病例:抽丝剥茧,一例罕见的老年肺栓塞晕厥患者的Brugada样心电图

2021-10-18 李玉昆  首都医科大学附属北京安贞医院 心在线

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病例介绍

一名61岁的老男男性患者因前列腺增生手术入院,既往无心肺相关疾病史。就诊时,查体未见异常。患者血象结果和血清电解质水平在正常范围内。入院时12导联心电图()如下(图A)。

图片

A. 入院心电图:窦性心律,无明显ST-T偏移

 

术后卧床一天后,患者上厕所时突发呼吸困难、晕厥。即测血压值75/38 mmHg,外周血氧饱和度为87%。视诊可见明显的颈静脉怒张。再次进行ECG检查,结果如图B。

 

图片

 

B.术后ECG示右胸导联(V1、V2)中ST段抬高,高度怀疑为1型Brugada心电图。

问提

图B中患者术后ECG的临床转归可能是什么?最有可能的诊断是什么?

解释

患者入院时的基线12导联ECG显示窦性心律,无明显ST-T偏移。术后重复行ECG,结果显示有房颤波形(160次/分)伴快速心室率、电轴右偏、S1Q3T3模式(I导联可见深S波,III导联可见Q波和T波倒置)、V4至V6导联ST段压低、III、V1和V2导联ST段抬高以及V1和V2导联产生额外的T波倒置,高度怀疑为1型Brugada 心电图,也就是产生Brugada表型。综上所述,ECG变化提示患者存在一定程度的右心室(RV)劳损改变。

结合患者术后卧床休息史、ECG显示右室劳损改变,以及晕厥伴呼吸困难。高度怀疑可能存在危及生命的急性肺栓塞(APE)。肺血管CT造影显示鞍状肺栓塞伴左右肺动脉主干的广泛血栓形成,右心室扩张。诊断为大面积APE,立即使用尿激酶输注溶栓。溶栓后患者恢复良好,10天后出院回家,接受规律抗凝治疗。

目前研究认为,急性肺栓塞住院期间死亡风险的最强心电预测因素为S1Q3T3模式、右束支阻滞、V1导联QR型、V1/Ⅲ导联ST段抬高、电轴右偏。此外,既往有病例报导显示:aVR导联的 ST段抬高和Ⅰ、V4~V6导联ST段压低与大面积肺栓塞有关。

结合该患者的ECG特征以及临床表现,强烈提示患者可能有大面积肺栓塞。但是值得警惕的是,突然晕厥以及心电图上的Brugada样心电波,很容易导致错误诊断为诊断Brugada综合征。

1.Brugada综合征

Brugada综合征(Brugada syndrome,BrS)是一种离子通道疾病,为常染色体显性遗传病,目前至少发现24个致病基因,仅有两个基因(SCN5A和CACNA1c)在基因型阳性的患者中所占比例>5%。我国Brugada综合征患者主要与SCN5A有关。研究发现,显示Brugada心电图改变者与短QT并存,其可能与SCN5A突变相关。

基因突变引起Brugada综合征的机制包括内向钠离子流或钙离子流的减少和外向钾离子流的增加。目前关于Brugada综合征的发病机制,有3种主要模型解释,包括复极异常、除极异常和神经嵴模型。尽管3种模型有所不同,但明确一致的是,右室流出道是主要的病理生理区域

心电图基本变化表现为

(1)V1~V3导联J点抬高;

(2)ST段抬高(≥0.2 mV);

(3)T波倒置、双向或正立;

(4)伴类似于右束支传导阻滞的改变;

(5)P-R间期可延长。

Brugada综合征心电图三种类型

(1)I型:穹窿型,J波幅度≥2 mm,T波倒置,ST段末部渐降(下斜型);

(2)II型:高马鞍型,J波幅度≥2 mm,T波正向或双向,ST段末部≥1 mm;

(3)III型:低马鞍型,J波幅度≥2 mm,T波正向,ST段末部<1 mm。

2. Brugada拟表型

Brugada拟表型是由Adrian Baranchuk等首次提出的一个新术语,主要帮助与Brugada综合征心电图鉴别,拟表型是一种遗传生物学概念,是指由于环境因素的作用使某一个体的表型与某一特定基因突变所产生的表型相同或相似。值得注意的是,拟表型是由于环境因素的影响,并非生殖细胞中基因本身发生的改变所致,因此这种表型改变不会遗传给后代。

引起Brugada拟表型的原因主要包括内环境紊乱(最常见的是高钾血症)、内分泌疾病(垂体功能减退)、机械压迫(纵隔肿瘤、漏斗胸)、缺血和肺栓塞、心肌和心包疾病等。发热和钠通道阻滞剂也可诱发Brugada样心电图。

