1 病例简介 男,33岁,体格检查、实验室检查及心电图均无明显异常.超声心动图(图 1)示:各房室腔大小正常,大动脉关系及发育未见异常;房、室间隔连续完整,未见动脉导管未闭;二、三尖瓣及主动脉瓣未见异常;于常规大动脉短轴切面见主肺动脉略扩张,内径2.9 cm,肺动脉瓣环内径正常,瓣上0.8 cm处探及隔膜样回声,长0.7 cm,凸向主肺动脉,致主肺动脉收缩期血流速度偏快,峰值流速 2.3 m/s,峰值压差21 mmHg.将探头上移并调整显示非标准高位大动脉短轴切面,可见肺动脉瓣四叶,收缩期瓣叶开放正常,未见狭窄,舒张期瓣叶关闭欠佳,见轻-中度反流.超声心动图诊断:肺动脉瓣四叶畸形( quadricuspid pulmonary valve,QPV),肺动脉瓣反流(轻-中度);肺动脉瓣上隔膜,肺动脉瓣上狭窄(轻度).

目的 探讨外周动脉斑块(颈动脉分叉处、股动脉斑块)与冠状动脉(冠脉)粥样硬化严重程度的相关性,分析外周斑块对严重冠状动脉粥样硬化性心脏病(冠心病)的临床预测价值.方法 纳入149例患者,依据颈部超声所示病变等级评分将患者分为5组,基于冠脉造影检查结果(CAG)计算患者冠脉钙化积分(Gensini积分、Leaman积分),比较各组间冠脉钙化积分差异;同时对有无股动脉斑块受试对象的冠脉钙化积分进行差异比较.用接受者操作特征曲线(ROC)对颈动脉分叉斑块、股动脉斑块及联合两者对严重冠心病进行预测效能分析,对结果的灵敏度、特异性及其曲线下面积(AUC)进行比较.结果 对于颈动脉分叉处及股动脉处斑块形成程度不同的患者,其冠脉钙化积分大小均存在显著差异(P均<0.0001).颈动脉分叉处斑块性质更严重时或存在股动脉斑块时,冠脉钙化程度往往更严重.ROC曲线分析颈部分叉斑块、股动脉斑块对严重冠心病预测的AUC分别是0.7394,0.6826;联合两者可提高AUC至0.7686.基于颈动脉分叉处斑块,预测冠心病严重性的灵敏度89.19％,特异度58.70％;基于股动脉斑块斑块,灵敏度81.08％,特异度55.43％;若两种因素同时考虑则灵敏度93.33％,特异度60.38％.结论 外周动脉斑块与冠脉粥样硬化严重程度存在相关性,颈动脉、股动脉血管超声可作为一个简单的非侵入性操作来评估冠脉粥样硬化的严重程度,颈动脉分叉斑块相较股动脉斑块对严重冠脉粥样硬化预测价值更高,联合两者,增加CAG术前筛查严重冠心病的可靠性.

目的 应用三维斑点追踪成像(3D-STI)技术评价非瓣膜性心房颤动(房颤)患者左心房功能及同步性.方法 选择阵发性房颤患者30例、持续性房颤患者25例和健康体检者30例分别为阵发性房颤组、持续性房颤组和对照组.应用3D-STI测量左心房三维整体纵向、圆周、径向应变(GLS、GCS、GRS)及各应变标化达峰时间标准差(SD-TPLS、SD-TPCS、SD-TPRS),计算左心房僵硬度(LASt),比较三组间的差异以及LASt与三维应变参数的相关性.结果 与对照组比较,阵发性房颤组和持续性房颤组左心房各应变参数降低,各应变标化达峰时间标准差和LASt增加(P＜0.05).与阵发性房颤组相比,持续性房颤组GLS、GCS、GRS降低,SD-TPLS和LASt增加(P＜0.05).LASt与GLS、GCS、GRS呈负相关(t=-0.85、-0.85、-0.78,P＜0.01),与SD-TPLS、SD-TPCS、SD-TPRS呈正相关(rs=0.69、0.51、0.64, P＜0.01).结论 阵发性房颤患者和持续性房颤患者左心房应变及同步性出现不同程度的减低,3D-STI可有效评估房颤患者左心房功能和同步性改变.

