人体心脏瓣膜钙化的临床及病理研究

发布时间：2018-05-06 21:17

本文选题：瓣膜 + 钙化　；参考：《北京协和医学院》2017年博士论文

【摘要】：目的总结北京医院已行尸体解剖老年患者中心脏瓣膜钙化的检出率,并分析临床与病理间的相关性。方法入选北京医院病理科1954年11月7日至2016年3月7日间,年龄60-106岁的老年患者的系统病理解剖资料,共1047例。回顾性分析经尸检病理证实的心脏瓣膜钙化的病例,总结瓣膜钙化检出率与年龄、临床疾病及冠状动脉粥样硬化间的相关性。结果1.1047例尸检病例中主动脉瓣钙化、二尖瓣钙化、主动脉瓣合并二尖瓣钙化及心脏瓣膜钙化检出率分别为 15.2%(159 例)、9.6%(101 例)、5.4%(57 例)、19.4%(203 例)。2.60-69岁、70-79岁、80-89岁、90-106岁不同年龄组心脏瓣膜钙化检出率分别为6.4%(15/234)、12.8%(37/289)、22.5%(70/311)、38.0%(81/213)(趋势 X2=82.52,P0.01);合并病理冠状动脉狭窄或高血压、冠心病、糖尿病、慢性肾病的患者心脏瓣膜钙化检出率较高。3.多因素回归分析,不同临床因素对发生瓣膜钙化的风险分别为年龄(0R=1.066,95%CI:1.048-1.086,P0.01)、高血压(0R=1.223,95%CI:0.859-1.741,P＞0.05)、冠心病(0R=2.238,95%CI:1.396-3.589,P0.01)、糖尿病(0R=1.053,95%CI:0.700-1.586,P0.05)、慢性肾病(0R=0.924,95%CI:0.610-1.399,P0.05)。4.与无心脏瓣膜钙化患者比较,心脏瓣膜钙化患者发生冠状动脉粥样硬化的风险增加(0R=2.983,95%CI:1.868-4.765,P 0.01)。结论随增龄,老年人心脏瓣膜钙化发生率增加;冠心病患者具有较高的发生瓣膜钙化的风险;瓣膜钙化与冠状动脉粥样硬化相关。目的评价经胸超声心动图(TTE)在老年患者左心瓣膜钙化诊断中的准确性。方法回顾性分析,收集1982-2015年在北京医院行心脏瓣膜病理检查的410例老年尸检患者,患者生前均行经TTE检查;根据死亡的不同年代分为3组:1982-1995年组、1996-2005年组、2006-2015年组;根据死亡的不同年龄分为3组:60-75岁组、76-90岁组、91-106岁组。结果1.以病理检查结果为金标准,TTE检查诊断老年左心瓣膜钙化的敏感性、特异性、诊断符合率、阳性似然比、阴性似然比、阳性预测值、阴性预测值分别为88.6%、28.2%、43.7%、1.234、0.405、0.298、0.878。2.与1982-1995年组比较,1996-2005年组、2006-2015年组随着时代发展,TTE检查诊断老年左心瓣膜钙化的敏感性、阳性预测值逐步增加,特异性、阳性似然比、阴性似然比、阴性预测值逐步下降。3.与60-75岁组比较,76-90岁组、91-106岁组随着患者年龄增长,TTE检查诊断老年左心瓣膜钙化的敏感性、阳性预测值逐步增加,特异性、诊断符合率逐步下降。4.以病理检查作为金标准,TTE检查诊断老年主动脉瓣瓣膜与二尖瓣瓣膜钙化的敏感性、特异性、诊断符合率、阳性似然比、阴性似然比、阳性预测值、阴性预测值分别为 88.2%与 44.0%、30.8%与 75.3%、42.7%与 71.5%、1.275 与 1.780、0.382 与 0.744、0.250 与 0.198、0.909 与 0.906。结论TTE检查对诊断老年左心瓣膜钙化尤其是主动脉瓣瓣膜钙化敏感性很高,不易漏诊,但特异性欠佳。目的研究风湿性心脏瓣膜病与非风湿性心脏瓣膜病所致心脏瓣膜钙化的病理特点异同。方法回顾性总结北京医院病理科标本库中,2002-2016年在心脏外科行瓣膜置换手术、病理瓣膜钙化阳性的心脏瓣膜标本,按照病因分成风湿性心脏瓣膜钙化组、非风湿性心脏瓣膜钙化组,观察两组间HE染色光镜表现;从标本库中选取风湿性主动脉瓣瓣膜钙化、风湿性二尖瓣瓣膜钙化与非风湿性主动脉瓣瓣膜钙化标本各1例行电镜检查及能谱分析。结果1.HE染色可见风湿性与非风湿性瓣膜钙化均可有不同程度的瓣膜钙化,严重者可呈骨样改变,钙化呈片状和点状分布;风湿性瓣膜钙化标本玻璃样变性较重,厚壁肌性血管多见,钙化一般较重;非风湿性瓣膜钙化标本粘液变性较为明显,厚壁肌性血管少见。2.电镜可见钙化物质呈点状和片状两种集合体形态,钙化集中区域呈片状分布,周边呈点状分布,钙化颗粒形态各异,直径在0.3-5μm;风湿性主动脉瓣瓣膜钙化、风湿性二尖瓣瓣膜钙化与非风湿性主动脉瓣瓣膜钙化电镜表现无明显差异。3.能谱分析提示不同病因、不同瓣膜钙化成分基本一样,主要为C、0、P、Ca元素,并含有Na、Mg;不同病例钙化部位Ca/P原子百分数比值在1.29-1.48,无统计学差异(p0.05),提示钙化的物相主要是钙的磷酸盐。结论虽然发病机制不同,风湿性与非风湿性瓣膜钙化病理表现在HE及电镜下无明显差异,钙化成分主要是钙的磷酸盐。
[Abstract]:Objective to summarize the detection rate of calcification in the center of the elderly patients with autopsy in Beijing Hospital, and to analyze the correlation between clinical and pathological changes. Methods a total of 1047 cases of senile patients aged 60-106 years from November 7, 1954 to March 2016 were selected and 1047 cases were retrospectively analyzed by autopsy pathology. The correlation between valve calcification rate and age, clinical disease and coronary atherosclerosis was confirmed. Results in 1.1047 autopsy cases, aortic valve calcification, mitral calcification, aortic valve calcification with mitral valve calcification, and cardiac valve calcification were 15.2% (159 cases), 9.6% (101 cases), 5.4, 5.4. % (57 cases), 19.4% (203 cases).2.60-69 years, 70-79 years old, 80-89 years old, 90-106 years old heart valve calcification detection rate was 6.4% (15/234), 12.8% (37/289), 22.5% (70/311), 38% (81/213) (trend X2=82.52, P0.01); combined pathological coronary stenosis or hypertension, coronary heart disease, diabetes, chronic kidney disease patients heart valve calcification test .3. multiple regression analysis showed that the risk of valvular calcification in different clinical factors were age (0R=1.066,95%CI:1.048-1.086, P0.01), hypertension (0R=1.223,95%CI:0.859-1.741, P > 0.05), coronary heart disease (0R=2.238,95%CI:1.396-3.589, P0.01), saccharicuria (0R=1.053,95%CI:0.700-1.586, P0.05), chronic kidney disease (0R=0.924,95%CI:0), and chronic kidney disease (0R=0.924,95%CI:0). .610-1.399, P0.05).4. and heart valve calcification in patients with heart valve calcification, the risk of coronary atherosclerosis in patients with heart valve calcification increased (0R=2.983,95%CI:1.868-4.765, P 0.01). Conclusion with age increasing, the incidence of cardiac valve calcification in elderly patients increased; coronary heart disease patients have a higher risk of valve calcification; valve calcification and crown. Objective to evaluate the accuracy of transthoracic echocardiography (TTE) in the diagnosis of left heart valve calcification in elderly patients. Methods a retrospective analysis was made to collect 410 aged autopsy cases in the Beijing Hospital for 1982-2015 years of cardiac valve pathological examination. All the patients were examined by TTE, and 3 groups were divided into 3 groups according to the age of death. 