彩色多普勒超声在老年退行性心脏瓣膜病诊断中的应用价值

目的:探讨彩色多普勒超声在老年退行性心脏瓣膜病诊断中的应用价值。方法:本研究选取2017年11月-2019年11月我院收治的876例心脏病患者,均接受心脏彩色多普勒超声检查,对其临床资料进行回顾性分析。结果:本组876例心脏病患者共检出老年退行性心脏瓣膜病281例,总检出率为32.08%;男性检出率显著高于女性(P<0.05)。80岁以上年龄段疾病检出率最高,显著高于70~79岁及60~69岁人群(P<0.05)。281例患者中单纯主动脉瓣受累占比61.57%,单纯二尖瓣受累占比18.86%,主动脉瓣、二尖瓣同时受累19.57%。主动脉瓣狭窄49例,二尖瓣狭窄7例;瓣膜功能障碍87例,主动脉瓣反流占70.11%,二尖瓣反流18.39%。结论:心脏超声检查在老年退行性心脏瓣膜病诊断中具有重要应用价值,可作为疾病诊断检查的重要手段。     

Adult valvular heart disease: a practical approach

The diagnosis and management of valvular heart disease is an important element of primary care practice. This article reviews the essential elements of four common valvular disorders, including signs and symptoms. The disorders reviewed are aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. The article places an emphasis on practical aspects of care.     

Radionuclide quantification of mitral and aortic regurgitation

Abstract. Gated equilibrium bloodpool scintigraphy was used to obtain the ratio of left and right ventricular stroke counts (end-diastolic minus end-systolic counts within ventricular areas of interest), the radionuclide equivalent of stroke volumes. This ratio or stroke count index (SCI) should be unity in normal subjects and increased in patients with aortic or mitral regurgitation, when left ventricular stroke output rises to compensate for regurgitant flow. Results of this non-invasive method were compared with semiquantitative angiographic grading of mitral (1 to 4+) or aortic (1 to 3+) regurgitation in ninety-seven patients. We found a SCI of 1.15 ± 0.18 (SD) in thirty-six control subjects without evidence of mitral or aortic regurgitation at cardiac catheterization. Subsequently, a ratio of 1.50 was chosen as the upper limit of normal for the analysis of thirty-seven patients with mitral regurgitation and twenty-four patients with aortic regurgitation. Clearly, elevated SCI values were obtained in the presence of grade 3 and 4 mitral regurgitation (eighteen out of twenty patients) and of grade 2 and 3 aortic regurgitation (seventeen out of eighteen patients). Only two out of seventeen subjects with grade 1 or 2 mitral incompetence had an elevated SCI, while none of six subjects with grade I aortic regurgitation had an abnormal SCI. If these lesser degrees of valvular incompetence are considered of minor significance, overall sensitivity of the radionuclide method in our patient population was 92%, specificity 95%. Occasional discrepancies between SCI and angiographic severity of left-sided valvular regurgitation are probably a result of methodological limitations. We could not demonstrate any relation with global left ventricular function as measured from the radionuclide ejection fraction. We conclude that the SCI may be used as a non-invasive tool for diagnosis and management of patients with valvular heart disease, both before and after interventions.     

The value of Doppler echocardiography in the management of patients with valvular heart disease: analysis of one year of clinical practice

Management recommendations based on Doppler echocardiographic examination and cardiac catheterization were compared in a prospective study in 100 consecutive patients who were admitted for evaluation and treatment of suspected valvular heart disease during 1988. Management recommendations were provided independently after both Doppler echocardiography and cardiac catheterization by different and blinded investigators. Criteria for severe (clinically significant) and moderate to mild (insignificant) valvular lesions and management recommendations were agreed on in advance. There was disagreement on the severity of aortic stenosis based on the aortic valve area and maximum instantaneous pressure gradient in 1 of 54 patients, which resulted in differing management recommendations. Mitral stenosis was severe (valve area less than or equal to 1 cm2) at Doppler echocardiography but not at cardiac catheterization in 5 of 14 patients. Because pulmonary artery pressure increase during exercise at cardiac catheterization also suggested severe obstruction, management recommendations were similar. There was a potentially significant disagreement on the severity of aortic regurgitation in 9 of 76 patients and of mitral regurgitation in 14 of 90 patients; however, this did not produce differing management recommendations because with most patients coexistent valvular lesions or an impaired ventricular function mainly determined the ultimate management decision. Although of good quality, Doppler echocardiographic examination was nonconclusive for clinical decision-making in 15% of the study population because of uncertainty about the severity of mitral regurgitation or aortic regurgitation or because of problems in assessing the degree of left ventricular dysfunction in patients with severe regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