目的 探讨三维斑点追踪成像(3D-STI)评价高血压合并阵发性房颇患者左心房功能的临床应用价值.方法 选取阵发性房颤(PAF)患者65例,分为阵发性房颤合并高血压组PAF-HT(+)32例,阵发性房颤不合并高血压组PAF-HT(-)33例.对照组为31例健康志愿者.应用3D-STI测量左房容积、左房射血分数(LAEF)、左房整体应变及同步性指标.结果 PAF-HT(+)组和PAF-HT(-)组左房整体应变、LAEF均较对照组减低,且PAF-HT(+)组低于PAF-HT(-)组.PAF-HT(+)组和PAF-HT(-)组同步性指标均较对照组延长,且PAF-HT(+)组高于PAF-HT(-)组.结论 阵发性房颤患者左房功能受损,且PAF-HT(+)组左房功能受损较PAF-HT(-)组更严重.3D-STI可用于评价高血压合并阵发性房颤患者左房功能,为临床诊断和治疗提供依据.

Left atrial (LA) adaptive changes associated with pre-eclampsia (PE) have not been adequately addressed. This study aimed to evaluate the usefulness of LA myocardial function indices in detecting early cardiac alterations in PE. Using speckle tracking echocardiography (STE), LA volumetric and myocardial parameters were acquired in PE women with preserved left ventricular (LV) systolic and diastolic function based on standard criteria and normotensive controls. LA compliance was assessed by the ratio of reservoir strain (LASr) to the estimated LA pressure (E/e’). Subtle systolic and diastolic abnormalities were identified as LV global longitudinal strain < 17.8% and mitral tissue e’ velocity < 7 cm/s septal or < 10 cm/s lateral, respectively. LASr/(E/e’) was prior to other LA measurements in detecting early LA function changes in PE. The rate of LASr/(E/e’) < 3 was significantly greater in the patients with subtle systolic impairments than those without (P < 0.05) in spite of similar proportion of LASr < 31% between them. Among PE women with subtle diastolic damages, the frequencies of anomaly and the values in both LASr/(E/e’) and LASr were significantly different to those without (P < 0.05). Moreover, the rate of LASr/(E/e’) < 3 was markedly higher than that of LASr < 31% in PE cases with subtle cardiac abnormalities (P < 0.05). In the setting of PE with preserved systolic and diastolic function, STE-derived LA strain and estimated LA compliance may be beneficial to identifying earlier cardiac alternations. LA compliance could outperform LASr in detecting cardiac anomalies earlier during a PE pregnancy with preserved LV performance.

1 临床资料 患者 男,73岁.因"发作性胸痛20年,进行性加重1周",于2019年10月10日在青岛大学附属医院就诊.现病史:患者近20年反复出现无明显诱因胸痛,夜间平卧入睡无憋醒,2016年6月于本院心内科给予前降支置入支架一枚,病情仍未缓解.既往病史:高血压病史20年;冠心病史6年,4年前行冠状动脉左前降支近端支架置入术.入院查体:主动脉听诊区可闻及舒张期杂音,P2稍亢,伴分裂,股动脉枪击音(-).超声心动图示:左心室扩大,左心室舒张末期内径6.2 cm,左心室射血分数38％,左心室壁节段性运动异常;主动脉瓣四叶式畸形,主动脉瓣重度反流(图1～2).冠状动脉造影示:左前降支支架通畅(图3).胸腹部增强CT结果及相关测量数据显示:瓣环为椭圆形,周长67 mm,平均内径21.3 mm,瓣膜见点状钙化;四叶式法氏窦(图4)周长124.2 mm,直径分别为34.5 mm、31.0 mm、32.5 mm、30.7 mm,左冠状动脉高度20.4 mm,右冠状动脉高度13.2 mm,胸腹主动脉未见明显异常,双侧股动脉最小直径≥7.6 mm.该患者心功能不全(美国纽约心脏病协会心功能分级Ⅲ级),纠正后反复再发,伴夜间阵发性呼吸困难.美国心胸外科学会评分系统示手术的病死率为9.32％,外科手术风险极高危,且四叶式主动脉瓣(quadricuspid aortic valve,QAV)罕见.经青岛大学附属医院心脏瓣膜团队评估,决定选择经导管主动脉瓣置入术(transcatheter aortic vale implantation,TAVI)进行瓣膜置入.

