经食管超声心动图测定冠状窦血流对心肌肥厚患者冠脉血流储备的诊断价值

目的 探讨多平面经食管超声心动图（ＴＥＥ）测定冠状窦血流评估心肌肥厚患者冠脉血流储备（ＣＦＲ）的可行性及对心肌肥厚的诊断价值。方法 对４２例心肌肥厚患者和１０例正常对照静脉注射潘生丁,分别测量静息状态（Ｒｅｓｔ）及注射潘生丁后（ＤＰＭ）冠状窦血流频谱收缩期、舒张期、舒张末期逆行心房波最大流速（Ｓ、Ｄ、Ａ）及流速积分（ＶＴＩ－Ｓ、ＶＴＩ－Ｄ、ＶＴＩ－Ａ）,以（ＶＴＩ－Ｓ＋ＶＴＩ－Ｄ）－（ＶＴＩ－Ａ）     

超声心动图评价房间隔缺损患者左心室收缩功能

用超声心动图检测２８例继发孔型房间隔缺损（ＡＳＤ）患者及４０例正常人左心室收缩功能（ＬＶＳＦ）。结果表明：ＡＳＤ患者左室射血分值（ＬＶＥＦ）、短轴缩短分数（ＬＶＦＳ）、每搏量（ＳＶ）、心输出量（ＣＯ）、主动脉瓣口血流速度（ＡＶ）、速度时间积分（ＡＶＩ）均较正常人明显降低（Ｐ＜０．００１～０．０５），左室射血前期（ＬＰＥＰ）延长（Ｐ＜０．０１）、射血时间（ＬＶＥＴ）缩短（Ｐ＜０．０５）、ＬＰＥＰ／ＬＶＥＴ增大（Ｐ＜０．０１），且ＬＶＥＦ、ＬＶＦＳ、ＳＶ、ＣＯ、ＡＶ、ＡＶＩ与肺／体循环量比值（Ｑｐ／Ｑｓ）呈中度负相关（ｒ＝－０．３９～－０．７８，Ｐ＜０．０５）。结论认为：ＡＳＤ患者ＬＶＳＦ存在一定程度的减退，并推测其机理可能与ＡＳＤ患者因右室容量超荷所致的左室扩张性降低、舒张末容积减小、室间隔运动异常及左室几何形态改变等有关     

超声心动图对室壁瘤切除术后左心功能的初步研究

１１例患者于室壁瘤切除术前后进行了超声心动图检查。其中男１０例，女１例，年龄３９至６８岁。心尖部室壁瘤９例，下后壁室壁瘤２例。１０例患者室壁瘤切除术（ＬＶＡ）的同时进行了ＣＡＢＧ。ＥＤＶ、ＥＤＶＩ、ＥＳＶ、ＥＳＶＩ和ＳＶ于ＬＶＡ后明显减少（Ｐ＜０．０５－０．００１），ＨＲ增加，ＥＦ、ＣＯ和ＣＩ无明显变化。二尖瓣血流频谱显示所有患者舒张功能类型和Ｅ峰流速、Ｅ峰压差、Ａ峰流速、Ａ峰压差及ＩＶＲＴ手术前后均没有明显改变（Ｐ＞０．０５）。所以，ＬＶＡ可明显减低室壁瘤患者的ＥＤＶ、ＥＤＶＩ、ＥＳＶ、ＥＳＶＩ，使上述指标趋于正常；ＳＶ可出现下降但ＥＦ、ＣＯ和ＣＩ无变化。二尖瓣血流频谱的变化显示ＬＶＡ对左室舒张功能无明显影响。上述结论还有待进一步证实。     

