导管消融治疗持续性心房颤动伴左室功能不全的初步随访

目的评价导管消融治疗持续性心房颤动伴左室功能不全的疗效。方法回顾分析连续10例接受导管消融的持续性心房颤动伴左室功能不全患者,短期随访观察术前、术后心功能的改变。结果9例患者成功完成导管消融术,术前平均左室射血分数(LVEF)0·41±0·01,左室舒张末期内径(LVEDD)56·00±7·21mm,左心房内径(LAD)44·22±5·91mm。术后平均随访2·78±1·78个月,平均LVEF增为0·46±0·06,LVEDD降为53·33±6·42mm,LAD降为42·11±4·65mm,与术前相比差异有统计学意义(P<0·05)。结论在慎重选择病例的基础上,导管消融术治疗持续性心房颤动伴左室功能不全安全、有效。     

心脏彩超对高血压左室肥厚伴左心衰竭的诊断价值分析

目的:探讨心脏彩超对高血压左室肥厚伴左心衰竭的诊断价值。方法:选择78例高血压左室肥厚伴左心衰竭者(心衰组),其中NYHA Ⅱ级组38例,Ⅲ级组40例;健康体检者(健康对照组)120例作为研究对象。所有对象均行心脏彩超检查,比较各组左室舒张末期内径(LVEDd)、左房内径(LAD)、左室射血分数(LVEF)、二尖瓣口舒张早期最大血流速度/二尖瓣舒张早期最大运动速度(E/Ea)的差异。结果:与健康对照组比较,观察组LVEDd[(45.63±5.32)mm比(57.24±11.16)mm]、LAD[(33.25±6.54)mm比(50.53±10.92)mm]、E/Ea[(8.01±4.21)比(14.21±3.52)]均显著升高,LVEF[(69.73±11.43)%比(54.36±10.51)%]显著降低,P均0.05。与Ⅱ级组比较,Ⅲ级组LVEDd[(57.12±9.53)mm比(66.20±7.35)mm]、LAD[(46.36±6.94)mm比(53.14±7.21)mm]、E/Ea[(12.89±3.02)比(15.17±3.53)]均显著升高,LVEF[(46.31±10.23)%比(38.75±8.61)%]显著降低,P0.05或0.01。结论:心脏彩超对于高血压左室肥厚伴左心衰竭具有一定的诊断价值,可用于评估此类患者的病情严重程度,值得临床推广及运用。     

射频消融术对老年高血压合并阵发性心房颤动患者左心重构的影响

目的:探讨经导管射频消融术对老年高血压合并阵发性心房颤动(房颤)患者左心功能的影响。方法:入选年龄≥65岁,高血压合并阵发性房颤的患者,手术组在电解剖标测(CARTO)指导下行经导管环肺静脉前庭线性射频消融电隔离肺静脉(CPVI)手术,药物组给予抗心律失常药物治疗。所有患者均严格降压治疗,控制血压达标(140/90mmHg,1mmHg=0.133kPa)。随访时间12个月。比较患者入组时及1年随访结束时左心房内径(LA)、左心室舒张末期容积(LVED)、左心室收缩末期容积(LVSD)、左心室射血分数(LVEF)、左心室室间隔厚度(IVS)和后壁厚度(LVPW)以及血N-端脑钠肽前体(NT-proBNP)的变化。结果:手术组共有33例患者完成手术并随访1年以上,药物组共有30例患者完成随访1年以上,所有患者在随访期内血压控制达标。手术组术后4例再发房颤,其中1例于第1次射频消融术后8个月再行射频消融术,其余3例在口服1种抗心律失常药物(胺碘酮或普罗帕酮)情况下可维持稳定的窦性心律;术前及术后1年LA分别为(38.1±2.1)mm及(35.1±1.9)mm(P0.05),LVED分别为(50.2±2.5)mm及(48.3±1.6)mm(P0.05),LVSD分别为(31.2±4.0)mm及(28.5±3.2)mm(P0.05),LVEF分别为(59.6±3.8)%及(60.8±9.7)%(P0.05),LVPW分别为(11.3±1.1)mm及(10.2±0.8)mm(P0.05),IVS分别为(11.7±1.0)mm及(10.1±2.0)mm(P0.05),血NT-proBNP水平分别为(332.3±146.5)pg/ml及(117.8±65.1)pg/ml(P0.05)。药物组患者均口服1种以上抗心律失常药物,其中9例维持稳定的窦性心律,未发生房颤,其余21例有1次以上发生房颤,其中11例因房颤入院治疗,1例因心力衰竭(心衰)入院治疗;基线及随访结束时LA分别为(38.9±2.2)mm及(40.5±2.7)mm(P0.05),LVED分别为(50.2±2.5)mm及(51.8±2.3)mm(P0.05),LVSD分别为(30.5±3.5)mm及(31.5±3.6)mm(P0.05),LVEF分别为(59.3±3.0)%及(57.3±2.9)%(P0.05),LVPW分别为(11.0±0.9)mm及(11.4±0.9)mm(P0.05),IVS分别为(11.4±0.9)mm及(11.7±2.9)mm(P0.05),血清NTproBNP水平分别为(307.5±171.4)pg/ml及(297.2±184.1)pg/ml(P0.05)。结论:老年高血压合并阵发性房颤患者行经导管射频消融术后可以降低LA、LVED、LVSD,IVS和LVPW,改善患者左心房和左心室的结构重构。     

