北野成昭(キタノナルアキ) 作『獣医志Wiki』はクリエイティブ・コモンズ 表示 - 非営利 - 継承 4.0 国際 ライセンスで提供されています。
心エコー
、ページの作成:「<html><html> <head> <meta http-equiv="Content-Type" content="text/html; charset=utf-8"> <meta http-equiv="Content-Style-Type" content="text/css"> <title></title>...」
<html><html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<meta http-equiv="Content-Style-Type" content="text/css">
<title></title>
<meta name="Generator" content="Cocoa HTML Writer">
<meta name="CocoaVersion" content="1265.21">
<style type="text/css">
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td.td37 {width: 184.0px; height: 79.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
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td.td40 {width: 207.0px; height: 79.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
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td.td45 {width: 147.0px; height: 58.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td46 {width: 113.0px; height: 58.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td47 {width: 207.0px; height: 58.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td48 {width: 119.0px; height: 58.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td49 {width: 179.0px; height: 58.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
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td.td51 {width: 184.0px; height: 74.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td52 {width: 147.0px; height: 74.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td53 {width: 113.0px; height: 74.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td54 {width: 207.0px; height: 74.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td55 {width: 119.0px; height: 74.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
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td.td65 {width: 184.0px; height: 63.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
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td.td68 {width: 207.0px; height: 63.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td69 {width: 119.0px; height: 63.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td70 {width: 179.0px; height: 63.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td71 {width: 56.0px; height: 57.0px; background-color: #c6ccd6; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td72 {width: 184.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td73 {width: 147.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td74 {width: 113.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td75 {width: 207.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td76 {width: 119.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
td.td77 {width: 179.0px; height: 57.0px; background-color: #fff9e7; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; border-color: #000000 #000000 #000000 #000000; padding: 2.0px 2.0px 2.0px 2.0px}
</style>
</head>
<body>
<p class="p1"><br></p>
<table cellspacing="0" cellpadding="0" class="t1">
<tbody>
<tr>
<td valign="middle" class="td1">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td2">
<p class="p2"><span class="s1">病態生理</span></p>
</td>
<td valign="middle" class="td3">
<p class="p2"><span class="s2">B</span><span class="s1">モード</span></p>
</td>
<td valign="middle" class="td4">
<p class="p2"><span class="s1"> </span><span class="s2">M</span><span class="s1">モード </span></p>
</td>
<td valign="middle" class="td5">
<p class="p2"><span class="s1">カラードプラ </span></p>
</td>
<td valign="middle" class="td6">
<p class="p2"><span class="s1">パルスドプラ</span></p>
</td>
<td valign="middle" class="td6">
<p class="p2"><span class="s1">連続波ドプラ</span></p>
</td>
<td valign="middle" class="td7">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td8">
<p class="p3"><span class="s1">正常</span></p>
</td>
<td valign="middle" class="td9">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td10">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td11">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td12">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td14">
<p class="p2"><span class="s1">①右胸骨左室流出路</span></p>
<p class="p2"><span class="s1">②右胸骨左室流入路</span></p>
<p class="p2"><span class="s1">③右胸骨左室短軸像</span></p>
<p class="p2"><span class="s1">④右胸骨心基底部短軸</span></p>