多普勒超声心动图对急性心肌梗塞患者溶栓治疗的评价

目的：探讨多普勒超声心动图对不同梗塞部位急性心肌梗塞（ＡＭＩ）溶栓治疗再通评价的意义。方法：对１６０例首次ＡＭＩ患者随机分成尿激酶溶栓治疗再通组和常规治疗对照组，采用彩色多普勒超声心动图测定左房内径（ＬＡＤ）、室间隔和左室后壁运动最小幅度（ＩＶＳＡ和ＬＶＰＷＡ）、左室射血分数（ＥＦ）、二尖瓣Ｅ点至室间隔距离（ＥＰＳＳ）和二尖瓣血流频谱Ａ峰最大速度与Ｅ峰最大速度比（Ａ／Ｅ）。结果：①溶栓治疗者再通率为５８．８２％（７０／１１９）。②急性前壁心肌梗塞（ＡＡＭＩ）患者的ＬＡＤ、ＥＰＳＳ和Ａ／Ｅ在溶栓组明显低于对照组（Ｐ＜０．０１，Ｐ＜０．０１，Ｐ＜０．０１）；溶栓再通组ＥＦ明显高于对照组（Ｐ＜０．０１）。③急性下壁心肌梗塞（ＡＩＭＩ）患者ＬＶＰＷＡ溶栓再通组高于对照组（Ｐ＜０．０５）；溶栓再通组Ａ／Ｅ明显低于对照组（Ｐ＜０．０１）。④ＡＡＭＩ＋ＡＩＭＩ患者ＥＦ在溶栓再通组明显高于对照组（Ｐ＜０．０１）；ＥＰＳＳ低于对照组（Ｐ＜０．０５）。结论：溶栓治疗可限制梗塞面积，挽救濒死心肌，改善左室功能。在梗塞部位上，前壁优于下壁，ＡＡＭＩ＋ＡＩＭＩ介于两者之间。     

高血压病心室活动同步性和收缩功能的核素心室造影研究

应用计算机－核素心室造影（ＥＲＮＡ）对１２０例各期高血压患者和２０例正常人进行左室收缩功能（ＬＶＳＦ）参数测定，并通过位相分析得到心室活动同步性（ＶＳＳ）参数心室相角程（ＰＳ）和半高竞（ＦＷＨＭ）。结果表明：高血压病Ⅰ期组ＬＶＳＦ参数在正常或超常水平；Ⅱ期患者与Ⅰ期患者比较，其ＬＶＥＦ和１／３ＥＦ降低（Ｐ＜０．０５）且ＰＳ和ＦＷＨＭ增宽（ＰＭ＜０．０５），提示存在ＶＳＳ损伤；Ⅲ期ＬＶＳＦ各参数均较Ⅰ、Ⅱ期明显降低（Ｐ＜０．０１），ＰＳ和ＦＷＨＭ更增宽（Ｐ＜０．０１）。ＬＶＥＦ与ＰＳ和ＦＷＨＭ呈负相关（ｒ＝－０．５４，－０．５０，Ｐ＜０．０５）。ＰＳ和ＦＷＨＭ增竟是ＶＳＳ损伤表现．计算机－ＥＲＮＡ在高血压病分期诊断、治疗和判断预后上有重要意义。     

尿毒症心脏病变的超声心动图及多普勒研究

目的：探讨超声心动图及多普勒在尿毒症患者所致心脏病变的诊断中的应用价值。方法：本文选用３０例超声心动图及多普勒资料完整的病例作为病例组并随机抽取正常人３０例作为对照组。结果：尿毒症组与对照组各测值统计学处理，差异显著。左室腔明显扩大，左室心肌重量和左空心肌重量指数明显增加（Ｐ＜０．０１），左室收缩功能ＥＦ与ＦＳ无差异（Ｐ＞０．０５），反映泵血功能的ＳＶ、ＥＳＶ、ＥＤＶ和ＣＯ增高（Ｐ＜０．０５－Ｐ＜０．０１）；反映左室舒张功能的二尖瓣血流频谱Ａ峰、ＡＩ、Ｅ／Ａ和 ＩＶＲＴ均有增大（ Ｐ＜ ０．０５－ Ｐ＜ ０．０１），肺静脉血流频谱 Ｄ波、ＤＩ和 ＲＦＩ明显减少， Ｓ／Ｄ ＡＲ和 ＡＲＤ均有明显增加（Ｐ＜０．０１），左室舒张功能下降明显。结论：超声心动图与多普勒在尿毒症患者心脏病变的检查诊断中有极高的应用价值。     

