冠狀動(dòng)脈心肌橋的臨床分析

1、漸圧夫孝碩士耕宛生專業(yè)網(wǎng)論文冠軼動(dòng)詠心肌橋的臨痣釧析專業(yè)學(xué)債碩主研究生肅狀動(dòng)關(guān)通常秤邃手心脫im鳩刪姻中如聚這段蹴動(dòng)關(guān)感勲閡l段行走手窒壁心肌樣隼申，在心航收縮時(shí)會(huì)皚躺聊由磁禎購栩麝繃妙肌纖堆覆議的動(dòng)脈段稱為璧冠狀動(dòng)脈，這段心肌紆耀稱為酈畑嘛心am，馳 認(rèn)為心肌橋星種剣嫻皺 個(gè)倒渤研做觀m特齣柝網(wǎng)凝琪室相湖軸速、昨傳硼獺 急性利畑鴉綜釧e、丿痢礪幌蜒癩性極縫心血管剛饑心肌橋的何種臨床蒔鏈可能增加心飆借新恢稱徜希般，i酈時(shí)詼楓廚心飆統(tǒng)血的病理生理機(jī)制尚存在爭(zhēng)諫尋致血細(xì)綢略趨擇止膽疑翎術(shù)細(xì)脈鯛樣硬化的心肌橋最優(yōu)化治療上看林誣廊砒m頗翻姑wi如嘶的腌廉赫衝探討可能與心肌離甌相關(guān)的臨渤此砒刪湖fe廊m

2、熾祥殲豳組必肌橋靂者旃蔽純蜥也較,燉而昨詢瞬刪媲鑲議.作者簡(jiǎn)免 餌1&冬（“徐幾男，左讀心血簞謝細(xì)七碩士，研究方向m冠心病弁入治療i出r®hi：lmi血閥n貳怖3>4）0 n g e 1 6 3coal）漸沈夫挙碩士斫究生專戦供蝕詒文統(tǒng)甘-100例畫拔就腸獵影診暢曲必肌橋的寤嫻務(wù)軸回畫了!泊w陽帥晞床 特循 并依辦心肌橋理看令并瓣鶴勵(lì)瞅禍樣傻他刪躺紳粛制硝施組 和復(fù)雜肌橋紐 対館了兩組惠耆翔財(cái)諦芙事傷勲議癥槪竣楸 榊足謨 痛丫兼桂心肌槓ow仏 酈輸栃孑酈廐分級(jí)分媒總«1嶽嗣固飾密廡密度髙密慶扁疑自'璽腹詠 心邂赭樹龍、心勒妙細(xì) 於沁辭物湍療腳躺刪解藻細(xì)

3、耐密°1u練處凰顧晰矽瞬陽帰籍廠磁訥諭"心沁)5)舗球卑12(緲件咽用d2舲例1 2h 1 2 9 6例患者行冠狀動(dòng)脈造影的資料.診斷為心肌橋102例，占7.9%,其中男女比例73：患者行冠狀動(dòng)脈造影的資料，診斷為心肌橋1 0 2例，占7. 9%,其中男女比例7 3：29,年齡27歲80歲，平均年齡(60.10±11.14)歲。102例心肌橋患者其中多2 9 ,年齡2 7歲8 0歲，平均年齡(60. 1 0_1 1 . 1 4)歲。10 2例心肌橋患者 84i(橋9例，左前降支心肌橋占86.3%,按照noble分級(jí)i級(jí)占47.4%, ii級(jí)塀段肌橋動(dòng)瞬常桶廈化痛變

4、關(guān)刺疔餅書婢心腿梗死堰例府猶襁斷脇蘇嶺9例，合并 健胡綁砂刪聊紳幣琳郵贛克畫埠1(矽陽5氷庶確戟痛1 3橋鈿刪醱傷n鮎艸艇婀鬲蔚傕靜穩(wěn)定心繆術(shù)曲蹴育程鼻陝皿禺級(jí)、血總膽聊觸懈鎮(zhèn)自、:髀胡ji輛、確瞰卿性羞異 擴(kuò)2闊舒弼功篩,帝斑能分級(jí)笫彬簫屣丿血滋5屁傘釧附犁、藥物細(xì)豔門、空腹血甯征花豁礙質(zhì)題兩組爾鞠翳酬硼)< p>0. 0 5),在心胸比和藥物治療出院癥狀緩解率方面兩組有顯著性差異(p<0. 0 1 ) o浙江夬學(xué)碩士研宛生耆業(yè)卿沁旌軟動(dòng)脈造形診瞬心躺南多稱細(xì)菊衝雀特定無件下;t真細(xì)酈崩瞬 樣礦樓腦易導(dǎo)敎來箱定心線稱急株心肌權(quán)死停心血備縦翼他w4imm 癥狀現(xiàn)翳耐刪幽伽刪除

5、況下，必如啊畫慮交架渝療。美鍵詞心肌銹；冠狀動(dòng)麻；冠躱動(dòng)眛罐影棗；動(dòng)脈粥樣題僦嘛窄collegecandidat masfirst a ffiliated hospstrobjeefiveusual ly. the coronary vess voxj.r s e °til oftheheart but may delsj pinto the myocardium for varying lengths and then 0 n the heart's surface reappearcoronary myocardi bridge (cmb)occnrswen a band

6、 o f cardiac muscle overl « i 1a 1i e s intramural segment o f a c o r on a r y irten： s t h e intramural $ 6 §1116e t be i ngf erred to n « ir tunneled* 'artery. coronary angiogracah reveal ( h e mi iking eecl ” s y s t o 1 i c m s narrowing induced by significant myocardial b r

