2024年7月12日 (五) 07:13的版本

1 摘要

目的：评价超声心动图诊断犬心包积液心脏肿块的敏感性和特异性。

设计：回顾性案例系列。

动物：107 只患有心包积液的狗。

程序：回顾了 1985 年至 2006 年在加州大学戴维斯分校兽医教学医院检查的心包积液狗的记录。狗狗进行了包括超声心动图、心包切除术或尸检。计算了心包积液各种病因的敏感性、特异性和转移率。

结果： 107 只心包积液犬通过手术 （n = 48 ） 、尸检 （44） 或两者皆进行 （15） 进行评估。超声心动图显示无肿块 （n = 41）、右心房 （RA） 肿块 （38）、心基 （HB） 肿块 （23）、心包肿块 （2）、HB 和 RA 肿块 （2） 以及右心室肿块 （1）。检测心脏肿块的敏感性和特异性分别为 82% 和 100%；分别为 82% 和 99% 用于检测 RA 质量；分别为 74% 和 98% 用于检测 HB 肿块。大多数 HB 肿块为神经内分泌或异位甲状腺组织，但 3 例为血管肉瘤，4 例为间皮瘤。大多数 RA 肿块是血管肉瘤，但该组还包括神经内分泌肿瘤、异位甲状腺组织、间皮瘤、淋巴肉瘤和肉瘤。肿瘤病因的转移率没有差异（50%-66%）。

结论与临床相关性：超声心动图对心包积液犬的 RA 或 HB 肿块的诊断和鉴别具有较高的敏感性和特异性。所有原因导致的心脏肿块的转移率都很高。（J Am Vet Med Assoc 2009;235:1456–1461)

2 正文

心包积液是狗中一种相当常见的获得性心脏病。据报道，在转诊兽医医院检查的狗的患病率为 0.43% （1/233），在有心脏病临床症状的狗中，患病率约为 7%。[1] 它是一种多发病因疾病，预后范围广泛，从良好到严重不等。[2] 狗心包积液的最常见原因包括右心房血管肉瘤、特发性心包炎和心脏基底化学感受器瘤。[3–5]

Pericardial effusion is a fairly common acquired cardiac condition in dogs. Prevalence has been reported to be 0.43% (1/233) for dogs examined at a referral veterinary hospital, and it accounts for approximately 7% of dogs with clinical signs of cardiac disease.[1] It is a multiple-etiologic disorder with a wide spectrum of prognoses that range from good to grave.[2] The mostcommon causes of pericardial effusion in dogs include hemangiosarcoma of the right atrium, idiopathic pericarditis, and chemodectoma of the heart base.[3–5]

确定心包积液的病因可提供有关适当治疗、临床进展和预后的宝贵信息。继发于肿瘤性原因的心包积液的狗预后不良，存活时间从 26 到 56 天不等，这比继发于非肿瘤性原因的心包积液的狗的较长生存时间 790 到 1,068 天要短得多。[3,6] 继发于心脏基础肿块的心包积液的狗通常比患有血管肉瘤的狗预后更好， 特别是当他们接受心包切除术时。[7–9] 接受心包切除术的心脏基底肿块的狗比未接受心包切除术的狗存活时间（中位生存时间，730 天）更长（中位生存时间，42 天）[7]。

Determination of the cause of pericardial effusion provides valuable information regarding appropriate treatment, clinical progression, and prognosis. Dogs with pericardial effusion secondary to neoplastic causes have a poor prognosis, with survival times ranging from 26 to 56 days, which is substantially shorter than the longer survival times of 790 to 1,068 days for dogs with pericardial effusion secondary to nonneoplastic causes.[3,6] Dogs with pericardial effusion secondary to a heart base mass typically have a better prognosis than dogs with hemangiosarcoma, especially when they undergo pericardectomy.[7–9] Dogs with heart base masses that underwent pericardectomy survived longer (median survival time, 730 days) than those that did not undergo pericardectomy (median survival time, 42 days).[7]

超声心动图是诊断心包积液以及评估病因的重要程序，包括心脏肿块的识别和定位、结构性或功能性心脏病的检测以及积液严重程度的评估，用于定义治疗计划。 首次检查的敏感性在 17% 到 50% 之间变化，重复检查时增加到 69%[4,11] 然而，尚未进行任何研究来评估超声心动图区分右心房肿块和心脏基底肿块的敏感性或特异性，这通常具有预后意义。此外，上述许多研究都是使用缺乏现代超声机的分辨率和帧速率的超声机进行的。

