左冠状动脉回旋支缺如1例

患者女,72岁,反复发作胸闷9年,加重1周入院.9年前患者无明显诱引反复发作胸闷,每次持续10 min至半小时不等,可自行缓解,曾被外院诊断为"隐性冠心病".于1年前症状发作频繁,并且活动后感心悸、气短、头晕,休息后可缓解,一直服用合心爽、阿司匹林等药物;近日症状明显加重.患者有50余年高血压病史和高血压病家族史.查体:血压150/100 mmHg,心界轻度增大,心率82次/min,律齐,各瓣膜听诊区未闻及杂音,心电图示V1～V5导联ST段下降.     

起源于肝动脉的迷走胃左动脉血管造影研究

目的观察起源于肝动脉的迷走胃左动脉的解剖学特征,讨论其在肝及胃相关血管介入诊疗技术中的临床意义.方法回顾性分析1 000例肝动脉数字减影血管造影(DSA)影像资料,包括212例腹腔干动脉造影和788例肝总动脉血管造影,统计起源于肝动脉的迷走胃左动脉的发生率,描述其解剖学特征.结果共发现82例、84支起源于肝动脉的迷走胃左动脉(8.2%,82/1 000),其中起源于肝左动脉者74支,起源于肝固有动脉者10支.结论起源于肝动脉的迷走胃左动脉并不少见,认识此动脉对于肝、胃、血管造影中正确诊断和实施相关介入治疗具有重要意义.     

Rare multiple fistulas with large saccular aneurysms originating from left anterior descending artery and left main coronary artery

A 49-year-old female patient consulted us for a cardiac evaluation before undergoing colon adenocarcinoma surgery. Three years prior, the patient underwent coronary angiography for dyspnea. The coronary angiography examination revealed a fistula originating from the left anterior descending artery and left main coronary artery, which had soft aneurysmal sacs and most likely drained into the pulmonary artery. Parasternal short axis echocardiography revealed a color flow that could be related to the fistula, but the other echocardiographic findings were normal. The patient did not accept the proposed examination and invasive treatment.     

Tei指数评价冠脉旁路移植术前后左室整体心功能变化

目的应用Tei指数评价冠脉旁路移植术(CABG)前后患者整体心室功能的变化.方法34例行CABG手术的冠心病患者根据术前LVEF测值分为A组(EF正常组)和B组(EF低下组),分别于术前、术后2～4周、3个月、6个月,应用Tei指数、左室射血分数(LVEF)和二尖瓣血流图检测左室整体心功能.结果术前,A、B两组Tei指数均较正常增高,且B组显著高于A组(P＜0.01).术后,两组Tei指数均逐渐下降,与术前比较以及术后各时间点间比较差异显著(P＜0.05或0.01),且术后不同时间点两组间比较差异显著(P＜0.01).采用LVEF和二尖瓣血流图评价时,术前A、B两组间均存在显著差异(P＜0.05);术后A组LVEF较术前增高不显著(P＞0.05),但E/A较术前明显增高(P＜0.01);B组LVEF较术前明显增高(P＜0.05),E/A早期减低,术后3个月至6个月逐渐升高.结论Tei指数综合考虑心室收缩和舒张功能,能较LVEF和E/A更准确地评价CABG前后患者整体心功能的变化.     

Percutaneous closure of a fistula from the left circumflex coronary artery to the coronary sinus in an infant

Coronary artery fistula is an abnormal direct connection between the coronary artery and any of the four chambers of the heart or great vessels. A fistula from the left circumflex coronary artery to the coronary sinus is a relatively rare situation. We report a case of 12-month-old infant with coronary artery fistula from the left circumflex coronary artery to the coronary sinus that was identified incidentally. The N-terminal pro-brain natriuretic peptide level was elevated. Additionally, the proximal segment of the left circumflex coronary artery was dilated. On the basis of these findings, percutaneous closure of the fistula was performed with a vascular plug. This procedure achieved no residual flow and good hemodynamics were observed during follow-up.     

Arcade mitral valve and anomalous left coronary artery originating from the pulmonary artery.