7、a coronary artery regarded i d g i n g o ffor lonj 11 innocent anatomi variants,cm b h a v e b e e n subsequent! acknowledged ° $cypotential co f u n s t a b 1 e hgin, atlle m y o c a rs a c|3rtitlhi condition.hovellich和皿features o f c m 打11blllcre the morbidity of ischemic heart diseaseisu n k

8、 n o w浙江大學(xué)碩士研究生眷業(yè)學(xué)位論文department of cardiology.the first affiliated hospital,college of medicinezhejiang univesitycandidate master of cardiology lv liang-dongsupervisor zhu jian-huaabstractobjectiveusually,the coronary vessels course over the epicardial surface of the heart but may dip into the myoca

9、rdium for varyi咚 lengths and then reappear on the heart's surface, coronary myocardial bridge(cmb) occurs when a band of cardiac muscle overlies an intramural segment of a coronary artery, the intramural segment being referred to as a finnclcct artery. coronary angiograms can reveal the milking

10、effect or systolic narrowing induced by significant myocardial bridging of a coronary artery. regarded for long as innocent anatomic variants, cmb have been subsequently acknowledged as potential causes of unstable ang血acute myocardial infaiction life-threatening cardiac arrhythmias and sudden cardi

11、ac death in a particular omditiom however;which clinical features of cmb will increase the morbidity of ischemic heart disease is unknown.because of incomplete understanding of the pathophysiology of cmb,their clinicalsignificance has been nbject of debate for the last quar century as a r e thel e r

12、suit, t h etreatment oplions is still controversial td study the clinic features of”" cmbdilute the hininl jguifitioteo f complicating atherosclerotic stenosis b e f o ra p e u t i c o p t i o ns o f i h i s i n t r i g u imethodsdata o f 1 0 c m b2m m1 qur hospital durin ° n e y e a riywa

13、s an a i y z e d retrospectively, then d i v i b yd e d into t w o gwhether there w a m p a red t h eg atherosclerotic stenosis before myocardialbridge and c 0nde r, nob 1 e 訂of b 1 o o glucose, blood fat, cirdiothoracicand outpatient symptomatic reliefthe incidence c m b wag 7. o fe9 % th percentag

14、e o c jwl located the left 3 fl fbdescending coronary arteryas 73：29was 8 6 . 3 %, t h e gen d e r ratiomeanagewag (60. 10*il 1. 14) yea rs. 3 8had complicated a t h e r o s c 1 estenosis b e f omyocardial bridge.hadd 1 3concomi tant acute m y o c a rdc i) mp i i c a t e d unstable pectoris angina .

15、dividing the pat ients into two groups by w hetherthere was atherosclerotic stenosis before cmb, they were simple cmb g r 0 ucomplex c m b group(n=j大學(xué)殞士研境哇辱業(yè)學(xué)樓e easily ringiu p c c t osignificance has beed itbe subject of dcbatcnfordhci last quarter <5j?wy as a resultjtte i m p i ebtreatment opti

16、ons is still controversialto study the clinic features of cmb and toevaluate the clinical signigcance of complicating atherosclerotic stenosis before cmbwill provide a better therapeutic options of this intriguing clinical entity;methodsdata of 102 cmb from 1296 patients in our hospital during one y

17、ear diagnosed by coronary angiography was analyzed retrospectively, then divided into two groups by whether there was atherosclerotic stenosis before myocardial bridge and compared the age. gender. noble gradingr cardiac functional grading,cardiac diastolic fiinctiorulevel of blood glucose.blood fat

18、cardiothoracic ratio and outpatient symptomatic relief proportion between two groups.resultsthe incidence of cmb was 7.9 %.the percentage of cmb located the left anterior descending coronary artery was 86.3%. the gender ratio was 73s 29 and the mean age was (60j&tll.l4) years. 38 cases had compl

19、icated atherosclerotic stenosis before myocardial bridgejo cases had concomitant acute myocardial infarction and 13 cases complicated unstable pectoris angina dividing the patients into two groups by whether there was atherosclerotic stenosis before cmb, they were simple cmb group(ii=5l)and complex

20、cmb group(n=38). complex cmb group more easily result in angina pectoris and acute myocardial infarction than simple cmb group(p<. 05?,between the twogroups, no significant difference was found about t h e age, gender, n o b 1 e grading.cardiac functional grading, cardiac d i a $ t o flinc t i oi

21、l (p>0. 05), level o f b 1 o o d g i u c o s ei i cand blood f a t, b u t there was significant differenc沱in cardiothoracic ratio and outpatients y m p t o m a t i c r e 1 iefproport i o n ( p < 0 . 0 1)conclusionthe clinical features o f c m b diagnosed b y coronary 11 e v 3 r i 8 b 16. mo s

22、t o f angiographythe patients * 1 h myocardial bridge a r c a s y m p t o m a t i e, but having p r e c m batheroselerotie s t a no s i $ may r e s u r i n i s e h em i c heart disease, h mgim p c c t o f i s suchand myocardia infarctio n. symptomatic patients mu s t b e treated .medical therapy1sho

23、uld be the first and pr incipa| itriteiy, ill interventions show be limited p a t ： e n t s嘰" refractory angina despite medical therapy. cmb patients with pre c m b atheroselerotie stenosis shoul d i： treated activety including sten implanting tk e y w o r d smyocardial bridge： coronary artery：

24、 c o 3 d ? i 0 g f 3 p k y： a11 e t g $ c i e r 01 i fs 1 e n ° s 1 sr o n a n yggroups.no significant difference was found about the age> gender noble grading, cardiac functional grading* cardiac diastolic function/p>00». level of blood glucose and blood fat9 but there was significa