Echocardiography is an essential procedure for diagnosis of pericardial effusion as well as evaluation of the cause, including the identification and location of cardiac masses, detection of structural or functional cardiac disease, and assessment of the severity of the effusion, for use in defining a therapeutic plan.10 There is a wide range in the reported sensitivity for echocardiographic detection of cardiac masses, which varies between 17% and 50% for first-time examinations and increases to 69% for repeat examinations.[4,11] However, no studies have been conducted to evaluate the sensitivity or specificity of echocardiography for distinguishing right atrial masses from heart base masses, which often has prognostic implications. In addition, many of the aforementioned studies were performed with ultrasound machines that lacked the resolution and frame rates of modern ultrasound machines.

此报告的研究具体目标是确定超声心动图在检测心包积液狗的心脏肿块、区分右心房肿块与心包积液的其他原因以及区分心基底肿块与心包积液的其他原因的敏感性和特异性。次要目标包括确定心脏内肿瘤的具体肿瘤原因和位置，比较心包积液肿瘤原因的转移率，以及描述心包积液狗的临床病理异常。

The specific objectives of the study reported here were to determine the sensitivity and specificity of echocardiography for detection of a cardiac mass in dogs with pericardial effusion, for distinguishing right atrial masses from other causes of pericardial effusion, and for distinguishing heart base masses from other causes of pericardial effusion. Secondary objectives included defining the specific neoplastic causes and locations of neoplasms within the heart, comparing metastatic rates of neoplastic causes of pericardial effusion, and characterizing clinicopathologic abnormalities in dogs with pericardial effusion.

3 材料和方法

病例选择：通过搜索 1985 年至 2006 年加州大学戴维斯分校兽医医学教学医院数据库确定了心包积液的狗。所有狗都由董事会认证的兽医心脏病专家或受监督的心脏病学住院医师进行了超声心动图检查。所有狗都必须至少通过使用超声心动图确定轻度心包积液才能被纳入研究，并且没有心包积液的超声心动图证据的狗不包括在内。通过超声心动图确定轻度或更大程度心包积液的狗被纳入研究，当时在那次就诊期间或随后的就诊期间进行心包切除术或尸检以确认心包积液的原因。接受胸腔镜心包切除术的狗被排除在外，因为在手术过程中无法看到整个心脏。所有患有心脏或心包肿块的狗的肿瘤病因的诊断是通过对手术或尸检期间获得的活检标本进行组织学评估做出的。除了患有感染性心包炎的狗外，心包积液的非肿瘤性原因的诊断也通过组织学进行诊断。

Case selection — Dogs with pericardial effusion were identified by searching the University of California-Davis Veterinary Medical Teaching Hospital database from 1985 through 2006. All dogs had an echocardiogram performed by a board-certified veterinary cardiologist or a supervised cardiology resident. All dogs were required to have at least mild pericardial effusion identified by use of echocardiography to be included in the study, and dogs with echocardiographic evidence of a cardiac mass without pericardial effusion were not included. Dogs with mild or greater pericardial effusion identified by echocardiography were included in the study when pericardectomy or necropsy was performed during that visit or a subsequent visit to confirm the cause of the pericardial effusion. Dogs undergoing thoracoscopic pericardectomy were excluded because of an inability to view the entire heart during that procedure. Diagnosis of the neoplastic cause in all dogs with cardiac or pericardial masses was made by histologic evaluation of biopsy specimens obtained during surgery or necropsy. Except for dogs with infective pericarditis, diagnosis of nonneoplastic causes of pericardial effusion was also made histologically.

病历审查：获得多个超声心动图视图，以彻底评估狗的心脏肿块;这些视图包括右胸骨旁短轴和长轴视图、左心尖视图，以及最重要的左颅骨旁长轴视图，该视图提供了右心房的最佳图像。在研究期间使用了三台超声波机（机器A，a，1985年至1991年;机器B，b，1991年至2000年;机器C，c，c，2000年至2006年）。心包积液原因的超声心动图特征包括右心耳质量、心脏基底质量、心包质量、心脏质量的其他位置（如果适用）或无肿块证据的类别。

Medical records review — Multiple echocardiographic views were obtained to thoroughly evaluate dogs for cardiac masses; those views included right parasternal short-axis and long-axis views, left apical views, and, most importantly, the left cranial parasternal long-axis view that provides the best images of the right atrium. Three ultrasound machines were used during the study period (machine A,a 1985 through 1991; machine B,b 1991 through 2000; and machine C,c 2000 through 2006). Echocardiographic characterization of the cause of the pericardial effusion included the categories right atrial-auricular mass, heart base mass, pericardial mass, other location of a cardiac mass (if applicable), or no evidence of a mass.