The use of color Doppler interrogation significantly improves accuracy in the evaluation of coronary artery anatomy. This was demonstrated in a patient in whom the left coronary artery originated from the posterior and medial aspect of the pulmonary artery, a particularly difficult coronary anomaly to detect by 2-dimensional imaging. In addition to the coronary artery anomaly, this patient also had an arcade mitral valve.     

超声心动图诊断左心室射血分数减低的左冠状动脉异常起源于肺动脉的效果分析

目的探讨左心室射血分数（LVEF）减低的左冠状动脉异常起源于肺动脉（ALCAPA）的超声心动图特点及手术效果。 方法选取2008年10月至2018年9月首都医科大学附属北京儿童医院ALCAPA患者28例,根据LVEF分为LVEF减低组（LVEF＜50%）19例和LVEF正常组（LVEF≥50%）9例,比较2组患者超声心动图表现,应用两独立样本t检验比较2组患者间超声参数的差异。手术患者（17例）分别于术后1 d、1个月、6个月、1年进行超声心动图随访,应用配对t检验与术前超声参数进行对比。 结果LVEF减低组患者LVEF为30%~48%,平均年龄5.4个月;LVEF正常组LVEF为60%~73%,平均年龄2.5岁。LVEF减低组与LVEF正常组相比,左心室舒张末期内径大［（131.95±24.24）mm/m² vs（85.67±20.26）mm/m²］,右冠状动脉内径小［（3.06±0.51）mm vs（4.01±0.62）mm］,差异具有统计学意义（t=-4.465、4.075,P均＜0.001）,易形成室壁瘤。LVEF减低组中10例行手术治疗,7例超声心动图随访至术后1年;与术前相比,术后1 d开始左心室舒张末期内径逐渐回缩［（109.98±16.06）mm/m²、（99.49±12.02）mm/m²、（89.48±10.90）mm/m²、（80.03±8.09）mm/m² vs（123.26±12.40）mm/m²］,差异具有统计学意义（t=-2.668、-7.519、-5.413、-6.526,P=0.004、0.001、0.012、0.007）,LVEF术后1个月开始恢复,术后6个月达正常水平［（45.50±9.57）%、（66.25±10.34）%、（67.25±4.50）% vs（38.83±7.05）%］,差异具有统计学意义（t=3.162、3.683、5.869,P=0.025、0.014、0.002）。 结论LVEF减低的ALCAPA患儿年龄小、心脏病变重,超声心动图可以准确作出诊断,但需要与心内膜弹力纤维增生症、扩张型心肌病相鉴别。ALCAPA手术治疗远期效果较好,超声心动图在术后随访中有重要作用。     

少见先天性冠状动脉变异的冠状动脉造影分析

目的 分析少见的先天性冠状动脉变异的冠状动脉造影的表现,探讨冠状动脉造影的诊断价值。方法 收集1997－1999年410例冠状动脉造影中的先天性冠状动脉变异共16例,其中壁冠状动脉8例,冠状动脉瘘6例及先天性右冠状动脉缺如2例。冠状动脉造影,动态下观察,并进行必要的测量。结果 8例壁冠状动脉均表现为收缩期狭窄,1级3例,2级4例,3级1例。狭窄段长度17．2mm,其中3级1例行冠状动脉旁路移植术。6例冠状动脉瘘,5例源自左冠状动脉,1例源自双侧冠状动脉,2例引流入肺动脉干,4例引流入右心室。2例右冠状动脉缺如,经冠状动脉造影及主动脉造影证实。结论 冠状动脉造影是诊断少见先天性冠状动脉变异的重要手段,动态下观察是发现病变的关键。     

Spontaneous dissection in the left main coronary artery

We present two cases of spontaneous left main stem coronary artery dissection. One was underdiagnosed with suboptimal percutaneous coronary artery intervention followed by acute vessel occlusion again during the hospitalization. The other one was identified and confirmed by intravascular ultrasound, followed by conservative medical treatment, with completed healing of SCAD during two-month follow up.     

