摘要目的 应用前后对照设计评价溶栓治疗以及肝素抗凝治疗是否可以有效改善急性肺血栓栓塞症(PTE)引起的左心室结构与功能改变.方法 收集2006年1月至2011年6月北京安贞医院急诊重症监护病房的住院急性PTE患者71例,其中男36例,女35例,平均年龄(64±13)岁；分为溶栓治疗组(37例)和肝素抗凝治疗组(34例).溶栓组患者治疗前及溶栓结束后24h内分别完成经胸多普勒超声心动评价,肝素抗凝组治疗前及肝素抗凝治疗5～7d后,均行多普勒超声心动图检查.同期收集来自同一医院体检中心的健康体检者51名,设为对照组,其中男29名,女22名,平均年龄(61±9)岁.经胸多普勒超声测量左心室舒张末期与收缩末期内径,计算左心室射血分数；测量左心室舒张早期(E)和左心房收缩期(A)二尖瓣前向血流速度,并应用E/A比值反映舒张早期与心房收缩期血流对左心室舒张充盈的相对贡献.结果 急性PTE患者治疗前,左心室舒张末期内径[(42±5) mm]显著低于对照组[(46±5)mm,t=3.629,P＜0.01],左心室舒张期E峰流速及E/A比值(0.8±0.3)显著低于对照组(1.2±0.3,t值分别为5.296,6.510,P＜0.01),A峰流速显著高于对照组(t =3.065,P＜0.05).与治疗前相比,治疗后PTE患者左心室舒张末期[(46±5)mm]与收缩末期内径[(30±6) mm]均明显增加(t值分别为5.284,3.983,P＜0.01),左心室舒张期E峰流速及E/A比值显著改善(t值分别为3.452,2.604,P＜0.05).两治疗组分别与治疗前比较结果显示,患者左心室舒张末期内径(t值分别为4.145,3.269)与收缩末期内径(t值分别为2.896,2.761)均明显增加(均P＜0.05),左心室舒张期E峰流速均显著提高(t值分别为2.505,2.492,均P＜0.05).治疗后PTE患者左心室舒张期E峰流速以及E/A比值仍显著低于健康对照(t值分别为2.615,3.837,均P＜0.01),A峰流速仍高于健康对照者(t=3.290,P＜0.01).结论 有效的溶栓治疗或肝素抗凝治疗可以改善急性PTE患者左心室功能.

abstractsObjective The purpose of the present study mainly aimed to evaluate whether thrombolysis and heparin anticoagulation for acute pulmonary thromboembolism (PTE) could improve the abnormal left ventricular diastolic filling induced by acute PTE.Methods A total of 71 acute PTE patients (36 males and 35 females; age 64 ± 13 years,range 24 -87 years) admitted to the emergency intensive care unit of Beijing Anzhen Hospital were consecutively recruited from January of 2006 to June of 2011.Fifty-one age-and gender-matched healthy controls (29 males and 22 females,age 61 ±9 years,range 31 -79 years)were also recruited from Health Center during the same period of time.PTE patients were classified into 2 treatment subgroups according to initial therapy,thrombolysis subgroup (n =37 ) and direct anticoagulation subgroup with heparin (n =34 ). Pre- and post-treatment,trans-thoracic Doppler echocardiography was used to assess left ventricular diameters and diastolic filling patterns.Trans-mitral flow velocities including early (E) and late atrial (A) filling velocities were measured,and E/A ratio was calculated reflecting the relative contribution of early and atrial filling.Results Compared with healthy controls,patients with acute PTE had significantly smaller left ventricular end-diastolic diameter ( t =3.629,P＜0.001),lower mitral E velocity and E/A ratio (t =5.296,6.510,both P ＜0.001 ),and higher A velocity ( t =3.065,P ＜ 0.01 ).After initial treatment including thrombolysis and direct anticoagulation with heparin for all patients with acute PTE,left ventricular end-diastolic diameter and end-systolic diameter were enlarged significantly ( t =5.284,3.983,both P ＜ 0.001 ),and mitral E velocity and E/A ratio were increased significantly (t =3.452,2.604,P ＜0.05,respectively).Subgroup analysis revealed that,both thrombolytic therapy and anticoagulation with heparin could significantly enlarge left ventricular end-diastolic diameter ( t =4.145,3.269,respectively) and end-systolic diameter ( t =4.145,3.269,respectively,all P ＜ 0.050),and increase mitral E velocity ( t =2.505,2.492,P ＜ 0.05,respectively).Compared with healthy controls,even after initial treatment with thrombolysis or heparin anticoagulation,PTE patients still showed lower mitral E velocity and E/A ratio ( t =2.615,3.837,P ＜ 0.05,respectively ),and higher A velocity (t =3.290,P ＜ 0.01 ).Conclusion The results strongly suggest that initial treatment for acute PTE with thrombolysis and heparin anticoagulation could improve the abnormal left ventricular diastolic filling induced by acute PTE.