Levine J C, Sanders S P, Colan S D, Jonas R A, Spevak P J
Department of Cardiology, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.
Cardiol Young. 2001 Jan;11(1):44-53. doi: 10.1017/s1047951100012415.
Infants with coarctation of the aorta may have obstructions at other sites within the left heart which are not always apparent on the initial echocardiogram. The magnitude of the risk of having the additional obstructions is not well described, with few reliable quantitative criterions for identifying patients at the highest risk. We determined the frequency of additional, late appearing, stenotic lesions within the left heart, and the predictive morphologic features on the initial cross-sectional echocardiogram. We identified all patients with coarctation of the aorta diagnosed by 3 months of age, excluding those with complex cardiac disease or definite additional stenotic lesions at presentation, leaving 101 patients for study. At follow-up, 31 stenotic lesions were diagnosed in 23 patients, 15 of whom had at least 1 intervention. Mitral stenosis was diagnosed in 11 patients, aortic stenosis in 10, subaortic stenosis in 8, and supravalvar aortic stenosis in 2. The probability for freedom from obstructive lesions was 81% at 1 year, 74% at 3 years, and 70% at 5 years. Echocardiographic predictors of mitral stenosis included smaller mitral valvar annuluses, presence of a mean transmitral gradient between 2.5 and 5.0 mmHg, and elongation of the area of intervalvar fibrous continuity. Predictors of aortic stenosis were smaller mitral valvar annuluses, an initial aortic valvar gradient between 15 and 20 mmHg, and obliteration of the commissure between the right and non-coronary leaflets of the aortic valve. Predictors of subaortic stenosis were smaller mitral valvar annuluses and elongation of the area of intervalvar fibrous continuity. Patients with Z-scores for the diameter of the mitral valve of less than -1 were at the highest risk for manifesting obstructive lesions at any level. Associated stenoses in the left heart are common in the setting of aortic coarctation. When Doppler data is equivocal, features of the cross-sectional echocardiogram can identify the sub-group of infants at increased risk.
患有主动脉缩窄的婴儿可能在左心的其他部位存在梗阻，这些梗阻在最初的超声心动图上并不总是很明显。存在额外梗阻的风险程度尚无充分描述，几乎没有可靠的定量标准来识别风险最高的患者。我们确定了左心内额外的、后期出现的狭窄病变的频率，以及初始横断面超声心动图上的预测形态学特征。我们识别出所有在3个月大时被诊断为主动脉缩窄的患者，排除那些患有复杂心脏病或就诊时明确存在额外狭窄病变的患者，剩下101名患者进行研究。在随访中，23名患者被诊断出31处狭窄病变，其中15人至少接受了1次干预。11名患者被诊断为二尖瓣狭窄，10名患者为主动脉狭窄，8名患者为主动脉瓣下狭窄，2名患者为主动脉瓣上狭窄。无梗阻性病变的概率在1年时为81%，3年时为74%，5年时为70%。二尖瓣狭窄的超声心动图预测因素包括较小的二尖瓣环、平均跨二尖瓣压差在2.5至5.0 mmHg之间以及瓣间纤维连续性区域的延长。主动脉狭窄的预测因素是较小的二尖瓣环、初始主动脉瓣压差在15至20 mmHg之间以及主动脉瓣右冠瓣和无冠瓣之间的瓣叶联合消失。主动脉瓣下狭窄的预测因素是较小的二尖瓣环和瓣间纤维连续性区域的延长。二尖瓣直径Z值小于-1的患者在任何水平出现梗阻性病变的风险最高。在主动脉缩窄的情况下，左心相关狭窄很常见。当多普勒数据不明确时，横断面超声心动图的特征可以识别出风险增加的婴儿亚组。