阿托伐他汀治疗心肌梗死后无症状心力衰竭效果及对预后的影响

目的:研究阿托伐他汀对心肌梗死后无症状心力衰竭(AHF)患者的疗效,及对预后的影响。方法:2014年7月~2015年7月本院收治的心肌梗死后AHF患者100例的临床资料,根据随机数字表法,患者被随机均分为常规治疗组和阿托伐他汀组(在常规治疗组基础上加用阿托伐他汀)。测量比较两组治疗前后心功能指标、血浆BNP、NT-proBNP水平、6min步行距离(6MWD)和心功能评分;疗程1年。结果:与治疗前比较,两组治疗后左室射血分数(LVEF)、6MWD均显著增加,左室舒张末期内径(LVEDd)、左室收缩末期内径(LVESd)、血浆BNP、NT-proBNP水平和心功能评分显著降低(P均=0.001)。与常规治疗组比较,阿托伐他汀组治疗后LVEF[(52.48±8.65)%比(57.86±9.70)%]和6MWD[(262.60±12.40)m比(282.65±15.50)m]升高更显著,LVESd[(36.23±2.13)mm比(30.08±2.05)mm]、LVEDd[(58.61±6.40)mm比(51.25±6.18)mm]、血浆BNP[(267.48±42.10)pg/ml比(149.40±32.30)pg/ml]、NT-proBNP水平[(524.65±138.60)pg/ml比(406.20±112.45)pg/ml]和心功能评分[(2.30±0.22)分比(1.15±0.10)分]降低更显著(P均0.01)。结论:阿托伐他汀能缓和心肌梗死后无症状心力衰竭患者左心室重构,降低血浆BNP、NT-proBNP水平,促进心功能改善,值得推广。     

高龄慢性心力衰竭患者血清CA125、尿酸水平与心功能的相关性

目的:探讨高龄慢性心力衰竭(CHF)患者血清糖蛋白抗原125(CA125)、尿酸(UA)水平与心功能之间的相关性。方法:纳入110例高龄住院患者,根据NYHA心功能分级标准分为心衰组65例(心功能Ⅱ级30例,心功能Ⅲ～Ⅳ级35例)和心功能正常组45例。分别检测比较两组以及不同心功能等级患者间CA125、CA199、癌胚抗原(CEA)、UA、N末端脑钠肽前体(NT-proBNP)水平、二尖瓣舒张早期峰值血流速度/二尖瓣舒张晚期峰值血流速度(E/A)和左室射血分数(LVEF)。结果:与心功能正常组比较,心衰组CA125[(15.9±6.3)U/ml比(40.1±12.2)U/ml]、UA[(319.2±61.3)μmol/L比(435.7±72.9)μmol/L]、NT-proBNP[(298.5±132.4)pg/ml比(1923.7±868.6)pg/ml]显著升高而E/A[(1.02±0.46)比(0.71±0.25)]、LVEF[(62.1±11.9)%比(48.7±14.7)%]显著降低(P均=0.001)。与心功能Ⅱ级组比较,心功能Ⅲ～Ⅳ级组CA125[(28.4±9.3)U/ml比(50.1±13.9)U/ml]、UA[(383.4±71.8)μmol/L比(478.4±73.9)μmol/L]、NT-proBNP[(853.2±361.5)pg/ml比(2841.3±1303.3)pg/ml]水平显著升高而E/A[(0.78±0.23)比(0.65±0.19)]、LVEF[(52.6±10.1)%比(45.3±13.1)%]显著降低(P0.05或0.01)。Pearson直线相关回归分析示:心衰组CA125、UA、NT-proBNP水平与E/A及LVEF均呈显著负相关(r=-0.679～-0.457,P0.05或0.01)。结论:CA125、UA和NT-proBNP水平与高龄CHF患者LVEF均呈显著负相关,有助于心衰严重程度的判断。     

