超声心动图检测右心功能指标对急性肺栓塞不同治疗方法的评价

目的:评价超声心动图对急性肺动脉血栓栓塞症(PTE)患者不同治疗方法治疗前后右心功能检测意义,探讨血栓栓塞面积对治疗的影响。方法:502例急性FIE患者,根据血栓栓塞面积分为溶栓组224例,其中大面积FIE 54例和次大面积PTE170例,抗凝组278例为非大面积FIE者。治疗前后超声心动图检测右心指标:右与左心室前后径比值(RVD／LVD)、右心室横径(RVTD)、右与左心室横径比值(RVTD／LNTD)、右与左心房横径比值(RATD／LATD)、右心房横径(RATD)、左心房横径(LATD)、右心室前壁厚度(RVAWT)、右心室壁运动幅度(RVAWM)、主肺动脉内径(PA)、三尖瓣反流压差(TRPG)、下腔静脉深吸气最小径(IVC min)。结果:右心功能变化:治疗前,RVD／LVD、RVAWM、RVTD、RVTD／LVTD、RATD／LATD、PA、TRPG指标溶栓组中次大面积者与大面积者、抗凝组(非大面积者)与大面积者比较,均有显著性差异(P<0．05)。抗凝组(非大面积者)与溶栓组中次大面积者比较(除外LATD、RVAWT、IVC min),均有显著差异性(P<0．05)。溶栓组治疗前后比较RVD／LVD、RVTD、RVTD／LVTD、LATD、RATD／LATD、RVAWM、PA及TRPG指标均有显著性差异(P<0．05)。抗凝组治疗前后比较RVD／LVD、RATD／LATD及TRPG指标有显著性差异(P<0．05)。结论:超声心动图检测右心功能指标是区分PTE血流动力学变化和帮助诊断分型及观察不同治疗方法疗效的敏感指标。提示超声心动图评价急性PTE右心功能有重要意义。     

经胸超声心动图对法洛氏四联症手术的评价

目的:探讨经胸超声心动图技术评价法对法洛氏四联症(TOF)手术疗效的价值。方法:用经胸超声心动图常规测量43例法洛氏四联症患者术前左、右室内径,主动脉骑跨程度,右室流出道、肺动脉狭窄程度和跨瓣压差,左室射血分数(LVEF),二、三尖瓣E、A峰值等,术后随访6-24个月。结果:术后主动脉根部内径缩小,左室舒张末内径增大,主肺动脉和右室流出道增宽,跨瓣压力阶差降低(P<0.05-P<0.01);LVEF在1-6个月时为0.520±0.058,仍低于正常值。结论:经胸超声心动图对于TOF手术后疗效的评价具有重要作用。     

急性肺血栓栓塞症患者溶栓治疗后的远期预后分析

目的　分析急性大面积肺血栓栓塞症 (PTE)患者溶栓治疗后的远期预后。方法　对2 60例急性PTE患者进行溶栓治疗并随访 ,分析其临床资料及引起远期临床事件 [死亡、再发深静脉血栓形成、再发PTE、慢性血栓栓塞性肺动脉高压和 (或 )右心衰竭、抗凝治疗出现大出血、依赖家庭氧疗 ]的危险因素。结果　 2 60例PTE患者在住院期间死亡 2 2例 (8 5 % ) ,其中 1 5例 (62 8% )死于PTE。随访 2 2 7例患者 ,为期 3 9～ 8 4年 ,死亡 72例 (31 7% ) ,其中有 2 1例患者死于再发PTE。对随访资料完整的 1 65例患者进行远期临床事件的危险因素分析 ,单因素分析显示 ,既往有血栓栓塞病史、抗凝治疗不足 6个月、植入下腔静脉滤器、溶栓后超声心动图仍显示右室功能障碍和 (或 )扩大、溶栓后超声多普勒仍测得肺动脉收缩压 >50mmHg、出院前核素肺通气 /灌注扫描显示肺血管床阻塞 >30 %与远期临床事件的发生相关 ;多变量分析显示 ,溶栓后超声心动图仍显示右室功能障碍和 (或 )扩大、溶栓后超声多普勒仍测得肺动脉收缩压 >50mmHg、出院前核素肺通气 /灌注扫描显示肺血管床阻塞 >30 %是PTE远期预后的独立危险因素。结论　通过高危因素的确立 ,可予患者更积极的治疗 ,改善患者的预后     