<p class="p2"><span class="s1">⑤左心尖部四腔断面</span></p>
<p class="p2"><span class="s1">⑥左心尖部五腔断面</span></p>
<p class="p2"><span class="s1">⑦左胸骨心基底部</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td15">
<p class="p4"><span class="s1">MR</span></p>
</td>
<td valign="middle" class="td16">
<p class="p2"><span class="s1">左心の容量負荷</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">左房圧の上昇→肺静脈、肺毛細血管圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">鬱血</span></p>
</td>
<td valign="middle" class="td17">
<p class="p2"><span class="s1">・</span><span class="s2">LA</span><span class="s1">、</span><span class="s2">LV</span><span class="s1">の拡大</span></p>
<p class="p2"><span class="s1">・</span><span class="s2">MV</span><span class="s1">の肥厚</span></p>
</td>
<td valign="middle" class="td18">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td19">
<p class="p2"><span class="s1">②⑤モザイク血流の確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期であること</span></p>
</td>
<td valign="middle" class="td20">
<p class="p5"><span class="s1">E</span><span class="s4">波が</span><span class="s1">1.5m/sec</span><span class="s4">以上で重度</span></p>
</td>
<td valign="middle" class="td20">
<p class="p2"><span class="s1">逆流速の測定</span></p>
<p class="p5"><span class="s4">初期：</span><span class="s1">5.5~6.0m/sec</span></p>
<p class="p2"><span class="s1">悪化すると遅くなる</span></p>
<p class="p6"><span class="s1"></span><br></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td21">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td22">
<p class="p4"><span class="s1">TR</span></p>
</td>
<td valign="middle" class="td23">
<p class="p2"><span class="s1">右心の容量負荷</span></p>
<p class="p2"><span class="s1">右房圧の上昇→全身静脈圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">腹水、胸水</span></p>
</td>
<td valign="middle" class="td24">
<p class="p5"><span class="s4">①</span><span class="s1">RA,RV</span><span class="s4">の拡大</span></p>
<p class="p2"><span class="s1">③心室中隔の平坦化</span></p>
</td>
<td valign="middle" class="td25">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td26">
<p class="p2"><span class="s1">②④⑤モザイク血流の確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期であること</span></p>
</td>
<td valign="middle" class="td27">
<p class="p5"><span class="s4">逆流速</span><span class="s1">1.5~2.5m/sec</span></p>
<p class="p5"><span class="s4">右室圧の上昇で</span><span class="s1">3.0~4.0m/sec</span></p>
</td>
<td valign="middle" class="td27">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td28">
<p class="p2"><span class="s1">肺高血圧症、肺動脈狭窄症に付随して起こるコトあり</span></p>
<p class="p2"><span class="s2">MR</span><span class="s1">の</span><span class="s2">3</span><span class="s1">割で</span><span class="s2">TR</span><span class="s1">を合併している</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td29">
<p class="p4"><span class="s1">HCM</span></p>
</td>
<td valign="middle" class="td30">
<p class="p2"><span class="s1">うっ血性心不全、ＭＲ</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">心房拡張</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">血流鬱血→血栓形成</span></p>
</td>
<td valign="middle" class="td31">
<p class="p2"><span class="s1">①③④左室後壁中隔壁の肥厚</span></p>
<p class="p2"><span class="s1">①流出路の傷害がないか確認</span></p>
<p class="p2"><span class="s1">②左房内に血栓がないか確認</span></p>
<p class="p2"><span class="s2">SAM</span><span class="s1">：</span><span class="s2">MV</span><span class="s1">の奇異運動がないか確認</span></p>
</td>
<td valign="middle" class="td32">
<p class="p2"><span class="s1">拡張末期径（</span><span class="s2">R</span><span class="s1">波直上）</span></p>
<p class="p5"><span class="s4">正常</span><span class="s1">4mm</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">ｽｲｰﾌﾟｽﾋﾟｰﾄﾞを早めに設定する</span></p>
</td>
<td valign="middle" class="td33">
<p class="p2"><span class="s2">2</span><span class="s1">次的変化の確認</span></p>
<p class="p2"><span class="s1">②</span><span class="s2">MR</span><span class="s1">がないか</span></p>
<p class="p2"><span class="s1">①⑥左室流出路障害の確認</span></p>
</td>
<td valign="middle" class="td34">
<p class="p2"><span class="s1">左室拡張障害の確認</span></p>
<p class="p2"><span class="s2">E/A</span><span class="s1">が１以下になる</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">さらに悪化すると偽正常化</span></p>
</td>
<td valign="middle" class="td34">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td35">