25、nt diflference in cardiothoracic ratio and outpatient symptomatic relief propottion(p<0.01).conclusionthe clinical features of cmb diagnosed by coronary angiography are variable. most of the patients with myocardial bridge are asymptomatic,but having pre-cmb atherosclerotic stenosis may result in

26、 ischemic heart disease , such as angina pectoris and myocardial infarction.symptomatic patients must be treated.medical therapy should be the first and principal strategyand interventions should be limited patients with refractory angina despite medical therapy.cmb patients with pre-cmb atheroscler

27、otic stenosis should be treated actively including stent implanting.keywordsmyocardial bridge； coronary artery： coronany angiography： atherosclerotic stenosis瀟毎夫峯碩土徘宛生歩馥學(xué)巔訛交毬軟勒脈通蒂有童手右阿詢翔刪竹如耒追颶姻臟誡如一 段軒走于窒集俺肌纖嫌申，辜心棒收編衾腫卅瑰曹臍隹的魏窄輔詡霧'則截心 肌纖蜒覆韓的勒豚段稱為璧屜狀動(dòng)膩$這覆亳鳳纖維稱為危軼渤酥疝肌株籀稱 心佩橋珀閃騷護(hù)內(nèi)y b¥qct0ial bri

28、dge驗(yàn)著楡肌橋諭斷兪標(biāo)龍謝澤搠妬的旭狀動(dòng)okikf: ：s»卅®w m5w條件卜fj導(dǎo)致家性心動(dòng)過速、房空傳導(dǎo)阻滯、急性冠狀動(dòng)脈綜合征、心肌頓抑其條件下可導(dǎo)致室性心動(dòng)過速房室傳導(dǎo)阻滯急性冠狀動(dòng)脈綜合征心肌頓抑甚l2i 診斷方法seidinger法穿刺股動(dòng)2診斷方法s e 1 d i n g e r橋%肅編縣矗盈動(dòng)脈造影方a 91.1.1病例卸選擇統(tǒng)計(jì)浙江大學(xué)附屈第一醫(yī)院心臟介入中心2005年12月至20061 . i病繭血癢統(tǒng)齊浙江大滬附屬笫-醫(yī)院心臟齊入中心2 0 0 5年1 2刀至2 0 0 6t «aw®、we&右船號(hào)左郴足浮黠鱷翻溝駆1

29、腳缺鄲觴谿脇宛傷璉!級(jí)：收 翱維翳矗喙鬱期腐絃絆孑辭了駕聖騎驚翳鳩? 5驗(yàn) 縱勰嬲麟彌儘麴鮭刪冏®耀離翹歸蘇翹巴n.漸蛋夫?qū)W碩出研笄生專豊學(xué)位 統(tǒng)排際鳳編惟心庭覇、心肌嶄后，將肌橋合并橋旗沏喲辦畫t艇孝稱為震蒯賺紈i酈制怖繃溺桶鮒極瑚鄭藏腳幼114研究咖徴嘆剃iw陳臘年做、師拗血爾旨空敝刪;、心躅欄嘶機(jī)心> 腳比4 w運(yùn)酗獵、右晰鮒魏當(dāng)溪、滋腳6讖癒淤?zèng)r、則疇濾歸病、 屬血虛、血脂異常、糠尿繍、肥厚性心肌?風(fēng)性濕性心庭犧馨胸床粗料,分術(shù) 心腳酈櫛劇樂rwl峨1w獅紺舷躺聃緬輛昭訕w禪僂炭卑率， 對(duì)比了兩者錚熱 徃臥 險(xiǎn)blb幷級(jí)分頊脂血盧腹硼血繊刪也紐心功施佈跆級(jí)、115統(tǒng)誨刪

30、嫌誡班法剛tz斯於he®統(tǒng)ih讖他纟刪除媲用苗帥掬鱗土標(biāo)準(zhǔn)羞（xx丹表刑，采菊崩昭笊臉殆娥換（躬g斜采權(quán)驗(yàn)；馳粧料采煩秩稠采用秩和 檢瞼：p<q5為有統(tǒng)轉(zhuǎn)綻綽意義。a.緒做愆1危刪腦刪扛橋的臨制擁征 空111 一般資繼楙味擺險(xiǎn)屬幣崩歸院妝m介m心閱傢年02施冏0第契2 0 0 6年1月共行冠狀動(dòng)脈造彩1296例，診斷為心肌橋患者102例，占7.9%,其中男女比月共行勉狀動(dòng)脈造影1 2 9 6例，診斷為心肌橋患者1 0 2例，占7. 9%,其中男女比例73： 29,年齡2780歲，平均年齡（60,10±11.14）歲。102例心肌橋患者其例7 3： 2 9 ,年齡2 7

31、8 0歲，平均年齡（60. 1 0 一一 -_i i . 1 4 ）歲。10 2例心肌橋患者其中多發(fā)心肌橋9例，左前降支中段同時(shí)合并第一對(duì)角支開口和右冠狀動(dòng)脈遠(yuǎn)段心中多發(fā)心肌橋9例，左前降-支中段同時(shí)合并第一對(duì)角支開口和右冠狀動(dòng)脈遠(yuǎn)段心肌橋1例，左前降支中段合并遠(yuǎn)段兩處心肌橋1例.左前降支中段合并遠(yuǎn)段心肌肌橋1例，左前降支屮段合并遠(yuǎn)段兩處心肌橋1例，左前降支屮段合并遠(yuǎn)段心肌橋3例，左前降支中段合并中遠(yuǎn)段心肌橋1例.左前降支中段兩處心肌橋1例，橋3例，左前降支中段合并中遠(yuǎn)段心肌橋i例，左前降支中段兩處心肌橋i例，左前降支中段合并右冠狀動(dòng)脈遠(yuǎn)段心肌橋1例，左前降支中段合并第三間隔支中左前降支中段合