Prevalence of left main coronary artery disease among patients referred to multislice computed tomography coronary examinations

We have evaluated the prevalence of left main coronary artery disease (LMCAD) among patients referred to multislice computed tomography (MSCT) coronary angiography examinations. The study Group comprised of 1,000 consecutive patients (750 male and 250 female; mean age 53±12 years) who underwent successful 64-slice MSCT examinations. Left main coronary artery (LMCA) was classified into three Groups: normal LMCA; nonsignificant LMCAD with coronary plaques resulting in obstructions ≤50%; and significant LMCAD corresponding to obstructions >50%. We have found that 24 patients (2.4%) had significant LMCAD. Additional 200 patients (20%) had nonsignificant LMCAD. Univariate analysis revealed that LMCAD was associated with age, male gender, diabetes, hypertension, hyperlipidemia, typical symptoms, history of previous myocardial infarction and previous percutaneous coronary intervention. Only age and male gender were found as independent predictors for LMCAD in multivariate analysis (P < 0.001 and P = 0.001, respectively,). Angiographic follow-up was avaliable for the 24 patients with significant LMCAD, and conventional coronary angiography confirmed the presence of significant LMCAD in all of these patients. Significant LMCAD was found in 2.4% of the 1,000 patients referred to 64-slice MSCT examinations. Age and male gender were the independent predictors for LMCAD.     

经胸超声冠状动脉血流成像预测左前降支狭窄

目的评价经胸超声冠状动脉血流显像技术(TTDE)预测左前降支(LAD)狭窄的准确性.方法 65名临床怀疑为冠心病的患者,在静息状态下用TTDE探测LAD血流,计算舒张期血流速度与收缩期血流速度的比值(DSVR).患者在TTDE检查后24 h内接受冠状动脉造影检查(CAG).结果 53例患者的LAD血流得到探测和测量,其中14例有LAD显著狭窄(≥70%,狭窄组),39例无显著狭窄(对照组).狭窄组LAD的舒张期峰值血流速度和平均血流速度与对照组无显著差异(P＞0.05),但收缩期峰值血流速度和平均血流速度均高于对照组(26.4±11.8 cm/s vs 21.1±6.1 cm/s和18.1±7.8 cm/s vs 14.7±4.0 cm/s,P<0.05).狭窄组的峰值DSVR和平均DSVR较对照组小(分别为1.4±0.4比 2.0±0.5和1.4±0.4比1.9±0.4,P<0.0001).以平均DSVR≤1.6作为异常时,预测LAD狭窄的敏感性和特异性分别为85.7%和79.5%.结论用TTDE测定DSVR是一种简便无创的预测LAD狭窄的新方法.     

Angiographic diagnosis of gastric volvulus with report of a complication following left gastric artery embolization

Gastric volvulus is a rare cause of upper gastrointestinal (UGI) tract obstruction and may present as acute UGI hemorrhage. The angiographic findings of gastric volvulus are discussed and a report of a complication of embolization of the left gastric artery in unsuspected mesenteroaxial stomach volvulus is given.     

左主干狭窄对不停跳冠状动脉旁路移植术的影响

目的研究冠状动脉左主干狭窄对不停跳非体外循环下冠状动脉旁路移植手术(OPCAB)结果的影响。方法87例行OPCAB手术的冠心病患者,将其中冠状动脉左主干狭窄(LMS)者24例设为LMS组,冠状动脉左主干正常(N-LMS)者63例设为N-LMS组,2组患者术前除冠状动脉左主干有无狭窄外其他体征基本相同。观察2组患者手术吻合口情况、手术时间、心包纵隔引流量、输血量、血管活性药物使用情况、ICU时间、总住院时间、住院期间病死率和术后并发症。结果2组患者吻合口情况、手术时间、住院期间病死率、输血量、二次开胸止血率及伤口感染等并发症比较差异无显著性;但LMS组心包纵隔引流量和血管活性药物使用量多于N-LMS组;术后心房颤动的发生率高于N-LMS组,ICU时间和总住院时间长于N-LMS组。结论冠状动脉左主干狭窄的OPCAB手术是安全的,但某些并发症高于冠状动脉左主干正常者;积极完善的术前准备,适当的手术时间,细致的心肌再血管化,良好的麻醉配合以及术后积极的对症处理,内环境稳定的维持,是减少冠状动脉左主干狭窄者并发症的重要因素。     