急诊床旁超声心动图在急性肺栓塞诊断价值探究

目的对床旁超声心动图在急性肺栓塞诊断中的价值进行探讨。方法抽取2012年1月~2015年1月由我院门诊确诊的46例急性肺栓塞患者的超声心动图资料作为本次研究的研究对象,观察床旁超声心动图是否可以观察到患者肺动脉主干的血栓回声征象、分叉处和右房的血栓回声征象以及右室的血栓回声征象,是否能够观察到患者肺动脉压力升高的间接征象、右室壁活动减弱的间接征象以及右心负荷增加的间接征象等,并对观察结果进行分析和总结。结果 46例患者都有右房室增大的情况发生,患者的肺动脉以及分支内径出现变宽的情况,右室前壁、左室后壁以及室间隔的收缩减弱,但是没有明显异常现象。患者左室、右室以及左房的舒张末期的横径都出现了增加的现象。46例患者都存在三尖瓣反流的现象,重度反流的患者有12例,中度反流的患者有23例,轻度反流的患者有5例,轻微反流的患者有6例。三尖瓣反流的速度为(348.96±79.85)cm/s,肺动脉收缩压的估测结果为(56.02±22.89)mm Hg。结论通过床旁超声心动图可以观察到患者肺动脉主干的血栓回声征象、分叉处和右房的血栓回声征象以及右室的血栓回声征象,并且能够观察到患者肺动脉压力升高的间接征象、右室壁活动减弱的间接征象以及右心负荷增加的间接征象等,利用床旁超声心动图可以对患者是否患有急性肺栓塞的情况进行明确的判定,在临床上具有非常重要的意义。     

急诊床旁超声心动图在急性肺栓塞诊断价值探究

目的对床旁超声心动图在急性肺栓塞诊断中的价值进行探讨。方法抽取2012年1月~2015年1月由我院门诊确诊的46例急性肺栓塞患者的超声心动图资料作为本次研究的研究对象,观察床旁超声心动图是否可以观察到患者肺动脉主干的血栓回声征象、分叉处和右房的血栓回声征象以及右室的血栓回声征象,是否能够观察到患者肺动脉压力升高的间接征象、右室壁活动减弱的间接征象以及右心负荷增加的间接征象等,并对观察结果进行分析和总结。结果 46例患者都有右房室增大的情况发生,患者的肺动脉以及分支内径出现变宽的情况,右室前壁、左室后壁以及室间隔的收缩减弱,但是没有明显异常现象。患者左室、右室以及左房的舒张末期的横径都出现了增加的现象。46例患者都存在三尖瓣反流的现象,重度反流的患者有12例,中度反流的患者有23例,轻度反流的患者有5例,轻微反流的患者有6例。三尖瓣反流的速度为(348.96±79.85)cm/s,肺动脉收缩压的估测结果为(56.02±22.89)mm Hg。结论通过床旁超声心动图可以观察到患者肺动脉主干的血栓回声征象、分叉处和右房的血栓回声征象以及右室的血栓回声征象,并且能够观察到患者肺动脉压力升高的间接征象、右室壁活动减弱的间接征象以及右心负荷增加的间接征象等,利用床旁超声心动图可以对患者是否患有急性肺栓塞的情况进行明确的判定,在临床上具有非常重要的意义。     

心脏起搏器植入术后并发右室巨大血栓一例

患者男性,60岁,因呼吸困难入院,5个月前行心脏双腔起搏器植入术。超声心动图及肺动脉CTA见右室巨大血栓及右房血栓,予低分子肝素治疗1周后复查超声心动图右室血栓明显减小,抗凝治疗有效。     