患者女,53岁,因发作性胸闷痛半个月就诊.体格检查:神志清楚、精神好,心率80次/min,律齐,各瓣膜听诊区未闻及病理性杂音.心电图提示:窦性心律.经胸超声心动图(TTE):各房室腔内径正常范围;各瓣膜未见明显异常,三尖瓣轻度反流;左室壁节段性运动未见异常;房、室间隔连续完整;大动脉起源、连接正常;肺静脉未见异常引流;左室射血分数62％;左房后外侧探及囊性包块,大小约3.9 cm×4.3 cm,与左房相通,开口处径线3.9 cm(图1).经食管超声心动图(TEE)检查:左心耳菲薄,呈瘤样扩张膨凸,开口处径线3.3 cm,深度4.6 cm,瘤腔内见云雾状回声,未见血栓形成(图2,3).TEE联合TTE诊断:左心耳瘤,瘤腔内未见血栓形成.由于患者左心耳瘤未压迫房室腔且无明显临床症状,暂未行外科手术治疗,仅建议定期随访观察.

Background Mitral regurgitation volume (MRvol) by quantitative pulsed Doppler (QPD) method previously recommended suffers from geometric assumption error because of circular geometric assumption of mitral annulus (MA). Therefore, the aim of this study was to evaluate the impact of different geometric assumption of MA on the assessment of MRvol by two-dimensional transthoracic echocardiographic QPD method. Methods This study included 88 patients with varying degrees of mitral regurgitation (MR). The MRvol was evaluated by QPD method using circular or ellipse geometric assumption of MA. MRvol derived from effective regurgitant orifice area by real time three-dimensional echocardiography (RT3DE) multiplied by MR velocity-time integral was used as reference method. Results Assumption of a circular geometry of MA, QPD-MA A4C and QPD-MA PLAX overestimated the MRvol by a mean difference of 10.4 ml ( P < 0.0001) and 22.5 ml ( P < 0.0001) compared with RT3DE. Assumption of an ellipse geometry of MA, there was no significant difference of MRvol (mean difference = 1.7 ml, P = 0.0844) between the QPD-MA A4C + A2C and the RT3DE. Conclusions Assuming that the MA was circular geometry previously recommended, the MRvol by QPD-MA A4C was overestimated compared with the reference method. However, assuming that the MA was ellipse geometry, the MRvol by the QPD-MA A4C + A2C has no significant difference with the reference method.

Background: Pre-eclampsia (PE) is a severe obstetric complication associated with many cardiovascular disorders. Left atrial (LA) function and its relevance to the cardiovascular adaptation changes associated with PE have not been adequately addressed. The aim of this study was to quantify LA myocardial deformation characteristics in women with PE using speckle tracking echocardiography (STE). Methods: Using STE, LA global longitudinal strain (LAGLS), phasic LA strain values and LASr/(E/e'), which was the value of LA reservoir strain (LASr) divided by the quotient of early mitral flow velocity (E) and diastolic mitral ring velocity (e'), were compared among nonpregnant controls (n=39), normotensive pregnant women (n=40), and PE (n=43) patients. Results: LAGLS, LASr and LA conduit strain reduced in PE group in spite of no difference of LA contraction strain among the three groups. LASr/(E/e'), the surrogate of LA compliance, was decreased during PE pregnancy. The multivariate regression analyses showed LAGLS was independently correlated with LASr/(E/e'), left ventricular global longitudinal strain and LA maximum volume. Conclusion: PE cases undergo impaired LA myocardial function and decreased atrial compliance. STE-derived LA strain may be a powerful diagnostic parameter to evaluate diastolic function with the progression of PE pregnancy.