<p class="p2"><span class="s1">メインクーン・アメショー・ペルシャに好発</span></p>
<p class="p2"><span class="s1">壁の肥厚：</span><span class="s2">8mm</span><span class="s1">以上で血栓発生が危惧</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td36">
<p class="p4"><span class="s1">DCM</span></p>
</td>
<td valign="middle" class="td37">
<p class="p2"><span class="s1">心筋の緊張→刺激電導異常→不整脈</span></p>
<p class="p2"><span class="s1">弁閉鎖不全→ＭＲ、ＴＲ</span></p>
</td>
<td valign="middle" class="td38">
<p class="p2"><span class="s1">①⑥四腔のバランスを確認</span></p>
<p class="p2"><span class="s2">MV</span><span class="s1">、</span><span class="s2">RV</span><span class="s1">でﾃｨｻﾞﾘﾝｸﾞがないか確認</span></p>
</td>
<td valign="middle" class="td39">
<p class="p2"><span class="s1">①③</span><span class="s2">FS</span><span class="s1">の測定</span></p>
<p class="p2"><span class="s1">①僧帽弁</span><span class="s2">M</span><span class="s1">モード</span></p>
<p class="p5"><span class="s1">EPSS</span><span class="s4">の測定</span></p>
</td>
<td valign="middle" class="td40">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td42">
<p class="p5"><span class="s1">FS</span></p>
<p class="p5"><span class="s1">20~25%</span><span class="s4"> 軽度</span></p>
<p class="p5"><span class="s1">15~20%</span><span class="s4"> 中程度</span></p>
<p class="p2"><span class="s2">15%</span><span class="s1">以下 重度</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td43">
<p class="p3"><span class="s1">心タンポナーデ</span></p>
</td>
<td valign="middle" class="td44">
<p class="p2"><span class="s1">心嚢内圧上昇→心腔拡張障害</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">静脈圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">うっ血肝、腹水、浮腫</span></p>
</td>
<td valign="middle" class="td45">
<p class="p2"><span class="s1">心房壁の虚脱</span></p>
<p class="p2"><span class="s1">心基底部周辺の腫瘤病変の精査</span></p>
</td>
<td valign="middle" class="td46">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td47">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td48">
<p class="p2"><span class="s2">CO(</span><span class="s1">心拍出量）</span></p>
<p class="p2"><span class="s2">SV(1</span><span class="s1">回拍出量）の測定</span></p>
</td>
<td valign="middle" class="td48">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td49">
<p class="p2"><span class="s1">心タンポナーデの原因疾患</span></p>
<p class="p2"><span class="s1">１漏出性 うっ血性心不全</span></p>
<p class="p2"><span class="s1"> 低アルブミン</span></p>
<p class="p2"><span class="s1"> 心膜横隔膜ヘルニア</span></p>
<p class="p2"><span class="s2">2</span><span class="s1">滲出性 感染性心膜炎</span></p>
<p class="p2"><span class="s1"> 非感染性心膜炎</span><span class="s2">(</span><span class="s1">特発性）</span></p>
<p class="p2"><span class="s2">3</span><span class="s1">出血性 外傷性 心臓腫瘍 特発性</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td50">
<p class="p3"><span class="s1">犬糸状虫症</span></p>
</td>
<td valign="middle" class="td51">
<p class="p2"><span class="s1">肺動脈の塞栓→肺血管抵抗の増大（肺高血圧）</span></p>
<p class="p2"><span class="s1">右室の後負荷上昇、求心性肥大</span></p>
</td>
<td valign="middle" class="td52">
<p class="p2"><span class="s1">④⑦肺動脈内に虫体</span></p>
<p class="p2"><span class="s1">①②</span><span class="s2">RA</span><span class="s1"> </span><span class="s2">RV</span><span class="s1">内に虫体がいないか</span></p>
<p class="p2"><span class="s2">RA</span><span class="s1">の拡大がないか</span></p>
<p class="p2"><span class="s1">右室壁の肥厚→肺高血圧</span></p>
</td>
<td valign="middle" class="td53">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td54">
<p class="p2"><span class="s1">肺動脈弁逆流 </span><span class="s2">TR</span><span class="s1">がないか</span></p>
</td>
<td valign="middle" class="td55">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td55">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td56">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td8">
<p class="p4"><span class="s1">PDA</span></p>
</td>
<td valign="middle" class="td9">
<p class="p2"><span class="s1">大動脈⇒肺動脈の短絡</span></p>
<p class="p2"><span class="s1">左心の拡大→ＭＲの合併</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">肺動脈⇒大動脈の短絡。</span></p>
</td>
<td valign="middle" class="td10">
<p class="p2"><span class="s1">①②左室の拡大がないか</span></p>
<p class="p2"><span class="s1">③真円状に拡張した左心室</span></p>
<p class="p2"><span class="s1">進行すると右心の円型化</span></p>
</td>