32、并右冠狀動(dòng)脈遠(yuǎn)段心肌橋1例，左前降支中段合并第三間隔支中段心肌橋1例單發(fā)心肌橋93例，其中左前降支心肌橋88例，占全部心肌橋86.3段心肌橋1例。單發(fā)心肌橋9 3例，英中左前降支心肌橋8 8例，占全部心肌橋8 6 . 3%,位于左前降支中段52例，位于左前降支中遠(yuǎn)段19例，位于左前降支遠(yuǎn)段13%,位于左前降支中段5 2例，位于左前降支屮遠(yuǎn)段1 9例，位于左前降支遠(yuǎn)段1 3斷汪夫鐵橄七暢窕生警樂學(xué)應(yīng)裾文g 巒n輸j眾舷蒯，刼硝磁洽關(guān)ii竝。鉗懈怒娜，刼瞇姍申鞍1w 卿跟刑瞬殊,列申碉艇岬段wo左用悔魂返屣決例例,第廁陽文11孤m2健軸1附癒刪克煦m m j級(jí)蟲的鎖笛i i i級(jí)占38 . 1%,

33、 ui級(jí)14.4%平均狹窄率324%其中合并舒張期狹窄19例，合并近段肌%, iii級(jí)1 4. 4%，平均狹窄率3 2.4%,其中合并舒張期狹窄1 9例，合并近段肌橋動(dòng)脈粥樣硬化病變38例。橋動(dòng)脈囁樣碩化病變3 8例。2.1.2臨床表現(xiàn)102例心肌橋患者中，心電圖異常q波8例.st-t改變31例，t2 . 1 . 2臨床表現(xiàn)1 0 2例心肌橋患者中，心電圖異常q波8例，s t_t改變3 1例,菠改變18例，胸片中心胸比異常（心胸比0.5）47例.有29例行平板運(yùn)動(dòng)試驗(yàn)，解韶f甌昭酬獻(xiàn)愉他辦看場(chǎng)私施跑箕強(qiáng)噸那運(yùn)動(dòng)試驗(yàn)，耿 k.誠伽心畸疇籍并細(xì)歸朋強(qiáng)辭峻淞舷t0就1w 5例, 擔(dān)脫鈿1vw,不穩(wěn)勢(shì)

34、端軌oh斜勢(shì)療魏肌辭掰鶴珊壓筒跚曙淄緊例， 耋衛(wèi)翟醐連騾弔議覽竊製餓幽y幽罟 例合并高血床心臟病2例,合并 就關(guān)m越ft瞬鱷齦系2 -血?jiǎng)”O(jiān)斛#毀蹶&感嵋性心絞痛、不穩(wěn)定心絞痛和心肌 梗死臨鷄購紛隸im窮就聽緇斜緘誡 擬肌瓣茹婕頤勵(lì)fflw卿刪刪解饑詒難炒脫情爛合聚刪般據(jù)心冊(cè)臟洱甦剰準(zhǔn)刪歓浚刪錨a品射。結(jié)方面統(tǒng)計(jì)學(xué)有羞異,©osiwhaw wa鍊 範(fàn)關(guān)見妻炮嘶堿聊房忙/ a）、心嶽刪鋼'胸比方面自顯著統(tǒng)計(jì)學(xué)差異，而在no b 1 e分級(jí)、血總膽固醇、低密度脂蛋白、高密度脂漸蔭夫?qū)W顧七斫究生專業(yè)學(xué)位沁舉白、窒腹血糠、心歸純齦於勸齡綁問斕細(xì)諱敬翱。單繃晰須和復(fù)余肌橋絹號(hào)肌

35、橋相芙備臨床溝網(wǎng)酣如俄d知i）頂目單wm (櫥£5 1 )復(fù)雜肌刪加8） 8 ）f穩(wěn)定性心絞痛570.242不穂定性心紋痛490.037急性心肌梗死280.014無相關(guān)臨床事件4014p<0 01砸兩ifif弾祁歸灣街妙佩0 b兩娜滋涉殲本洵藁尊齣顯著性差異單細(xì)i礦翔稠刪瞞組顱瞬囲軸總（埶燧）危險(xiǎn)因素單麹刪翎1（滬5r）復(fù)綁mfi做絹3助n = b 8 ） p年齡（歲59.31 + 10. 7361.24±l2.070.430性別（男/女，例）35/1628/100.606noble分級(jí)l76±0 721.72±0. 780 817chogl/l)

36、4. 30±0. 984.10 ±0. 900.331ldl-c(mfflol/1>2,14±0612.01 ±0.580. 335hdl(mi»ol/l)1 30±0 30l20±0.310.186fbs(nmol/l)5.07±1.864.82 ±0.950.486e/a1. ll±0.88098±0.320. 825心胸比0.47 土 0.040.5l±0,070. 005nyha分級(jí)l33±0.591.55+0.720.131肱q 06.兩給何鮒第占潢

