军事飞行人员升主动脉扩张病变临床资料分析及航空医学鉴定.pdf

204空军航空医学2 0 2 3年0 6 月第40 卷第3期AviationMedicineofAirForce，Vo l.40，No.3，Ju n e，2 0 2 3军事飞行人员升主动脉扩张病变临床资料分析及航空医学鉴定曹钰琨，杨婷，张婧，任兴华，薛恒怡，缪京莉，周云飞，张海涛摘要】目的初步探讨军事飞行人员升主动脉扩张病变的临床特征、治疗方式及医学鉴定原则。方法回顾分析空军特色医学中心2 0 19年12 月一2 0 2 2 年5月收治的6 例升主动脉扩张军事飞行人员临床诊治和航空医学鉴定资料，结合国内外相关文献提出意见和建议。结果本组病例均为男性，中位年龄44.5岁，中位飞行时间3950 h，首次诊断时均无明显临床症状，无显著血流动力学异常。2 例合并二叶式主动脉瓣畸形，体检发现心脏杂音，动脉病变直径 45mm，存在手术指征，其中1例手术后恢复良好给予飞行合格，另1例暂要求保守治疗，给予暂时飞行不合格。其余4例依据实际情况分别给予限制条件下飞行合格。结论升主动脉扩张病变发展到一定程度将严重威胁飞行安全，无手术指征飞行人员可视情况给予飞行合格，术后需综合评估后谨慎给予特许飞行合格。【关键词 升主动脉扩张；合格鉴定；飞行人员中图分类号 R856.5D0I;10.3969/j.issn.2097-1753.2023.03.004Clinical features and aeromedical evaluation of 6 cases of ascending aortic dilatation amongaircrewsCAO Yukun*YANG Ting,ZHANG Jing,REN Xinghua,XUE Hengyi,MIAO Jingli,ZHOU Yunfei,ZHANG Haitao.*Department ofCardiovascular Medicine,Air Force Medical Center,PLA,Air Force Medical University,Bejing 100142,ChinaCorresponding author:ZHANG Haitao,E-mail:Abstract Objective To explore the clinical characteristics,treatment methods and medical identification principles ofascending aortic dilatation in military aircrews.Methods The clinical data of six aircrews with ascending aortic dilatationadmitted to the Air Force Medical Center between December 2019 and May 2022 was analyzed respectively and relatedliterature was reviewed.Results All cases in this group are male.The average age of these aircrews was 44.5 years and theaverage flight time of these aircrews was 3 950 h.There were no obvious clinical symptoms or hemodynamic abnormalitiesdetected during the first diagnosis.Among the two cases of bicuspid aortic valves,cardiac murmur was found during physicalexamination.The diameter of arterial lesions exceeded 45 mm,and cardiac surgery was recommended.One case recovereduneventfully and was qualified as a waiver while the other case refused surgical treatment provisionally and was temporarilydisqualified.The other four cases were qualified for fight under restricted conditions.Conclusion Ascending aorta dilatationcan pose a serious threat to flight safety.Pilots can be qualified for flight if cardiac surgery is not needed.Pilots after operationcan be qualified as waivers after comprehensive evaluation.Key words Ascending aortic dilatation;Eligibility determination;Aircrews升主动脉扩张病变（ascendingaorticdilatation，AAD）是临床上一种严重威胁患者生命的大血管疾病，当血管直径45 50 mm或扩张速度5mm/6个月时破裂风险激增，必须手术治疗，其诱发与进展和作者单位：10 0 142 北京，空军军医大学空军特色医学中心心血管内科（曹钰琨、张婧、任兴华、薛恒怡、缪京莉、周云飞、张海涛）；100853北京，解放军总医院第一医学中心口腔科（杨婷)通信作者：张海涛，E-mail:文献标识码 A文章编号】2 0 97-17 53（2 0 2 3)0 3-2 0 4-0 4血流动力学异常及细胞分子水平改变有关。