非体外循环下左心室重建联合冠状动脉旁路移植术治疗左心室室壁瘤

目的评价在非体外循环下行左心室重建术＋冠状动脉旁路移植术治疗左心室室壁瘤的效果。方法左心室室壁瘤患者103例,在非体外循环下先行冠状动脉旁路移植术,其中乳内动脉与前降支吻合80例,大隐静脉-前降支或其他血管吻合21例,2例未搭桥,然后用2-0聚丙烯线围绕前间壁及心尖部室壁瘤基底部全层荷包缝合室壁瘤及室壁瘤的游离壁以消除死腔。结果术后发生低心排综合征10例,脑卒中2例,开胸止血2例,室性心律失常3例,死亡3例;手术前左心室舒张末内径（66.59±9.76）mm,术后减少到（50.00±5.30）mm（P〈0.05）;左心室舒张末容积由术前（165.20±59.48）mL减少到（85.60±23.70）mL（P〈0.05）;左心室射血分数由术前（35.70±0.05）%增加到（50.00±0.04）%（P〈0.05）。结论非体外循环左心室重建术＋冠状动脉旁路移植术治疗左心室室壁瘤手术操作简单,并发症少,近期疗效良好。     

多普勒组织成像技术对冠心病患者二尖瓣环运动曲线的探讨

目的 本文旨在运用多普勒组织成像技术观察冠心病患者二尖瓣环运动曲线以评估其左室收缩和舒张功能。 方法32例冠心病患者和20例正常人作对照研究,测定其二尖瓣环后间隔、侧壁、下壁、前间隔和后壁六处各位点的Sa、Ea、Aa及Ea/Aa之比。 结果 1.冠心病患者和正常人二尖瓣环的DTI运动曲线为规律波群,有三个主波,收缩波Sa波,舒张早期Ea波,舒张晚期Aa波 2.冠心病患者二尖瓣环六个节点Sa、Ea及Ea/Aa较正常组显著下降(P<0.01)3.冠心病患者二尖瓣环六个节点平均Sa与左室射血分数呈正相关(r=0.689,P<0.01)平均Ea/Aa与二尖瓣血流曲线E/A之比也有良好相关性(r=0.427 P<0.05)4.正常组与冠心病组心尖四腔观二尖瓣环侧壁Sa、Ea/Aa之比与六个节点平均参数相关系数最大。 结论 DTI测量二尖瓣环运动曲线能同时测定左室收缩、舒张功能,从而提供了一种新的、安全的、直接可靠的、简便的方法。     

非体外循环冠状动脉搭桥术治疗低射血分数的左主干并三支病变患者疗效分析

目的 探讨非体外循环冠状动脉搭桥术(OPCABG)治疗低左心室射血分数(LVEF)的左主干并三支病变患者的疗效.方法 2010年1- 12月我院收治低LVEF的左主干并三支病变的冠心病患者28例,均在全身麻醉下行OPCABG.分别于术前和术后3d进行血红蛋白(Hb)、血小板计数(PLT)、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、尿素氮(BUN)、肌酐(Cr)的检测;术后3个月行心脏超声检查记录LVEF、左心室舒张末期内径(LVED)测定值,并与术前检查结果进行比较.结果 1例因肺感染死于呼吸衰竭,剔除其数据.术前和术后3 d27例患者Hb分别为(137.94±19.40)、(111.06±12.71)g/L,PLT分别为(210.43±48.26)、(148.40±52.20)×109/L,差异均有统计学意义(t值分别为5.239、4.869,P均＜0.01);术前和术后3 dALT分别为(27.66±11.51)、(29.02±16.40) U/L,AST分别为(26.55±10.12)、(27.75±8.14) U/L,BUN分别为(6.51±1.00)、(6.88±2.53) mmol/L,Cr分别为(96.35±15.25)、(95.11±24.38) μmol/L,差异均无统计学意义(t值分别为0.335、0.882、1.625、0.803,P均＞0.05).术前及术后3个月LVEF分别为(36.23±3.41)％、(47.23±5.13)％,LVED分别为(62.23±5.93)、(58.08±5.02)mm,术后3个月LVEF较术前提高(t=6.904,P＜0.01),LVED明显缩小(=2.790,P＜0.05).结论 OPCABG治疗低LVEF的左主干并三支病变患者早期效果满意,对患者全身重要器官影响有限.但远期疗效及预后还需进一步随访分析.     