心肌淀粉样变患者左心室功能的评价

目的应用超声心动图的常规参数及二维斑点追踪成像评价心肌淀粉样变患者的左心室功能的改变。方法入选2006年9月至2014年11月在北京协和医院住院期间诊断为心肌淀粉样变(CA)的患者50例,根据LVEF分为CA(LVEF<50%)组(29例)和CA(LVEF≥50%)组(21例),以健康体检者41例为对照组。收集临床病历资料,进行超声心动图常规参数测定及二维斑点追踪成像分析。结果 CA(LVEF<50%)组较CA(LVEF≥50%)组左心房收缩末内径[(43.72±4.89)mm比(37.43±6.82)mm,P<0.01]、左心室舒张末内径[(45.10±6.23)mm比(39.33±4.12)mm,P<0.01]、左心室收缩末容积[42(37~59)ml比17(14~24)ml,P<0.01]和舒张末容积[72(63~106)ml比50(46~62)ml,P<0.01]及脑钠肽水平[664(327~1 338)ng/L比308(179~461)ng/L,P=0.04]明显升高。CA(LVEF<50%)组左心室整体收缩期纵向峰值应变(GLS)、径向峰值应变(GRS)以及圆周峰值应变(GCS)的绝对值小于CA(LVEF≥50%)组及健康对照组[GLS:(-8.46±3.94)比(-13.77±4.05)比(-19.77±2.65);GRS:(15.32±10.00)比(25.18±14.02)比(35.18±12.18);GCS:(-10.18±4.52)比(-18.09±6.56)比(-19.00±3.51);均为P<0.05];CA(LVEF≥50%)组的GLS与GRS绝对值小于健康对照组(均为P<0.05),而GCS与健康对照组差异无统计学意义(P=0.56)。结论 CA患者可逐渐出现左心室整体收缩功能异常及左心重构,二维斑点追踪成像表明LVEF正常的部分CA患者已存在心肌收缩功能减低。     

缬沙坦对冠心病患者心功能和炎性因子水平的影响研究

目的:分析缬沙坦对冠心病患者心功能和炎性因子水平的影响。方法:我院183例冠心病患者被分为常规治疗组(101例)和联合治疗组(82例,在常规治疗组基础上加用缬沙坦),两组均治疗6个月。观察比较两组治疗前后LVEF、左室收缩末期内径(LVESd)、左室舒张末期内径(LVEDd)、左室后壁厚度(LVPWT)、N末端B型利钠肽前体(NT-proBNP)和高敏C反应蛋白(hsCRP)水平。结果:治疗6个月后,与常规治疗组比较,联合治疗组LVEF[(42.62±0.89)%比(48.62±0.87)%]显著升高,LVESd[(36.04±0.34)mm比(30.12±0.26)mm]、LVEDd[(58.24±0.43)mm比(48.29±0.36)mm]、LVPWT[(10.54±0.51)mm比(8.98±0.49)mm]、NT-proBNP[(294.50±14.63)pg/ml比(176.40±10.46)pg/ml]和hsCRP[(2.42±0.32)mg/L比(1.89±0.36)mg/L]水平均显著降低,P均=0.001。结论:缬沙坦可显著抑制冠心病患者的心室重构和炎性反应,有助于改善心功能。     

小剂量左西孟旦与多巴酚丁胺治疗扩张型心肌病难治性心力衰竭的疗效比较

目的探讨左西孟旦注射液治疗扩张型心肌病难治性心力衰竭的疗效与安全性。方法将72例扩张型心肌病难治性心力衰竭患者随机分为两组,两组给予常规药物治疗(如利尿剂、地高辛等),观察组(n=36)用左西孟旦注射液12.5mg加5%葡萄糖注射液45ml以0.1μg/(kg·min)持续静脉泵注约35h(直至药物用完)。对照组(n=36)用多巴酚丁胺注射液以3μg/(kg·min)持续静脉泵注约35h。观察治疗后的纽约心功能、左室射血分数(LVEF)、每搏输出量(SV)、左室舒张末内径(LVEDD)、脑钠肽(BNP)变化及不良反应。结果观察组心功能改善总有效率明显高于对照组(83.33%比58.33%,P0.05),观察组治疗前后LVEF[(30.11±7.65)%比(36.72±8.43)%]、SV[(51.46±20.75)ml比(69.81±20.13)ml]、BNP[(2377.56±735.72)pg/ml比(1644.38±623.61)pg/ml]明显改善,差异有统计学意义(P0.05)。对照组治疗前后LVEF[(29.12±6.71)%比(32.67±7.53)%]、SV[(50.39±19.62)ml比(59.98±21.05)ml]、BNP[(2527.06±865.32)pg/ml比(1964.73±647.51)pg/ml]也明显改善,差异有统计学意义(P0.05)。两组治疗后LVEF[(36.72±8.43)%比(32.67±7.53)%]、SV[(69.81±20.13)ml比(59.98±21.05)ml]和BNP[(1644.38±623.61)pg/ml比(1964.73±647.51)pg/ml]比较差异也有统计学意义(P0.05)。两组在治疗前后LVEDD比较差异均无统计学意义(P0.05)。两组不良反应率比较差异无统计学意义(30.55%比25.00%,P0.05)。结论小剂量左西孟旦注射液治疗扩张型心肌病难治性心力衰竭疗效显著,优于多巴酚丁胺,不良反应少。     

