维持性血液透析患者心脏瓣膜钙化相关危险因素分析

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者心脏瓣膜钙化发生的相关危险因素。方法入选2011年7月前在上海交通大学医学院附属瑞金医院血液透析中心的MHD患者,年龄超过18周岁,透析龄在3个月以上,排除心脏外科瓣膜手术后患者。应用超声心动图检测心脏瓣膜钙化,采用双位点酶联免疫吸附法(ELISA)检测血浆C段成纤维细胞生长因子23(fibroblast growth factor 23,FGF23)。应用Logsitic回归分析心脏瓣膜钙化的相关危险因素。结果资料完整的患者共110例,男性64例,女性46例,平均年龄55.2岁(20~85岁),平均透析龄41.7月(3.0~225.5月)。110患者中,共有28例(25.5%)发生心脏瓣膜钙化(主动脉钙化或二尖瓣瓣膜钙化),其中主动脉瓣膜钙化(AVC)25例(22.7%),二尖瓣瓣膜钙化(MVC)10例(9.1%),AVC和MVC双瓣膜钙化6例(5.5%)。比较合并瓣膜钙化和非瓣膜钙化2组患者各项临床指标,发现合并瓣膜钙化患者年龄更大、透析龄更长、白蛋白水平更低,血磷水平更高,FGF23水平更高。应用多因素Logistic回归,结果发现老龄(OR=1.106)、透析龄长(OR=1.031)、低白蛋白(OR=0.852),高血磷(OR=7.420)是透析患者发生心脏瓣膜钙化的主要危险因素(通过性别、总蛋白、尿素氮、肌酐、尿酸、血钙、胆固醇、三酰甘油、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)、全段甲状旁腺素(iPTH)和LgFGF23校正后,Backward Stepwise,P<0.001,Nagelkerke R Square 0.555)。结论 MHD患者主动脉及二尖瓣钙化多发,其中以主动脉瓣膜钙化更多见。老龄、透析龄长、低白蛋白、高血磷是心脏瓣膜钙化的独立危险因素。     

维持性血液透析合并继发性甲状旁腺功能亢进患者发生转移性钙化的影响因素分析

目的 观察维持性血液透析合并继发性甲状旁腺功能亢进患者转移性钙化的发生情况,探讨其发生转移性钙化的影响因素。方法 行维持性血液透析治疗合并继发性甲状旁腺功能亢进患者70例,均行腹部侧位及全身骨骼X线片、超声心动图、甲状旁腺彩超及甲状旁腺核素扫描检测患者腹主动脉、心脏瓣膜及关节周围软组织钙化情况,根据是否发生转移性钙化将70例患者分为钙化组49例和非钙化组21例。比较2组年龄、透析龄、身高缩短长度、吸烟史、高血压、糖尿病、心血管病病史比率,透析前血清碱性磷酸酶、血钙、血磷、血肌酐及25-羟维生素D₃、白蛋白、高敏C反应蛋白、成纤维细胞生长因子23水平等临床资料;采用多因素logistic回归分析维持性血液透析合并继发性甲状旁腺功能亢进患者发生转移性钙化的影响因素。结果 70例维持性血液透析合并继发性甲状旁腺功能亢进患者发生转移性钙化49例,发生率为70%,其中腹主动脉钙化19例(38.8%),心脏瓣膜钙化12例(24.5%),关节周围软组织钙化7例(14.3%),合并≥2个部位钙化11例(22.4%)。钙化组年龄[(53.63±9.63)岁]、透析龄[(14.00±...     