Accurate quantification of mitral regurgitation (MR) severity is critical for appropriate clinical decision making regarding surgical intervention. General imaging three-dimensional quantification (GI3DQ) method allows for direct measurement of mitral regurgitant jet volume (MRJvol) with the help of three-dimensional (3D) color flow Doppler imaging. The aim of this study was to evaluate diagnostic value of MRJvol by GI3DQ for MR grading severity, using the guideline recommended integrated approach as a reference. The study included ninety-seven patients with varying degree of MR, and all MR cases were divided into central MR group (n = 44) and eccentric MR group (n = 53). The MRJvol was measured by GI3DQ. The severity of MR was graded on the basis of recommended integrated approach as mild, moderate, or severe. As assessed by receiver operating characteristic analysis, MRJvol by GI3DQ at a cutoff value of 43.4 ml yielded 76.9% of sensitivity and 86.9% of specificity to differentiate moderate from severe MR in all cases, a cutoff value of 47.5 ml yielded 98.9% of sensitivity and 94.4% of specificity to differentiate moderate from severe MR in central MR, and a cutoff value of 40.7 ml yielded 80.0% of sensitivity and 78.6% of specificity to differentiate moderate from severe MR in eccentric MR. MRJvol measured by GI3DQ could assess MR severity, especially in central MR group, which has higher sensitivity and specificity to differentiate moderate from severe MR.

•Early onset preeclampsia shows more worsened longitudinal layer-specific strain.•The prominent myocardial damage occurred in endocardium in early onset preeclampsia.•Early onset preeclampsia shows higher inner-to-outer gradient of longitudinal strain.

患者女,48岁.因体检发现右肺占位入院.CT提示:右肺上叶前段见斑片状磨玻璃影,边界模糊,大小约2.2 cm×1.5 cm×1.3 cm,拟行右肺上叶切除+淋巴结切除术.术前于右肺肿瘤处在CT引导下置入Hookwire定位针,但术中未发现定位针.遂行紧急胸部CT检查显示:左心房及左心室内见探针样金属密度影,总长度约6 cm,心包腔内微量积液(图1).急诊超声心动图示:左室腔内见金属定位针回声,总长度约3.5 cm,一端位于近心尖的左室后壁心内膜处,另一端靠近二尖瓣下方,随心动周期轻微摆动,二尖瓣瓣叶启闭未受影响,微量心包积液(图2).遂行急诊心外科手术,术中见一细针自左心房经二尖瓣进入左心室,心房段较细,末端位于右肺上、下静脉之间,未穿透左房壁,心室段较粗,末端位于左心室近心尖处,二尖瓣结构未受损.手术将定位针完整取出(图3).

多种疾病可对左心房结构和功能造成影响.超声心动图可无创评价左心房容积和功能,并提供多个定量指标对疾病进行诊断和评估预后.基于二维超声心动图的椭圆体模型法和辛普森法可以测量不同功能时相左心房的容积,评估左心房功能.斑点追踪、实时三维超声心动图和速度向量成像等新技术可以更加全面地反映左心房功能.本文对超声心动图评价左心房容积和功能的研究进展进行综述.

