老年人中重度钙化性主动脉瓣狭窄合并冠心病的心肌病理特点分析

摘要

目的 总结老年住院死亡行尸体解剖病例中中重度钙化性主动脉瓣狭窄患者的冠状动脉病变及心肌的病理改变特点,并分析其死亡原因. 方法 入选我院病理科资料库中1969年4月1日至2013年10月31日60～100岁病例的系统病理解剖资料,共909例;回顾性分析其中经病理证实存在中重度钙化性主动脉瓣狭窄的病例17例,总结其冠状动脉病变特点、心肌病理改变及死亡原因. 结果 在60～69、70～79、80～89、90～100岁病例中,病理诊断主动脉瓣狭窄的检出率分别为1.1％(2/190)、1.9％(5/266)、3.7％(11/297)和6.4％(10/156),随增龄主动脉瓣狭窄的检出率明显增高(x2=10.08,P=0.018).17例中重度钙化性主动脉瓣狭窄病例的平均年龄为(83.1±9.2)岁,平均心脏质量(550.0±105.8)g;平均左室壁厚度(17.8±4.6) mm、室间隔厚度(15.5±6.4)mm.病理诊断冠心病13例(76.5％),其中严重冠状动脉狭窄5例(29.4％);最常见的累及血管的是左前降支(LAD),共8例(47.0％).合并冠心病的所有13例患者中均有心肌梗死病理改变,其中急性心肌梗死(AMI)6例(35.3％),陈旧性心肌梗死(OMI) 11例(64.7％),同时合并AMI和OMI 4例(23.5％),左室前壁为最常见累及部位.AMI中有透壁心肌梗死1例、非透壁心肌梗死2例、心内膜下心肌梗死2例、小灶性心肌梗死1例;OMI中有透壁心肌梗死1例、非透壁心肌梗死2例、心内膜下心肌梗死4例、小灶性心肌梗死4例,OMI的临床漏诊率高达81.8％.死亡原因居首位的为心血管疾病,共12例(70.6％),其中心肌梗死6例(35.3％)、心力衰竭3例(17.6％)、心律失常3例(17.6％);猝死6例(35.3％),所有猝死患者的病理均有心肌梗死表现. 结论 中重度钙化性主动脉瓣狭窄的老年患者合并冠心病比例较高,且合并冠心病者心室肌病理上均有心肌梗死改变,心内膜下和小灶性心肌梗死多见,但临床漏诊率高,死亡首位原因为心血管疾病,有心肌梗死的患者猝死发生率高,临床工作中应重视对钙化性主动脉瓣狭窄患者进行心肌病变评估.%Objective To characterize autopsy pathological changes of the coronary artery and left ventricular myocardium in elderly patients with moderate to severe calcified aortic stenosis,and to analyze the causes of death.Methods Seventeen cases of moderate to severe calcified aortic stenosis were identified from an autopsy database of Beijing Hospital containing 909 elderly patients(aged from 60-100 years)collected from April 1,1969 to October 31,2013.All cases were confirmed by autopsy and were analyzed retrospectively.The characteristics of coronary artery lesions,myocardial pathological changes and causes of death were summarized.Results Aortic stenosis was detected in 1.1％(2/190),1.9％(5/266),3.7％(11/297)and 6.4％(10/156)of patients in the 60-69,70-79,80-89 and 90-100 age groups,increasingly prevalent with age(x2=10.08,P=0.018).In addition,seventeencases were confirmed to have moderate to severe calcified aortic stenosis.Of these cases,13 (76.5％) had coronary artery disease and 5 (29.4 ％)had severe coronary stenosis.The left anterior descending (LAD) artery was most commonly involved(47.0 ％).No thrombus was found in the coronary arteries,and only one had chronic total occlusion(5.9 ％).Myocardial infarction was confirmed in all 13 patients with coronary artery disease,including six cases(35.3％)of AMI,11 cases(64.7 ％)of OMI and four cases (23.5 ％)of AMI and OMI.Among AMI cases,transmural infarction was shown only in one case,with two cases of non-transmural infarction,two cases of subendocardial infarction and one case of focal myocardial infarction.Among OMI cases,transmural infarction was shown in one case,with two cases of non-transmural infarction,four cases of subendocardial infarction and four cases of focal myocardial infarction.The clinical misdiagnosis rate of OMI was as high as 81.8％.Patients died mainly from cardiovascular disease(70.6 ％),with six cases (35.3 ％) from myocardial infarction,three from heart failure(17.6％) and three from malignant arrhythmia (17.6 ％).Six of the cases suffered from sudden cardiac death(35.3％)with biopsy-confirmed myocardial infarction changes.Conclusions The incidence of CAD in elderly patients with calcific aortic stenosis is high.Pathological changes of myocardial infarction,especially of subendocardial and focal infarction,occur in patients with moderate to severe aortic stenosis and coronary heart disease with a high clinical misdiagnosis rate.Aortic stenosis implicates both the valve and myocardium.Assessment of myocardial lesions in patients with calcific aortic stenosis should be carefully conducted in clinical practice.