风湿性心脏病单纯二尖瓣狭窄左心房内径与瓣口面积、左心房压力相关性研究

目的:探讨风湿性心脏病单纯二尖瓣狭窄左心房内径与二尖瓣口面积、左心房压力的关系。方法:回顾性分析242例单纯二尖瓣狭窄成功行经皮二尖瓣球囊扩张术患者临床资料,按有无心房颤动分为窦性心律组(122例)与心房颤动组(120例),分别对2组左心房内径、瓣口面积、左心房平均压力进行相关分析,并用逐步回归分析法建立多元线性回归模型。结果:窦性心律组和心房颤动组的左心房内径与瓣口面积、左心房平均压呈直线相关,瓣口面积与左心房平均压亦呈直线相关;窦性心律组得多元线性回归方程为左心房内径=52.147-6.756×瓣口面积+0.158×左心房平均压,方程检验的F值=12.346(P0.01);心房颤动组得多元线性回归方程为左心房内径=51.609+0.179×左心房平均压,方程检验的F值=4.472(P0.05)。结论:单纯二尖瓣狭窄瓣口面积、左心房压力是影响左心房内径的重要因素,在病程的不同阶段发挥作用不同。     

多普勒组织成像评估左向右分流先天性心脏病平均右心房压

目的探讨应用组织多普勒技术测量三尖瓣环运动相关参数,评估左向右分流先天性心脏病平均右心房压（mRAP）的价值。方法应用组织多普勒技术测量41例心脏病患者三尖瓣环收缩期峰值速度（Sm）、舒张早期峰值速度（Em）、舒张末期峰值速度（Am）、右心室等容收缩间期（IVCTm）、右心室等容舒张间期（IVRTm）,IVCTm、IVRTm用心率校正得出IVCTc、IVRTc;多普勒测量三尖辩口舒张早期前向峰值血流速度（E）;计算Em／Am、E／Em,以心导管测量先天性心脏病患者的mRAP。结果mRAP≥8mmHg的患者,IVRTc较短,而E／Em较高。IVRTc与mRAP呈负相关（r=-0.81,P〈0.01）,E／Em与mRAP呈正相关（r=0.83,P〈0.01）,其中IVRTc≤84.5ms或E／Em≥6.5判定mRAP≥8mmHg敏感度、特异度分别86.7％、72.0％,93.3％、84.6％。结论多普勒组织成像检测三尖瓣环IVRTc及E／Em能定量估测左向右分流先天性心脏病mRAP。     

Clinical review: Guyton - the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac output

Arthur Guyton's concepts of the determinative role of right heart filling in cardiac output continue to be controversial. This paper reviews his seminal experiments in detail and clarifies the often confusing concepts underpinning his model. One primary criticism of Guyton's model is that the parameters describing venous return had not been measured in a functioning cardiovascular system in humans. Thus, concerns have been expressed in regard to the ability of Guyton's simplistic model, with few parameters, to model the complex human circulation. Further concerns have been raised in regard to the artificial experimental preparations that Guyton used. Recently reported measurements in humans support Guyton's theoretical and animal work.     

左心房直径与左心房容积指数预测心房颤动复发的比较

目的探讨左心房直径（LAD）与左心房容积指数（LAVI）对转律成功患者心房颤动复发的预测价值。方法选择2007年7月至2009年10月于我院药物或电转律成功并给予胺碘酮预防复发的心房颤动患者124例,对比心房颤动复发组与未复发组的临床特征,并进行logistic回归分析,以比较LAD和LAVI对于心房颤动复发的预测价值。结果 117例患者完成研究,1年内32例复发,复发率为27.4%。心房颤动复发组LAD、LAVI均高于未复发组,LAD（39.5±6.5）mm vs（36.2±4.2）mm（P〈0.01）,LAVI 40.2±8.5 vs 32.4±6.6（P〈0.01）;两组年龄、左心室射血分数、是否服用其他抗心律失常药以及是否合并有器质性心脏病差异无统计学意义。Logistic多元回归显示,LAVI为心房颤动复发的独立危险因素（OR=3.170,95%可信区间=1.463~6.868,P〈0.01）。结论与LAD比较,LAVI是更为准确的预测心房颤动复发的临床指标。     