Background: The association between interleukin-8 (IL-8) gene polymorphism -251 A>T and susceptibility to coronary artery disease (CAD) has been investigated previously; however, results remain controversial. Thus, a meta-analysis was conducted to reassess the effects of this polymorphism on CAD risks. Methods: The PubMed, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases were searched for relevant studies published up to December, 2018. The pooled odds ratios (OR) were calculated using STATA 13.0 software for allelic (A vs T) as well as homozygote (AA vs TT), heterozygote (AT vs TT), recessive (AA vs AT + TT), and dominant (AA + AT vs TT) genotype models, respectively. Results: Ten case-control studies (3744 cases and 3660 controls) were included. Overall, a significant association of IL-8 gene -251 A > T polymorphism with an increased risk of CAD was only observed in the dominant genotype model (OR = 1.48), but not others. In the subgroup analysis, significantly increased risks were also found for Chinese (OR = 1.64), polymerase chain reaction-restriction fragment length polymorphism genotyping (OR = 1.61), acute coronary syndrome (ACS) type (OR = 1.92 for 3 datasets; OR = 1.88 for 4 datasets), high quality (OR = 1.64), and age/gender matching status (OR = 1.55) under the dominant model. Furthermore, significantly increased risks were also found for ACS type under allelic (OR = 1.32 for 3 datasets; OR = 127 for 4 datasets), homozygote (OR = 1.64 for 3 datasets; OR = 1.50 for 4 datasets), heterozygote (OR = 1.32 for 3 datasets; OR = 1.30 for 4 datasets), and recessive (OR = 1.40 for 3 datasets; OR = 1.28 for 4 datasets) models. Conclusion: This meta-analysis suggests that Chinese patients carrying -251A allele of IL-8 may have an increased risk for the development of CAD, especially ACS.

目的 应用三维斑点追踪成像评价不同血压控制程度的高血压患者左心室早期收缩功能.方法 选择2017年3月至2018年7月就诊的2级高血压患者140例,根据治疗情况分为未治疗组(A组,n=45)、血压控制正常组(B组,n=50)、血压控制不良组(C组,n=45),选择正常血压者为对照组(n=30).所有受检者入院后非同日测量3次血压,获取平均收缩压、舒张压及心率,接受二维及三维超声、三维斑点追踪成像检查,获取早期收缩功能指标,包括左心室整体纵向峰值应变(GLS)、圆周峰值应变(GCS)、径向峰值应变(GRS)、左心室整体峰值扭转角度(Ptw)、扭矩等参数.结果 高血压A、B、C组GLS和GCS减低,且A组较对照组GLS[(-14.8±3.0)％比(-21.9±2.3)％,P＜0.05]、GCS[(-16.5±2.7)％比(-23.7±2.6)％,P＜0.05]明显减低,C组较B组GLS[(-14.7±3.1)％比(-18.1±2.6)％,P＜0.05]、GCS[(-16.3±2.8)％比(-19.0±2.3)％,P＜0.05]明显减低.A、C组较对照组GRS[(38.2±8.5)％,(37.8±8.4)％比(48.6±6.3)％,均P＜0.05]减低.与对照组相比,A、B、C组Ptw增强,A、C组扭矩增强,C组Ptw明显高于B组(P＜0.05).分别对A组和C组GLS行多元线性回归分析,结果显示收缩压对GLS影响最大(分别β=0.680、0.684,P＜0.05).结论 应用三维斑点追踪成像可以评价高血压患者早期收缩功能,且不同血压控制程度的高血压患者左心室早期收缩功能受损程度明显不同.

Objective:The purpose of this study was to investigate the correlation between left atrial parameters and left ven-tricular diastolic dysfunction in essential hypertensive patients and the correlation with E/Em parameters. Methods:90 patients with essential hypertension as hypertension group and 50 healthy volunteers as control group,left atrial index,including left atri-al diameter (LAD),left atrial volume (LAV) were measured by conventional echocardiography. According to the body surface area (BSA),calculating left atial dimension index (LADI) and left atrial volume index (LAVI). LV diastolic function was as-sessed by measurements of peak early transmitral flow velocity ( E )、peak late transmitral flow velocity ( A ) by adopting PW-Doppler (the E/A ratio),peak early diastolic mitral annular velocity (Em) by adopting tissue Doppler and the E/Em ratio. In addition,18 left ventricular wall segments in the early and late diastolic myocardial strain and strain rate obtained by tissue Doppler,record the total heart diastolic function decreased ventricular segment number. Results:Compared with normal control group,left atrial diameter and volume were significantly increased in patients with hypertension (P<0.05),and ventricular dias-tolic dysfunction was significantly higher than the normal control group (all P<0.05);according to the left atrial volume index (LAVI),the cases of hypertension were divided into three groups:group A (left atrial size in normal group),group B (mild left atrial enlargement group) and group C (severe left atrium enlargement group). Compared with group A,total number of ventric-ular diastolic dysfunction segments and E/Em in group B and group C increased (P<0.05). Compared with group A,the Mean Em in group B and C were decreased (P<0.05). LAVI was positively correlated with total ventricular segment with diastolic dysfunction and E/Em (r=0.89,r=0.92,P<0.01). Conclusion:The left atrium remodeling is closely related to the left ventricular diastolic function,and the left atrial volume index (LAVI) has a good correlation with E/Em,and LAVI can be used as an in-dex to evaluate the left ventricular diastolic function.

