Clinical Key Improving Clinical Decisions and Processes Clinical

Clinical. Key - Improving Clinical Decisions and Processes Clinical. Key - 改��床决策和�程 How to get better answers faster to challenging questions in cardiology？ 如何快速回答挑�性 心�病��？ 注: 此案例成型于2012年，因此仍是Clinical. Key老版界面，与新版 Clinical. Key (2014年 9月升�）有所不同，供大家参考。

Clinical Case �床案例 (1/3) § § 72 year old woman presents with worsening fatigue, ankle edema, abdominal bloating & dyspepsia for 6 months. 患者女，72�，疲�、踝关�水�、腹�和消化不良�行性加重 6个 月 Fatigue started 3 years ago when echocardiogram showed 疲� 始�于 3年前，当�的超声心���示： § § § § normal biventricular size & function 双室大小功能正常 mild mitral regurgitation �度二尖瓣反流 mild to moderate tricuspid regurgitation �到中度三尖瓣反流 mildly enlarged atria �度心房增大 Doppler findings consistent with impaired left ventricular relaxation and elevated filling pressures 多普勒彩超�果与左心室舒�受�，充盈�增 高一致 Treated with a thiazide diuretic. 既往治�：���利尿� No other significant past history. 无其他重要既往史 2

Clinical Case�床案 例 (2/3) § Physical examination 体格�� § § § § § blood pressure of 134/70, heart rate of 89 irregular 血� 134/70, 心率89， 不�� clear lung fields 肺野清晰 jugular venous pressure of 12 cm with a prominent v wave. �静脉�力 12 cm, V波�著 apical impulse not palpable 心尖搏� 不能触及 slight right ventricular tap along left sternal border, first & second heart sounds were normal 沿胸骨左�右心室�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�听�，第四 心音& 全收�期心��音 2/6�，吸气�增� Liver edge palpable & tender 肝���可触及，�� Abdomen distended 腹� 2+ lower leg edema. 下肢 2度水� 3

Clinical Case�床案例 (3/3) § Initial laboratory work 初步��室�� § § ECG心�� § § atrial fibrillation with average rate of 86, but no other abnormalities 房�， 平均心率86，无其他异常 Echocardiogram 心�超声 § § § mildly elevated liver function tests, BNP of 279, INR of 1. 4, creatinine of 1. 1 肝功�度增高， �尿� � BNP 279, (凝血指� )INR 1. 4, 肌� 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�度增大，功能正常 marked bilateral atrial enlargement 左右心房明�增大 mild mitral & severe tricuspid regurgitation, with normal valve anatomy 二尖 瓣�度反流，三尖瓣重度反流，瓣膜解剖正常 Diastolic function 舒�功能 § § could not be determined due to atrial fibrillation 由于房�无法确定 estimated PASP is 52 mm. Hg and LVOT VTI is low 估� PASP 52 mm. Hg， LVOT VTI低 4

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/PMC 3125005/ 5

§ Treatment plan – questions 治�方案和�� ？ Treatment with loop diuretic 利尿�治� § § Treatment with beta blocker β受体阻滞�治� § § § Improved edema & abdominal distention, but fatigued remained especially on exertion, and low appetite. 水�腹�症状减�，但是仍有疲�感，特� 是�累�，食欲差 Increased fatigued so stopped 由于疲�感加 重，停止 Cardioversion rejected as therapeutic option due to atrial sizes 由于心房增 加，未用心��复律治� Questions: �� § Medical therapy for significant tricuspid regurgitation? �著三尖瓣反流的�物治�方案？ § Indications for surgery in significant tricuspid regurgitation, possibly due to annular dilatation and right atrial dilatation? �著三尖瓣反流的手�指征，可能由于三尖瓣�和右心室� � ？ § If surgery contemplated - repair, annuloplasty, biologic valve, or mechanical valve? 若要手� – 如何修�，瓣�成形�，生物瓣膜�是机械瓣膜？ 6

7

8

9

10

11

12

13

14

15

16

17

• • 61 pts isolated severe TR had surgery 61例孤立性重度三尖瓣反流接受 �手� 93% had previous left valve surgery 93% 曾有左瓣膜手�史 Operative mortality 10% � 中死亡率10% Long term 3 died and 6 were rehospitalized for cardiovascular problems �期随� 3人死亡，6人因心血管��再入院 Over 32 months follow up 75% event free survival 32个月随�， 75% 存 活正常 61% improved their functional class 61% 功能改善 Predictors of good outcome: RV area <20 cm 2 and Hgb >11 良好�后的 影响因素：右心室面�小于 20平方cm， Hgb大于11 18

19

20

21

22

§ § § Small, retrospective, observational study of the results of TV annuloplasty for functional TR 功能型TR的TV瓣�成形�小型回�性�察研究 Assumption: Annular dilatation is the major cause of function TR 假�：�形��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�后指 � : Preop LVEF <37% and TV的活�情 况 Predictors of hospital discharge residual TR: EF and preop TR severity 残存TR再入院��指� ：EF和TR�重程度 Severity of TR during follow-up related to RV pressure 随�期� TR的�重程度与 RV�力相关 23

Clinical Case Conclusions 案例 �� In support of surgery: 支持手� § ü ü ü ü Symptomatic despite medical therapy 尽管�物治�，症状仍然 存在 Severe tricuspid regurgitation 重度三尖瓣反流 Mild pulmonary hypertension �度肺高� Mildly dilated RV with normal function �度 RV��，功能正常 Normal TV anatomy TV解剖正常 Normal LV systolic function LV收�功能正常 No previous cardiac surgery 既往无心�手�史 No significant co-morbidities 无明� 并存疾病 24