门静脉和肝中静脉内径与肝纤维化相关性的临床研究

目的探讨慢性肝病患者的门静脉和肝中静脉内径与肝纤维化程度的相关性。方法173例经过肝活检病理确诊的慢性肝病患者,超声测量其门静脉主干内径(DPV)和肝中静脉内径(DMHV),然后将DPV和DMHV与肝纤维化分期作相关性分析。结果肝纤维化S4期的DPV[(11.74±1.32)mm]高于S3期[(11.01±1.22)mm]、S2期[(10.44±1.35)mm]、S1期[(10.13±0.62)mm]和S0期[(10.08±1.55)mm],P<0.01;DPV与肝纤维化分期的相关性(rs=0.376,P<0.01)。S4期的DMHV[(4.30±1.76)mm]小于S3期[(6.11±1.77)mm]、S2期[(6.50±1.68)mm]、S1期[(7.31±1.71)mm]和S0期[(8.01±0.68)mm],P<0.01;DMHV与肝纤维化分期的相关性(rs=-0.471,P<0.01);联合DPV和DMHV诊断S4期的曲线下面积为0.771,大于DPV(0.711)和DMHV(0.761)。结论DPV和DMHV与慢性肝病的肝纤维化程度均有较好的相关性,DPV和DMHV联合检测对于早期肝硬化的诊断有更好的临床价值。     

合并左心房扩大的高血压患者雷米普利治疗前后左心房内径变化

目的:观察左心房扩大的高血压病患者使用雷米普利治疗前后心房内径变化情况。方法:100例合并左心房扩大的高血压病患者,给予雷米普利片(5～20mgqd)治疗,随访12月,观察治疗前后左心房内径变化情况。结果:和治疗前比较,治疗后左心房内径与治疗前比较明显减小(35.08±4.12vs38.15±3.82mm,P<0.05),有显著性差异。结论:左心房扩大的高血压病患者,应用雷米普利药物治疗,能够明显减轻左心房扩大,改善高血压病导致的心脏靶器官损害。     

合并房颤的高血压病患者左房内径与左室射血分数的关系研究

目的研究发生房颤的高血压病患者左房内径与左室射血分数(LVEF)的相关性。方法 56例高血压病患者,根据心电图示有无房颤或房颤病史分为2组:高血压病组和高血压病合并房颤组。应用超声心动图检测左房内径、左房容积(LAV)、左房容积指数(LAVI)、LVEF。分析LVEF与心脏超声内径关系。结果与高血压病组比较,高血压病合并房颤组左房内径、LAV及LAVI均增大,LVEF减小,差异均有统计学意义(P<0.001)。LVEF与左房内径、LAV、LAVI呈负相关(r值分别为-0.555、-0.589、-0.602,P<0.001)。结论高血压病合并房颤患者较高血压病患者左房扩大更明显,左室功能更减弱,此现象可能与左房结构重构触发左室重构有关。     

左心房内径和炎性因子变化对心房颤动的影响

目的探讨左心房内径和炎性因子在心房颤动(AF)发生和发展的作用。方法 45例持续性AF患者和45例阵发性AF患者作为AF组,选取同期住院无心房颤动病史的窦性心律患者45例为对照组。研究对象行超声心动图检测左心房内径(LAD),行免疫比浊法和ELISA检测患者血清高敏C-反应蛋白(hs-CRP),白细胞介素-6(IL-6)和肿瘤坏死因子(TNF-α)。结果心房颤动组LAD值和hs-CRP、IL-6、TNF-α水平均高于对照组,差异有统计学意义(P0.05)。AF患者LAD与hs-CRP、IL-6和TNF-α正相关(P0.05)。与阵发性AF组比较,持续性AF组中、高危水平hs-CRP的LAD水平均明显增加,差异有统计学意义(P0.05)。阵发性AF组和持续性AF组组内比较,高危水平hs-CRP患者的LAD水平均比中危组明显增加(P0.05)。结论 AF组患者血清hs-CRP、IL-6和TNF-a水平与LAD有关。     

