉Banding环缩术,术中收缩期肺动脉环缩处压差(systolic trans pulmonary artery banding pressure,Trans-PABP)20～30 mm Hg(1 mm Hg=0.133 kPa);(3)重度狭窄组(T2组,n=7),术中Trans-PABP≥30～50 mm Hg.术后1个月行64排CT扫描评估,2个月二次开胸手术测定动脉血气分析及血常规,测量各组血管直径及Trans-PABP,处死动物切取心肺组织测量房间隔缺损(ASD)和Banding环直径.结果 C组动物因麻醉意外,术后10 h死于呼吸衰竭1例.T1组术后21 d死于肠梗阻、肠坏死1例.T2组死亡2例,分别于术后24 b和39 d因急性和慢性右心功能衰竭死亡.T1和T2组存活动物房间隔造口+肺动脉环缩术均获得成功.术后超声测定T1和T2组房缺大小分别为(8.0±0.5)mm、(8.9±1.4)mm(P＞0.05),Trans-PABP术后至2个月持续显著增加,T1组由(19.1±5.6)mm Hg增加至(24.1±3.0)mm Hg(P＜0.01),T2组由(34.2±3.9)mm Hg增加至(43.6±6.4)mm Hg(P＜0.01).术前三组间氧分压(PaO2)和血细胞比容(Hct)差异均无统计学意义.术后2个月T1、T2组PaO2显著低于C组,且T2组低于T1,T1、T2组Hct显著高于C组,且T2组高于T1组(P＜0.05).64排CT扫描示T1组主动脉直径(AOD)明显低于C组,T1、T2组肺动脉环缩处直径显著低于各自的AOD(P＜0.01).结论 采用球囊扩张房间隔造口+肺动脉环缩的方法成功的建立了理想的肺血减少型先心病模型,该模型简单可靠、经济实用,十分接近临床的病理生理状态,为该类疾病的临床研究奠定了坚实的实验基础.

Abstract：

Objective To establish an animal model of congenital heart defect with decreased pulmonary blood flow for better understanding the pathophysiology of pulmonary vascular development and related regulatory mechanisms of congenital heart defect with decreased pulmonary blood flow. Method One to two months old pigs were randomly divided into three groups: control group(group C, n = 6)with right chest small incisions induced transient pulmonary blood reduction;light-moderate stenosis groups (group T1, n = 7):artificial atrial septum defect(ASD)plus controlled pulmonary artery banding to generate a systolic pressure gradient of 20-30 mm Hg(1 mm Hg = 0. 133 kPa);severe stenosis groups (group T2, n = 7): similar surgical procedures as group T1, and controlled pulmonary artery banding to generate a systolic pressure gradient ≥ 30 ～50 mm Hg. 64-slice computed tomography scanning was performed at one month post operation. Arterial blood gas analysis, hemoglobin value, pulmonary vessel,ASD and banding ring diameters and trans-pulmonary artery banding pressure(Trans-PABP)were determined at two months post operation. Results One pig died due to tracheal intubation accident in the C group, one pig died due to bowel obstruction in the T, group and two pigs died due to acute right heart failure and chronic heart failure respectively in T2 group. 64-slice CT angiography results showed that aortic diameter of T1 group was significantly lower than that of C group and banding diameter was significantly lower than aortic diameter in the T1 and T2 groups at one month post operation. Two months after operation, the size of ASD were(8.0 ± 0. 5)mm and(8.9 ± 1.4)mm(P ＞ 0. 05)respectively in the T1 and T2 groups after operation. The Trans-PABP was significantly higher in the T1 and T2 groups than in C group(P ＜0. 01), and the Trans-PABP was significantly higher in the T2 group than in T1 group(P ＜0. 01). PaO2 and SaO2 in the T1 and T2 groups were significantly lower than those in C group. Conclusion Artificial atrial septum defect combined pulmonary artery banding procedures could be successfully used to establish model of congenital heart defect with decreased pulmonary blood flow and this model could help to understand the pathophysiology and monitor therapy efficacy for patients with congenital heart defect with decreased pulmonary blood flow.     