37、灌舟亦p，h兩齟甸籤計(jì)帯如蜩蒼性隹做.若件 ； 異豳獅嘶輔？（葩蜩弭彌嘛看命命農(nóng)炎出臆鯛柝窮猱緩巖廨曙見礒1p。兩艇蹄衆(zhòng)物箔痼的出馳刪瞰繳髒綁以檢谿驟蝕）砒 喃顯著，有顯著 性鋼澎辦單繃1刪她細(xì)蹄i靜物細(xì)祈澈刪隸（翊+3）蹄時(shí)單純肌橋fs（w）復(fù)雜肌橋俎（側(cè)）緩解（例）258未緩解（例）1114pq備兩御陶敘滯嶷臉詢、ob瓶組何統(tǒng)計(jì)需如育星蒂性粒畀顯著性冶并烹.討毗蠱心肌僑的謝爲(wèi)瀬邂影的勒像學(xué)特征上，本研究與艾刪誨相鶴 扱第發(fā) 坳抵，妍炭隸僮為左前降支購文發(fā)曲瞬為阻3% ）3曲肌橋頤薛敲躺脈臨矗造彩中楡出率対蛾這弟敝尢莊仇5%憐卿，痛研剜喺檢佛率強(qiáng)率;w 與皮獻(xiàn)相文獻(xiàn)相 窩,但瞬瀬滬檢發(fā)現(xiàn)觀5

38、%?哪5嘟專 咖與刪妙瞬能斷榜®i柝虧橋彌卜列創(chuàng)頤痂翊£與刪t心肌橋與壁冠脈的解剖關(guān)系:；憊幀聊彌斷締細(xì)o鵬朧細(xì)怨購爹少近端冠脈粥樣硬化產(chǎn)生fffi觥iffi師葩痙 奪的彩響；血管擴(kuò)張刑與血管收縮劑的影響；造s縮峨胸陋爛嗓。審嗣時(shí) 純命血骨內(nèi)超聲眥陶及尿脈應(yīng)雷憎威蝕曲®a蹄施測(cè)提高血肌橋檢出率出率, 創(chuàng)&費(fèi)用較髙，目前臨昧詵液磁tee冊(cè)展。超心肌橋的臨床意見urn認(rèn)加刪附訐舷i性孌異/is齡礪遜現(xiàn), 在襦建me魏下可r導(dǎo)鄒沁綾痛、室性心動(dòng)過速.房室傳導(dǎo)阻滯.制性冠狀動(dòng)嗨斯蔭夫挙幀士研昇生寺業(yè)學(xué)位統(tǒng)合徐心肌頓擁甚率心源桂獰死籌心血替事怡萇機(jī)制顧能與右80蛹舷

39、血儈掰lossx復(fù)愛燜離致胤小板聚築，血桂形威湖冠彩醐而翹就脈血鐵繍少膏美$亦謔蜜心肌橋患耆晉審有=定憶佩關(guān)嘛血購心剛酈甲w 運(yùn)動(dòng)試驗(yàn)蜩餾 髀細(xì)軸烤做同咖潮劇険輕閉鳩癡衲梆l, 也姍懿新，駅厚型瘤肌躲 鳳滉低心啊勢(shì) 榊赦睹爭(zhēng)電亦郴學(xué)刪井 發(fā)心施管緒，輛酈誡臧顧fl刪碉痛$年生存率與是香舎并心肌蘇 死偃也鬲確磁現(xiàn)雀急性下璧心瞬死酸密帆 wawsi支的心肌轎魁頤淋克鞘不良報(bào)示因手地覘矽腳律掬禍怖困勵(lì)心順i嗣固相美臨床翩城心血 管靳砸刪橋前訊彖動(dòng)嘛長(zhǎng)期酌爨壓和屬部罪帶的磺碩辱魏通殿樹働脈舷勒瞬 樣離仏為研舷冠昧董影發(fā)現(xiàn)令航破眺m蛾怫檄耿辭副&肌橋87.琢。矽勰薦屜網(wǎng) 皺硯必缺肌橋近股*

40、71;ao樣斑竦性隸喪除劉毆旄稗袒遊6 %,說聊fe第胸履庸檢査踐巍橋箭血管病變的敏斡蜒粹瞬礙狀跚她縣 m 轎可籠通過贏流如應(yīng)力和血働鯽緒拗嫌藉因素財(cái)變潑翩脈産僥抿披效應(yīng), 因戯程麵軼動(dòng)脈堆場(chǎng)和病瑾檢査發(fā)現(xiàn)彌櫛硬化較少鋼及蟹冠畑脈慮胸輙血 悌促近年嘶；應(yīng)痢 盹謐爵魅®m 蜩魅爾廨痢廠堀澎目貫蚯蹶壓 迫持績(jī)列舒張期豪本嬸究em融渤翩帝ii&6溯術(shù)鮒卿線冷可能融準(zhǔn) 融狀動(dòng)脈存在病變用jfflh?通遜例刪瞅.心飆禱合養(yǎng)橋前動(dòng)脈啊樣硬化狹窄圭鑒詢懈心峽血黑榜齡性酬編舍 紙本確究發(fā)現(xiàn)復(fù)雜肌橋組較單純肌橋組更昜發(fā)牝?；鲁厝?、，顧碗畀梱 施認(rèn)為埼心帆橋臨床心血管事件相知ft主要是締i前辺僦

41、辦碩創(chuàng)解/iwfwl 橋本身.并且對(duì)單純肌橋組和復(fù)雜肌橋組的臨床特征wtx.嵋現(xiàn)刪慮n o b 1 e分級(jí)、血總膽固醇、低密度脂蛋白、高密度脂蛋白、空腹血糖、心超舒張功能、心功能分級(jí)等多方面無差異，但在心胸比方面兩組有顯著性差別，提示合并 橋前動(dòng)脈粥樣便化狹窄與心胸比可能有關(guān)。目前對(duì)于勺臨床癥狀的心肌橋首選的治療方法為藥物治療，主耍以b受體阻滯劑、鈣離了描抗劑為主，木研究觀察了單純肌橋組和復(fù)雜肌橋紐部分患者藥物的療效，前者在選用適量的藥物治療后在出院時(shí)臨床癥狀緩解率明顯優(yōu)于后者，提示復(fù)雜肌橋組應(yīng)在治療策略應(yīng)該有選擇性的選用藥物治療。有小樣本的研究嘲 表明心肌橋下血管或合并近段靶血管病變時(shí)行藥物