环肺静脉电隔离术对心房颤动患者左心房、左心耳、左心房顶部结构的影响

目的应用64排螺旋CT观察环肺静脉电隔离（CPVA）术对心房颤动患者左心房（LA）、左心耳（LAA）、LA顶部结构的影响。方法心房颤动患者共28例,行CPVA术3~14.8（6.5±3.9）个月后进行随访,根据术后有无复发分为成功组（22例）和复发组（6例）。应用64排螺旋CT测量CPVA术前、后LA[包括LA横径（LA1）、上下径（LA2）和前后径（LA3）、LA容积]、LAA（包括LAA口长径、短径和面积、LAA长度、LAA容积）、LA顶部（包括LA顶长度、距离和深度）的相关径线。结果成功组CPVA术后的LA1、LA2、LA3、LA容积、LAA口长径、LAA口面积、LAA容积、LAA长度、LA顶长度、LA顶距离术后比术前减小,术前术后分别为LA1（6.97±0.87）cm vs（6.32±0.94）cm,LA2（6.02±0.84）cm vs（5.63±0.63）cm,LA3（3.71±0.64）cm vs（3.46±0.59）cm,LA容积（83.61±25.98）cm3vs（66.11±22.84）cm3,LAA口长径（3.01±0.54）cm vs（2.64±0.62）cm,LAA口面积（4.99±1.79）cm2vs（4.11±1.94）cm2,LAA容积（11.11±4.34）cm3vs（9.59±4.82）cm3,LAA长度（3.99±0.84）cm vs（3.74±0.82）cm,LA顶长度（4.02±0.89）cm vs（3.55±0.76）cm,LA顶距离（3.90±0.88）cm vs（3.43±0.73）cm（均P〈0.05）;LAA口短径和LA顶深度无明显变化（P〉0.05）。复发组CPVA术前、后比较,除了LA2较术前减小（6.43±1.04）cm vs（5.92±1.27）cm（P〈0.05）,余LA、LAA、LA顶部结构无明显变化（P〉0.05）。结论成功组CPVA术后的LA、LAA、LA顶部较术前减小,即结构重构可以逆转;而复发组CPVA术前、后比较LA、LAA、LA顶部无明显变化,未出现逆重构。     

Placement of a defibrillation lead in the left subclavian vein from the right cephalic vein

This case report highlights the feasibility and stability of transvenous placement of a second defibrillation lead in the left subclavian vein from a right cephalic vein approach. This was undertaken in a right-sided implant of an active can cardioverter defibrillator to lower defibrillation thresholds that would have otherwise precluded implant.     

Reliability of right atrial pressure monitoring to assess left ventricular preload in critically ill septic patients

Right atrial pressure (RAP) can be used as a guide to fluid therapy in critical care settings. RAP and pulmonary capillary wedge pressure (WP) were measured in 27 septic patients without cardiac disease and on mechanical ventilation. An r of .61 was obtained with a regression line defined by the equation WP = 7.38 + (0.53 x RAP) +/- 3.15. However, a large SD of data points can invalidate the clinical usefulness of this equation. The reliability of various RAP interval values in predicting optimal WP was then studied in these patients. We concluded that RAP values less than or equal to 5 mm Hg were highly specific (97%) in predicting low or normal WP (less than or equal to 12 mm Hg).     

左心房内径与非瓣膜性房颤患者缺血性脑卒中风险的相关性分析

目的探讨左房内径(LAD)与老年非瓣膜性房颤患者缺血性脑卒中风险的关系。方法将325例非瓣膜性房颤患者根据缺血性脑卒中史分为房颤伴脑卒中组(n=127)和房颤不伴脑卒中组(n=198),比较2组血糖、肌酐清除率、血脂、合并疾病、LAD等临床资料,采用Logistic回归分析评估LAD与缺血性脑卒中风险的相关性,并绘制受试者工作特征(ROC)曲线,评估LAD对缺血性脑卒中的预测价值。结果房颤伴脑卒中组的平均年龄、女性患者比率、合并心力衰竭及高血压患者比率、房颤血栓危险度(CHA_2DS_2-VASc)评分、LAD、肌酐(Cr)、尿酸(UA)均高于房颤不伴脑卒中组,阵发性房颤患者比率及估算的肾小球滤过率(e GFR)水平低于房颤不伴脑卒中组(P 0.05或P 0.01)。多因素Logistic回归分析结果显示,LAD与缺血性脑卒中风险呈正相关(P 0.01)。ROC分析表明,LAD对缺血性脑卒中风险有一定的预测价值(P 0.01),LAD联合CHA_2DS_2-VASc评分的ROC曲线下面积(AUC)为0.904。结论 LAD与非瓣膜性房颤患者缺血性脑卒中风险呈正相关,LAD联合CHA_2DS_2-VASc评分可以更好预测非瓣膜性房颤缺血性脑卒中风险。     