Doppler echocardiographic approach to the blood flow of the left anterior descending coronary artery

Assessment of flow in the left anterior descending coronary artery by Doppler echocardiography appeared to be possible in some patients in which the coronary artery system might be wide and/or the displacement of the coronary artery might be reduced because of cardiac enlargement or of impaired cardiac function. A study of this possibility was carried out in 78 patients, 20 cases with hypertrophic cardiomyopathy, 10 with dilated cardiomyopathy, 20 with aortic valve disease, and 28 following valve replacement for aortic valve disease. The anterior interventricular sulcus was a helpful landmark to search for the left anterior descending artery. The characteristic feature of the coronary flow pattern, that the flow ran mainly during diastole, was also helpful in finding the coronary artery. Complementary roles of ultrasonic imaging and Doppler ultrasound evaluation should be emphasized for identifying a thin echo-free space in the sulcus as the coronary artery. The left anterior descending coronary artery was imaged in 26 of the 78 patients. The peak velocity ranged 24 cm/s to 75 cm/s in different patients. Because the present study was carried out in patients with some particular diseases, these results do not indicate that current techniques can be routinely used for assessing the coronary flow. The detection rate will be increased with improvements in image resolution and the Doppler sensitivity. Although the detection rate of the coronary artery was not satisfactory in the present stage, the effect of sublingual administration of nitroglycerin on coronary circulation was noninvasively assessed in some patients, where reduction of the flow velocity by about 27% was observed in real time.     

应用二尖瓣环舒张早期运动速度评价冠心病患者左心室舒张功能

目的探讨组织多普勒成像(TDI)测得的二尖瓣环舒张早期速度评价左心室舒张功能的临床应用价值,以及不同冠状动脉病变对左心室舒张功能的影响。方法54例胸痛患者经冠状动脉造影检查,排除冠心病的14例作为对照组,冠心病的40例分为一支病变组、两支病变组、三支轻度组和三支重度组。测量二尖瓣环间隔部和侧壁部舒张早期峰速度Esep和Elat,计算两者的均值Ea以及二尖瓣舒张早期血流速度(E)与三者的比值E/Esep、E/Elat和E/Ea。结果冠心病组与对照组相比,Esep、Elat、Ea、E/Esep、E/Elat和E/Ea均有差异,且病变越重,差异越明显。以冠状动脉造影为金标准,E/Ea>8.35诊断冠心病的敏感度和特异度分别为75%和100%。结论二尖瓣环舒张早期速度是评价左心室舒张功能的良好指标。E/Ea评价的左心室舒张功能可帮助诊断冠心病和判定冠状动脉病变的严重程度。     

左心室功能不全冠心病患者支架术与冠状动脉旁路移植术的对比研究

目的 比较左心室功能不全的冠心病患者经皮冠状动脉介入治疗(PCI)支架术与冠状动脉旁路移植术(CABG)对住院与临床随访结果的影响.方法 147例左心室功能不全的冠心病患者,根据血运重建方式的不同将其分为PCI组(60例)和CABG组(87例),记录其,临床与冠状动脉造影特征、血运重建情况和住院,临床结果等资料,并进行临床随访.主要观察终点为住院与随访主要不良心脑血管事件(MACCE)(包括全因死亡、新发心肌梗死、卒中和再次血运重建).所有资料采用SPSS 13.0软件进行统计分析,以P＜0.05为差异有统计学意义.结果 PCI组和CABG组相比,院内MACCE发生率差异无统计学意义(1.7%与9.2%,P＞0.05);院内病死率差异无统计学意义(1.7%与8.0%,P＞o.05).多因素Logistic回归分析表明,院内MACCE风险相当(OR=3.03,95%C/0.27～34.48,P＞0.05).平均随访22个月(中位数时间668 d)显示,2组MACCE发生率差异无统计学意义(16.0%与13.8%,P＞0.05),再次血运重建差异均无统计学意义(8.0%与1.7%,P＞0.05).多因素Cox回归分析显蟊,2组随访MACCE风险基本相当(HR=1.35,95%CI 0.44～4.13,P＞0.05).结论 合并左心室功能不全的冠心病患者,PCI支架术与CABG的住院及随访MACCE发生率均相当.随着药物洗脱支架的广泛应用,PCI术的远期效果有望进一步提高.