超声心动图评价成人房间隔缺损封堵术后心脏结构和功能的变化

目的探讨超声心动图评价成人房间隔缺损(atrial septal defects,ASD)介入封堵术后心脏形态和功能变化。方法经超声心动图和心电图检查确诊为ASD并成功施行ASD封堵术的患者74例,年龄(35.63±12.74)岁,ASD直径为(16.29±5.11)mm。于封堵器堵闭术后24h、1个月、3个月、6个月和12个月进行经胸超声心动图追踪测量主动脉内径、左心室舒张末内径、左心室收缩末内径和右心室前后径,肺动脉内径和肺动脉瓣血流速度,右心房和右心室的上下径、主动脉瓣口血流速度、二尖瓣口血流速度、三尖瓣口血流速度和左心室射血分数,同时测量封堵器的直径和长度,并进行统计学分析。结果术后24h与术前相比,右心房内径、右心室内径、肺动脉内径、三尖瓣口血流速度和肺动脉瓣口血流速度均显著减少(P0.01);左心房内径、左心室内径、主动脉内径、二尖瓣口血流速度和主动脉瓣口血流速度均显著增加(P0.05);左心室射血分数无明显变化。房室大小和血流速度在术后24h内变化明显,在术后1个月后的随访中逐渐趋于稳定。结论封堵器介入封堵ASD,既纠正了解剖畸形,又改善了左心和右心系统的几何结构。     

不同部位右室起搏对心功能的影响

目的：比较右室心尖部起搏与右室间隔部起搏对心功能的影响。方法：将48例高度房室传导阻滞患者随机分为右室心尖部起搏组（25例）或右室间隔部起搏组（23例）。随访术后的超声心动图左室舒张末期内径和射血分数变化以及临床的NYHA心功能分级变化。结果：24个月后,右室间隔部起搏组左室舒张末期内径,射血分数及NYHA分级较术前无明显变化。但右室心尖部起搏组与术前相比,左室舒张末期内径有增大趋势,射血分数显著减低,NYHA心功能分级级别增高。结论：右室间隔部起搏较右室心尖部起搏更有利于双心室电激动的同步性,且不产生对心功能的不良影响。     

不同部位右室起搏对心功能的影响

目的:比较右室心尖部起搏与右室间隔部起搏对心功能的影响. 方法:将48例高度房室传导阻滞患者随机分为右室心尖部起搏组(25例)或右室间隔部起搏组(23例).随访术后的超声心动图左室舒张末期内径和射血分数变化以及临床的NYHA心功能分级变化. 结果:24个月后,右室间隔部起搏组左室舒张末期内径,射血分数及NYHA分级较术前无明显变化.但右室心尖部起搏组与术前相比,左室舒张末期内径有增大趋势,射血分数显著减低,NYHA心功能分级级别增高.结论:右室间隔部起搏较右室心尖部起搏更有利于双心室电激动的同步性,且不产生对心功能的不良影响.     

多普勒超声心动图在肺动脉栓塞诊断中的应用

目的探讨经胸彩色多普勒超声心动图在肺动脉栓塞诊断中的应用价值。方法对9例经胸超声心动图提示并经临床确诊的肺动脉栓塞患者的声像图进行回顾性分析。结果发现主肺动脉主干及左右肺动脉近端栓子3例,右心房栓子(位于起搏器导管上)1例,9例均出现右房室增大,三尖瓣反流,肺动脉血流频谱呈"拳指征"等右心负荷过重及肺动脉高压超声征象。结论超声心动图可通过检出肺动脉及右心系统内栓子等直接征象以及右心负荷过重、肺动脉高压等间接征象而直接或间接提示肺动脉栓塞。     

Right Atrial and Ventricular Infarction

In order to compare the results of transesophageal echocardiography (TEE) in diagnosis of right atrial (RA) and right ventricular (RV) infarction with those of transthoracic echocardiography (TTE), 11 patients admitted to the coronary care unit with the diagnosis of posteroinferior left ventricular (LV) acute myocardial infarction (MI) and electrocardiographic suspicion of extension to RV were studied. In two of the 11 patients, RA infarction was identified on the basis of akinesis of the RA free wall, dilatation of the atrial cavity, spontaneous echo contrast, mural thrombosis, and poor atrial contribution to RV filling. In all 11 patients, RV infarction was determined by akinesis of one or more segmental regions, dilatation of the cavity in four patients, and tricuspid regurgitation in seven. Only six cases of RV infarction were diagnosed with TTE. The findings indicate that TEE provides additional information to TTE for determining RA and RV infarction during the early stages of MI.     