心电图对肺动脉高压的诊断价值探讨

目的 参照右心导管检查结果,评价常规12导联心电图在肺动脉高压诊断中的应用价值.方法 入选超声心动图估测肺动脉收缩压≥36 mm Hg(1 mm Hg=0.133 kPa)的64例疑诊肺动脉高压患者为研究对象,右心导管检查前30 min行12导联心电图检查.根据右心导管检查结果排除肺动脉高压者26例,确诊肺动脉高压者38例(特发性肺动脉高压23例,结缔组织病相关性肺动脉高压15例).比较两组间心电图参数差异.通过ROC曲线计算心电图各指标诊断肺动脉高压的敏感性、特异性、阳性预测值及阴性预测值.采用Spearman相关性计算肺动脉高压组心电图参数与血液动力学指标相关性.结果 心电图诊断右心室肥大的各指标在肺动脉高压组中的发生率显著高于排除肺动脉高压组.Ⅰ导联S波振幅＞0.21 mV、QRS电轴＞87°、R_(v1) + S_(v5)＞0.76 mV诊断肺动脉高压的敏感性分别为89%、86%、84%,特异性分别为81%、92%、83%.采用Spearman相关性分析显示,QRS电轴与肺动脉平均压的相关性最高(r=0.75,P＜0.001);R_(v1) + S_(v5)与肺血管阻力的相关性最高(r=0.74,P＜0.001);R_(v1) + S_(v5)和I导联S波振幅与心指数相关性较高(r=-0.62,P＜0.001).结论 常规12导联心电图检查在肺动脉高压筛查中有重要价值,Ⅰ导联S波振幅＞0.21 mV、QRS电轴＞87°、R_(v1) + S_(v5)＞0.76 mV等右心室肥大征象时应考虑到肺动脉高压可能.QRS电轴、R_(v1) + S_(v5)以及Ⅰ导联S波振幅对评估肺动脉高压患者血液动力学受损的严重程度有临床意义.     

Impact of morphologic characteristics of central pulmonary thromboemboli in massive pulmonary embolism

STUDY OBJECTIVE: To assess the impact of morphologically different central pulmonary artery thromboemboli in patients with massive pulmonary emboli (MPEs) on short-term outcome. DESIGN: A prospective registry of consecutive patients. SETTING: An 11-bed closed medical ICU at a 860-bed community general hospital PATIENTS: Forty-seven patients with shock or hypotension due to MPE and central pulmonary thromboemboli detected by transesophageal echocardiography who were treated with thrombolysis between January 1994 and April 2000. PROCEDURES: Patients were divided into two groups according to the following characteristics of the detected thromboemboli: group 1, thrombi with one or more long, mobile parts; and group 2, immobile thrombi. Right heart catheterization was performed. RESULTS: The incidence of both types of thromboemboli was comparable. Groups 1 and 2 showed no differences in demographic data, risk factors for pulmonary embolism, length of preceding clinical symptoms, percentage of patients in shock, hemodynamic variables, serum lactate levels on hospital admission, and treatment. Seven fatal cases due to obstructive shock and right heart failure were present in group 2, but none were present in group 1 (7 of 23 patients vs 0 of 24 patients, respectively; p < 0.05). At 12 h, the cardiac index was lower in group 2 than in group 1 (2.6 +/- 1.0 vs 3.1 +/- 0.9 L/min/m(2), respectively; p < 0.05), and the central venous pressure (15.0 +/- 6.2 vs 12.5 +/- 3.7 mm Hg, respectively; p < 0.05) and total pulmonary resistance (12.9 +/- 5.9 vs 8.6 +/- 2.7 mm Hg/L/min/m(2), respectively; p < 0.001) were higher in group 2 compared to group 1. On hospital admission, inclusion in group 2 (p < 0.03; hazard ratio, 9.53; 95% confidence interval [CI], 1.19 to 76.47) and preexisting chronic medical or neurologic disease (p < 0.01; hazard ratio, 16.4; 95% CI, 1.97 to 136.3) were independent predictors of 30-day mortality. CONCLUSION: On hospital admission, morphology of the thromboemboli and the presence of pre-existing chronic medical or neurologic disease are independent predictors of 30-day mortality. Patients with immobile central pulmonary thromboemboli have a worse short-term outcome than those with mobile central pulmonary thromboemboli.     

Comparative Efficacy of a Two-Hour Regimen of Streptokinase Versus Alteplase in Acute Massive Pulmonary Embolism: Immediate Clinical and Hemodynamic Outcome and One-Year Follow-Up

Objectives. This study sought to compare the efficacy of 2-h regimens of alteplase and streptokinase in acute massive pulmonary embolism. The primary end point was immediate hemodynamic improvement, and secondary end points included early clinical efficacy and safety, as well as 1-year clinical outcome.Background. Several thrombolytic regimens have been compared for the past 10 years in randomized studies, showing that 2-h infusion regimens of alteplase or urokinase lead to faster hemodynamic improvement than former 12- to 24-h administration protocols in acute massive pulmonary embolism. Many trials have focused on immediate hemodynamic and angiographic outcomes, but none has addressed long-term follow-up after thrombolysis.Methods. Sixty-six patients with acute massive pulmonary embolism (Miller score >17 and mean pulmonary artery pressure >20 mm Hg) were randomly assigned to receive either a 100-mg 2-h infusion of alteplase (n = 23) or 1.5 million IU of streptokinase over 2 h (n = 43). In both groups, heparin infusion was started at the end of thrombolytic infusion and adapted thereafter. Total pulmonary resistance was monitored over a 12-h period. Pulmonary vascular obstruction was assessed 36 to 48 h after thrombolytic therapy. One-year follow-up information included death, cause of death, recurrent pulmonary embolism, chronic thromboembolic pulmonary hypertension, stroke and bleeding.Results. Both groups had similar baseline angiographic and hemodynamic characteristics of severity, with maintained cardiac output in 64 (97%) of 66 patients. The results (mean ± SD) demonstrated that despite a faster total pulmonary resistance improvement observed at 1 h in the alteplase group compared with the streptokinase group (33 ± 16% vs. 19 ± 16%, p = 0.006), a similar hemodynamic efficacy was obtained at 2 h when both thrombolytic regimens were completed (38 ± 18% vs. 31 ± 19%). There was no significant difference in either pulmonary vascular obstruction at 36 to 48 h or bleeding complication rates. One-year event-free survival was similar in both groups, as most events were related to concomitant diseases.Conclusions. These results suggest that a 2-h regimen of streptokinase can be routinely used in patients with massive pulmonary embolism and maintained cardiac output without obviously compromising efficacy or safety.     