Mediastinal, left, and right atrial pressure variations with different modes of mechanical and spontaneous ventilation

Variations in mediastinal, left, and right atrial pressures (MedP, LAP, RAP, respectively) were measured by means of catheters and tubes positioned in ten patients with nonvalvular cardiac surgery. For each pressure, a maximum, minimum, and mean value was determined in relation to its oscillations during the respiratory cycle. Thus, we compared the variations in MedP, LAP, and RAP in controlled mechanical ventilation (CMV), CMV with 5 cm H2O PEEP, synchronous intermittent mandatory ventilation (SIMV), SIMV with 5 cm H2O PEEP, continuous positive airway pressure (CPAP), and spontaneous respiration (SR). We built an experimental model to compare the measurements obtained by air-filled tubes inserted at surgery with those obtained by esophageal balloons filled with water. The maximum MedP did not vary significantly in these patients except when SIMV and SR were compared; however, the minimum MedP diminished significantly (p less than .001) in SIMV, SIMV-PEEP, CPAP, and SR, with negative inspiratory values reaching significant proportions. The mean values of MedP, LAP, and RAP showed a similar tendency although to a lesser degree. The experimental model revealed a strong linear relation between the values obtained with air-filled tubes and those obtained with water-filled esophageal balloons (r = .99, p less than .001). These results suggest that the mean values of MedP, LAP, and RAP do not reflect the dynamic variations in ventricular filling pressure accurately, nor the important negative inspiratory peaks that appear in different types of ventilation using spontaneous cycles with and without PEEP. These inspiratory peaks can overload the left ventricle by hydrostatic gradients, and lead to pulmonary edema in susceptible patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Correlation of right atrial pressure and blood flow velocities in the common femoral vein obtained by duplex Doppler sonography.

PURPOSE: The purpose of this study was to correlate the right atrial pressure with the blood flow velocity and pulsatility index (PI) values obtained with duplex Doppler sonography of the common femoral vein. METHODS: Thirty consecutive patients with suspected right-sided heart failure who had right atrial pressure measurements for correlation were included in the study. The common femoral veins were examined with duplex Doppler sonography. Irrespective of the presence or absence of clinical right-sided heart failure, patients were divided into 2 groups on the basis of their right atrial pressures. The mean flow velocities and PIs in the common femoral veins of the 2 groups were compared. RESULTS: In patients with elevated right atrial pressure (> or = 8 mm Hg), the mean minimum flow velocity + standard deviation (-0.15 +/- 0.11 m/second) in the common femoral vein was significantly lower than that in patients with normal right atrial pressure (< 8 mm Hg) (0.01 +/- 0.10 m/second) (p < 0.001). There was no significant difference in the mean maximum flow velocities in the common femoral vein between the patients with elevated right atrial pressure (0.25 +/- 0.08 m/second) and the patients with normal right atrial pressure (0.21 +/- 0.09 m/second). The mean PI in patients with elevated right atrial pressure (7.75 +/- 3.19) was significantly higher than the mean PI in patients with normal right atrial pressure (1.55 +/- 1.30; p < 0.001). There was a weak negative correlation between the minimum flow velocity and the pressure in the right atrium in patients with elevated right atrial pressure (p = 0.05; r = -0.4760). The amplitude of retrograde waves seen in patients with normal right atrial pressure was significantly smaller than in patients with elevated right atrial pressure (p < 0.05). CONCLUSIONS: The association of a decreased minimum velocity, especially a negative value, and an increase in PI in the common femoral vein may indicate an elevated right atrial pressure. Sonographic assessment of retrograde flow velocity in the common femoral vein may be useful in monitoring the response to medical treatment to decrease atrial pressure.     

Non-pulmonary vein epicardial foci of atrial fibrillation identified in the left atrium after pulmonary vein isolation