经食管超声心动图在风心病二尖瓣狭窄手术方式选择中的应用

目的：评价经食管超声心动图(TEE)在风心病二尖瓣狭窄手术方式选择中的应用价值。方法：67例风心病二尖瓣狭窄患者术前作经胸超声(TTE)和TEE检查，重点探查左房血栓、左心耳血栓、左房雾影、瓣膜返流和瓣膜病变等情况。结果：TTE检查拟行二尖瓣置换术21例，球囊成形术46例。46例球囊成形术者又经TEE检查后，新发现左心耳血栓12例，改二尖瓣置换术；10例二尖瓣轻度返流，TEE证实为中度返流，改二尖瓣置换术。结论：TEE在风心病二尖瓣狭窄手术方式选择中有决定性的作用，对左房血栓、左心耳血栓、左房雾影检出及二尖瓣返流的定量判断较准确、可靠。     

风湿性心脏病并发左心房血栓的危险因素探讨

目的　探讨风湿性心脏病并发左心房血栓的发生率及危险因素。方法　采用非条件Logistic回归模型分析二尖瓣狭窄患者并发左心房血栓的危险因素。结果　风湿性心脏病并发左心房血栓的发生率为 10 .77% ;二尖瓣狭窄、二尖瓣关闭不全、主动脉瓣病变和联合瓣膜病的发生率分别为 15 .6 3%、1.2 5 %、0和 2 .11%。二尖瓣狭窄并发左心房血栓的预测因子是左房自发性超声对比现象 (leftatrialspontaneousechocontrast ,LASEC) (相对危险比3.0 9,P<0 .0 0 0 0 )和房颤 (相对危险比 1.74 ,P =0 .0 0 2 3)。结论　风湿性心脏病二尖瓣狭窄患者最易发生左心房血栓 ;LASEC和房颤是决定二尖瓣狭窄发生左心房血栓的危险因素。二尖瓣狭窄伴房颤、LASEC的患者应积极抗凝治疗     

多平面经食管超声心动图在风心病手术方式选择中的价值

目的：研究应用多平面经食管超声心动图(TEE)和彩色多普勒血流显像(CDFI)相结合，评价该技术在风湿性心瓣膜病手术方式选择中的价值。方法：57例风心病术前应用经胸超声(TTE)和经食管超声两种方法进行检查，重点探查左房血栓、左房云雾影、瓣膜返流和瓣膜病变等方面并对两种方法进行比较。结果：TEE检查：拟行二尖瓣置换30例；球囊扩张15例；主动脉瓣病变5例，3例瓣膜置换、2例未确定，拟6例双瓣置换。TEE检查后：原30例拟行二尖瓣置换中改二尖瓣修复术3例，改双瓣置换3例；原15例拟行球囊扩张者，新发现左心耳血栓8例，改二尖瓣置换5例；原3例主动脉瓣置换及2例主动脉瓣病变未确定者均行主动脉瓣置换；原6例双瓣置换，1例改主动脉瓣置换加二尖瓣修复术；均与手术相符。结论：TEE在风湿性心瓣膜病手术方式选择中有决定性作用，在左房血栓、左房云雾影的检出及二尖瓣返流的定量和主动脉瓣病变的判断中TEE较TTE优越，诊断结果是可靠的。     

Respective timing of maximal color Doppler jet areas and of peak velocity of jets in left-sided valvular lesions: clinical implications

Time intervals between the R wave of the electrocardiogram and maximal dimension of jet areas of color Doppler and the R wave of the electrocardiogram and peak velocity of valvular jets of continuous-wave Doppler were compared by use of paired and correlative studies for a group of 55 patients with a total of 71 left-sided lesions. Mean values of both time intervals, mean difference, and its standard error were equal to zero for stenoses. Time intervals of 71% for mitral stenosis and 52% for aortic stenosis did not differ by more than 0.01 second; correlation coefficients were 0.96 for mitral stenosis and 0.85 for aortic stenosis. For regurgitations, differences in mean values and a mean difference with a standard error were found but remained unsignificant. However, the percentage of differences in time intervals below or equal to 0.01 second decreased to 35 for aortic regurgitation and 13 for mitral regurgitation, which showed the widest 95% range of differences. Correlation coefficients were 0.84 for the aortic regurgitation and 0.33 for mitral regurgitation. Thus the close relationship of time intervals suggests that standardized timing of area measurements at peak velocity is feasible for stenoses and remains under consideration for aortic regurgitation. Timing of measurements should remain empiric for mitral regurgitation.     