Pathogenesis of pulmonary infarction

Pulmonary embolism discovered at autopsy is still as prevalent as previously reported in the last three to four decades. Only a certain percentage of pulmonary emboli result in pulmonary infarction. Recently published studies have suggested that importance of the size of the occluded pulmonary artery in the occurrence of infarction. Our study of 45 autopsy subjects in which there were pulmonary emboli shows a 31 percent incidence of pulmonary artery branches of 3 mm in diameter or less, but emboli in larger arteries may show frequent extensions into their smaller distal branches without producing infarct. Pulmonary infarction also occurs more commonly in patients dying of cardiovascular or malignant diseases than it does in those dying of other diseases, and the combination of shock and congestive left heart failure appears to be the most significant hemodynamic risk factor in the development of pulmonary infarction. However, the increased risk of pulmonary infarction in patients with malignancy may not be accounted for by the existence of these two hemodynamic risk factors alone.     

The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease

The hemodynamic status of 20 patients free of prior cardiopulmonary disease was related to the degree of pulmonary embolic obstruction estimated by selective pulmonary angiography. Angiographic estimation of obstruction ranged from 13 to 68 percent. Systemic arterial hypoxemia occurred in virtually all patients (95 percent) including those with only 13 percent obstruction, thus suggesting that angiographically detectable emboli virtually do not occur without producing systemic hypoxemia. Mean pulmonary arterial pressure was increased in 14 patients (70 percent) and was consistently increased when obstruction exceeded 30 percent. Elevation of the level of mean right atrial pressure was found in 10 patients (50 percent) and was usually associated with obstruction in excess of 35 percent and mean pulmonary arterial pressure in excess of 30 mm Hg. Good correlation was observed between mean pulmonary arterial pressure and angiographic estimation of obstruction (P < 0.01), mean right atrial pressure and obstruction (P < 0.01), mean pulmonary and right atrial pressures (P < 0.01), and pO₂ and obstruction (P < 0.05). Cardiac index was characteristically normal or mildly increased, being below the lower limit of normal in only 4 patients (20 percent). In patients who had not experienced cardiac failure, the cardiac index appeared to increase as systemic arterial pO₂ decreased (P < 0.01) once hypoxemia was well established. Mean pulmonary arterial pressure never exceeded 40 mm Hg, despite massive obstruction in some patients, thereby suggesting that this level approximates the maximal pressure response of the previously normal right ventricle.     

肺血减少型先天性心脏病幼猪动物模型的立及其未成熟肺血管的形态学变化

目的 采用一种新型的杂交方法建立肺血减少型先天性心脏病幼猪动物模型,探讨肺血减少对未成熟肺血管发育形态学的影响.方法 采用生后1～2个月的实验用小型幼猪,共20只.随机分为3组.假手术组(S组,n=6):右进胸微创小切口制成一过性肺血减少;手术组1(T1组,n=7):右进胸微创小切口,经右心房表面送入自制球囊扩张器行人工房间隔造口术,并且肺动脉Banding 环缩,使跨环缩处压差为20～30 mm Hg(1 mm Hg=0.133 kPa);手术组2(T2组,n=7):手术过程同T1组,使跨环缩处压差为30～ 50 mm Hg.三组均于开胸后、手术结束时、术后2个月取右肺中叶外侧段大小1.0 cm ×0.8 cm ×0.8 cm的肺组织,weihgt弹性纤维+van Gieson染色,光镜下观察其病理形态学变化.结果 S组动物存活5只,T1组动物存活6只,T2组动物存活5只,T1组、T2组在开胸后、手术结束时肺细小动脉内径与S组之间的差异均无统计学意义(P均＞0.05),T1组术后2个月时肺细小动脉内径明显高于S组(P＜0.05),T2组术后2个月时肺细小动脉内径明显高于S组(P＜0.01),T1组术后2个月时单位面积肺细小动脉数目(APSC)明显低于S组(P＜0.05),T2组术后2个月时肺APSC明显低于S组(P＜0.01),提示肺细小动脉中膜变薄、管腔扩张,同时伴有外周肺小动脉数量减少,并随肺血流的减少,细小动脉发育不良程度加重.结论 肺血减少时幼猪肺细小动脉发育呈现明显不良或退化,说明保持正常的肺血流或尽早改善肺血减少状态是促进外周肺血管正常发育和改善全身状况的关键.