作者:郑梅
北京积水潭医院心内科
作者简介
郑梅
北京积水潭医院
北京积水潭医院心内科 副主任医师 2009年毕业于北京大学医学部 博士研究生。
现任 北京心血管青年委员会委员 北京医师协会高血压专业委员会委员 北京慢病研究会心血管病分会委员。
前言
病例摘要
患者84岁,老年女性。主因“活动后呼吸困难2年,发作性晕厥1次”入院。患者2年前走路后出现呼吸困难伴乏力,休息数分钟可缓解,无头晕,黑朦,无咳嗽,咳痰,无胸闷胸痛。冠脉造影检查未见异常。超声心动图检查提示主动脉重度狭窄。未引起注意。1月前走路时出现呼吸困难伴晕厥,意识完全丧失,小便失禁。无四肢抽搐,持续10分钟后意识恢复。头颅核磁检查未见异常。排除快速或缓慢心律失常引起的晕厥,考虑与重度主动脉狭窄有关。为求进一步诊治入院。
既往史:高血压20年,口服苯磺酸氨氯地平和琥珀酸倍他乐克,血压控制良好。
入院查体:T36.3℃,P75次/分,R18次/分,BP137/63mmHg,一般情况可,自由体位,神志清楚,双肺呼吸音清,未闻及干湿性啰音。心律齐,主动脉瓣听诊区可闻及收缩期杂音。双下肢无水肿。实验室检查未见异常。
心电图示:窦性心律 左室高电压 ST-T改变 PR 0.18S,QRS小于0.12S(图1)。
图1:窦性心律 左室高电压 ST-T改变 PR 0.18S,QRS小于0.12S
超声心动图示:主动脉瓣狭窄重度伴关闭不全(轻度),EF58%(图2)。
图2:超声心动图
主动脉CTA评估:TYPE1型二叶瓣,重度钙化,左右可见钙化融合脊,法式窦结构可,双冠高度可,升主动脉增宽,最宽处约46 mm,心脏角度不大,左室大,心尖部可见囊状造影剂填充,考虑多系小室壁瘤,术中需谨慎操作,主动脉弓部走行较平缓(图3)。
图3:主动脉CTA
诊断:主动脉瓣狭窄(重度)心功能II级(NYHA分级)窦性心律 高血压病2级(很高危险组)
入院后经过团队评估和术前准备,对患者行经股动脉TVAR手术,手术过程顺利。心电监护:患者术中出现即刻III°AVB,术后6小时恢复窦性心律伴完全性左束支阻滞,心室率波动在75-100次/分。患者术后96小时出现四肢抽搐,眼睑外翻。心电监护示III°AVB(图4)。植入永久性起搏器治疗。术后恢复好。
图4:术后心电图
讨论
结论
参考文献:
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