超声心动图对左心房黏液瘤患者分级评价价值的研究

目的探讨超声心动图对左心房黏液瘤患者分级评价的价值。方法本研究回顾性搜集2010～2011年在复旦大学附属中山医院行左心房黏液瘤切除术患者48例,分别对超声心动图评价肿瘤内径最大值与术中测量结果及术前肺动脉收缩压行相关性分析,据轻度肺动脉高压标准(肺动脉收缩压40mmHg)对应的肿瘤内径最大值,将患者分为两组(A组、B组),对比手术前后组内变化及组间超声心动图指标差异。结果超声心动图测量肿瘤最大径与术中测量值相关性较好(r=0.78,P<0.01),与肺动脉收缩压有相关性(r=0.55,P<0.01)。A组与B组患者性别、年龄、术前临床症状、差异无统计学意义(P>0.05),术前组间左心房前后径(P<0.01)、左心室收缩末前后径(P<0.05)及肺动脉收缩压(P<0.01)差异有统计学意义;术后组间左心房前后径(P<0.05)及三尖瓣反流程度(P<0.01)差异有统计学意义。A组术后左心房前后径较术前缩小,差异有统计学意义(P<0.01),B组术后主动脉窦部内径(P<0.01)、左心房前后径(P<0.01)、左心室舒张末前后径(P<0.05)及肺动脉收缩压(P<0.01)较术前减小、二尖瓣及三尖瓣反流程度较术前降低(P均<0.01)。结论左心房黏液瘤患者肺动脉收缩压与瘤体最大径相关;瘤体最大径32.57mm可以作为患者病情的简单分级标准;左心房黏液瘤患者术后预后好,超声心动图在左心房黏液瘤术前分级评价及术后随访中有不可替代的辅助价值。     

应用全方向M型超声研究二尖瓣置换术后房间隔运动速度变化

目的 应用全方向M型超声心动图测量二尖瓣置换术前、术后房间隔运动速度变化,评估左心房功能.方法 选择行二尖瓣置换术患者49例,年龄34～69岁,平均(54.27±9.30)岁,其中男23例,女26例.分别于手术中术前、术后对所有患者进行经食管超声心动图监测,应用全方向M型超声心动图测量收缩期和舒张期房间隔运动峰值速度.应用经胸超声心动图测量左心房容积变化率、左心房前后径、左心室舒张末容积、左心室射血分数.结果 二尖瓣置换术后,房间隔运动峰值速度、左心房容积变化率、左心室舒张末容积及左心室射血分数较术前升高(P＜0.05).术前、术后房间隔运动峰值速度与左心房容积变化率存在相关性(r =0.389、0.354,P＜0.05).结论 全方向M型超声心动图测量的房间隔运动峰值速度能够评价二尖瓣置换术前、术后左心房功能变化.     

左心房黏液瘤与肺动脉高压及心功能不全的相关性研究--附30例报告

目的:探讨左心房黏液瘤瘤体大小与肺动脉高压及心功能不全之间的相关关系.方法:按纽约心脏学会心功能分级标准,把30例左心房黏液瘤病人分为Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级4组,分别在体外循环建立前和撤除体外循环管道后测量其肺动脉压,并在黏液瘤切除后称量瘤体重量,分析瘤体重量和肺动脉高压、心功能不全的关系.结果:心功能Ⅱ级、Ⅲ级和Ⅳ级患者肺动脉高压的发生率明显大于心功能Ⅰ级患者(均为P＜0.01).心功能Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级患者的瘤体重量分别为(21±9)g、(29±10)g、(40±10)g、(73±19)g;肺动脉高压的发生率分别为0、36%、6/6、5/5.切除黏液瘤后,心功能Ⅱ级、Ⅲ级、Ⅳ级患者的平均肺动脉压分别由术前的(3.6±1.2)kPa、(4.5±1.3)kPa、(6.4±0.9)kPa降为术后的(2.4±0.9)kPa、(2.8±1.2)kPa、(3.1±1.1)kPa(均为P＜0.01).结论:左心房黏液瘤的瘤体大小与患者的肺动脉高压及心功能不全的程度密切相关.     

无冠窦瘤破裂入右心房超声表现1例

患者男,25岁.因心慌、气短1个月人院.超声心动图表现如下:各房室腔明显扩大,右心房5.5cm,右心室4.0 cm,左心房5.3 cm,左心室5.7cm;主动脉窦无冠窦壁菲薄呈瘤样向右心房侧膨出,形成窦瘤,瘤体基底宽约0.9 cm,顶端可见破口(图1上),大小约0.5 cm,破口下缘紧邻三尖瓣隔瓣叶根部,可见由主动脉→右心房的双期连续性血液分流(图1 下),最大分流压差46 mm Hg (6.12kPa).超声心动图提示:先天性心脏病,主动脉窦无冠窦瘤破裂人右心房,肺动脉高压(中度).该病例后经手术证实.     

