随着全球人口老龄化,钙化性主动脉瓣疾病(calcifying aortic valve disease,CAVD)已经成为严重威胁人类健康的疾病.CAVD患者的影像学评估方法包括超声心动图、多层螺旋计算机断层扫描(multi-slice computed tomography,MSCT)、心脏磁共振成像和核素等.超声心动图是CAVD患者主动脉瓣狭窄程度、瓣叶结构、钙化程度、心功能状态评价的重要影像学方法,也在经导管主动脉瓣置换围手术期评估中发挥重要作用.本文就超声心动图在CAVD中应用的研究进展作一综述.

Objective To analyze the influence factors of new-onset complete left bundle branch block（CLBBB） after transcatheter aortic valve replacement（TAVR） in patients with aortic stenosis（AS）, and to explore the impact of CLBBB on postoperative cardiac remodeling reversal. Methods Totally 55 patients with AS who underwent TAVR were enrolled. Among them, new-onset CLBBB after TAVR and lasted for at least 1 month was observed in 16 patients（CLBBB group）,while 31 patients did not develop new CLBBB after operation and 8 patients developed new CLBBB within 1 day after operation but CLBBB disappeared within 1 month were included in NO-CLBBB group. The hemoglobin（Hb）, N-terminal pro-brain natriuretic peptide（NT-proBNP）, creatinine（Cr）, creatine kinase-MB（CK-MB） and troponin（cTn） before and 1 day after TAVR were compared between groups. Echocardiographic parameters, as well as NYHA cardiac function classification before and 1 month after TAVR were also compared between groups. Results Serum cTn at 1 day after TAVR was significantly higher than that before in both groups（both P＜0.05）, and there was no significant difference between groups（both P＞0.05）. The interventricular septum thickness at end-diastole（IVSD）, aortic valve peak pressure gradient（PPG） and aortic valve mean pressure gradient（MPG） of CLBBB group were significantly higher than those of NO-CLBBB group before TAVR（all P＜0.05）. In NO-CLBBB group, 1 month after TAVR, the left ventricular mass（LVM）, IVSD, left ventricular posterior wall thickness at end-diastole（LVPWD）, pulmonary artery systolic pressure（PASP）, PPG and MPG decreased, while aortic valve orifice area（AVA） increased compared with those before operation（all P＜0.01）. In CLBBB group, IVSd, PPG and MPG decreased 1 month after TAVR, while AVA increased compared with those before operation（all P＜0.01）. There was no significant difference of the other indexes between and within groups（all P＞0.05）. Conclusion After TAVR for treating AS, PPG, MPG and IVSD were impact factors of new CLBBB. New-onset CLBBB affected postoperative cardiac remodeling reversal.

心脏瓣膜病是母体和胎儿不良结局的重要原因之一.妊娠期女性对瓣膜狭窄的耐受性差,容易发生心力衰竭,而对瓣膜反流的耐受相对较好.人工机械瓣膜置换术后女性在妊娠期间既有瓣膜血栓风险,又有抗凝治疗带来的出血风险.患有心脏瓣膜病的女性在计划妊娠前应接受充分的妊娠心血管风险评估.中重度二尖瓣狭窄患者、有症状的重度主动脉瓣狭窄患者、有症状的重度二尖瓣、主动脉瓣反流或重度二尖瓣、主动脉瓣反流合并左心室功能障碍患者应在计划妊娠前对瓣膜进行修复或置换.对于患有心脏瓣膜病的女性,在妊娠期间、分娩过程中、分娩后均要密切观察血流动力学的变化,并根据瓣膜病变的类型和严重程度,制定个体化的治疗方案.