This study aimed to assess the changes of RA function in patients with obstructive sleep apnea syndrome (OSAS) using velocity vector imaging (VVI) and to evaluate the application of VVI technology.

1 病例简介 男,39岁,主诉:发热半个月.体格检查:心尖区Ⅲ/6级杂音,肺动脉瓣第二心音亢进.实验室检查:白细胞计数12.5×109/L,中性粒细胞0.88,血沉95 mm/h.超声检查见图1.超声诊断:二尖瓣瓣周瘘管.术中二尖瓣瓣周处可见脓肿,大小约2.0 cm×2.0 cm,中央破溃形成瘘管,大小约1.5 cm× 1.7 cm,左心房与左心室经瘘管相通,未累及二尖瓣叶,左心房脓肿处探及微小赘生物2枚,心包积液透明略显浑浊.术中切除赘生物,清创脓肿,由于脓腔较大,清创遗留的缺损采取自体心包修复.术后超声显示二尖瓣环处结构连续完整,术前瘘管处反流消失.

Objective: To evaluate the value of two-dimensional strain rate imaging (STE) in detecting the alteration of regionally left ventricular long-axis systolic function in patients with slow coronary flow (SCF). Methods: 24 patients who were with SCF but without significant coronary artery stenosis in LAD were included in left anterior descending artery (LAD) group, and 15 patients with slow flow in right coronary artery (RCA) were included in RCA group, and 20 patients who were without significant coronary stenosis or abnormal corrected thrombolysis in myocardial infarction frame count (CTFC) were included in control group. CTFC was carried on 3 groups. Peak systolic strain rate (PSRs) were measured at basal, middle and apical segments in left ventricular walls, including the septal, lateral, inferior and anterior. Results: CTFC of left anterior descending coronary artery blood flow (39.88 ± 7.48) was significantly higher in LAD group than control group (19.84 ± 5.91, P<0.01). CTFC of right coronary artery blood flow (23.78 ± 8.15) was significantly higher in RCA group than control group (21.55 ± 8.12, P<0.01). PSRs of anterior wall in LAD group and interior wall in RCA group were significantly lower than that in control group (P<0.01). Linear regression showed that the CTFC of left anterior descending artery was negatively correlated with the PSRs of anterior wall (r=-0.55, P<0.01), as well as the CTFC of right coronary artery and the PSRs of interior wall in RCA group (-0.86, P<0.01). Conclusions: STE can evaluate the regional left ventricular long-axis systolic function in the patients with SCF.

三尖瓣反流(TR)是常见的瓣膜疾病,22%~53%[1]的二尖瓣或二尖瓣和主动脉瓣双瓣病变可伴TR,以功能性三尖瓣反流(FTR)多见.FTR多继发于左心瓣膜疾患,是二尖瓣疾病最常见的并发症[1].既往研究认为,二尖瓣置换术后TR会有不同程度减轻;而近年观察发现,近50%[1]术前不存在TR的患者二尖瓣外科术后出现不同程度TR,一些术前较轻的TR患者,术后TR反而渐进性加重;因此,正确认识二尖瓣术后TR的原因,可以帮助临床合理选择手术方案,有效改善患者生存质量及远期预后.二尖瓣术后TR的原因及三尖瓣的处理指征目前仍无统一定论,现就相关研究现状及进展做一综述.