Recurrent stress incontinence

PREVIEW

Recognition and management of valvular heart disease have evolved considerably in the past two decades, thanks in large part to advances in echocardiography. In this article, Drs Harris and Robiolio summarize the initial patient assessment, diagnostic procedures, and treatment options for mitral regurgitation, aortic insufficiency, mitral stenosis, and aortic stenosis.     

Aortic dissection presenting with acute pulmonary edema

Background

Acute aortic dissection is a cardiovascular emergency with high mortality that necessitates prompt diagnosis and immediate treatment. Though asymmetric extremity pulses/blood pressures and mediastinal widening on chest roentgenogram are often clues to diagnosis, aortic regurgitation (AR) of variable degrees could be the only sign on initial assessment. Mostly resulting from dilated aortic ring with valvular insufficiency, the AR could be caused by different pathogenic mechanisms. Herein we report a case of Stanford type A aortic dissection presenting with acute pulmonary edema. Physical examination detected severe AR murmur and bedside echocardiogram confirmed prolapsed dissecting intima flap with interference of aortic valve closure as a specific mechanism.

Prevalence of Cardiac Valve Abnormalities in Afebrile Injection Drug Users

OBJECTIVES: To determine the prevalence of occult valvular pathology in afebrile injection drug users (IDUs) compared with an afebrile, non-IDU population. To characterize the type of valvular pathology present in light of current recommendations regarding periprocedural antibiotic prophylaxis against endocarditis. METHODS: This was a comparative, cross-sectional study involving a convenience sample of 98 patients with a history of injection drug use, and 99 non-IDU patients presenting to a large urban ED. Patients were excluded if they had one or more of the following: a history of cardiac valve abnormality, a history of endocarditis, fever on presentation, or a cardiac murmur. Data were collected that included demographics, medical history, and details of injection drug use. Transthoracic echocardiography (echo) was performed on each subject in the ED, and read in a blinded fashion by a single board-certified cardiologist. RESULTS: Among 98 IDUs and 99 non-IDUs, 12% of the IDUs had aortic valve thickening, compared with 5.1% of the non-IDUs (99% CI for difference of 7.8% = -3.0% to 18.6%). Forty-four percent of the IDUs had mitral valve thickening, compared with 25% of the non-IDUs (99% CI for difference of 18.3% = 0.9% to 35.7%). Eleven percent of the IDUs vs 1% of the non-IDUs had tricuspid valve thickening (99% CI for difference of 10.4% = 1.6% to 19.2%). No patient had pulmonic valve thickening. Six percent of the IDUs vs 0% of the non-IDUs had mitral annulus thickening (99% CI for difference of 6.3% = -0.1% to 12.8%). Twelve percent of the IDUs vs 3% of the non-IDUs had mitral chordae thickening (99% CI for difference of 9.5% = -0.4% to 19.4%). Tricuspid chordae thickening was recorded in 2% of the IDUs vs 0% of the non-IDUs (99% CI for difference of 2.1% = -1.7% to 6.0%). Most important, the prevalence of valvular regurgitation was small, and evenly distributed in the two groups. No valvular vegetations were seen. CONCLUSION: Both non-IDUs and IDUs have occult valvular pathology. There is an increased prevalence in IDUs of tricuspid and mitral valve thickening. The prevalence of valvular regurgitation, a reported indication for periprocedural antibiotic prophylaxis, was small and the affected valves were not statistically different between the two groups. These findings question the selected routine use of antibiotic prophylaxis in IDU patients undergoing invasive procedures.     