A positive outcome in patient with massive acute pulmonary embolism and right atrial mobile thrombus fragmented during thrombolysis: a serial echocardiographic examination

The case report presents a patient with acute, massive pulmonary embolism diagnosed by transthoracic echocardiography, with the mobile thrombus visualized in the right atrium. During the thrombolytic therapy the thrombus was fragmented and migrated to the pulmonary artery, with a rapid transient worsening of the clinical status of the patient. The continuation of thrombolysis led to the gradual improvement of the patient condition. In this case report the importance of serial echocardiographic examinations in revealing right heart masses, the right ventricle overloading and the effectiveness of treatment is shown.     

Association of coronary sinus diameter with pulmonary hypertension

Background: Impaired venous drainage secondary to increased right atrial pressure (RAP) may result in coronary sinus (CS) dilatation. Methods: Two hundred fifteen patients referred for transthoracic echocardiography were included in the study. CS diameters were measured from apical four‐chamber view with the transducer being slightly tilted posteriorly to the level of the dorsum of the heart. Pulmonary artery systolic pressure (PASP) is estimated by measurement of tricuspid regurgitation velocity (v) and estimate RAP based on size and collapsibility of inferior vena cava (VCI) with the formula PASP: 4v²+RAP. Patients with PASP >35 mmHg were considered to have pulmonary hypertension (PH). Results: CS diameter was measured in 80.3% of the patients with normal PASP (8.1 ± 2.4 mm) and 93.1% of the patients having PH (12.3 ± 2.5 mm). PASP was significantly correlated with CS diameter (r = 0.647, P < 0.001), RA volume index (r = 0.631, P < 0.001), RV volume index (r = 0.475, P < 0.001), VCI diameter (r = 0.365, P < 0.001), and left ventricular ejection fraction (LVEF) (r =–0.270, P < 0.001). CS diameter was also correlated significantly with estimated RAP (r = 0.557, P < 0.001), RA volume index (r = 0.520, P < 0.001), RV volume index (r = 0.386, P < 0.001), LVEF (r =–0.327, P < 0.001), and VCI diameter (r = 0.313, P < 0.001). Multivariate analyses, testing for independent predictive information of CS size, VCI diameter, RA and RV volume indexes, and estimated RAP for the presence of PH revealed that estimated RAP (beta = 0.465, P < 0.001) and CS size (beta = 0.402, P = 0.003) were the significant predictors. Conclusions: Coronary sinus is dilated in patients with pulmonary hypertension. Coronary sinus diameter significantly correlates with PASP, RAP, right heart chamber volumes, LVEF, and VCI diameter.     

The role of echocardiography in suspected and established PE

Acute obstruction of more than 30% of the pulmonary arterial bed often results in abnormal right ventricular (RV) transthoracic Doppler echocardiography (TTE), usually defined as RV dysfunction, dilatation, or hypokinesis. The presence of such changes strongly increases the clinical probability of pulmonary embolism (PE) (specificity, 81 to 94%; PPV, 71 to 86%) and indicates a worse prognosis, especially if a patent foramen ovale is found at contrast TTE. Normal RV echocardiography indicates a good prognosis. Integrating TTE with venous ultrasound and transesophageal imaging increases the possibility of immediate definitive justification for specific therapy. This strategy permits direct visualization of thrombi either in proximal veins, pulmonary arteries, or right heart chambers. Mobile thrombi require immediate thrombolysis or urgent embolectomy. Whether any echo-based criteria might identify normotensive patients with PE who should receive thrombolytic therapy remains a subject for an overdue large prospective trial.     