二维多普勒超声对缺血性心肌病左室重构变化的研究

目的对缺血性心肌病（ＩＣＭ）患者的左室重构（ＬＶＲ）病理生理变化进行分析研究。方法应用ＨＰ ７７０２０ＡＣ型彩色多普勒血流显像仪（探头频率３．５ＭＨｚ）分别对５６例ＩＣＭ患者和５０例正常对照组进行分析评价。结果显示ＩＣＭ组的各项指标与正常组比较有显著性差异（Ｐ＜０．０１～０．００１）。ＩＣＭ组的ＬＶＥＤｄ、ＥＤＶ、ＥＳＶ、ＥＳＳ、ＰＶＡ、ＬＡＴ、ＬＡＦ显著增大，ＥＦ、ＣＯ、ＬＶＳＣＩ、ＭＶＣＦ、ＰＶＥ、ＰＦＲ及ＰＶＡ／ＰＶＥ显著降低（Ｐ＜０．０１～０．００１）。结论认为ＩＣＭ病人ＬＶＲ的主要病因与心肌缺血引起的梗塞区膨展、左室扩张、容量负荷及室壁应力的增加有关，而ＥＳＶ、ＥＤＶ及ＥＦ可作为了解ＩＣＭ远期预后的最佳指标     

二维超声心动图对急性心肌梗塞后左室重构的分析研究

应用二维超声心动图对３６例急性心肌梗塞患者的左室重构病理生理变化进行分析评价。结果显示：心肌梗塞患者的ＬＶＤｄ，ＬＶＥＤＶ，ＬＶＥＳＶ，Ｅｄｂ，Ｅｓｂ及ｍｅａｎ ｂ显著增大（ｐＰ＜０．０５－－０．０１），ＥＦ、ＬＶＳＣＩ及ＭＶＣＦ显著降低（Ｐ＜０．０５－０．０１）。结论认为：急性心肌梗塞后左室重构的主要病因是梗塞区膨展、左室扩张、容量负葆增加及室壁应力增大，可直接导致心肌梗塞后并发症的出现。     

高血压患者冠状循环改变的经食管超声研究

目的：探讨高血压患者冠状循环的改变,方法：采用经食管超声心动图（TEE）技术,探测30例高血压患者和10例对照的冠状窦解剖结构和血流动力学变化。结果：与对照组相比,高血压病患者收缩压（SBP）,舒张压（DBP）,左室重量指数（LVMI）,冠状窦前向血流（CSF）及冠状窦直径明显增加（P＜0．05－0．001）,与对照组相比,心肌肥厚组LVMI,SBP,DBP,冠状窦直径,CSF均明显增加（P＜0．05－0．001）,与对照组相比,心肌肥厚组LVMI,SBP,DBP,冠状窦直径,CSF均明显增加（P＜0．05－0．001）,而无心肌肥厚组仅LVMI明显增加（P＜0．01）,与无心肌肥厚组相比,心肌肥厚组LVMI,SBP,CSF明显增加（P＜0．05－0．001）,结论：高血压患者冠状循环发生了显著改变,左室心肌重量增加起这一改变的主要原因,应用TEE探测冠状窦血流为评价高血压病患者冠状循环损害提供了新方法。     