心房颤动患者氨基末端脑钠肽前体水平与左心房大小的临床研究

目的探讨左心室收缩功能正常的心房颤动患者血清氨基末端脑钠肽前体(NT-proBNP)水平与左心房内径(LAD)的关系及临床意义。方法选取左心收缩功能正常的阵发性心房颤动患者31例、持续性心房颤动患者30例和永久性心房颤动患者33例,另选30名窦性心律者为对照组,比较不同类型心房颤动患者与窦性心律者血清NT-proBNP水平,并观察血清NT-proBNP水平与LAD大小的关联。结果心房颤动患者血清NT-proBNP水平较窦性心律者升高,差异有统计学意义[(305.2±170.9)ng/L比(57.2±31.9)ng/L,P<0.01]。其中持续性心房颤动组的LAD和NT-proBNP较阵发性心房颤动组均显著升高[LAD:(33.7±4.9)mm比(30.5±3.3)mm,P<0.05;NT-proBNP:(261.8±124.9)ng/L比(143.7±26.2)ng/L,P<0.05];永久性心房颤动组的LAD和NT-proBNP较阵发性心房颤动组均显著升高[LAD:(37.5±2.9)mm比(30.5±3.3)mm,P<0.05;NT-proBNP:(599.0±33.5)ng/L比(143.7±26.2)ng/L,P<0.05];永久性心房颤动组的LAD和NT-proBNP较持续性心房颤动组均显著升高[LAD:(37.5±2.9)mm比(33.7±4.9)mm,P<0.05;NT-proBNP:(599.0±33.5)ng/L比(261.8±124.9)ng/L,P<0.05]。不同类型心房颤动组的LAD越大(中位值分别为30.5、33.7和37.5 mm),患者血清NT-proBNP的水平越高(中位值分别为143.7ng/L、261.8ng/L和599.0 ng/L)多元线性逐步回归分析显示,LAD、心房颤动类型和病程是高血清NT-proBNP水平的独立预测因素(均为P<0.01)。结论在左心室收缩功能正常的不同类型心房颤动患者中,血清NT-proBNP水平明显高于窦性心律者,可能与患者心房结构重构及心房颤动类型和病程密切相关。     

重复应用左西孟旦治疗老年顽固性心力衰竭的疗效

目的:研究重复应用左西孟旦注射液治疗老年顽固性心力衰竭患者的疗效。方法:选择我院收治的顽固性心力衰竭患者135例,分为常规治疗组、左西孟旦单次组(常规治疗基础上第1天给予左西孟旦注射液治疗)和左西孟旦重复组(常规治疗基础上于第1天及第8天给予左西孟旦注射液治疗),每组各45例,连续治疗14d。观察治疗前后三组患者LVEF、每搏输出量(SV)、左室收缩末内径(LVESd)、左室舒张末内径(LVEDd)及血浆N末端脑利钠肽前体(NT-proBNP)水平等的变化。结果:与治疗前比较,三组治疗后LVEF、SV均显著提高,LVESd均显著减小,血浆NT-proBNP水平均显著降低(P均=0.001);治疗后,与常规治疗组比较,左西孟旦单次组和重复组LVEF[(38.49±2.11)%比(40.29±4.07)%、(42.84±5.6)%]、SV[(60.62±3.69)ml比(63.29±3.82)ml、(65.02±3.81)ml]均显著升高,LVESd [(53.20±2.57)mm比(51.78±2.57)mm、(51.47±2.63)mm]均显著减小,血浆NT-proBNP [(3419.29±866.52)pg/ml比(2730.46±682.96) pg/ml、(2339.78±728.05) pg/ml]水平均显著降低(P0.05或0.01);且与左西孟旦单次组比较,左西孟旦重复组治疗后LVEF、SV提高更显著,血浆NT-proBNP水平降低更显著(P0.05或0.01)。结论:重复应用左西孟旦治疗老年顽固性心力衰竭,可更显著改善患者心脏功能。     