A case of paradoxical embolism "in situ" associated with massive pulmonary embolism: role of echocardiography

A 49-year-old man was admitted in transfer for further management of a pulmonary embolism (PE) and possible mitral valve vegetation. Transthoracic echocardiography performed at our institution showed evidence of right ventricular (RV) enlargement and dysfunction. Within the right atrium was a serpentine mobile thrombus which traversed the interatrial septum at the level of the fossa ovalis and extended into the left atrium to the level of the anterior mitral valve leaflet. Because of the patient's dyspnea, RV dysfunction, and large clot burden, thrombolytic therapy was considered and would have been administered had the thrombus in situ not been identified. In light of the thrombus in situ and the concern about possible systemic embolization with thrombolytic therapy, the patient underwent successful surgical thrombectomy. This case highlights the importance of echocardiography in the management of patients with PE. We believe that all patients should undergo echocardiography prior to receiving thrombolytic therapy for pulmonary emboli. Careful interrogation of the interatrial septum for the presence of a thrombus in situ is warranted. Thrombectomy should be considered in individuals with PE who have a thrombus in situ.     

Thrombolysis in acute nonmassive pulmonary embolism: potential role of multidetector-row spiral computed tomography in decision making

In the setting of suspected or confirmed nonmassive pulmonary embolism (PE), transthoracic echocardiography (TTE) is an important tool to identify patients who could benefit from thrombolytic therapy, because of right ventricle (RV) dysfunction, and to monitor the dynamic response of the RV to reperfusion therapy. Unfortunately, certain patient characteristics such as obesity, lung disease, postsurgical state, or respiratory distress often lead to inadequate ultrasonographic imaging quality. In such patients, multidetector-row spiral computed tomography (MSCT) may become even more important. We present a female obese patient with acute nonmassive PE in whom TTE did not allow a reliable evaluation of the RV. Conversely, MSCT, beyond a direct demonstration of intravascular thrombi, detected multiple signs suggesting RV dysfunction. According to these findings, thrombolysis was safely performed, obtaining a rapid clinical improvement and a regression of RV dysfunction.     

The use of the right ventricular diameter and tricuspid annular tissue Doppler velocity parameter to predict the presence of pulmonary hypertension.

AIMS: Detecting the presence of pulmonary hypertension (PH) is important especially with unexplained dyspnoea and suspected thromboembolism. Although PH can be detected invasively by right ventricular (RV) catheterisation, accurate non-invasive assessment by echocardiography has many advantages. This however relies on the presence of tricuspid regurgitation (TR). We examined if the presence of PH can be predicted echocardiographically without relying on TR. METHODS AND RESULTS: Seventy-six consecutive patients with TR were recruited, and another 32 were used for prediction study. RV end-diastolic diameter (RVD) was measured in the apical view and tissue Doppler imaging (TDI) parameters were obtained from the lateral tricuspid annulus motion. Pulmonary artery systolic pressures (PASP) were estimated from TR. The RVD, and the TDI duration from start of isovolumic contraction to peak systole, T(peak), correlated with PASP. However, the RVD/T(peak) ratio offered the best correlation and, at a cutoff of 22 cm/s, predicted the presence of PH with 80% sensitivity and 83% specificity. The same results were obtained even if the study was confined to patients with or without RV dysfunction. The ratio displayed a good correlation with catheter-derived PASP in nine separate patients. CONCLUSION: While RVD and T(peak) can adequately detect the presence of PH, RVD/T(peak) acted as the best predictor for PH. The results apply regardless of the presence or absence of RV dysfunction.     

Right atrial size and function in patients with pulmonary hypertension associated with disorders of respiratory system or hypoxemia.