Nowadays, the prevalence and mortality of cardiovascular disease are still on the rise. Acute coronary syndrome (ACS) is the most serious type of cardiovascular disease, which can lead to arrhythmia, heart failure, and even sudden death. In recent years, with the technological advances of intracavitary imaging and the emerging research results, new progress has been made in the pathogenesis of ACS. According to the pathogenesis, ACS is divided into four categories: plaque rupture with inflammation, plaque rupture without inflammation, plaque erosion, and coronary artery spasm. It is of great significance to classify and treat ACS according to the pathogenesis for reducing the residual risk of cardiovascular disease, improving the living quality and prognosis of patients with ACS, and reducing the burden of cardiovascular disease in China. This article reviews the pathogenesis and treatment of ACS.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a kind of inherited cardio-myopathy, which is characterized by fibro-fatty replacement of right ventricular myocardium, leading to ventricular arrhythmia. However, rapid atrial arrhythmias are also common, including atrial fibrillation, atrial flutter and atrial tachycardia. Long term rapid atrial arrhythmia can lead to further deterioration of cardiac function. This case is a 51-year-old male. He was admitted to Department of Cardiology, Peking University Third Hospital with palpitation and fatigue after exercise. Electrocardiogram showed incessant atrial tachycardia. Echocardiography revealed dilation of all his four chambers, especially the right ventricle, with the left ventricular ejection fraction of 40% and the right ventricular hypokinesis. Cardiac magnetic resonance imaging found that the right ventricle was significantly enlarged, and the right ventricular aneurysm had formed; the right ventricular ejection fraction was as low as 8%, and the left ventricular ejection fraction was 35%. The patients met the diagnostic criteria of ARVC, and both left and right ventricles were involved. His physical activities were restricted, and metoprolol, digoxin, spironolactone and ramipril were given. Rivaroxaban was also given because atrial tachycardia could cause left atrial thrombosis and embolism. His atrial tachycardia converted spontaneously to normal sinus rhythm after these treatments. Since the patient had severe right ventricular dysfunction, frequent premature ventricular beats and non-sustained ventricular tachycardia on Holter monitoring, indicating a high risk of sudden death, implantable cardioverter defibrillator (ICD) was implanted. After discharge from hospital, physical activity restriction and the above medicines were continued. As rapid atrial arrhythmia could lead to inappropriate ICD shocks, amiodarone was added to prevent the recurrence of atrial tachycardia, and also control ventricular arrhythmia. After 6 months, echocardiography was repeated and showed that the left ventricle diameter was reduced significantly, and the left ventricular ejection fraction increased to 60%, while the size of right ventricle and right atrium decreased slightly. According to the clinical manifestations and outcomes, he was diagnosed with ARVC associated with arrhythmia induced cardiomyopathy. According to the results of his cardiac magnetic resonance imaging, the patient had left ventricular involvement caused by ARVC, and the persistent atrial tachycardia led to left ventricular systolic dysfunction.

目的 了解心力衰竭高危人群对心力衰竭的认知情况以及心力衰竭知识讲座提高认知水平的作用.方法 2019年6月至12月北京大学第三医院心力衰竭防治小组针对心力衰竭高危人群举办心力衰竭知识讲座6次,参加人员为心力衰竭A期和B期患者,共420例.在知识讲座前和讲座后,分别进行心力衰竭认知的问卷调查.心力衰竭的认知包括心力衰竭的病因、严重程度、临床表现、就诊和自我管理等5个方面的内容.结果 回收问卷363份,最终合格的问卷为345份,有效回收率为82.14％.心力衰竭高危患者对心力衰竭的认知存在很大不足,能够将问卷列出的8种导致心力衰竭的疾病均选择正确者为54例(15.7％);能够将问卷列出的5个心力衰竭临床表现均选择正确者为66例(19.1％);仅有205例(59.4％)患者表示出现了心力衰竭的症状,会尽早就诊;自我管理方面,只有128例(37.1％)患者认为应该限制饮水量,98例(28.4％)患者认为应该避免感染.在知识讲座后,课后得分高于课前,差异有统计学意义(P<0.05).结论 对心力衰竭高危患者进行心力衰竭知识的健康教育非常有必要.

卵圆孔是胎儿时期心脏房间隔的一个生理性通道,大多数人出生后原发隔与继发隔相互贴近、融合,使卵圆孔关闭,如果原发隔与继发隔未融合导致两者之间遗留裂隙,称为卵圆孔未闭(patent foramen ovale,PFO).多数情况下,PFO对血流动力学无明显影响,不会引起临床症状.随着对PFO认识的深入,PFO与多种疾病尤其是隐源性卒中(cryptogenic stroke,CS)的发病有关[1].PFO封堵是预防CS再发的有效方法,本文就PFO相关疾病及PFO封堵术的研究进展文献总结如下.