Multiple left ventricular thrombi in a patient with left ventricular noncompaction

The major clinical features of myocardial noncompaction are heart failure, arrhythmias, and thromboembolic events. Prominent myocardial trabeculae and deep recesses characteristic of myocardial noncompaction can cause stagnant blood flow and the formation of left ventricular clots. We describe the case of a 62-year-old woman who presented with symptoms of heart failure secondary to left ventricular noncompaction. Transthoracic and transesophageal echocardiography revealed multiple left ventricular thrombi, which had formed despite the patient's long-term therapy with aspirin.Anticoagulative therapy should be considered for patients with myocardial noncompaction who also have risk factors for thromboembolism, such as atrial fibrillation, a history of systemic embolism, or severe left ventricular systolic dysfunction. However, chronic antiplatelet therapy may not sufficiently prevent clot formation in patients who have myocardial noncompaction and severe left ventricular systolic dysfunction.     

Impaired left ventricular functional reserve in hypertensive patients with left ventricular hypertrophy

To determine whether patients with hypertension and especially those with left ventricular hypertrophy have subtle changes in cardiac function, we measured the increase in left ventricular ejection fraction and in systolic blood pressure to end-systolic volume index ratio with exercise in 40 hypertensive patients and 16 age-matched normotensive volunteers. Twenty-two hypertensive patients without hypertrophy had normal end-systolic wall stress at rest and exercise responses. In contrast, the 18 patients with echocardiographic criteria for left ventricular hypertrophy demonstrated a significant increase in end-systolic wall stress at rest compared with normal subjects (69 +/- 16 vs. 55 +/- 15 10(3) x dyne/cm2, p less than 0.05) despite having normal resting left ventricular size and ejection fraction. In patients with left ventricular hypertrophy, the increase in ejection fraction with exercise was less than in the normotensive control subjects (7 +/- 7 vs. 12 +/- 8 units, p less than 0.05), and delta systolic blood pressure to end-systolic volume with exercise was reduced (3.3 +/- 3.8 vs. 8.3 +/- 7.7 mm Hg/ml/m2, p less than 0.05). The hypertensive patients with hypertrophy displayed a shift downward and to the right in the relation between systolic blood pressure to end-systolic volume ratio and end-systolic wall stress compared with control subjects and hypertensive patients without left ventricular hypertrophy. Thus, hypertensive patients with left ventricular hypertrophy by echocardiography and normal resting ejection fraction exhibit abnormal ventricular functional responses to exercise. This finding may have implications in identifying patients at higher risk for developing heart failure.     

Subacute left ventricular rupture supported with a percutaneous left ventricular assist device

Cardiac rupture is a fatal complication of transmural myocardial infarction that is associated with high mortality. We describe the successful management of a case of subacute cardiac rupture and cardiogenic shock supported by a percutaneous left ventricular assist device (LVAD) as a bridge to surgery.     

Post-extrasystolic left ventricular peak pressure with and without left ventricular failure.

18 patients without valvular pathology, coronary artery disease, or idiopathic hypertrophic subaortic stenosis were haemodynamically and angiographically investigated in order to analyse the effects of a ventricular extrasystolic beat upon the post-extrasystolic left ventricular peak pressure. In eight normal patients (group I), the post-extrasystolic peak pressure (P.ES.P.P.) was lower than that of the pre-extrasystolic beat; in 10 patients with symptoms of left ventricular failure (group II) the P.ES.P.P. significantly increased. The reasons are: 1) cardiac origin: stroke volume increased more in group II; 2) arterial origin. a) aortic compliance was lower in group II (this is probably related to the older age of patients in group II), and by decrease in end-diastolic aortic pressure was smaller in group II. Part of this arterial effect (2b) may probably be explained from the fact that post-extrasystolic compensatory pauses are equal in both groups, but the decay time of arterial pressure during diastole (assuming an exponential decay) is larger in group II. At the same age and with the identical aortic compliance only the two factors 1 and 2b play a part in the changes in P.ES.P.P.     

Isolated left ventricular non-compaction in association with ventricular tachycardia

A 32-year-old young male was found to have non-sustained, repetitive, monomorphic ventricular tachycardia of right bundle branch morphology during routine pre-anaesthetic evaluation for orthopaedic surgery. Echocardiography and left ventricular angiogram were suggestive of isolated non-compaction of left ventricular apex with systolic dysfunction. He was successfully managed with anti-arrhythmic drugs and had an uneventful 9-month follow-up. The index case is an unusual association of asymptomatic, non-sustained ventricular tachycardia with isolated ventricular non-compaction.