可能有2个原因,导致医生没有考虑该患者的高钾血症:(1)ECG上没有高尖对称的T波,(2)入院时患者的血清钾水平在正常范围内。

对于Brugada综合征,植入式心律转复除颤器是唯一有效的治疗方法,而在Brugada拟表型中,早期针对原因进行特异性治疗,可以预防心源性死亡。在本病例中,患者被诊断为大面积肺栓塞,而针对性的溶栓治疗迅速帮助患者血流动力学恢复正常。

在大面积肺栓塞和肺血管阻力升高的前提下,右室前负荷突然增加,又进一步加重既往存在的右室应变,并进一步导致右心室室壁透壁性心肌缺血。右心室缺血受累可以解释急性缺血性心脏事件期间表现为1型或2型Brugada拟表型的ST段抬高现象。因此,肺栓塞相关的透壁性心肌缺血,可以解释该患者的Brugada样心电图。

虽然ECG改变在肺栓塞中特异性和敏感性不足,但心电图变化与右心室功能障碍的血流动力学参数有很强的相关性。因此,ECG在评估APE的严重程度和死亡风险方面具有重要作用。Brugada拟表型是APE的罕见心电图表现,常提示危及生命的大面积肺栓塞。因此,大面积APE引起的Brugada拟表型应引起临床上医生的注意。

肺栓塞患者住院死亡风险最强的ECG预测因素为S1Q3T3型、右束支阻滞、V1导联QR型、V1、Ⅲ导联ST段抬高、电轴右偏。

研究显示,aVR导联的ST段抬高和I、V4~V6导联的ST段压低与大面积肺栓塞相关。

引起Brugada拟表型的原因主要包括代谢失衡(最常见的是高钾血症)、内分泌疾病(垂体功能减退)、机械压迫(纵隔肿瘤、漏斗胸)、缺血和肺栓塞、心肌和心包疾病等

在Brugada综合征中,植入式心律转复除颤器是唯一有效的治疗方法,而在Brugada拟表型中,早期针对病因的特异性治疗可以预防心源性死亡。

右心室缺血受累可以解释急性缺血性心脏事件期间,表现为1型或2型Brugada波的ST段抬高现象。

引用文献

Brugada Electrocardiographic Pattern in an Older Man With Syncope. JAMA Intern Med. 2021 Oct 11. doi: 10.1001/jamainternmed.2021.4838. 

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    2023-03-25 ms5000000231866243