心脏瓣膜钙化对血液透析患者冠状动脉钙化积分的预测价值

目的利用超声心动图研究终末期肾病血液透析患者心脏瓣膜钙化情况,探讨瓣膜钙化对冠状动脉钙化的预测价值。 方法对169例慢性肾病V期血液透析患者进行超声心动图检查评价心脏瓣膜钙化情况,并用多层螺旋CT扫描计算冠状动脉钙化积分。按照冠状动脉钙化积分11~100、101~400和≥400将患者分为3个危险等级;并根据心脏瓣膜钙化情况,将所有患者分为：无瓣膜钙化组、主动脉瓣钙化组、二尖瓣钙化组以及主动脉瓣、二尖瓣同时钙化组。Logistic回归分析瓣膜钙化与冠状动脉钙化积分危险分级之间的比值比。 结果受检的169例血液透析患者中88例（52.07%）患者存在瓣膜钙化。当患者出现主动脉瓣钙化时,冠状动脉钙化积分≥400的比值比为4.61,95%可信区间为1.22~17.4（P=0.02）,出现二尖瓣钙化时,冠脉钙化积分≥400的比值比为5.31,95%的可信区间为1.37~20.5（P=0.01）,当出现主动脉瓣、二尖瓣同时钙化时,冠状动脉钙化积分≥400的比值比为16.94,95%可信区间为5.16~55.58（P=0.001）。 结论血液透析患者心脏瓣膜钙化与冠状动脉钙化之间存在显著的相关性,超声心动图评价瓣膜钙化可以预测透析患者冠状动脉钙化的出现及危险分级。     

老年终末期肾病血液透析患者血清FGF-23、sST2水平变化及对心脏瓣膜钙化的预测价值CSCD

目的探讨老年终末期肾病(end-stage renal disease,ESRD)血液透析患者血清成纤维细胞生长因子23(fibroblast growth factor-23,FGF-23)、可溶性生长刺激表达基因2蛋白(soluble growth stimulation expressed gene2,sST2)水平变化及对心脏瓣膜钙化的预测价值。方法选取2018年6月~2021年6月新疆医科大学第七附属医院收治的106例老年ESRD血液透析患者为观察组,选取同期106例健康体检者为对照组。对比2组血清FGF-23、sST2水平,观察组随访至2022年1月,统计心脏瓣膜钙化发生率,分析心脏瓣膜钙化的影响因素及FGF-23、sST2在心脏瓣膜钙化中的交互作用,评估FGF-23、sST2预测心脏瓣膜钙化的价值。结果观察组血清FGF-23(t=35.539,P<0.001)、sST2水平(t=45.748,P<0.001)高于对照组;FGF-23及sST2高表达会增加心脏瓣膜钙化风险(OR=4.539、4.265,95%CI:2.527~8.154、2.008~9.057,均P<0.001);调整混杂因素后,FGF-23、sST2对心脏瓣膜钙化的发生存在正向交互作用,协同效应为二者单独存在产生效应之和的2.631倍(SI=2.631);FGF-23、sST2联合预测心脏瓣膜钙化的AUC大于单一指标(AUC=0.851,95%CI:0.767~0.913,P<0.001)。结论老年ESRD血液透析患者血清FGF-23、sST2水平呈异常高表达,二者在心脏瓣膜钙化中有协同作用,二者联合可有效提升预测效能。     

分析超声心动图在老年钙化性心脏瓣膜病中的应用

目的：分析超声心动图在老年钙化性心脏瓣膜病中的应用，为临床早期诊断提供影像学依据。方法：收集155例老年退行性心脏瓣膜病患者临床资料，将最终确诊为心脏瓣膜钙化的85例患者设为病例组，未出现心脏瓣膜钙化的70例患者作为对照组。两组患者均进行超声心动图检查，分析钙化性心脏瓣膜病超声心动图指标特征。结果：85例老年钙化性心脏瓣膜病患者中，钙化性心脏瓣膜病检出率为89.41%（76/85），其中主动脉瓣膜钙化患者42例，二尖瓣钙化患者21例，联合瓣膜钙化患者13例，无钙化患者9例；85例老年钙化性心脏瓣膜病，主动脉瓣与二尖瓣瓣膜反流共52例，占61.18%；主动脉瓣与二尖瓣瓣膜狭窄共24例，占28.24%。病例组左室舒张末期内径、左房内径均高于对照组，左室射血分数低于对照组，差异有统计学意义（P＜0.05）。结论：老年钙化性心脏瓣膜病患者超声心动图具有明显特征，经检查可发现存在左心室重构及左心功能减退的倾向，可作为早期诊断的影像学依据，且操作简单、安全无创。     