敏感性和特异性是根据第一次超声心动图检查计算的，用于超声心动图检测心脏肿块与无肿块，检测心脏基础质量与其他原因，以及检测右心房质量与其他原因。为了评估超声心动图在系列检查期间的诊断能力是否有所提高，还通过使用多次检查的狗的最终超声心动图检查结果来计算超声心动图检测心脏肿块与其他原因的敏感性和特异性。使用二维超声心动图对心包填塞证据进行主观评估，当右心房、右心室或两者兼有心包积液舒张衰竭时，诊断为心包填塞。

Sensitivity and specificity were calculated on the basis of the first echocardiographic examination for echocardiographic detection of a cardiac mass versus no mass, for detection of a heart base mass versus other causes, and for detection of a right atrial mass versus other causes. To assess whether there was improved diagnostic capability of echocardiography during serial examinations, sensitivity and specificity of echocardiography for detection of a cardiac mass versus another cause were also calculated by use of findings from the final echocardiographic examination in dogs examined multiple times. Subjective evaluation for evidence of cardiac tamponade was performed by use of 2-D echocardiography, and cardiac tamponade was diagnosed when there was diastolic collapse of the right atrium, right ventricle, or both in addition to pericardial effusion.

记录了临床特征，包括信号和体重。对所有狗都进行了胸 X 光片检查，主观特征是是否存在球状心脏轮廓、是否存在心脏占位效应以及是否存在转移性肺部疾病。右心衰竭被识别并表征为腹水、胸腔积液或两者兼而有之，并通过使用超声检查确诊。标准做法包括在体格检查中检测到心律失常时进行心电图检查。对所有狗进行的临床病理学测试包括全血细胞计数和血清生化分析。在一些狗中分析了心包液，包括细胞学评估以及可能的需氧和厌氧微生物培养。

Clinical characteristics were recorded, which included signalment and body weight. Thoracic radiographs were obtained for all dogs and were characterized subjectively by the presence or absence of a globoid cardiac silhouette, presence or absence of a cardiac mass effect, and presence or absence of metastatic pulmonary disease. Right-sided heart failure was identified and characterized as ascites, pleural effusion, or both and was confirmed by use of ultrasonography. Standard practice included obtaining an ECG when there was an arrhythmia detected during physical examination. Clinicopathologic tests performed on all dogs included a CBC and serum biochemical analysis. Pericardial fluid was analyzed in some dogs, which included cytologic evaluation and possibly aerobic and anaerobic microbial culture.

统计分析：采用Fisher精确检验比较肿瘤性病因的转移率，比较肿瘤性病因和非肿瘤性病因的双腔积液、胸腔积液或腹水的发生率。显著性定义为 P < 0.05 的值。还通过审查医疗记录获得了生存数据，尽管许多狗在后续监测中丢失了。在后续监测中丢失的狗在最后一次医疗进入的日期被审查。针对心包积液的最常见原因生成了 Kaplan-Meier 曲线。使用 Tarone-Ware 秩检验确定显著性。中位生存时间是通过使用非参数生存分析计算的。学生 t 检验用于比较患有心包积液的肿瘤性和非肿瘤性原因的狗的年龄。在接受完全尸检的狗中计算转移率。

Statistical analysis — The Fisher exact test was used to compare the rate of metastasis for neoplastic causes and to compare the rates of bicavitary effusion, pleural effusion, or ascites between neoplastic and nonneoplastic causes. Significance was defined as values of P < 0.05. Survival data were also obtained from review of medical records, although many dogs were lost to follow-up monitoring. Dogs that were lost to follow-up monitoring were censored at the date of the last medical entry. Kaplan-Meier curves were generated for the most common causes of pericardial effusion. The Tarone-Ware rank test was used to determine significance. Median survival times were calculated by use of nonparametric survival analysis. Student t tests were used to compare ages of dogs with neoplastic and nonneoplastic causes of pericardial effusion. Metastatic rate was calculated in dogs that underwent complete necropsies.