多平面经食管超声心动图观察主动脉瓣病变

本文对３１例主动脉瓣病变患者进行了多平面经食道超声心动图（ＭＴＥＥ）的研究，其中主动脉瓣狭窄１２例（主动脉瓣二瓣化７例，风湿性３例，退行性病变２例），主动脉瓣关闭不全１９例（风湿性１０例，升主动脉夹层动脉瘤４例，赘生物３例，单纯脱垂２例）。主要从食管中上段的一系列切面观察主动脉瓣的形态结构。ＭＴＥＥ在确定主动脉瓣病变的病因方面明显优于ＴＴＥ。在判断主动脉瓣狭窄和主动脉瓣返流的程度方面ＭＴＥＥ具有重     

老年退行性心脏瓣膜病诊断中彩色多普勒超声的应用分析

目的 分析彩色多普勒超声在老年退行性心脏瓣膜病诊断中的应用价值,并探讨其超声心动图特点.方法 应用Madison 8000多普勒超声仪对650例60岁以上老年患者进行多切面探查,探头频率为2.5 MHz,观察患者房室大小和瓣膜的形态结构、流返部位和程度.结果 退行性心脏瓣膜病发病率随患者年龄增长呈升高趋势,主要累及主动脉瓣,多伴有主动脉瓣返流,二尖瓣较少累及.结论 应用彩色多普勒超声可直接观察老年退行性心脏瓣膜病患者瓣膜厚度与回声强度与活动度,此外还可发现瓣环钙化状况与返流程度,值得临床推广应用.     

Advances in percutaneous valvular intervention

We are entering a new era in the percutaneous treatment of valvular heart disease. Novel techniques and devices have given rise to the possible treatment of a range of valvular heart diseases that previously necessitated surgical therapies, including aortic stenosis, pulmonary regurgitation and mitral regurgitation. Despite the enormous potential of these percutaneous therapies, enthusiasm needs to be balanced by an understanding of the challenges that need to be overcome before such therapies can be widely embraced. This review provides a critical assessment of the status of the major developments in percutaneous valvular intervention to date, and provides the authors' perspective on the current role and future potential of these techniques.     

Errors in performance and interpretation of echocardiograms

Diagnostic ultrasound affords important information about cardiac structure and motion. However, because of the unique manner in which data are acquired and displayed during echocardiography, diagnostic errors and misinterpretations are not uncommon. This paper discusses the characteristic echocardiographic patterns of a variety of important cardiac conditions: mitral stenosis and mitral regurgitation, aortic regrugitation, idio-pathic hypertrophic subaortic stenosis, left atrial myxoma, pericardial effusion and right ventricular volume overload. Potential pitfalls in achieving the correct diagnosis in each of these conditions are emphasized, with illustrative examples of correct and incorrect interpretations. Good technique and appropriate clinical correlation are important in the performance of accurate ultrasound cardiac examinations.     

Effects of valve dysfunction on Doppler Tei index.

BACKGROUND: Recently proposed Doppler Tei index, defined as the sum of isovolumic contraction time or mitral valve closure to aortic valve opening time and isovolumic relaxation time or aortic valve closure to mitral valve opening time divided by ejection time, is a simple measure which enables noninvasive estimation of combined systolic and diastolic function and prediction of patients' prognosis. However, effects of valve dysfunction on Tei index have not been investigated. This study was designed to compare Tei index before and after surgical valve replacement or repair to evaluate effects of valve dysfunction on Tei index. METHODS: Participants consisted of 76 consecutive patients with aortic or mitral valve surgery (26 patients with aortic stenosis [AS], 16 with aortic regurgitation, 17 with mitral stenosis, and 17 with mitral regurgitation). Doppler Tei index was evaluated before and after the surgery by obtaining (a-b)/b, where a is the interval between the cessation and onset of Doppler mitral filling flow and b is the aortic flow ejection time. RESULTS: Tei index significantly increased after surgery in patients with AS (0.38 +/- 0.07 to 0.49 +/- 0.06, P <.001), aortic regurgitation (0.60 +/- 0.20 to 0.70 +/- 0.18, P <.01), mitral stenosis (0.34 +/- 0.03 to 0.39 +/- 0.04, P <.01), and decreased with no significance in mitral regurgitation (0.50 +/- 0.03 to 0.46 +/- 0.03). Percent change in Tei index after valve surgery was maximal in patients with AS (27 +/- 6 vs 17 +/- 2 vs 16 +/- 6 vs -9% +/- 6%, AS vs aortic regurgitation vs mitral stenosis vs mitral regurgitation, P <.001). CONCLUSION: Tei index significantly changes after valve surgery especially in patients with AS. Considerations for the effects of valve dysfunction on Tei index are required for its application to evaluate ventricular function in patients with valve disease.     