生脉注射液对缺血性心脏病患者心脏功能的影响

目的：观察生脉注射液对缺血性心脏病患者心脏功能的影响。方法：４８例缺血性心脏病患者静滴生脉注射液２５～３０ｍｌ，每日１次，连用２周，治疗前后分别测常规导联心电图、血脂及心脏功能各参数。结果：生脉注射液对缺血性心脏病患者心电图ＳＴＴ的改变有恢复作用（８５％），并有一定的降血脂作用（Ｐ＜０．０５）；对心脏功能左室射血时间（ＬＶＥＴ）、射血前期（ＰＥＰ）、射血分数（ＥＦ）、等容收缩期（ＩＣＴ）、心搏出量（ＳＶ）、心输出量（ＣＯ）、冠状动脉灌注压（ＣＡＰ）、心内膜下心肌存活率（ＥＶＲ）、心缩力指数（ＨＩ）、心搏指数（ＳＶＩ）和心脏指数（ＣＩ）均有显著影响（Ｐ均＜０．０５）；心电图ＳＴＴ改变与等容舒张期（ＩＲＴ，ｒ＝－０．３８）、ＬＶＥＴ（ｒ＝０．６６）、ＥＶＲ（ｒ＝－０．６２）、ＣＡＰ（ｒ＝－０．５１）和ＣＩ（ｒ＝－０．２７）均具有相关性（Ｐ均＜０．０５）。结论：生脉注射液能增强心肌收缩力，改善心肌顺应性与协调性，提高冠状动脉灌注压及心肌存活率，提高ＥＦ与ＣＩ，对缺血性心脏病患者不失为是改善心脏功能的有效药物之一。     

Coronary Occlusion and Coronary Insufficiency

Acute coronary attacks may be divided clinically, electrocardiographically, pathologically and therapeutically into (i) classical angina pectoris, (2) acute coronary insufficiency and (3) acute coronary occlusion. In 1000 consecutive cardiac consultations, 450 of 618 cases with organic heart disease had coronary artery disease. Of these 450 cases, 38 per cent had chronic coronary insufficiency (angina pectoris or congestive failure), 26 per cent had acute coronary insufficiency, and 36 per cent had acute coronary occlusion. The differentiation between coronary occlusion and insufficiency which can be made electrocardiographically in 95 per cent of cases is discussed in this paper.     

冠状动脉微栓塞后冠状动脉阻抗变化的实验研究

目的:经导管建立冠状动脉微栓塞模型,观察冠脉微栓塞后冠脉阻抗的变化情况。方法:15头小型猪,通过导管方法建立急性冠脉微栓塞模型,观察微栓塞前、微栓塞后2、6h及1周时冠脉阻抗和冠脉阻抗储备的变化情况。结果:在微栓塞前、微栓塞后2h、6h及1周时基础冠脉阻抗分别为2.448±1.891mmHg·mL-1·s-1,3.229±2.872mmHg·mL-1·s-1,3.197±3.227mmHg·mL-1·s-1和3.466±2.683mmHg·mL-1·s-1;冠脉一次谐波阻抗分别为0.538±0.559mmHg·mL-1·s-1,1.604±1.727mmHg·mL-1·s-1,0.834±0.858mmHg·mL-1·s-1和1.233±1.809mmHg·mL-1·s-1;最小冠脉阻抗分别为1.778±1.352mmHg·mL-1·s-1,2.577±2.276mmHg·mL-1·s-1,2.710±2.733mmHg·mL-1·s-1和3.039±2.671mmHg·mL-1·s-1;冠脉一次谐波最小阻抗分别为0.388±0.395mmHg·mL-1·s-1,0.947±0.844mmHg·mL-1·s-1,1.639±1.9780mmHg·mL-1·s-1,0.716±0.624mmHg·mL-1·s-1(其中微栓塞后6h与微栓塞前相比有显著差异,P<0.05)。冠脉阻抗储备分别为1.463±0.235,1.265±0.105,1.160±0.068和1.276±0.266(其中微栓塞后6h与微栓塞前相比有显著差异,P<0.05)。对冠脉阻抗数据进行校正后发现,冠脉阻抗储备和冠脉一次谐波最小阻抗是反映微栓塞后微循环功能变化最为敏感的指标。结论:急性冠脉微栓塞后冠脉阻抗呈逐渐升高又恢复正常的变化趋势,而冠脉阻抗储备呈逐渐下降又恢复正常的变化趋势。     