维持性血液透析患者骨密度与心脏瓣膜钙化的相关性分析CSCD

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者骨密度的变化及与心脏瓣膜钙化(cardiac valve calcification,CVC)的相关性。方法选取在安徽医科大学第二附属医院住院的MHD患者97例,根据心脏瓣膜钙化情况分为非联合瓣膜钙化组、心脏联合瓣膜钙化组,比较2组患者骨密度差别,并使用二分类Logistic回归探讨心脏联合瓣膜钙化的影响因素。结果纳入97例MHD患者中,二尖瓣和主动脉瓣联合瓣膜钙化组30例(30.93%);与非联合瓣膜钙化组相比,联合CVC组患者腰椎骨密度显著降低(t=-3.650,P=0.001)。与非联合瓣膜钙化组相比,联合CVC组患者年龄较大,透析龄长,中性粒细胞淋巴细胞比值(neutrophil-lymphocyte ratio,NLR)显著升高。联合CVC组患者血磷、全段甲状旁腺激素(intact parathyroid hormone,iPTH)水平较非联合钙化组显著升高(t=3.580、2.465,P=0.001、0.016)。二分类Logistic回归分析发现,高磷血症(OR=16.301,P=0.001)、高iPTH血症(OR=1.002,P=0.004)、高NLR(OR=1.561,P=0.042)、低腰椎骨密度水平(OR=0.003,P=0.010)与心脏联合瓣膜钙化相关。结论高血磷、高iPTH血症、高NLR、低腰椎骨密度是联合心脏瓣膜钙化的危险因素。     

老年主动脉瓣退行性变超声心动图特征及临床相关因素分析

目的观察老年主动脉瓣退行性变伴狭窄的瓣膜结构特征,分析老年人发生主动脉瓣退行性变的临床危险因素。方法入选主动脉瓣退行性变伴狭窄的患者137例(狭窄组),及年龄、性别匹配的无瓣膜狭窄患者105例(对照组)。行超声心动图检查,记录并比较两组患者瓣膜结构特征及心脏结构的参数、血流动力学参数;比较两组患者临床常见危险因素的状况,并对相关危险因素进行Logistic回归分析。结果主动脉瓣退行性变伴狭窄患者中,轻度狭窄者占65%(89例)。狭窄组与对照组患者相比,左室舒张末内径(LVEDD,P=0.416)与射血分数(EF,P=0.271)的差异无统计学意义;狭窄组患者主动脉瓣上流速、跨瓣平均压差及室间隔基底段厚度均明显高于对照组,差异具有显著性(P0.05)。相关因素经Logistic回归分析显示,尿酸(OR=1.732)、血钙浓度(OR=3.107)和C反应蛋白水平(OR=1.321)进入回归方程。结论老年主动脉瓣退行性变的瓣膜狭窄多数为轻度,且LVEDD及EF多在正常范围;尿酸、血钙和C-反应蛋白浓度可能是老年主动脉瓣狭窄的临床相关因素。     

持续非卧床腹膜透析患者心脏瓣膜钙化的相关危险因素分析

持续非卧床腹膜透析(CAPD)是终末期肾脏疾病(ESRD)患者的肾脏替代治疗方式之一。随着腹膜透析(PD)产品和技术的日臻完善,CAPD患者的生活质量、社会回归率及长期生存率明显改善,但CAPD患者心血管疾病的发病率仍较高,严重影响其预后。心脏瓣膜钙化(CVC)对心血管疾病的发生具有非常重要的预测价值,与ESRD患者心血管事件、心血管死亡及全因死亡密切相关。本研究通过回顾性分析我院腹膜透析中心2017年1月至2018年06月收治的112例稳定透析6个月以上的CAPD患者的一般资料、各项实验室指标及心脏彩超结果,探讨心脏瓣膜钙化的相关危险因素,为早期防治心脏瓣膜钙化、减少心血管疾病的发生提供一定的理论依据。     