此疾病早期往往无明显临床症状，超声和CT检查中也极易忽视。如果能够控制相关危险因素，一般进展较为缓慢，可正常工作训练而无需手术治疗。飞行人员尤其是高性能战斗机飞行员长期暴露于快增长且剧烈波动的高加速度环境中，同时受到辐射、低温、噪声、震动等多种因素刺激，升主动脉如果不能耐受相关负荷，很可能发空军航空医学2 0 2 3年0 6 月第40 卷第3期AviationMedicineofAirForce，Vo l.40，No.3，Ju n e，2 0 2 3生病理性扩张影响飞行人员健康最终威胁飞行安全。国内外航空医学对AAD尚未制定相关分级和鉴定标准，临床研究甚至特许飞行病例也罕见报道。笔者通过分析空军特色医学中心2 0 19 年12 月一2 0 2 2 年5月收治的6 例AAD飞行人员临床资料，结合相关文献复习，对此类疾病的航空医学鉴定进行初步探讨。1对象与方法1.1对象选取2 0 19年12 月一2 0 2 2 年5月在空军特色医学中心确诊为AAD的军事飞行人员6 例。均为男性，年龄2 551岁，中位年龄44.5岁，飞行总时间55012 0 0 0 h，中位飞行时间3950 h。其中，歼（强）击机飞行员2 例，教练机飞行员1例，运输机飞行员2例，直升机机械师1例。1.2检查方法使用epiq7c彩色多普勒超声诊断仪(Philips公司，荷兰），探头频率2.53.5MHz，由专科心血管超声医师完成测量。患者取左侧卧或仰卧位行心血管扫查，测量升主动脉根部和升主动脉主干内径，取测量最大值。正常值标准：主动脉根部2 1 35mm，升主动脉2 1 35mm，38 m m 即升主动脉扩张。超声检查明确后予以CT检查，采用双源CT（西门子公司，德国）进行扫描。若2 种测量方法结果不一致，重新测量寻找原因；结果一致，确定为真实值。1.3医学鉴定以飞行人员能够胜任飞行工作，不危及飞行安全为基本原则，充分考虑AAD的自然病程、临床分期及疾病转归过程，对于临床表现轻、心血管功能无明显影响、病情稳定者，结论为飞行合格；对于病变较明显、影响心血管功能、危及飞行安全者，结论为飞行不合格。2结果2.1临床特征6 例患者均为体检时发现AAD。4例患者（病例1、2、4和5）无不适主诉和阳性体征，测量升主动脉根部及主干内径均 45mm，随访观察期间增长速度 50 mm或者内径增长速度 5mm/6个月，在合并二叶瓣畸形等情况下升主动脉内径 45mm即可考虑手术，该指征来源于欧美心脏病协会相关指南。主动脉瓣少量反流无高尿酸高脂血症，无左肾多发囊肿；高同型半胱氨酸房早、室早甲状腺结节；高尿酸；无高脂；轻度地中海贫血窦律，大致正甲状腺癌根治术；高无常血压；高脂血症；高尿酸飞行合格（限双座限特技）飞行合格副驾）改机种飞行合格（无人机）飞行合格暂时飞行不合格（地面观察3个月复查）空军航空医学2 0 2 3年0 6 月第40 卷第3期AviationMedicineofAirForce，V o l.40，No.3，Ju n e，2 0 2 3目前认为，当军事飞行人员患病进展至此时，高载荷和持续加速度极大增加了空中失能风险，所以应考虑暂停飞行训练，给予飞行不合格。在升主动脉直径38 mm但尚未进展到45 50 mm时，需充分考虑有无其他异常（包括症状、体征、心脏结构及功能等），可给予暂时飞行不合格，地面观察训练后测量升主动脉直径扩张速度，评判是否能继续飞行。综上所述，AAD在疾病初期往往缺乏明显临床表现，需要注重飞行人员此疾病的预防和筛查，通过年度体检超声及CT等手段早发现、早诊治、早鉴定。AAD早期阶段病情进展缓慢，但地面体能训练以及飞行载荷可能是疾病发展的重要因素。航空医学鉴定应根据病变的严重程度、发展速度及是否需要手术治疗，并结合飞行人员的个人飞行意愿、体能情况、飞行机种、飞行职务综合评定。【参考文献】1 Hiratzka LF,Bakris GL,Beckman JA,et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVMguidelinesfor the diagnosis and management of patients with ThoracicAortic Disease:a report of the American College of CardiologyFoundation/American Heart AssociationTaskForce on PracticeGuidelines,American Association for Thoracic Surgery,American College of Radiology,American Stroke Association,Society of Cardiovascular Anesthesiologists,Society forCardiovascular Angiography and Interventions,Society ofInterventional Radiology,Society of Thoracic Surgeons,andSociety for Vascular MedicineJ.Circulation,2010,121(13):e266-e369.2 Cuspidi C,Meani S,Fusi V,et al.Prevalence and corelates ofaortic root dilatation in patients with essential 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