Jim Thomas教授   美国克利夫兰诊所

　　<International Circulation>: What progress has been made in evaluation of structural heart disease through echocardiography?

　　Prof. Jim Thomas: There have been dramatic advances in echocardiography， and really， there’s no structural heart intervention that can be done without the use of echocardiography before， during and after a procedure. If we look at some of the more novel procedures like trans-catheter-aortic-valve replacement -- there we use echocardiography in all of our cases. We use it to first of all make sure we have the annular dimension measurement correctly and also to be certain that the device is placed in an appropriate position across the aortic annulus. Usually， that goes just fine. But where echocardiography really comes in to play is if there’s a complication， and you have literally 30 to 60 seconds to decide which of a host of potential disasters have occurred， so that you can correct it. There may be severe aortic regurgitation; there may be severe wall motion abnormalities from a coronary contusion; there may be mitral regurgitation from a misplaced applicator; there may be an aortic dissection. We’ve seen all of these in our experience， and you literally have seconds to make a change， to try to correct the situation， and that’s really where echocardiography shines.

　　《国际循环》：超声心动图评估结构性心脏病取得了哪些进展？

　　Jim Thomas教授：超声心动图取得了非常大的进展，现在对结构性心脏病干预前、中、后均需要超声心动图检查。行经导管主动脉瓣置入术等新型手术的患者均需应用超声心动图检测来确保测量尺寸的准确性及确定支架横跨主动脉弓后放置在适宜位置。通常情况下，手术能顺利实施，而超声心动图则能帮助我们确定是否存在并发症，以便在30～60秒内确定严重主动脉瓣关闭不全、冠状动脉挫伤导致的严重室壁运动异常、放置不当引发二尖瓣关闭不全、主动脉夹层动脉瘤等潜在问题并及时予以纠正。根据我们的经验，在手术过程中上述情况均可发生，而你仅有数秒的时间对其进行改变和纠正。超声心动图则是实现这一目标的重要工具。

　　<International Circulation>: What is the value of evaluating diastolic function by echocardiography in predicting the prognosis?

　　Prof. Jim Thomas:  Diastolic function is one of those really difficult entities to assess， and I think part of the problem is that what we call diastolic function is really a whole spectrum of different types of disorders. There can be disorders of left ventricular relaxation; disorders of abnormal left ventricular stiffness; disorders of atrial dysfunction， and they all can contribute to what we clinically call diastolic dysfunction. Echocardiography is really able to tease out where the lesion is by looking at events earlier， such as the annular velocity movement， issues related to the stiffness of the ventricle， such as the deceleration time of the mitral e-wave. It also allows us to look at issues related to atrial function， where you can look at forward and reverse A-wave in the pulmonary veins， and a number of other similar situations. There’s been a lot of work done over the last 25 to 30 years， showing that the echocardiographic assessment of diastolic function， while not perfect， certainly gives us some important prognostic information. We’ve just finished a large study looking at about 60，000 echocardiograms on relatively normal individuals who came through our echolab. Those who had any degree of diastolic dysfunction showed a significantly worse survival over the next ten years， as compared to those who had purely normal diastolic disjunctions. So even minor disorders of diastolic function in an otherwise young and healthy patient， they can be associated with a bad prognosis.

　　《国际循环》：超声心动图评估心脏舒张功能在预测患者预后方面的价值如何？

　　Jim Thomas教授：舒张功能真的很难评估，我认为其主要的问题是我们所说的舒张功能障碍实际上是不同类型疾病的统称。患者可能存在左心室舒张障碍，左心室僵硬度异常、左心房功能障碍，这些都会导致我们临床所说的舒张功能障碍。超声心动图能通过识别瓣环运动速度等早期事件以及反映室壁僵硬度的二尖瓣E波减速时间来确定病灶的所在，还有助于通过了解肺静脉正向及反向A波来了解心房功能。过去25～30年的大量研究显示，虽然采用超声心动图评估舒张功能并不完美，但却能为我们提供重要的预后信息。我们刚刚结束的一项大型研究对来我们超声室就诊的相关正常人群近60 000份超声心动图进行分析，结果发现，与舒张功能正常者相比，存在任何程度舒张功能障碍的患者未来10年内的生存率更低。所以，年轻及健康人群中即使舒张功能仅存在微小障碍也提示预后不良。