目的 探讨心腔内超声(CartoSound)三维标测指导下射频消融室间隔治疗肥厚型梗阻性心肌病(HOCM)的安全性及疗效.方法 在CartoSound三维标测技术指导下,对5例HOCM患者行经皮室间隔射频消融治疗,以收缩期二尖瓣瓣叶前向运动(SAM)对应的左室室间隔部位作为消融靶点,应用Smartouch盐水灌注消融电极,消融能量35～40 W,冷盐水灌注流速20 m L/m in,温度43℃,贴靠压力5～10 g,每次放电时间60 s.以左室流出道(LVOT)压力阶差下降50％ 或SAM区域心肌活动显著减弱作为消融有效终点.比较术前、术后LVOT压力阶差变化,记录围术期并发症发生情况,评价疗效和安全性.结果 术中累计消融放电15～42次,消融范围占SAM区域比值22.9％ ～76.6％.术后即刻LVOT压力阶差由术前(105±93.6)mmHg下降至(40.6±37.2)mmHg(P<0.001).随访至术后6个月,患者临床症状消失,心功能改善;术后6个月室间隔厚度由术前(16.1±2.9)mm下降至(13.3±2.4)mm(P=0.115);LVOT压力阶差由术前(105±93.6)mmHg逐步下降至(94.7±71.9)mmHg(术后7日,P=0.146)、(30.72±12.9)mmHg(术后1个月,P<0.01)、(19.4±17.8)mmHg(术后6个月,P<0.01).5例患者均未出现手术并发症.结论 经心腔内超声CartoSound指导下室间隔射频消融术治疗HOCM安全、有效.

目的 :比较病历示教法与传统教学方法对住院医师病历书写能力的影响.方法 :入选住院医师分为实验组(病历示数,n=21)和对照组(传统教学,n=21).通过匿名评估受试者的病历比较两种教学方法对受试者病历书写能力的影响.结果 :实验组病历书写成绩显著高于对照组(P=0.04).同时病历示教组内,病历书写成绩与参加课程次数相关,P=0.03.结论 :病历示教法有助于提高住院医师病历书写水平.

冠状动脉慢性完全闭塞(CTO)病变是临床中较为常见的严重冠状动脉病变.这些患者通常年龄更大,合并疾病更多.CTO病变的经皮冠脉介入术治疗难度较大,成功率相对低,且并发症的发生更多,但在经验丰富中心CTO病变经皮冠脉介入术的成功率已经达到80％ ～90％.CTO病变血运重建的获益目前还存在争议.观察性研究和注册研究显示,开通CTO病变可以缓解心绞痛症状,改善心功能,提高运动耐量,甚至可以减少心血管事件的发生,但是尚缺乏随机对照研究的支持.

Objective To investigate dynamic changes of plasma macrophage migration inhibitory factor(MIF) in patients with acute ST-segment elevated myocardial infarction (STEMI).Methods We continuously recruited 204 STEMI patients with primary percutaneous coronary intervention (PCI).Age and sex-matched patients with stable angina (n =30) and healthy subjects (n =65) were selected as control groups.Plasma MIF levels of admission,24 h and 72 h after PCI were measured by enzyme linked immunosorbent assay(ELISA).STEMI patients were followed up for 36 months.Results Compared with control groups,plasma MIF levels of STEMI patients were significantly higher at admission and maintained at high levels until 24 h to 72 h[53.1 (36.4,81.9) ng/ml,53.8(40.7,67.7) ng/ml,50.8(38.9,66.0) ng/ml,respectively,P ＜0.001] post-PCI and had no significant changes(ANOVA P ＞ 0.05).Plasma MIF levels of admission was correlated positively with peak levels of creatine kinase-MB and troponin T (r =0.439 and 0.316,both P ＜ 0.001),negatively with left ventricular ejection fraction(LVEF) (r =-0.338,P ＜0.001).Plasma MIF levels at admission and 24 h post PCI were associated with high sensitive-C reactive protein(r =0.173 and 0.148,both P ＜ 0.05).MIF at 24 h post PCI correlated with dynamic monocyte counts within 72 h after STEMI(r =0.305,0.195 and 0.237,all P ＜ 0.05).Also,MIF levels at 72 h post PCI were associated with monoeyte counts at 24 h and 72 h post PCI(r =0.175 and 0.146,both P ＜ 0.05).Patients with higher MIF levels at admission (≥ 53.1 ng/ml) had 2.4-fold risk of major adverse cardiovascular and cerebral events (MACCE) during 36 months follow-up (95 ％ CI:1.12-5.20,P =0.025).Conclusions In patients with STEMI,the lasting elevated levels of plasma MIF during early phase after STEMI appear to be associated with enzymatic infarct size,acute cardiac function,inflammatory factor and circulatory monocyte counts.Admission MIF level was correlated with prognosis and can help predict longterm adverse outcomes.

