主动脉瓣狭窄合并消化道出血病例分析

The clinical features of gastrointestinal bleeding complicating aortic stenosis

目的通过对主动脉瓣狭窄合并消化道出血病例的分析，提高对海德综合征的认识。方法总结分析北京大学第一医院近10年共14例主动脉瓣狭窄合并消化道出血患者的临床资料及预后。结果14例患者均为中、重度钙化性主动脉瓣狭窄合并消化道大出血，13例年龄≥65岁。13例行消化系统影像学检查，6例发现肠道血管畸形。11例重度主动脉瓣狭窄患者中6例行主动脉瓣置换术，术后未再发生消化道出血；5例采取保守治疗，2例猝死。结论对原因不明的老年消化道出血患者应及时行超声心动图和消化道内镜检查，有助于海德综合征的早期诊治。主动脉瓣置换术是改善本病预后的根本方法。

Objective To deepen the understanding about Heyde＇s syndrome by investigating the clinical characteristics and prognosis of the patients with aortic valve stenosis complicating with gastrointestinal bleeding. Methods Patients with aortic valve stenosis and gastrointestinal bleeding coincidently admitted to our hospital from 2001 to 2011 were retrieved and analyzed. Results In all the 443 157 in-patients, 474 patients were diagnosed with aortic valve stenosis （0. 11% , 474/443 157 ） and 14 patients （9 males and 5 females, aged 53-87 years old） with gastrointestinal bleeding coincidently（2. 95% , 14/474）. Among the 14 patients, 3 were moderate aortic valve stenosis, 11 severe aortic valve stenosis. The aortic valve peak flow velocity was 324-709 （480. 54 ± 188.25 ） cm/s and the mean aortic valve pressure gradient was 21.04-91.56 （ 56. 93 ± 29. 90） mm Hg （ 1 mm Hg = 0. 133 kPa） . Heavy gastrointestinal bleeding was manifested in all the 14 patients with 1 of haematemesis and 13 of hematochezia. Hemoglobin （Hb） and red blood cell （RBC） count were significantly lower than the normal range [ （69 ± 28 ） g/L and （ 2.71± 2.04） × 1012/L, P 〈 0. 05 ]. Their mean corpuscular volume （MCV） , mean corpuscular hemoglobin （ MCH）, mean corpuscular hemoglobin concentration （ MCHC ）, platelet （PLT） count, prothrombin time （PT） and international normalized ratio （INR） were in normal range [ （90. 21 ±2. 94） fl, （29.39 ± 1.99） pg, （327.57 ± 14.82） g/L, （185.13 ± 22,55） x 109/L, （11.4 ± 1.04） s and 1.22 ±0.44, respectively]. Among all the 14 patients, 13 were over 65 years old and they all accepted gastrointestinal imaging （ 13/14 ） . Vascular malformation of intestine was found in 6 patients with 4 lesions located in descending colon and 2 located in sigmoid colon. Hemorrhage foci were found in 2 patients with one of colon cancer, and another of duodenal ulcer, while no definite hemorrhage foci were found in the other 11 patients. A total of 6 patients with severe aortic valve stenosis underwent aortic valve replacement （AVR） successfully （6/11） and no recurrent gastrointestinal bleeding was ever found. Conservative treatment was performed in the other 5 patients with severe aortic valve stenosis （5/11） and resulted in sudden death in 2 patients （2/5）. Conclusions Prompt echocardiography and gastrointestinal endoscopy should be performed in the elderly patients with obscure gastrointestinal bleeding to facilitate the early diagnosis and treatment of Heyde＇s syndrome. AVR is a fundamental procedure to improve the prognosis of Heyde＇s syndrome.