低钙透析液对血液透析患者冠状动脉血管钙化的影响

心血管疾病(CVD)是终末期肾病(ESRD)患者的主要并发症之一,占尿毒症患者总死亡率的50%.其中血管、心瓣膜和心肌的钙化是ESRD患者导致CVD的主要原因, 90%的冠状动脉均存在血管钙化,年轻透析患者比正常人早几十年发生血管钙化[1].尿毒症患者普遍存在钙磷代谢紊乱,影响软组织和皮肤,特别是血管和心瓣膜,钙化常先于心血管事件的发生[2].作者探讨不同钙浓度透析液对维持性血液透析患者冠状动脉血管钙化的影响及可能的机制,以期降低ESRD患者的死亡率.     

超声诊断在老年性瓣膜退行性病变中的应用效果及准确率

目的:探讨超声诊断在老年性瓣膜退行性病变(SDVHD)中的应用效果及准确率。方法:选取自泗洪分金亭医院2019年1月—2020年12月收治的120例老年SDVHD患者为观察组,选取同期收治的100例老年健康体检者为对照组。两组均给予超声诊断,比较两组诊断结果。结果:观察组心脏瓣膜瓣环参数、心脏瓣膜瓣叶参数高于对照组,,差异有统计学意义(P <0.05);瓣膜反流比例91.67%;无瓣膜反流比例为8.33%;主动脉瓣钙化比例为43.33%;主动脉瓣狭窄比例为13.33%;二尖瓣钙化比例为43.33%;无瓣膜功能障碍比例为29.17%;瓣膜功能障碍比例为70.83%;其中占比最高的是主动脉反流,占比为48.24%。结论:超声诊断用于老年SDVHD患者中可明确疾病类型、了解瓣膜受累情况及瓣膜功能障碍情况,为后续疾病治疗提供参考依据、达到改善预后作用,值得临床推广应用。     

Surgical pathology of pure aortic stenosis: a study of 374 cases

The gross surgical pathologic features of the aortic valve were reviewed in 374 patients who had had clinically pure aortic stenosis and aortic valve replacement at our institution during the years 1965, 1970, 1975, and 1980. The most common cause of aortic stenosis, accounting for 46% of our cases, was calcification of a congenitally bicuspid valve. In the remainder, stenosis was produced by postinflammatory fibrocalcific disease (including rheumatic disease) in 35%, by degenerative calcification of an aging valve in 10%, and by calcification of a congenitally unicommissural valve in 6%. The cause of aortic stenosis was indeterminate in 4%. Valvular lesions included various degrees of dystrophic calcification, commissural fusion, and cuspid fibrosis. Calcification tended to occur more extensively and at a younger age in men than in women. Furthermore, it tended to produce stenosis and to necessitate valve replacement earliest in patients with unicommissural valves (mean age, 48 years), later in those with bicuspid or postinflammatory valves (mean age, 59 and 60 years, respectively), and latest in those with degenerative stenosis (mean age, 72 years). In our study, the relative incidence of postinflammatory aortic stenosis remained unchanged from 1965 to 1980, despite the steadily decreasing incidence of acute rheumatic fever reported in western countries. Our data suggest that (1) the incidence of chronic rheumatic heart disease has not yet begun to decrease appreciably, (2) many episodes of acute rheumatic fever may be subclinical, or (3) some forms of nonrheumatic aortic valve disease may produce gross alterations indistinguishable from those of classic chronic rheumatic valvulitis.     