经胸超声心动图诊断心房占位性病变

目的 探讨经胸超声心动图对心房占位性病变的诊断价值。方法 回顾性分析79例超声心动图诊断为心房占位性病变患者,分析其超声心动图特征,并与手术病理结果进行对照。结果 79例中,左心房血栓47例（47/79,59.49%）,左心房黏液瘤23例（23/79,29.11%）,右心房黏液瘤3例（3/79,3.80%）,心内平滑肌瘤病为静脉内平滑肌瘤累及右心房4例（4/79,5.06%）,肺腺癌转移至右心房2例（2/79,2.53%）。术前超声心动图诊断与手术病理结果相符72例,2例诊断不足,误诊2例,漏诊3例。结论 超声心动图可作为诊断心房占位性病变的首选影像学检查方法,为临床治疗提供重要参考依据。     

经食管及经胸超声心动图诊断心源性栓塞性脑梗死的价值

目的比较经食管超声心动图和经胸超声心动图在心源性栓塞性脑梗死(cardio-embolic cerebral infarction,CECI)诊断中的价值。方法 57例隐源性脑梗死患者,均行经食管超声心动图和经胸超声心动图检查,比较2种方法对CECI的检出率。结果经胸超声心动图检出CECI 7例(12.3%),其中主动脉粥样硬化斑块2例为高危性CECI,卵圆孔未闭2例、二尖瓣增厚2例、二尖瓣脱垂1例为低危性CECI,未发现房间隔缺损、左心房自发声学影像;经食管超声心动图检出CECI 22例(38.6%),其中主动脉粥样硬化斑块2例为高危性CECI,卵圆孔未闭2例、二尖瓣增厚2例、二尖瓣脱垂7例、房间隔缺损5例、房间隔膨出瘤3例、左心房自发声学影像1例为低危性CECI;经食管超声心动图对CECI的检出率高于经胸超声心动图(P0.05)。结论与经胸超声心动图比较,经食管超声心动图在CECI诊断中更具优势。     

成人单纯性右心房横纹肌瘤经食管超声心动图表现1例

<正>患者女,33岁。既往体健。妊娠37+周行产前常规体格检查,心电图提示:窦性心律,T波改变,右心房肥大(P波高尖)。经胸超声心动图检查:右心房稍大,余各腔室大小基本正常,心脏功能正常,右心房内见一大小约41 mm×35 mm×29 mm团状中等回声,形态不规则,基底部显示不清,似附着于房间隔,有一定活动度,舒张期突向三尖瓣口,三尖瓣开放如常;CDFI示上述肿块内未探及明显血流信号。经胸超声心动图提示:右心房实性占位,考虑黏液瘤可能性大。经食管超声心动图检查:右心房内见实性肿块,可见蒂结构附着于右心房前壁近房顶部(图1),肿块具有明显活动度,无明显形态变化,上下腔静脉内     

超声心动图在完全型大动脉转位房间隔球囊造口术中的作用

目的探讨超声心动图在完全型大动脉转位(TGA)床旁房间隔球囊造口术中的作用.方法选取经常规超声确诊,并明确存在心血管内分流不良,具有房间隔球囊造口术适应证的15例TGA患者,采用超声心动图术中监测引导手术过程,并于术前及术后,采用剑突下双心房切面显示并观察房间隔缺损大小及测量血流速度;术后评测体循环动脉氧分压及血氧饱和度.结果 15例患者均在实时床旁超声监测下成功行床旁房间隔球囊造口术,其中8例合并房间隔缺损(ASD)的患者ASD直径由术前(1.2±0.5)mm扩大至(5.5±1.2)mm,7例不合并ASD的患者新造ASD直径为(5.5±1.2)mm;连续多普勒测量心房水平分流速度由术前(190.0±52.0)cm/s降为术后(20.0±10.5)cm/s(P＜0.05);体循环动脉氧分压由术前(23.49±4.3)mm Hg升高为(37.98±8.5)mm Hg(P＜0.01),血氧饱和度由(60.0±8.5)%升高为(73.0±10.0)%(P＜0.05).结论床旁超声心动图可以有效、可靠、实时监测床旁房间隔球囊造口术全过程.     

心脏黏液瘤的外科治疗体会

目的 总结心脏黏液瘤的诊断及外科治疗体会.方法 回顾性分析山东大学齐鲁医院1990年1月至2007年5月收治的127例及厦门心脏中心近4年所收治的6例心脏黏液瘤患者临床资料.术前均经二维超声心动图明确诊断,其中肿瘤位于左心房109例、右心房22例、双心房2例.均在体外循环下取胸部正中切口,经右心房-房间隔途径摘除黏液瘤.同期行二尖瓣成形术11例,三尖瓣成形术6例.切除肿瘤均送检病理.结果 术后早期因严重低心排血量综合征死亡2例,术后新发脑栓塞6例,左下肢栓塞1例,肺栓塞1例.余患者术后未出现严重并发症,自觉症状较术前明显好转,心脏体征消失,痊愈.病理检查结果 均显示为心脏黏液瘤.结论 心脏黏液瘤多为良性,但引起的临床后果严重,一经诊断应尽早手术摘除;术中严防肿瘤脱落是手术成功的关键,且应注意术后随访;二维超声心动图是诊断心脏黏液瘤的最佳方法 .     

超声心动图预测房间隔缺损合并房间隔瘤患者封堵器型号的应用探讨

目的探讨在房间隔缺损合并房间隔瘤患者介入封堵手术中,使用超声心动图预测房间隔缺损封堵器型号大小的可行性。方法回顾性分析我院成功进行封堵治疗的房间隔缺损合并房间隔瘤患者62例,对比手术前与手术中超声心动图测量房间隔缺损大小的差别,并与所选择房间隔缺损封堵器型号大小进行比较,对术前、术中测值与封堵器型号大小进行相关性分析。结果 62例房间隔缺损合并房间隔瘤患者缺损大小术前测值为(27.27±4.07)mm,术中测值为(31.42±4.41)mm,所选取封堵器型号大小为(32.42±5.53)mm,术前与术中测值之间,以及两者与选取封堵器型号大小之间差异均有统计学意义(P<0.05),而术中测值与封堵器型号的相关性较术前测值更高(r=0.921vs r=0.752)。结论术前及术中使用超声心动图对房间隔缺损合并房间隔瘤患者的缺损大小测量存在差异,术中测量房间隔缺损大小与封堵器型号大小的选取更为相符。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.