<td valign="middle" class="td11">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td12">
<p class="p2"><span class="s1">肺動脈弁以降の肺動脈内に広がるモザイク血流の観察</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p2"><span class="s1">連続的な血流で収縮期に最高値を示す血流を測定</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td14">
<p class="p2"><span class="s2">B</span><span class="s1">モード</span></p>
<p class="p2"><span class="s1"> 左心室が○型になる</span></p>
<p class="p2"><span class="s1">連続波ドプラ</span></p>
<p class="p5"><span class="s4"> 肺高血圧がない </span><span class="s1">4.0~5.5m/sec</span></p>
<p class="p2"><span class="s1"> 肺高血圧に進行 </span><span class="s2">4.0m/sec</span></p>
<p class="p2"><span class="s1"> 進行 収縮期性パターン</span></p>
<p class="p2"><span class="s1"> さらに進行 観察されなくなる</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td57">
<p class="p4"><span class="s1">VSD</span></p>
</td>
<td valign="middle" class="td58">
<p class="p2"><span class="s1">初期：左心系の容量負荷→ＭＲの併発、大動脈弁逆流</span></p>
<p class="p2"><span class="s1">中期：右心室圧の上昇→心室中隔の扁平化</span></p>
<p class="p2"><span class="s1">末期：さらに右心室圧上昇→右心室の肥大、拡大</span></p>
</td>
<td valign="middle" class="td59">
<p class="p2"><span class="s1">①②</span><span class="s2">LA</span><span class="s1">、</span><span class="s2">LV</span><span class="s1">の拡張がないか</span></p>
<p class="p2"><span class="s1">③</span><span class="s2">LV</span><span class="s1">が真円状に拡張</span></p>
</td>
<td valign="middle" class="td60">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td61">
<p class="p2"><span class="s1">①</span><span class="s2">LV</span><span class="s1">から</span><span class="s2">RV</span><span class="s1">に噴出する血流を確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期に噴出する</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">三尖弁狭窄、肺動脈弁逆流と類似するので注意</span></p>
</td>
<td valign="middle" class="td62">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td62">
<p class="p2"><span class="s1">①収縮期性の波型を確認する</span></p>
</td>
<td valign="middle" class="td63">
<p class="p5"><span class="s4">肺高血圧なし </span><span class="s1">5.0~6.0m/sec</span></p>
<p class="p5"><span class="s4">中期 </span><span class="s1">4.5m/sec</span><span class="s4">以上</span></p>
<p class="p2"><span class="s1">末期 血流なくなる</span></p>
<p class="p2"><span class="s2">※MR</span><span class="s1">、</span><span class="s2">AR</span><span class="s1">が付随している場合は早期の対策が必要</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td64">
<p class="p4"><span class="s1">ASD</span></p>
</td>
<td valign="middle" class="td65">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td66">
<p class="p5"><span class="s4">①</span><span class="s1">RA,RV</span><span class="s4">が拡張</span></p>
<p class="p2"><span class="s1">③</span><span class="s2">RV</span><span class="s1">が拡張</span></p>
<p class="p2"><span class="s1">④</span><span class="s2">PA</span><span class="s1">に異常がなければ</span><span class="s2">ASD</span><span class="s1">の疑いを持つ</span></p>
</td>
<td valign="middle" class="td67">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td68">
<p class="p2"><span class="s1">②</span><span class="s2">LA</span><span class="s3">→</span><span class="s2">RA</span><span class="s1">に流入する血流を確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">モザイクではなく層流で観察されることが多い</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">後大静脈からの還流血流との鑑別が大事</span></p>
</td>
<td valign="middle" class="td69">
<p class="p2"><span class="s1">②④⑥短絡血流</span><span class="s2">2m/sec</span><span class="s1">以下</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td69">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td70">
<p class="p2"><span class="s2">ASD</span><span class="s1">を診断した後は必ず両房室弁機能の評価を行う</span></p>
<p class="p2"><span class="s2">MR</span><span class="s1">、</span><span class="s2">TR</span><span class="s1">が認められる場合は早期治療が必要</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td71">
<p class="p4"><span class="s1">PS</span></p>
</td>
<td valign="middle" class="td72">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td73">
<p class="p2"><span class="s1">①②右心室の求心性肥大</span></p>
<p class="p2"><span class="s1">右心室壁厚の肥大</span></p>
<p class="p2"><span class="s1">③平坦化した心室中隔</span></p>
<p class="p2"><span class="s1">④⑦流出路、肺動脈弁の形状確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">運動性の異常、高輝度</span></p>
</td>