BACKGROUND AND AIM: Pulmonary hypertension (PH) determines various adaptive changes in right ventricular (RV) geometry which may progressively lead to hypertrophy, mechanical dysfunction and dilatation with pump failure. Right atrium (RA) is theoretically involved in this physiopathological process, but its role has never been investigated. We hypothesized that RA increases volume and function to assist RV during the chronic pressure overload exposition due to PH. METHODS: We prospectively enrolled 66 consecutive patients referred to our echolab with a diagnosis of PH [defined as pulmonary artery systolic pressure (PASP) >30 mmHg] associated with disorders of the respiratory system and/or hypoxemia and normal RV systolic function. Ejection force was taken up as index of RA systolic function and calculated according to the Manning's formula. Thirty-three healthy subjects for whom PH was definitely excluded by echoDoppler evaluation were used as controls. RESULTS: PASP was 42+/-10 and 20+/-8 mmHg in PH patients and controls, respectively; p=0.00001). In comparison with controls, PH patients exhibited higher RA volume (37+/-13 vs 32+/-13 ml, p=0.04) and RA ejection force (6.7+/-3.0 vs 3.5+/-1.8 Kdynes, p=0.00001). Both variables were positively related to PASP (r=0.23 and 0.48, p=0.02 and 0.00001, respectively). CONCLUSIONS: In patients with chronic PH, RA size and systolic function significantly increase and parallel signs of activation of the Frank-Starling mechanism in both right chambers. The magnitude of these phenomena is positively related to PASP levels.     

Echocardiographic evaluation of pulmonary arterial hypertension in patients with progressive systemic sclerosis and related syndromes.

In order to evaluate the usefulness of echocardiography in detection and characterization of pulmonary arterial hypertension (PAH) in scleroderma patients, we performed M-mode, two-dimensional, and Doppler echocardiography in 71 patients with progressive systemic sclerosis (PSS) and related syndromes: mixed connective tissue disease (MCTD) and overlap syndromes. We estimated systolic pressure gradients across the tricuspid valve from the peak velocity of tricuspid regurgitation (TR) by color-flow guided continuous wave Doppler. TR velocities of analyzable quality for gradient estimation were obtained in 28 patients (39%), of whom 12 showed PAH (peak TR velocity > or = 2.5 m/sec). In comparison, analyzable TR was recorded in 19 (35%) of 55 patients with left-sided cardiac disease. None of the 12 with Doppler-estimated PAH showed left ventricular dilatation or decreased fractional shortening by M-mode and two-dimensional measurements. Nonsimultaneous cardiac catheterization confirmed PAH in 8 of 9 with Doppler-estimated PAH and in 3 of 12 without analyzable TR who had hemodynamic study. Doppler-estimated right ventricular systolic pressures (RVSP) correlated well with catheterization-measured pulmonary arterial systolic pressures (PASP) (< 0.01). Our results indicate that Doppler echocardiography is useful in detecting subclinical PAH and estimating PASP in patients with collagen vascular disease. The results of pulmonary function studies suggest that PAH in MCTD is mainly caused by pulmonary vasculopathy.     

Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy

OBJECTIVES: Because pulmonary thromboendarterectomy (PTE) can result in an immediate reduction in pulmonary artery (PA) pressure, we sought to evaluate the effect of PTE on severe tricuspid regurgitation (TR) without tricuspid annuloplasty. BACKGROUND: Few data exist regarding the frequency and magnitude of functional TR improvement after reduction in PA pressure. METHODS: We identified 27 patients with severe TR, defined by a regurgitant index (RI) >33%, who underwent PTE. The RI, tricuspid annular diameter (TAD), apical displacement of leaflet coaptation, and estimated PA systolic pressure were determined on pre- and post-PTE echocardiograms. Patients were stratified based on resolution (RI < or =33%) or persistence (RI >33%) of severe TR. RESULTS: Comparing pre- and post-PTE echocardiography results, severe TR resolved in 19 of 27 (70%) patients. This group had a more effective PA systolic pressure reduction after PTE (49 +/- 20 mm Hg vs. 32 +/- 16 mm Hg by echocardiography, p = 0.075, and 37 +/- 16 mm Hg vs. 16 +/- 13 mm Hg by catheter measurement, p = 0.004). No difference was observed in TAD, apical displacement of the tricuspid valve, or other features compared with the group with persistent severe TR. There was a trend toward longer hospital stays in the group with persistent severe TR (19 +/- 15 days vs. 14 +/- 9 days; p = 0.55). CONCLUSIONS: After significant PA pressure reduction by PTE, severe functional TR with a dilated annulus may improve without annuloplasty despite dilated tricuspid annulus diameters.