Temporal changes in the causes of aortic stenosis: a surgical pathologic study of 646 cases

Among 646 patients with pure aortic stenosis who underwent valve replacement at our institution between 1981 and 1985, the three most frequent causes were calcification of congenitally bicuspid aortic valves (38%), degenerative (senile) calcification of tricuspid aortic valves (33%), and postinflammatory (presumably rheumatic) calcification and fibrosis (24%). Among the 324 patients younger than 70 years of age, calcified bicuspid valves were observed in 50%. In contrast, among 322 patients 70 years of age or older, degenerative calcification accounted for 48% of the stenotic aortic valves. During the 5 years of the study, the relative frequency of postinflammatory disease decreased from 30% to 18%, and that of bicuspid valves decreased from 37% to 33%. In contrast, the relative frequency of degenerative calcification increased from 30% to 46%. Consequently, degenerative (senile) calcification is currently the most common cause of aortic stenosis among patients undergoing valve replacement at our institution. This finding may be related to changes in life expectancy in the general population, alterations in patient referral practices, and an increased willingness of surgeons to operate on older patients. Regardless of cause, the observed temporal changes in etiologic factors for aortic stenosis may indicate a potential source of increasing health-care costs among the elderly population.     

Multiple aortic root echoes: clinical, radiographic, and angiographic correlations

Multiple diastolic echoes in the aortic root on M-mode echocardiography may represent fibrosis or calcification of the aortic wall, aortic leaflets, or proximal portions of the coronary arteries. In this study, 83 patients with multiple diastolic echoes were evaluated by cardiac fluoroscopy and the incidence of valvular, coronary, and aortic wall calcification was determined. In patients with multiple diastolic echoes who have no evidence of significant aortic stenosis (aortic valve opening less than or equal to 1.0 cm) or aortic insufficiency (fine fluttering of the anterior leaflet of the mitral valve), the presence of multiple diastolic echoes was highly associated with significant coronary artery calcification (64%) with over two-thirds having multivessel involvement. Patients referred for echocardiography who are free of significant aortic stenosis or aortic insufficiency by echocardiographic criteria who are found to have multiple diastolic echoes in the aortic root should be evaluated further for the possible presence of significant multivessel coronary artery disease.     

超声心动图评价二瓣化主动脉瓣瓣膜功能

目的 探讨超声心动图在二瓣化主动脉瓣病理生理进展评价中的应用,分析二瓣化主动脉瓣各年龄瓣膜病变的程度.方法 回顾性分析135例二瓣化主动脉瓣患者超声资料及病例资料,结合临床资料分析患者病程进展中瓣膜功能的变化.结果 二瓣化主动脉瓣关闭不全最常见,本组资料中为68例(50%),单纯狭窄仅19例(14%).狭窄并关闭不全者29例(22%),瓣膜功能正常者19例(14%).各年龄组内主动脉瓣病变均以关闭不全多见.病程晚期的手术患者各年龄组内主动脉病变亦均以关闭不全为主.结论 超声心动图能对主动脉瓣的病变作出早期诊断.二瓣化主动脉瓣最常见的瓣膜病变是主动脉瓣关闭不全.     

孤立性主动脉瓣狭窄病因的超声分析

为明确超声心动图检查中，孤立性主动脉瓣狭窄（ＡＳ）的病因及相应的影像特点，对１９９０年以来在我院超声心动图室发现的６６例孤立性ＡＳ（４４例合并关闭不全）进行分析。结果为先天性二瓣畸形（４８．５％），退行性病变（２１％），风湿病变（１５．２％）是ＡＳ的主要病因。但老年组（年龄＞６５岁），以退行性病变为主（６６．６％）。它导致主动脉瓣狭窄最晚，平均６７岁，先天性二叶瓣畸形，平均４９岁，风湿病变，平均４３岁。先天性二瓣畸形及退行性病变引起的瓣膜狭窄与瓣叶的增厚、钙化及固定有关，无或仅有轻微的连合处融合，风湿病变以连合处的融合为特点。研究表明：年龄对孤立性主动脉瓣狭窄的病因诊断有重要的影响；不同病因导致的主动脉瓣狭窄有不同的超声影像特点。     

超声心动图评价二瓣化主动脉瓣瓣膜功能

目的 探讨超声心动图在二瓣化主动脉瓣病理生理进展评价中的应用,分析二瓣化主动脉瓣各年龄瓣膜病变的程度.方法 回顾性分析135例二瓣化主动脉瓣患者超声资料及病例资料,结合临床资料分析患者病程进展中瓣膜功能的变化.结果 二瓣化主动脉瓣关闭不全最常见,本组资料中为68例(50%),单纯狭窄仅19例(14%).狭窄并关闭不全者29例(22%),瓣膜功能正常者19例(14%).各年龄组内主动脉瓣病变均以关闭不全多见.病程晚期的手术患者各年龄组内主动脉病变亦均以关闭不全为主.结论 超声心动图能对主动脉瓣的病变作出早期诊断.二瓣化主动脉瓣最常见的瓣膜病变是主动脉瓣关闭不全.     