<td valign="middle" class="td74">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td75">
<p class="p2"><span class="s1">④⑦収縮期に右室→肺動脈に噴出するモザイク血流を確認</span></p>
</td>
<td valign="middle" class="td76">
<p class="p2"><span class="s1">血流速計測</span></p>
<p class="p5"><span class="s4">軽度 ＜</span><span class="s1">3.5m/sec</span></p>
<p class="p5"><span class="s4">中程度</span><span class="s1">3.5~5.0m/sec</span></p>
<p class="p5"><span class="s4">重度 ＞</span><span class="s1">5.0m/sec</span></p>
</td>
<td valign="middle" class="td76">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td77">
<p class="p2"><span class="s1">合併症（</span><span class="s2">TR,ASD</span><span class="s1">、</span><span class="s2">VSD</span><span class="s1">）の確認を行う</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td36">
<p class="p4"><span class="s1">AS</span></p>
</td>
<td valign="middle" class="td37">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td38">
<p class="p2"><span class="s1">②③左心室壁の求心性肥大</span></p>
<p class="p2"><span class="s1">①異常な大動脈弁下構造</span></p>
</td>
<td valign="middle" class="td39">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td40">
<p class="p2"><span class="s1">①⑥収縮期大動脈遠位モザイク血流</span></p>
</td>
<td valign="middle" class="td41">
<p class="p2"><span class="s1">大動脈血流</span><span class="s2">2.0m/sec</span><span class="s1">以上で診断</span></p>
<p class="p5"><span class="s4">軽度＜</span><span class="s1">3.8m/sec</span></p>
<p class="p5"><span class="s4">中程度</span><span class="s1">3.8~5.0m/sec</span></p>
<p class="p5"><span class="s4">重度</span><span class="s1">5.0m/sec</span><span class="s4">以上</span></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td42">
<p class="p2"><span class="s1">不整脈、</span><span class="s2">MR</span><span class="s1">の確認</span></p>
</td>
</tr>
</tbody>
</table>
<p class="p1"><br></p>
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</style>
</head>
<body>
<p class="p1"><br></p>
<table cellspacing="0" cellpadding="0" class="t1">
<tbody>
<tr>
<td valign="middle" class="td1">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td2">
<p class="p2"><span class="s1">病態生理</span></p>
</td>
<td valign="middle" class="td3">
<p class="p2"><span class="s2">B</span><span class="s1">モード</span></p>
</td>
<td valign="middle" class="td4">
<p class="p2"><span class="s1"> </span><span class="s2">M</span><span class="s1">モード </span></p>
</td>
<td valign="middle" class="td5">
<p class="p2"><span class="s1">カラードプラ </span></p>
</td>
<td valign="middle" class="td6">
<p class="p2"><span class="s1">パルスドプラ</span></p>
</td>
<td valign="middle" class="td6">
<p class="p2"><span class="s1">連続波ドプラ</span></p>
</td>
<td valign="middle" class="td7">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td8">
<p class="p3"><span class="s1">正常</span></p>
</td>
<td valign="middle" class="td9">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td10">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td11">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td12">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td14">
<p class="p2"><span class="s1">①右胸骨左室流出路</span></p>
<p class="p2"><span class="s1">②右胸骨左室流入路</span></p>
<p class="p2"><span class="s1">③右胸骨左室短軸像</span></p>
<p class="p2"><span class="s1">④右胸骨心基底部短軸</span></p>
<p class="p2"><span class="s1">⑤左心尖部四腔断面</span></p>
<p class="p2"><span class="s1">⑥左心尖部五腔断面</span></p>
<p class="p2"><span class="s1">⑦左胸骨心基底部</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td15">
<p class="p4"><span class="s1">MR</span></p>
</td>
<td valign="middle" class="td16">
<p class="p2"><span class="s1">左心の容量負荷</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">左房圧の上昇→肺静脈、肺毛細血管圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">鬱血</span></p>
</td>
<td valign="middle" class="td17">
<p class="p2"><span class="s1">・</span><span class="s2">LA</span><span class="s1">、</span><span class="s2">LV</span><span class="s1">の拡大</span></p>
<p class="p2"><span class="s1">・</span><span class="s2">MV</span><span class="s1">の肥厚</span></p>
</td>
<td valign="middle" class="td18">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td19">
<p class="p2"><span class="s1">②⑤モザイク血流の確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期であること</span></p>
</td>
<td valign="middle" class="td20">
