【翻译】慢性血栓栓塞性肺动脉高压（新英格兰医学杂志系列034）

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【翻译】慢性血栓栓塞性肺动脉高压（新英格兰医学杂志系列034） [精华]

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2008-05-11 12:35

Chronic Thromboembolic Pulmonary Hypertension

A previously healthy 35-year-old man had increasing dyspnea on exertion over a period of several months. The results of a physical examination and transthoracic echocardiography suggested that he had pulmonary arterial hypertension and severe tricuspid regurgitation. A contrast-enhanced helical computed tomographic (CT) scan of the chest was obtained to look for evidence of pulmonary thromboembolism and to assess the lung parenchyma. Contiguous axial CT images through the main pulmonary arteries (Panel A) showed eccentric endothelialized thrombi in both pulmonary arteries (arrows). A CT image obtained at the level of the aortic arch (Panel B ) showed a disparity in the pulmonary vasculature, with more visible pulmonary-artery branches in the left lung (arrows) than in the right. A CT image obtained at the same level with lung windows (Panel C) demonstrated a mosaic pattern of attenuation; the areas of higher attenuation (arrows) were areas of lung that are normally perfused.
The combined pulmonary findings of eccentric endothelialized thrombi, disparity of the vessels, and mosaic attenuation on thoracic CT images in a patient with pulmonary arterial hypertension suggest the presence of chronic thromboembolic pulmonary hypertension. The CT findings that are characteristic of this disorder differ from those associated with acute pulmonary thromboembolism in that the filling defects (emboli) are eccentrically located within the pulmonary-artery branch rather than centrally located.

In this patient, as in most patients with chronic thromboembolic pulmonary hypertension, the cause of hypercoagulability was not found. Despite the placement of an inferior vena cava filter and treatment with warfarin, the patient's dyspnea progressed. He subsequently underwent pulmonary thromboendarterectomy, which relieved his symptoms. A repeated echocardiogram showed minimal tricuspid regurgitation and a normal right ventricle.

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2008-05-11 12:35

如图所示

专家视点……倾力奉献……心胸外科讨论版最新推出医学双语之《新英格兰医学杂志》专版，开阔您的视野，提高您的专业英语水平！

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约瑟福

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2008-05-11 17:19

35岁男性，既往健康，诉劳力性呼吸困难数月。体格检查和经胸超声心动图提示存在肺动脉高压和重度三尖瓣反流。进行胸部对比增强螺旋CT寻找肺动脉栓塞的证据，并评估肺实质。主肺动脉层面可见双侧肺动脉偏心的内皮状的血栓 (图 A)；主动脉弓层面提示双肺不一致，左肺可见更多的肺血管分支 (图 B )；同样的平面在肺窗则可见镶嵌样衰减图象，高度衰减地区域(箭头)是灌注正常的肺区。CT上同时合并偏心的内皮状的血栓、血管床的不一致、镶嵌样衰减图象的肺动脉高压病人提示为慢性血栓栓塞性肺高压。这可与急性肺动脉血栓栓塞导致的肺动脉的充盈缺损影通常为中心型的相鉴别。
此病人与大多数慢性肺动脉高压病人一样，血液高凝的原因不明。尽管植入了下腔静脉滤网并使用华发林治疗，病人仍然进行性的呼吸困难，随后病人接受了肺动脉内膜血栓切除术，症状得到了缓解。术后超声心动图显示微量三尖瓣反流和正常的右心室。

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