一年前心室腔不大,LVEF正常,一年后复查LVEF降至35%,心脏收缩功能有下降趋势,提示存在心肌本身病变,难以用单纯肾动脉狭窄解释。心电图巨大导致T波,不能用交感风暴、记忆效应解释,近三年心电图进展为CLBBB,考虑与心肌病变有关。病因分析:(1)现冠心病可除外(造影正常);(2)发作时血压虽高,但平素系统监测基础血压正常,高血压心肌损害无依据;(3)IgG和尿Kappa链略高,但血清蛋白电泳正常,心室壁不厚,患者无严重体循环淤血表现,心肌淀粉样变性无依据;(4)虽有房颤,但平时心室率在90次/分以下,心律失常性心肌病不考虑;(5)虽有双房明显扩大,但无心室腔缩小,嗜酸粒细胞不高,无严重体循环淤血征象,限制型心肌病无依据。(6)有房颤,双房大,但甲功正常,甲亢性心脏病无证据。目前心肌病变病因不清,进一步可考虑行心肌活检提供诊断思路。
6参考文献
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图5. 心尖四腔切面 图6. 胸骨旁左心室长轴切面
图7. 二尖瓣口血流多谱勒测量E波图8. 组织多普勒测量E’波