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers–Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.     

经皮二尖瓣球囊成形术8例分析

应用Inone法经皮二尖瓣球囊成形术治疗风湿性心脏病单纯二尖瓣狭窄3例，二尖瓣狭窄伴轻度二尖瓣返流3例，二失瓣狭窄伴主动脉瓣关闭不全2例，均获成功。手术后二尖瓣面积、肺动脉压，左房平均压均较手术前明显改善，部分心功能改善。术前病例选择，术中房问隔穿刺及球襄直径的选择，对增加成功率，预防并发症极为重要。     

Morphometric Study of Human Myocardium in Acquired Valvular Diseases

To study the effect of various valvular heart diseases on the quantitative histology of myocardium, 38 human hearts with valvular lesions were examined (11 aortic stenoses, nine mitral stenoses, nine mitral incompetences and nine combined aortic and mitral valve lesions). The control group consisted of ten hearts without any valvular lesions. With morphometrical methods the volume fractions of myocardial components (myocardial fibres, interstitial space and diffuse connective tissue), the numerical density of arterioles and the mean fibre diameter were estimated.

Myocardial fibrosis was more severe in hearts with valvular lesions than in the controls (5.4% vs 3.3%, P<0.01), but did not correlate with the anatomical severity of the valvular lesions. The most severe myocardial fibrosis was found in hearts with mitral imcompetence (6.7%). Fibre hypertrophy was most severe in hearts with aortic stenosis and in hearts with mitral incompetence (22 urn and 23 urn, respectively). In hearts with severe valvular lesions the mean fibre diameter was 23 u.m and in hearts with mild to moderate lesions 19 urn (P<0.01). Good correlation was observed between the mean fibre diameter and the weight of the left ventricle (A = 0.81, P<0.01). The volume fractions of connective tissue and interstitial space were significantly higher and the volume fraction of myocardial fibres was correspondingly lower in the subendocardium than in the subepicardium in hearts with either pressure overload (aortic stenosis) or volume overload (mitral incompetence). In conclusion, myocardial fibrosis occurs in patients with various valvular lesions, but the severity of the fibrosis does not correlate with the anatomical severity of valvular lesions. Marked transmural differences were observed in the volume fractions of myocardial components between the subendocardium and the subepicardium in patients with aortic stenosis and in patients with mitral incompetence. These transmural differences should be taken into account when endomyocardial biopsies are used in clinical practice.     

Morphometric study of human myocardium in acquired valvular diseases

To study the effect of various valvular heart diseases on the quantitative histology of myocardium, 38 human hearts with valvular lesions were examined (11 aortic stenoses, nine mitral stenoses, nine mitral incompetence and nine combined aortic and mitral valve lesions). The control group consisted of ten hearts without any valvular lesions. With morphometrical methods the volume fractions of myocardial components (myocardial fibres, interstitial space and diffuse connective tissue), the numerical density of arterioles and the mean fibre diameter were estimated. Myocardial fibrosis was more severe in hearts with valvular lesions than in the controls (5.4% vs 3.3%, P less than 0.01), but did not correlate with the anatomical severity of the valvular lesions. The most severe myocardial fibrosis was found in hearts with mitral incompetence (6.7%). Fibre hypertrophy was most severe in hearts with aortic stenosis and in hearts with mitral incompetence (22 microns and 23 microns, respectively). In hearts with severe valvular lesions the mean fibre diameter was 23 microns and in hearts with mild to moderate lesions 19 microns (P less than 0.01). Good correlation was observed between the mean fibre diameter and the weight of the left ventricle (r = 0.81, P less than 0.01). The volume fractions of connective tissue and interstitial space were significantly higher and the volume fraction of myocardial fibres was correspondingly lower in the subendocardium than in the subepicardium in hearts with either pressure overload (aortic stenosis) or volume overload (mitral incompetence). In conclusion, myocardial fibrosis occurs in patients with various valvular lesions, but the severity of the fibrosis does not correlate with the anatomical severity of valvular lesions.(ABSTRACT TRUNCATED AT 250 WORDS)