42、涂層支架置入術(shù)，不受心肌橋 影響，當(dāng)出現(xiàn)支架內(nèi)再狹窄時(shí)可再次行血管成形術(shù)，遠(yuǎn)期療效仍可令人滿意，因此 在藥物治療效果不佳或者不能耐受藥物治療的癥狀性心肌橋患者，尤其在介并橋 前動(dòng)脈粥樣硬化的心肌橋患者當(dāng)中，必要時(shí)可采用支架治療。冠狀動(dòng)脈心肌橋作為一種變異性疾病，因其臨床表現(xiàn)無特異性，而在特定下尤其在合并橋前動(dòng)脈憫樣硬化，易引起心血管臨床凈件，故在臨床診斷方面應(yīng)該警惕其町能潛在的危害，同時(shí)在治療方案方面在首先藥物治療下，嚴(yán)格篩選必要時(shí)采用支架治療或者手術(shù)治療。參考文獻(xiàn)1 . k a 1 m i a v c4k o r a d i a n, b r ja. myocardial bridge： a

43、 clinical r e v i e w .川 ca t h e t e r e a i 1cardio v as inter v, 2 0 0 2 , 5 7 ( 4 ) ： 5 5 2 - 5 5 6 e2n obel j , b o u t a mg, pel i tclert iht 的 ocahial bridging and mill ing e f f e$ $ ac t 0 f山！"l "讓；打 descending coronary artery： normal v a r *0 b $ i t11c t i 0 n! j am ji a n tcard

44、ial, 1976, 3 7 ( 7 ) ： 9 9 3 - 9 9 9.3. y a m a g u c h i m, t a n g k a w a t t a n a pfh am 1 i n rl hyocardibjd&jng a s « factora 1in heart disorders： critical review a hypothesis.明 a c i a a n讖 1 9 9 6 , 1 5 7： 248- 2 6 0.n aom, e tal. myocardialh, t a n i u e h idging o f t h e leftnob

45、le分級(jí)、血總膽固醇、低密度脂蛋白高密度脂蛋白.空腹血糖.心超舒張功r能.心功能分級(jí)等多方面無差異，但在心胸比方面兩組有顯箸性差別，提示合并 橋前動(dòng)脈"松樣硬化狹窄與心胸比可肚有關(guān)r目前對(duì)于有臨床癥狀的心肌橋首選的治療方法為藥物治療，主要以0受體阻 滯劑.鈣離子拮抗劑為主，本研究觀察了單純肌橋組和復(fù)雜肌橋組部分患者藥物 的療效，前者在選用適童的藥物治療后在出院時(shí)臨床癥狀緩解率明顯優(yōu)于后者， 提示復(fù)雜肌橋組應(yīng)在治療策略應(yīng)該有選擇性的選用藥物治療。有小樣本的研究閻 表明心肌橋下血管或合并近段耙血符病變時(shí)行藥物涂層支架置入術(shù)，不受心肌橋 影響，當(dāng)出現(xiàn)支架內(nèi)再狹窄時(shí)可再次行血管成形術(shù)，遠(yuǎn)期療

46、效仍可令人滿意，因此 在藥物治療效果不佳或者不能附受藥物治療的癥狀性心肌橋患者，尤其在合并橋 前動(dòng)脈粥樣硬化的心肌橋患者當(dāng)中，必要時(shí)可采用支架治療。冠狀動(dòng)脈心肌橋作為一種變異性疾病，因其臨床表現(xiàn)無特異性,而在特定下尤其在合并橋沛動(dòng)脈粥樣硬化，易引起心血管臨床事件，故在臨床診斷方面應(yīng)該警 惕其可能潛在的危害.同時(shí)在治療方案方面在首先藥物治療下，嚴(yán)格篩選必要時(shí) 采用支架洽療或者手術(shù)治療.參考文獻(xiàn)1. kalaria vqkoradia mbreall ja-myocardial bridge: a clinical review. j catheter cardiovasc interv,2002

47、,57(4):552-556.2. nobel jtbourassa mqpetitclerc & et al.myocardiai bridging and milling effect of the left anterior descending coronary artery : normal variant or obstmction?j am j cardial, 1976,37(7):993-9993. yamaguchim, tangkawattana 匕 hamlin rl. myocardial brid ging as a factor in heart diso

48、rders:critical review and hypothesis.jacta anat, 1996,157:248-260.4. yano ybshino h, taniuchi m, et al. myocardial bridging of the left anterior漸江大學(xué)離切擁生專業(yè)報(bào)論文妬趴證 輪理呻“聊阿x re嚴(yán)u禪也仙*期皿1戦ypwh誠ttwmlflqiwrj ci in351200124:202-208.cardi01p200 1 24： 202-208 5< ge jb, jeremias a, rupp a, et al. new signs ch

49、aracteristic of myocardial bridging5. g e j b, j e r e pi i a s 氣 ruppa, e t qi. n c w s i g cji a r <l c t e r i s l i c of myocardiai 焦bjn?卿ed by intracoronary ultrasound and doppler.(j eur heart j, 1999, 20:17q7*nl7w*t ed by intracoronary ultrasound a doppler.朋 eurheart j , 1999, 2 0 :6. 圣寧夫，潘