Surgical pathology of combined aortic stenosis and insufficiency: a study of 213 cases

The gross surgical pathologic features of the aortic valve were reviewed in 213 patients who had had clinically combined aortic stenosis and insufficiency and aortic valve replacement at our institution during the years 1965, 1970, 1975, and 1980. The three most common causes were postinflammatory disease (69%) and calcification of congenitally bicuspid (19%) and unicommissural (6%) aortic valves. Other causes included infective endocarditis (2%) and congenitally quadricuspid or malformed tricuspid aortic valves (1% each); the cause was indeterminate in 1%. In the postinflammatory and bicuspid states, calcification tended to be more extensive in men than in women. The relative incidence of postinflammatory disease in our study did not change appreciably from 1965 to 1980, despite the steadily decreasing incidence of acute rheumatic fever reported in western countries.     

Correlation of high sensitivity C-reactive protein and calcific aortic valve disease

OBJECTIVE: To determine whether a difference exists in the levels of high sensitivity C-reactive protein (Hs-CRP) in patients with and without calcific aortic valve disease (CAVD). PATIENTS AND METHODS: This cross-sectional study consisted of 110 patients who had undergone echocardiographic examination from January 2005 to February 2006 at our institution. Information on demographic variables, coronary risk factors, and medications was obtained. More than 200 patients were excluded on the basis of any evidence of infection, active connective tissue disorder, rheumatoid arthritis, recent episodes of bleeding, acute fractures, bowel obstruction, or acute coronary syndrome or use of corticosteroids, nonsteroidal anti-inflammatory drugs, or antibiotic treatment. The values of Hs-CRP, total cholesterol, and erythrocyte sedimentation rate were included. RESULTS: Of the 110 study subjects, 38 patients had aortic sclerosis, 36 patients had aortic stenosis, and 36 were controls. The mean Hs-CRP level in the control group was significantly lower (4.84 +/- 6.9 mg/L) compared with the levels in the groups with aortic sclerosis (14.9 +/- 19.6 mg/L) and aortic stenosis (13.6 +/- 17.3 mg/L) (P = -.01). No statistically significant difference was found between the patients in the aortic sclerosis and aortic stenosis groups. Among the patients with aortic stenosis, no significant correlation existed between Hs-CRP levels and aortic stenosis severity. CONCLUSIONS: The Hs-CRP seems to have a significant association with CAVD during its early stage. The study findings did not have sufficient evidence to suggest the use of Hs-CRP as a marker of progression of calcific aortic stenosis. The Hs-CRP may have a role in identifying patients in the early stages of CAVD and in whom medical treatment may be beneficial to halt the progression to irreversible aortic valvular calcification and stenosis.     

Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis

Calcification of normal tricuspid and congenital bicuspid valves is the most common cause of aortic stenosis in industrialized countries. There is compelling evidence that thickening and calcification in aortic valve disease is a complex inflammatory process and not simply age-related degeneration. Both aortic sclerosis and stenosis represent phenotypic expressions of one disease continuum. Patients with symptomatic severe aortic stenosis benefit from aortic valve replacement. However, management in the absence of symptoms remains challenging. While a delay of aortic valve replacement due to lack of symptom recognition may result in a dismal outcome, unselected premature aortic valve replacement may be associated with unbalanced risks of cardiac surgery. Echocardiography is the standard for evaluating the severity of aortic stenosis; however, most of the current echocardiographic parameters have limitations in predicting the onset of symptoms. This review summarizes the current guidelines and the emerging application of echocardiographic techniques in the management of asymptomatic severe aortic stenosis.