Objective To understand thedemand forthe knowledge in cardiology of doctors from other departments, and to provide ideas and basis for the future reform of continuing medical education. Methods We surveyed 1 109 consultations with cardiologists in Peking University Third Hospital from May 1st to August 31th, 2013. The department distributions and the reasons for the consultations with cardiologists were collected, and the differences between surgical and nonsurgical departments were analysed by using χ2 tests, in order to identify the demands of knowledge among doctors from different departments. Results The numbers of consultations from surgical and nonsurgical departments were 902 (81.3%) and 207 (18.7%) separately. The reasons for the consultations were significantly different between surgical and nonsurgical departments (P<0.001). The most common four reasons for consultations in surgical departments were hypertension, coronary heart disease, arrhythmia and ECG changes, while the reasons in nonsurgical departments were arrhythmia, coronary heart disease, hypertension and heart failure. Conclusion Doctors may need targeted training according to their demands in continuing medical education.

目的:探讨急性心肌梗死并发心脏破裂的临床特征及超声心动图的特点.方法:回顾性分析8例急性心肌梗死并发心脏破裂患者的临床资料.结果:7例院内死亡,1例院外死亡.超声心动图均可见大量心包积液,2例可见破口,心脏停搏,胸外按压时可见彩色血流束由左室破裂口进入心包腔.1例可见收缩期血流由左室游离壁破口进入心包腔,舒张期血流由心包腔流入左心室腔内.结论:急性心肌梗死并发心脏破裂多发生于前壁,初发心肌梗死,女性高于男性,病情进展快,病死率高,超声心动图能对急性心肌梗死并发心脏破裂作出快速准确诊断.

Objective To investigate 5-year survival after ST-segment elevation myocardial infarction(STEMI)in Beijing Yanqing district. Methods A total of 691 STEMI patients admitted to Beijing Yanqing hospital from August 2002 to December 2010 were followed up for as long as 5 years. The end point was all cause death. Five-year survival curve was computed for patients who had received primary percutaneous coronary intervention(pPCI)and patients who had not received pPCI. Predictors of death within 5 years were identified by multivariable cox regression analysis. Results In 691 patient,442 patients(64.0％)had not received pPCI,and 249 patients(36.0％)had received pPCI. The 5-year survival rates were 73.8％ and 93.6％in patients who had not received pPCI and patients who had received pPCI separately. The predictors of death within 5 years in patients who had not received pPCI were female,age,chronic obstructive pulmonary disease, Killip's class ≥ 2 in hospital,myocardial infarction of anterior wall and not receiving elective PCI,while the predictors in patients who had received pPCI were age and gastrointestinal bleeding. Conclusions The 5-year survival rate in patients who had received pPCI was obviously higher than in patients who had not received pPCI. The predictors of death within 5 years were different in the two groups.

Background The left atrial size has been considered as a useful marker of adverse cardiovascular outcomes. However, it is not well known whether left atrial area index (LAAI) has predictive value for prognosis in patients with unstable angina pectoris (UAP). This study was aimed to assess the association between LAAI and outcomes in UAP patients. Methods We enrolled a total of 391 in-hospital patients diagnosed as UAP. Clinical and echocardiographic data at baseline were collected. The patients were followed for the development of adverse cardiovascular (CV) events, including hospital readmission for angina pectoris, acute myocardial infarction (AMI), congestive heart failure (CHF), stroke and all-cause mortality. Results During a mean follow-up time of 26.3 +/- 8.6 months, 98 adverse CV events occurred (84 hospital readmission for angina pectoris, four AMI, four CHF, one stroke and five all-cause mortality). In a multivariate Cox model, LAAI [OR: 1.140, 95% CI: 1.016-1.279, P = 0.026], diastolic blood pressure (OR: 0.976, 95% CI: 0.956-0.996, P = 0.020) and pulse pressure (OR: 1.020, 95% CI: 1.007-1.034, P = 0.004) were independent predictors for adverse CV events in UAP patients. Conclusions LAAI is a predictor of adverse CV events independent of clinical and other echocardiographic parameters in UAP patients.