50、浩，童國(guó)新心肌橋和心肌橋近端合并嚴(yán)靈動(dòng)脈粥樣硬化病變的介入治1707.1716.療療效觀察 j中華心血管病雜志2005,33(8):684-686.6 .王寧夫，潘浩，童國(guó)新.心肌橋和心肌橋近端合并嚴(yán)重動(dòng)脈粥樣硬化病變的介入治療療效觀察.明中華心血管病雜志，2 0 0 5, 3 3 ( 8 ) ： 6 8 4 - 6 8 6.癥狀性心肌橋的診療迦展advances c inn cnrrento <iggpo$tjc;、and treatment n sg幗i終 © of fsymptomatic myocardial bridges y m p t o m a tic myoc

51、ardial bridge呂良冬綜述朱建華審校呂良冬綜述朱建華審校摘要 冠狀動(dòng)脈心肌橋（簡(jiǎn)稱心肌橋,myocardial bridging, mb）是一種先天性冠摘要冠狀動(dòng)脈心肌橋（角稱心肌橋，myocardial bridging, mb）兔一種先天性冠揭示f=二二蔚獺收縮期狹窄的影像學(xué)表現(xiàn)文獻(xiàn)報(bào)道心肌橋的尸檢發(fā)生率為15%85%在 勰喙觀鱗髓鬱咯科噩甥輙麟學(xué)褊境盛韋啟在it霧魁紬卞爲(wèi)論轟豔衆(zhòng)魏熾sv*跚縛fe絆家究包括冠狀動(dòng)脈定暈造影、血管內(nèi)超聲和冠脈內(nèi)多著勒的發(fā)展，對(duì)心肌橋的缺血機(jī)折翟夫?qū)W碩七斫宛生寺業(yè)學(xué)瞬文制開始有了很多瓣飾汰如 親対嘶睡歸蘇性渝酈瞬軸刪舫研滋慵況, 蘇冠狀動(dòng)啊嘛即懈泊

52、疥輛蹄作諭述。h柳腳心肌缺血變由于鄢遠(yuǎn)段聞管餉隆脈鹹備稔統(tǒng)聆下降弓燔弓錄濟(jì)翩磁冠狀 勒藤的收縮期魏窄搏線劉籍橐申険期和摩樹詞藤肉佛血樹力學(xué)帰繼屈企麗 理制酣m 霍這企融曲理劇上當(dāng)心砌騒潮時(shí)沁iw加快血臧期縮，短, 心肌灌注時(shí)間縮短，且心肌收堀增強(qiáng)可加重壓迫，最終疑缺血燼心臟酬捕玻 生*而11冠狀動(dòng)脈因反篡燮壓酬幽燧廁用啦鍛由j幷鈿歸血漉動(dòng)力孥棄亂易嫌狡動(dòng)蘇粥樣哽亀窪此棊酣上發(fā)生斑堤截?zé)岢鲅?、血棣腦戚 及冠然動(dòng)刪牽,紘而題辭乘晞綠侖禪皴發(fā)生h 1墜匯粧利冊(cè)盧程紐狄販鋼瞬乖舒稠拗心肌血漁緇洼主夔發(fā)卻編制軌漏冠瞇造影顯示的mbtm瞬瀕玻生曲瞰 縮輒理鮒柵櫛肖嗣她閒鹼釀僱腌麻拒一系卿i襯熬惟藝解可険城

53、i 缺血,囲刪輛imb應(yīng)該溯繃張期血濂.feurasaa1等通試麹幅述抵整瞬舫勵(lì)羯潮匕、動(dòng)周期 申的塔影圖儆朗iwfcwi期獲窄麺過祐躺的刪6構(gòu)楓勉的收縮期刪湖審現(xiàn)靈窄現(xiàn)彖薙華舒鮒亂卑坳1b伽 喲占（穌刪加溺初2 roidmi（隔在收縮期短騎草刪嫌期短暫壓迫犬的囤屣気導(dǎo)癒mw仍匿氐爭(zhēng)齣m為（6駆園 血磁少心貓翊閑麺過速和冠 脈刪烯朗觸涮満注,bbu斶s鷗等回顧逓鋤伽魁能心雎質(zhì)恿者屈脈量化適脈量化造 影的第魁收刪聯(lián)阿瑚希瞬報(bào)s度7ux同時(shí)糊晦張審卿擁娜內(nèi) 段平均管i腔盛醱漓磁剛製於41乳1并且艸6進(jìn)嚴(yán)莎磁加t緒彩一結(jié)果。u2瞬嫻馳伽刪加學(xué)異?？?#39;多養(yǎng)勒血流漏定刪瀏87%的徵膽橋腺音壁魁狀

54、勵(lì)腦他血細(xì)陰顯牌誡備,呈d浙江夫?qū)W碩七確究生專致學(xué)位湃j1飾矯瞬”減瞬聯(lián)刊剎細(xì)速譙成知神購嗡無嘶嗣血 詭建康駅建秫，瞬后下耨輛覷購處糠ftb卿齡，械綁卅倆魂 速度再次迅逢卞陥 刪隔脇熨遞向骯流.栃沏劇息時(shí)平期蜂淹鞭和梢 舒張翔峰流謔播明報(bào)高予近殿號(hào)瞬 挪冊(cè)砌端繃舫劇礪加魏少，柚肌 橋內(nèi)陳肘林幅軀搦姻.辭蟲劇飆1劇血因地泗騒血蹦濾堿變 圭察發(fā)生崔舒糊,而崢咖極履愛倫孩牛.樓韋鹹府可進(jìn)士步徽銚嘲晰 嶽流圉麗 飾漲早期ny呻凰麻舒張期解命輔拇,遵陽翊枷t加'劇心飆験血.庇常融翩1倔滅絡(luò)鏑為4511卅6心1,而mb患者確涵血澹儲(chǔ)般曲流傭略為2. om 1 a伽匕出卵冠帕逾緖僦iw 是由舒張楓麹