BACKGROUND: Pulmonary vein (PV) isolation (PVI) has been demonstrated to be an effective technique for curing atrial fibrillation (AF). AF foci that cannot be isolated by PVI (non-PV foci) can become the cause of AF recurrence. The purpose of this study was to investigate the characteristics of non-PV AF foci. METHODS AND RESULTS: Two hundred consecutive patients with symptomatic AF underwent electrophysiologic studies. In all patients, successful ostial or antral PVI was achieved with a multielectrode basket catheter (MBC). In 45 patients, spontaneous AF was induced even after PVI. In 23 of those patients, 30 AF foci were found in the left atrium (LA) (12 in the PV antrum, and 18 in the LA wall). Twenty-six of those foci were eliminated by focal ablation guided by an MBC. Five of those foci (four in the PV antrum and one in the LA posterior wall) were speculated to be located epicardially because a small potential preceding the LA potential was recorded from the MBC electrodes during AF initiation at the successful ablation site where single large potentials were recorded during sinus rhythm and a longer duration of radiofrequency energy delivery was needed to eliminate them. CONCLUSIONS: MBC mapping with induction of spontaneous AF may be useful for identifying non-PV AF foci in the LA after PVI. In some of those non-PV foci, mainly around the PVI lesions, a few electrophysiologic findings suggesting an epicardial location were observed. This may be a rationale for the efficacy of extensive PV ablation.     

Effect of pulmonary vein isolation on left atrial appendage flow in paroxysmal atrial fibrillation

Background

Left atrial appendage (LAA) functional modification in the context of pulmonary vein isolation has been a focus point of research and LAA emptying flow velocity (LAAEFV) is considered to reflect LAA contractility, stunning, and fibrosis.

Objective

In the present study, we sought to prospectively evaluate short‐term LAAEFV changes after radiofrequency (RF) or cryoballoon ablation in paroxysmal AF.

Methods

This was a prospective substudy of the Effect of Cryoballoon and RF Ablation on Left Atrial Function (CryoLAEF) study ( ClinicalTrials.gov Identifier: NCT02611869). Thirty patients, randomly assigned to RF or cryoablation, were prospectively followed. Transesophageal echocardiograms were performed at baseline and at 3 months postablation to measure LAAEFV.

Results

All measurements were performed in sinus rhythm. Overall, LAAEFV was 44.2 [38.5–62.8] cm/s at baseline and was increased to 70.8 [64.8–77.6] cm/s at 3 months’ postablation (P < 0.001). Baseline LAAEFV was 52.5 [37.7–68.0] cm/s in the RF group and 42.8 [38.7–52.9] cm/s in the CryoBalloon group (P  =  0.653). At 3 months, the corresponding values were 68.5 [61.9–76.6] cm/s and 73.9 [69.2–79.9] cm/s, respectively (P  =  0.081 for the difference between the two groups at 3 months). The median change in LAAEFV was 11.0 [4.7–26.2] cm/s in the RF group versus 29.6 [15.8–37.0] cm/s in the CryoBalloon group (P  =  0.033).

Conclusion

LAA function is improved after catheter ablation with RF or balloon cryoablation in patients with paroxysmal AF, evaluated while in sinus rhythm both at baseline and on follow‐up.

     

Feasibility of intracardiac echocardiography imaging from the left superior pulmonary vein for left atrial appendage occlusion

Intracardiac echocardiography (ICE) is considered an alternative imaging modality for left atrium appendage occlusion (LAAO) to avoid general anesthesia. However, the quality of ICE images obtained from right atrium can be suboptimal compared with transesophageal echocardiography (TEE) imaging. Although placing an ICE probe into left atrium can improve imaging quality, there are limited data regarding procedure outcomes of ICE-guided LAAO versus TEE-guided LAAO. One hundred forty four patients who underwent LAAO with Amplatzer Cardiac Plug, Amulet, or Watchman device were enrolled from two referral institutes. TEE-guided LAAO was performed under general anesthesia or deep sedation (n?=?103), and ICE-guided LAAO was conducted under local anesthesia (n?=?41). An ICE probe was placed into left superior pulmonary vein (LSPV) via transseptal approach. The procedure success and complication rates of the ICE-guided LAAO were comparable with the TEE-guided LAAO (100 vs. 97.1%, p?=?1.0; 2.4 vs. 6.8%, p?=?0.734, respectively). The procedure time and total radiation dose were significantly lower in ICE-guided group compared with TEE-guided group (58.0 [55.0, 61.0] min vs. 80.0 [58.0, 95.0] min, p?<?0.001; 456.0 [359.0, 604.0] mGy vs. 625.0 [439.0, 1502.5] mGy, p?<?0.001, respectively). In multivariate analysis, younger age, the last time period of procedure, and local anesthesia were independent factors affecting shorter procedure time. ICE imaging from the LSPV provided optimal views for LAAO procedure with a significant reduction of total procedure time through performing under local anesthesia. This approach can be very useful for LAAO procedure especially in patients who are ineligible for general anesthesia.