经皮腔内冠状动脉成形术造影分析

本文报道７０例经皮腔内冠状动脉成形术（ＰＴＣＡ）的造影初步经验。作者们将冠心病冠状动脉造影发现的冠状动脉狭窄形态分为单纯型与复杂型。本组结果显示，稳定型劳累性心绞痛常为单纯型病变，而冠心病的其它类型常为复杂型病变。还发现，单纯型病变在经皮腔内冠状脉动脉成形术后，很少发生再狭窄，但复杂型则常发生再狭窄。本文还讨论了当前经皮腔内冠状动脉成形术的造影特点和Ｘ线投照技术的重要性。     

经皮冠状动脉腔内成形术与旋磨术治疗冠心病

本文报告我院1992年7月至1994年11月间采用经皮冠状动脉腔内成形术治疗13例冠心病,对18支血管18处病变进行扩张,狭窄度由78±11％降至17±11％;采用经皮冠状动脉腔内斑块旋磨治疗6例冠心病,对13支血管17处斑块进行旋磨,狭窄度由86±9％降至14±6％。PTCA和PTCRA是治疗冠状动脉粥样硬化安全而有效的方法。     

Coronary stents

Since the introduction of coronary stents into clinical practice in the late 1980s, the number of stent implantations has increased so rapidly that stents are currently used in over 80 percent of all percutaneous coronary interventions. Although stent implantation was initially limited to large vessels with proximal and discrete lesions, improvements in stent design and implantation technique now allow their deployment in more complex lesions in smaller and diffusely diseased vessels. The overall acceptance of stents by interventional cardiologists can be attributed to favorable acute and longterm results compared to balloon angioplasty alone. Interventionalists have also been quick to embrace the smoother and larger lumen after stenting, in a shorter procedure time and with no additional risk, especially since the risk of stent thrombosis has been overcome by the introduction of dual antiplatelet therapy with Aspirin and Ticlopidine or Clopidogrel. Although restenosis and the need for reinterventions is lower after stenting compared to balloon angioplasty it still remains significant with about 15 percent of all patients returning for an other revascularization procedure. Meanwhile, a completely new generation of stents promises to eliminate the problem of restenosis. Drug-eluting stents, coated with antiproliferative substances have been successfully tested in small randomized trials. The restenosis rates at 6 and 12 months were extremely low ranging between zero and nine percent, with no clinical drawbacks so far. If these results hold up in longer follow up and in real life practice with more complex lesions stented the treatment of symptomatic coronary artery disease will change even more dramatically.     

Coronary angioplasty

The decision to initiate long-term treatment of ventricular arrhythmias has always been difficult because of the substantial morbidity produced by many drugs and the potential for inducing proarrhythmia. Five recently introduced antiarrhythmic agents promise to enhance the physician's chances of prescribing effective therapy. In this article, the authors review the pharmacokinetic properties and efficacy of these newer agents and offer a clinical perspective on their use.     

Coronary Thrombolysis

Randomized trials have demonstrated the overall benefits and risks of thrombolytic therapy for acute myocardial infarction, and have evaluated adjunctive drug therapies, adjunctive and primary angioplasty, various approaches to the timing of thrombolysis, and post-thrombolysis management. Three questions, which remain unanswered, are addressed in this Point-Counterpoint Series. The GUSTO trial provides convincing evidence of the greater efficacy of rt-PA by comparison to SK, but the size of the benefit is uncertain, as are the risk benefit ratios and cost-effectiveness in various patient subgroups. The issues of whether or not routine angiography is appropriate for patients who have received coronary thrombolysis remains unresolved. For the present, clinical guidelines are likely to advise against routine angiography, while many cardiologists, concerned about the shortcomings of available studies, may wish to undertake coronary angiography in many of their patients, even though definitive proof of its benefit is lacking. Although randomized clinical trials suggest a benefit of primary angioplasty over thrombolytic therapy, further studies are required to clarify the comparative benefits in terms of clinically important outcomes and cost-effectiveness.