Transcript ClinicalKey - Improving Clinical Decisions and Processes ClinicalKey - 改进临床决策和过程 How to get better answers faster to challenging questions in cardiology？ 如何快速回答挑战性心脏病问题？ 注:此案例成型于2012年，因此仍是ClinicalKey老版界面，与新版ClinicalKey (2014年9月升级）有所不同，供大家参考。

ClinicalKey - Improving Clinical Decisions and Processes
ClinicalKey - 改进临床决策和过程
How to get better answers faster to challenging questions in cardiology？
如何快速回答挑战性心脏病问题？
注:此案例成型于2012年，因此仍是ClinicalKey老版界面，与新版ClinicalKey
(2014年9月升级）有所不同，供大家参考。
Clinical Case 临床案例 (1/3)
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72 year old woman presents with worsening fatigue, ankle edema, abdominal
bloating & dyspepsia for 6 months.
患者女，72岁，疲劳、踝关节水肿、腹胀和消化不良进行性加重6个月
Fatigue started 3 years ago when echocardiogram showed
疲劳始发于3年前，当时的超声心电图显示：
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normal biventricular size & function 双室大小功能正常
mild mitral regurgitation 轻度二尖瓣反流
mild to moderate tricuspid regurgitation 轻到中度三尖瓣反流
mildly enlarged atria 轻度心房增大
Doppler findings consistent with impaired left ventricular relaxation and elevated filling
pressures 多普勒彩超结果与左心室舒张受损，充盈压增高一致
Treated with a thiazide diuretic.
既往治疗：噻嗪类利尿剂
No other significant past history.
无其他重要既往史
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Clinical Case临床案例 (2/3)
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Physical examination
体格检查
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blood pressure of 134/70, heart rate of 89 irregular 血压134/70, 心率89，不规则
clear lung fields 肺野清晰
jugular venous pressure of 12cm with a prominent v wave. 颈静脉压力12cm, V波显著
apical impulse not palpable 心尖搏动不能触及
slight right ventricular tap along left sternal border, first & second heart sounds were
normal 沿胸骨左缘右心室杂音, 第一、二心音正常
fourth heart sound & grade 2/6 pansystolic mumur at lower left sternal border that
increased in intensity with inspiration 胸骨左下缘听诊，第四心音& 全收缩期心脏
杂音2/6级，吸气时增强
Liver edge palpable & tender 肝脏边缘可触及，质软
Abdomen distended 腹胀
2+ lower leg edema. 下肢2度水肿
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Clinical Case临床案例(3/3)
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Initial laboratory work 初步实验室检查
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ECG心电图
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atrial fibrillation with average rate of 86, but no other abnormalities 房颤，平均心率86，
无其他异常
Echocardiogram 心脏超声
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mildly elevated liver function tests, BNP of 279, INR of 1.4, creatinine of 1.1
肝功轻度增高， 脑尿钠肽BNP 279, (凝血指标)INR 1.4, 肌酐1.1
normal left ventricular size and function 左心室大小功能正常
mildly dilated right ventricle with normal function 右心室轻度增大，功能正常
marked bilateral atrial enlargement 左右心房明显增大
mild mitral & severe tricuspid regurgitation, with normal valve anatomy 二尖瓣轻度反流，
三尖瓣重度反流，瓣膜解剖正常
Diastolic function 舒张功能
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could not be determined due to atrial fibrillation 由于房颤无法确定
estimated PASP is 52 mmHg and LVOT VTI is low 估计PASP 52 mmHg，LVOT VTI低
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Tricuspid regurgitation 三尖瓣反流
Source: Indian J Endocrinol Metab. 2011 Apr-Jun; 15(2): 137–139,
Mohammad Hayat Bhat et al.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125005/
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Treatment plan – questions 治疗方案和问题？
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Treatment with loop diuretic 利尿剂治疗
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Treatment with beta blocker β受体阻滞剂治疗
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Improved edema & abdominal distention, but fatigued remained especially on exertion, and
low appetite. 水肿腹胀症状减轻，但是仍有疲劳感，特别是劳累时，食欲差
Increased fatigued so stopped 由于疲劳感加重，停止
Cardioversion rejected as therapeutic option due to atrial sizes 由于心房增加，未用心
脏电复律治疗
Questions:问题
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Medical therapy for significant tricuspid regurgitation?
显著三尖瓣反流的药物治疗方案？
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Indications for surgery in significant tricuspid regurgitation, possibly due to
annular dilatation and right atrial dilatation?
显著三尖瓣反流的手术指征，可能由于三尖瓣环和右心室扩张？
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If surgery contemplated - repair, annuloplasty, biologic valve, or mechanical
valve?
若要手术 – 如何修补，瓣环成形术，生物瓣膜还是机械瓣膜？
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61 pts isolated severe TR had surgery 61例孤立性重度三尖瓣反流接受过手术
93% had previous left valve surgery 93% 曾有左瓣膜手术史
Operative mortality 10% 术中死亡率10%
Long term 3 died and 6 were rehospitalized for cardiovascular problems 长期随访3人
死亡，6人因心血管问题再入院
Over 32 months follow up 75% event free survival 32个月随访，75% 存活正常
61% improved their functional class 61% 功能改善
Predictors of good outcome: RV area <20cm2 and Hgb >11 良好预后的影响因素：
右心室面积小于20平方cm， Hgb大于11
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Small, retrospective, observational study of the results of TV annuloplasty for
functional TR
功能型TR的TV瓣环成形术小型回顾性观察研究
Assumption: Annular dilatation is the major cause of function TR
假设：环形扩张是功能性TR的主要原因
Predictors of residual TR (mod-severe) at one year: Preop LVEF <37% and
Tethering of the TV
(中重度)TR一年期生存预后指标:Preop LVEF <37% and TV的活动情况
Predictors of hospital discharge residual TR: EF and preop TR severity
残存TR再入院预测指标：EF和TR严重程度
Severity of TR during follow-up related to RV pressure
随访期间TR的严重程度与RV压力相关
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Clinical Case Conclusions 案例结论
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In support of surgery:支持手术
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Symptomatic despite medical therapy 尽管药物治疗，症状仍然存在
Severe tricuspid regurgitation 重度三尖瓣反流
Mild pulmonary hypertension 轻度肺高压
Mildly dilated RV with normal function 轻度RV扩张，功能正常
Normal TV anatomy TV解剖正常
Normal LV systolic function LV收缩功能正常
No previous cardiac surgery 既往无心脏手术史
No significant co-morbidities 无明显并存疾病
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Thanks！
谢谢！
如果您想了解更多ClinicalKey临床案例征集大赛相关问题，欢迎致电
或致函爱思唯尔医学部北京办公室：
电话： 010 8520 8718
电邮：[email protected]
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