55、蹄購敏。l 3褲的解謝離婪托生鯽際素影嗚幽收mm程鹿薇簸蘇果車期粛翻肉陣瀚臓的困穩(wěn)關(guān)榊煉為如附帳度、厚度鍥及創(chuàng)配；切瞬她痛、）屬狀動(dòng)脈造影和癇囑檢頤嘶擷?倔嘶桶秫腹及甌帥昭 種“懈按越應(yīng)苛爾寵翩嘛切應(yīng)加®噬微細(xì)翳既銅解卷護(hù)瞬狒牽所 軟的釉憾頒應(yīng)酚灑潮瞬我血m瞬擾敵逆變拗闕蹦卿翻昨舷達(dá), 勵(lì)時(shí)又促使內(nèi)度輛&侖威希謙以而廬生一定陸動(dòng)懈擲紳壯 細(xì)贈(zèng)極s 表明壁包狀動(dòng)脈的撕r曲阪爾蟹酬ima刪解晌麻膠®継成j而劇4w顧咖瞬 殖的含成型州顧緬胞.畑圖芒：慚發(fā)現(xiàn)壁疑刪畑to刪性物蘭他曲jwr皮型一 氧化氮含劇飢內(nèi)皮索和血管觀溝鍬o）彌誌較j0頤驅(qū)皴朋顯棒抵冋對(duì) 該處冠如脈聲軸翊

56、應(yīng)曲抒恤朋極質(zhì)迫點(diǎn)彌曲蹄刪俺低碗態(tài)功脈 鯛樣鎖化發(fā)生率他很低上鎧噌用ol娜 發(fā)現(xiàn)她股矚嶽觀豳酬有蒯蒯»塊粥樣斑塊。糙販蠱血齡曲瓣am輒能與存翻m籀曲流勒加礙除關(guān)漸迂夫?qū)W碩圭研宛生爭(zhēng)業(yè)報(bào)訟文尸檢及造彩均沁鴻聯(lián)他舷畀濟(jì)嘶鋼九長(zhǎng)度凰他咖0呻不朱潮 厚 度從1 阿輕嶼不衛(wèi)啊聊愉i務(wù)桝痢動(dòng).就碾嚕靈陽異妙血肌樋啊痢饑束位 聾與走陽粗影聃聯(lián)縮期蛋迫稈隊(duì)縱誅犁心獅因與左前降支關(guān)乘籥咖煩刪該 血酚竊豳嫩繡期嶽濂溝換4而且形喑轎張?jiān)?、申卿血?爾勒際低滋炮脈 的血湎離希.甦脈供血主龔產(chǎn)瞬期,翎愀葉爵張朗星鯛縛,酬儁籀賢勒血施測(cè)定顯親心率墉娜赭卿隅刪耐醉絶,i酗懈楸to肺®姬jw血。jn有兼摭

57、的心肌橋的諭存原則是減輕心肌橋下璧冠狀動(dòng)脈的壓址閘的無特屏性悄療，顧兼鮒嘶解餌鋤瀚療“恥淆癇秤耕諭療。e 1藥魏渤洽丿財(cái)* 刪晞脇ij非弄?dú)潆H曜磔贊商禹幫搪覘利捕娩血極籲喊 其申b受體阻滯柵砌臓陸 官可降低心她絢擁卿r劇鋼味的壓追鬧腹環(huán)， 相對(duì)的延長(zhǎng)舒髓亂提髙郵腳脈鋼瞬;,棘而改善心肌血供減絢鍬.張朗懈 謔刪im 刪臟翊輛asm”發(fā)現(xiàn)訥«o戰(zhàn)和迸段的翻財(cái)期血碘礎(chǔ)均 可堆加，且軽血蹄備援近于近段水平.smhak進(jìn)舗報(bào)遭爛展換體阻激刑飆滯劑6 個(gè)月航心絞痛踴財(cái)臟素心肌顯像所示魏血?jiǎng)h河卿顯g緖,其遠(yuǎn)期療蝴跚待 進(jìn)一步證實(shí).但是該類藥物對(duì)血臂痙攣所致心絞痛顧能南不衲膨臟，而韭二m毗 曉類鈣離

58、予拈抗劑卻可應(yīng)用手&受體阻滯劑有禁忌感有翩!煽爛齣就可j隔低 £'肌收編創(chuàng)和蹄，改善心肌血漩灌注，井且能鋼朋e管葩，是昂前涵癥曲肌橋 的另一有數(shù)藥飆在右冠狀動(dòng)除嘶劇的漓畸'曲廨牌中j常命枷他滯和 負(fù)性傳導(dǎo)，而刪瞬車財(cái)嗽改善心肌灌注，且泊疥和im®很少導(dǎo)致嚴(yán)靈嫌性沁 率及傳胖巴。薊爾畤，同前存齢議;曲磁射熾拗檢沁率曲唸關(guān)創(chuàng)脈受issa,同腦砂讖砂嘛后別翹羹擠am飆籥刪橢船帥腫何儆瀚®加厘 算至誘宿報(bào)昭無兔長(zhǎng)期便用，但心絞癖發(fā)術(shù)盼麗卿確彌陶昨解癥狀, 商能是無謹(jǐn)緩解合并的磁軟創(chuàng)蘇瘁事起作用，除羋魏対需憂觸觥彌血 糞藥輛滾爭(zhēng)酚顆加鱒瓠其他誦如掏m廨和囁脇轍錚,郴