    正好遇到了,学习了,谢谢😊

    0

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  3. [GetPortalCommentsPageByObjectIdResponse(id=2121717, encodeId=1a2a2121e17f4, content=正好遇到了,学习了,谢谢😊, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20230407/a53a5beb1236447c940a67c0284e99be/c7fc01a3d5344c56b5c952ea1d881368.jpg, createdBy=3df08593064, createdName=ms5000000231866243, createdTime=Sat Mar 25 08:09:33 CST 2023, time=2023-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2081246, encodeId=0a17208124697, content=<a href='/topic/show?id=e1ab3e481d' target=_blank style='color:#2F92EE;'>#Brugad#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3748, encryptionId=e1ab3e481d, topicName=Brugad)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Wed Mar 30 01:12:27 CST 2022, time=2022-03-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264783, encodeId=c2db1264e83ad, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311662, encodeId=b03e13116624f, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467631, encodeId=0ed5146e631d9, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1590759, encodeId=75721590e59c4, content=<a href='/topic/show?id=86e23e49d6' target=_blank style='color:#2F92EE;'>#Brugada#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3749, encryptionId=86e23e49d6, topicName=Brugada)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=939917859602, createdName=nymo, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1061556, encodeId=7cf5106155601, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=医者仁者, createdTime=Mon Oct 18 18:09:41 CST 2021, time=2021-10-18, status=1, ipAttribution=)]
    2021-10-20 般若傻瓜
  4. [GetPortalCommentsPageByObjectIdResponse(id=2121717, encodeId=1a2a2121e17f4, content=正好遇到了,学习了,谢谢😊, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20230407/a53a5beb1236447c940a67c0284e99be/c7fc01a3d5344c56b5c952ea1d881368.jpg, createdBy=3df08593064, createdName=ms5000000231866243, createdTime=Sat Mar 25 08:09:33 CST 2023, time=2023-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2081246, encodeId=0a17208124697, content=<a href='/topic/show?id=e1ab3e481d' target=_blank style='color:#2F92EE;'>#Brugad#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3748, encryptionId=e1ab3e481d, topicName=Brugad)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Wed Mar 30 01:12:27 CST 2022, time=2022-03-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264783, encodeId=c2db1264e83ad, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311662, encodeId=b03e13116624f, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467631, encodeId=0ed5146e631d9, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1590759, encodeId=75721590e59c4, content=<a href='/topic/show?id=86e23e49d6' target=_blank style='color:#2F92EE;'>#Brugada#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3749, encryptionId=86e23e49d6, topicName=Brugada)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=939917859602, createdName=nymo, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1061556, encodeId=7cf5106155601, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=医者仁者, createdTime=Mon Oct 18 18:09:41 CST 2021, time=2021-10-18, status=1, ipAttribution=)]
    2021-10-20 lily1616
  5. [GetPortalCommentsPageByObjectIdResponse(id=2121717, encodeId=1a2a2121e17f4, content=正好遇到了,学习了,谢谢😊, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20230407/a53a5beb1236447c940a67c0284e99be/c7fc01a3d5344c56b5c952ea1d881368.jpg, createdBy=3df08593064, createdName=ms5000000231866243, createdTime=Sat Mar 25 08:09:33 CST 2023, time=2023-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2081246, encodeId=0a17208124697, content=<a href='/topic/show?id=e1ab3e481d' target=_blank style='color:#2F92EE;'>#Brugad#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3748, encryptionId=e1ab3e481d, topicName=Brugad)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Wed Mar 30 01:12:27 CST 2022, time=2022-03-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264783, encodeId=c2db1264e83ad, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311662, encodeId=b03e13116624f, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467631, encodeId=0ed5146e631d9, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1590759, encodeId=75721590e59c4, content=<a href='/topic/show?id=86e23e49d6' target=_blank style='color:#2F92EE;'>#Brugada#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3749, encryptionId=86e23e49d6, topicName=Brugada)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=939917859602, createdName=nymo, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1061556, encodeId=7cf5106155601, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=医者仁者, createdTime=Mon Oct 18 18:09:41 CST 2021, time=2021-10-18, status=1, ipAttribution=)]
    2021-10-20 syscxl
  6. [GetPortalCommentsPageByObjectIdResponse(id=2121717, encodeId=1a2a2121e17f4, content=正好遇到了,学习了,谢谢😊, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20230407/a53a5beb1236447c940a67c0284e99be/c7fc01a3d5344c56b5c952ea1d881368.jpg, createdBy=3df08593064, createdName=ms5000000231866243, createdTime=Sat Mar 25 08:09:33 CST 2023, time=2023-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2081246, encodeId=0a17208124697, content=<a href='/topic/show?id=e1ab3e481d' target=_blank style='color:#2F92EE;'>#Brugad#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3748, encryptionId=e1ab3e481d, topicName=Brugad)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Wed Mar 30 01:12:27 CST 2022, time=2022-03-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264783, encodeId=c2db1264e83ad, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311662, encodeId=b03e13116624f, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467631, encodeId=0ed5146e631d9, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1590759, encodeId=75721590e59c4, content=<a href='/topic/show?id=86e23e49d6' target=_blank style='color:#2F92EE;'>#Brugada#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3749, encryptionId=86e23e49d6, topicName=Brugada)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=939917859602, createdName=nymo, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1061556, encodeId=7cf5106155601, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=医者仁者, createdTime=Mon Oct 18 18:09:41 CST 2021, time=2021-10-18, status=1, ipAttribution=)]
    2021-10-20 nymo
  7. [GetPortalCommentsPageByObjectIdResponse(id=2121717, encodeId=1a2a2121e17f4, content=正好遇到了,学习了,谢谢😊, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20230407/a53a5beb1236447c940a67c0284e99be/c7fc01a3d5344c56b5c952ea1d881368.jpg, createdBy=3df08593064, createdName=ms5000000231866243, createdTime=Sat Mar 25 08:09:33 CST 2023, time=2023-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2081246, encodeId=0a17208124697, content=<a href='/topic/show?id=e1ab3e481d' target=_blank style='color:#2F92EE;'>#Brugad#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3748, encryptionId=e1ab3e481d, topicName=Brugad)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Wed Mar 30 01:12:27 CST 2022, time=2022-03-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264783, encodeId=c2db1264e83ad, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311662, encodeId=b03e13116624f, content=<a href='/topic/show?id=053f59e677a' target=_blank style='color:#2F92EE;'>#晕厥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59767, encryptionId=053f59e677a, topicName=晕厥)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1467631, encodeId=0ed5146e631d9, content=<a href='/topic/show?id=ef32e9539e8' target=_blank style='color:#2F92EE;'>#罕见#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79539, encryptionId=ef32e9539e8, topicName=罕见)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=29f36868190, createdName=syscxl, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1590759, encodeId=75721590e59c4, content=<a href='/topic/show?id=86e23e49d6' target=_blank style='color:#2F92EE;'>#Brugada#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3749, encryptionId=86e23e49d6, topicName=Brugada)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=939917859602, createdName=nymo, createdTime=Wed Oct 20 06:12:27 CST 2021, time=2021-10-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1061556, encodeId=7cf5106155601, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=医者仁者, createdTime=Mon Oct 18 18:09:41 CST 2021, time=2021-10-18, status=1, ipAttribution=)]
    2021-10-18 医者仁者

    学习!

    0

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