Percutaneous mechanical circulatory support (PMCS) devices are effective in the treatment of patients with cardiogenic shock and acute decompensated heart failure, as a bridge to the recovery of heart function or further treatment. The intra-aortic balloon pump (IABP) is now the most widely used PMCS. New PMCS devices including Transseptal device of Tandem-Heart, transaortic valve device of Impella and extracorporeal membrane oxygenation (ECMO) might provide more effective hemodynamic supports. Doctors should choose appropriate PMCS devices and their working modes, according to patient's clinical conditions, based on the working principles and hemodynamic effects of the devices, in order to achieve the best effects and help patients live through the crisis of diseases.

[ABSTRACT]Objective: To investigate the effect of case based learning(CBL) teaching model in changing postgraduate students’ attitude towards doctor-patient communication skills(DPCS) learning. Methods: CBL teaching model was applied to doctor-patient communication skills learning in postgraduate students from internal medicine department. Communication Skills Attitude Scales(CSAS) were filled in twice both before and after CBL. Results: There was no significant difference between the scores of positive attitude subscale before and after CBL(P>0.05), however, the scores of negative attitude subscale was significantly reduced after CBL(P<0.001). Conclusion:CBL teaching model had changed postgraduate students’ attitude towards DPCS learning.

心电图是诊断学带教的难点之一。结合临床医学八年制学生的特点及培养目标，在教学中将大班理论授课与小组见习相结合，以提高学生阅读心电图的实战能力；强调按顺序读图的重要性，培养学生良好的阅读习惯；提高学生对心电图学习的兴趣，并用多种方法强化记忆；通过心电图网络信息管理系统收集大量心电图，以供教学使用，最终取得良好的教学效果。

对北京市两所高中的高二年级学生及其家长进行问卷调查,以了解暴力伤医事件对高中生高考报考医学类专业意向的影响.结果显示,16.2％的学生和18.8％的家长表示有报考医学类专业的意向;88.6％的学生和89.4％的家长表示关注过暴力伤医事件,26.3％的学生和39.7％的家长认为暴力伤医事件对是否报考医学类专业存在影响.

OBJECTIVE:To explore the relationship between the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/Em) and exercise capacity in patients with atrial fibrillation.METHODS:A total of 94 consecutive patients with non-valvular atrial fibrillation and preserved left ventricular ejection fraction admitted into our department from December 2011 to June 2013 were included. Echocardiography and cardiopulmonary exercise test were performed. According to E/Em, they were divided into two groups of normal E/Em (E/Em ≤ 9) and elevated E/Em (E/Em>9). The parameters of exercise capacity, including VO2max/kg, anaerobic threshold/kg (AT/kg) and exercise time duration were compared between two groups. And the determinants of VO2max/kg were identified by multivariate regression analysis.RESULTS:The number of patients was 57(60.6%) with normal E/Em and 37 (39.4%) with elevated E/Em. As compared to those with normal E/Em, the patients with elevated E/Em had lower VO₂max/kg [(26 ± 4) vs (20 ± 4) ml × min⁻¹ × kg⁻¹, P < 0.001], lower AT/kg [(25 ± 4) vs (19 ± 5) ml ×min⁻¹ × kg⁻¹, P < 0.001] and shorter exercise time duration [(7.2 ± 1.3) vs (5.8 ± 1.3) min, P < 0.001]. Multivariate regression analysis revealed that three significant variables were independently associated with VO₂max/kg: age (r = -0.412, P < 0.001), gender ((25 ± 5) and (21 ± 4) ml × min⁻¹ × kg⁻¹ for males and females separately, P < 0.001) and E/Em (r = -0.535, P < 0.001).CONCLUSION:E/Em was independently associated with exercise capacity in patients with atrial fibrillation.