1982-1995 year group, 1996-2005 year group, 2006-2015 year group, 3 groups according to the age of death: 60-75 year old group, 76-90 year old group, 91-106 year old group. Results 1. with pathological examination results as gold standard, TTE examination diagnosis of senile left heart valve calcification sensitivity, specificity, diagnostic coincidence rate, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative The predicted values were 88.6%, 28.2%, 43.7%, 1.234,0.405,0.298,0.878.2. and 1982-1995 year group, 1996-2005 year group, 2006-2015 year group with the age development, TTE examination was used to diagnose the sensibility of senile left heart valve calcification, the positive predictive value increased gradually, the specificity, positive ratio, negative likelihood ratio, negative predictive value gradually decreased.3. and 60-75. The age group, 76-90 year old group, 91-106 year old group, with the age of the patients, the TTE examination was sensitive to the diagnosis of senile left heart valve calcification, the positive predictive value increased gradually, the specificity, the diagnostic coincidence rate gradually decreased with the pathological examination as the gold standard. The TTE examination was used to diagnose the sensitivity and specificity of the senile active valve valve and mitral valve calcification. Diagnostic coincidence rate, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value were 88.2% and 44%, 30.8% and 75.3%, 42.7% and 71.5%, 1.275 and 1.780,0.382 and 0.744,0.250 and 0.198,0.909 and 0.906. TTE examination were very sensitive to the diagnosis of senile left heart valve calcification, especially aortic valve calcification. Objective to study the pathological characteristics of cardiac valve calcification caused by rheumatic valvular heart valvular disease and non rheumatic valvular heart valvular disease. Methods a retrospective summary of the heart valve replacement surgery in the heart surgery department and the valve calcification positive valve specimens in the Beijing Hospital for 2002-2016 years were reviewed. The causes were divided into rheumatic heart valve calcification group, non rheumatic heart valve calcification group, and observed two groups of HE staining light microscopy. 1 cases of rheumatic aortic valve calcification, rheumatic mitral valve calcification and non rheumatic valvular valvular valve calcification were examined by electron microscopy and energy spectrum analysis. The results of 1.HE staining were observed. It can be seen that rheumatic and non rheumatic valvular calcification can have valvular calcification in varying degrees. Serious patients can have bone like changes, calcification is flaky and punctate; rheumatic valvular calcification specimens are heavier, thicker wall myogenic vessels are more common, calcification is generally heavier, non rheumatic valvular calcification specimens have more obvious mucous degeneration and thick wall myosmosis. The rare.2. electron microscope showed that the calcified substance showed two kinds of aggregations in the form of dot and flake. The calcified concentrated area was distributed in a flaky area, the surrounding area was punctually distributed, the calcified particles were different, the diameter was in the 0.3-5 mu m, the rheumatic valvular valve calcification, the rheumatic mitral valve calcification and the non rheumatic valvular valve calcification were not clear. The difference of.3. spectrum analysis suggested that different valvular calcification components were basically the same, mainly C, 0, P, Ca, and Na, Mg; the percentage ratio of Ca/P atom in calcification sites in different cases was not statistically different (P0.05), suggesting that calcified substance was mainly calcium phosphate. Conclusion although the pathogenesis is different, rheumatism and non The pathological findings of rheumatic valvular calcification were not significantly different under HE and electron microscopy. Calcium was the main component of calcification.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R542.5

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