<p class="p5"><span class="s1">E</span><span class="s4">波が</span><span class="s1">1.5m/sec</span><span class="s4">以上で重度</span></p>
</td>
<td valign="middle" class="td20">
<p class="p2"><span class="s1">逆流速の測定</span></p>
<p class="p5"><span class="s4">初期：</span><span class="s1">5.5~6.0m/sec</span></p>
<p class="p2"><span class="s1">悪化すると遅くなる</span></p>
<p class="p6"><span class="s1"></span><br></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td21">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td22">
<p class="p4"><span class="s1">TR</span></p>
</td>
<td valign="middle" class="td23">
<p class="p2"><span class="s1">右心の容量負荷</span></p>
<p class="p2"><span class="s1">右房圧の上昇→全身静脈圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">腹水、胸水</span></p>
</td>
<td valign="middle" class="td24">
<p class="p5"><span class="s4">①</span><span class="s1">RA,RV</span><span class="s4">の拡大</span></p>
<p class="p2"><span class="s1">③心室中隔の平坦化</span></p>
</td>
<td valign="middle" class="td25">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td26">
<p class="p2"><span class="s1">②④⑤モザイク血流の確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期であること</span></p>
</td>
<td valign="middle" class="td27">
<p class="p5"><span class="s4">逆流速</span><span class="s1">1.5~2.5m/sec</span></p>
<p class="p5"><span class="s4">右室圧の上昇で</span><span class="s1">3.0~4.0m/sec</span></p>
</td>
<td valign="middle" class="td27">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td28">
<p class="p2"><span class="s1">肺高血圧症、肺動脈狭窄症に付随して起こるコトあり</span></p>
<p class="p2"><span class="s2">MR</span><span class="s1">の</span><span class="s2">3</span><span class="s1">割で</span><span class="s2">TR</span><span class="s1">を合併している</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td29">
<p class="p4"><span class="s1">HCM</span></p>
</td>
<td valign="middle" class="td30">
<p class="p2"><span class="s1">うっ血性心不全、ＭＲ</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">心房拡張</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">血流鬱血→血栓形成</span></p>
</td>
<td valign="middle" class="td31">
<p class="p2"><span class="s1">①③④左室後壁中隔壁の肥厚</span></p>
<p class="p2"><span class="s1">①流出路の傷害がないか確認</span></p>
<p class="p2"><span class="s1">②左房内に血栓がないか確認</span></p>
<p class="p2"><span class="s2">SAM</span><span class="s1">：</span><span class="s2">MV</span><span class="s1">の奇異運動がないか確認</span></p>
</td>
<td valign="middle" class="td32">
<p class="p2"><span class="s1">拡張末期径（</span><span class="s2">R</span><span class="s1">波直上）</span></p>
<p class="p5"><span class="s4">正常</span><span class="s1">4mm</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">ｽｲｰﾌﾟｽﾋﾟｰﾄﾞを早めに設定する</span></p>
</td>
<td valign="middle" class="td33">
<p class="p2"><span class="s2">2</span><span class="s1">次的変化の確認</span></p>
<p class="p2"><span class="s1">②</span><span class="s2">MR</span><span class="s1">がないか</span></p>
<p class="p2"><span class="s1">①⑥左室流出路障害の確認</span></p>
</td>
<td valign="middle" class="td34">
<p class="p2"><span class="s1">左室拡張障害の確認</span></p>
<p class="p2"><span class="s2">E/A</span><span class="s1">が１以下になる</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">さらに悪化すると偽正常化</span></p>
</td>
<td valign="middle" class="td34">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td35">
<p class="p2"><span class="s1">メインクーン・アメショー・ペルシャに好発</span></p>
<p class="p2"><span class="s1">壁の肥厚：</span><span class="s2">8mm</span><span class="s1">以上で血栓発生が危惧</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td36">
<p class="p4"><span class="s1">DCM</span></p>
</td>
<td valign="middle" class="td37">
<p class="p2"><span class="s1">心筋の緊張→刺激電導異常→不整脈</span></p>
<p class="p2"><span class="s1">弁閉鎖不全→ＭＲ、ＴＲ</span></p>
</td>
<td valign="middle" class="td38">
<p class="p2"><span class="s1">①⑥四腔のバランスを確認</span></p>
<p class="p2"><span class="s2">MV</span><span class="s1">、</span><span class="s2">RV</span><span class="s1">でﾃｨｻﾞﾘﾝｸﾞがないか確認</span></p>
</td>
<td valign="middle" class="td39">
<p class="p2"><span class="s1">①③</span><span class="s2">FS</span><span class="s1">の測定</span></p>
<p class="p2"><span class="s1">①僧帽弁</span><span class="s2">M</span><span class="s1">モード</span></p>
<p class="p5"><span class="s1">EPSS</span><span class="s4">の測定</span></p>
</td>
<td valign="middle" class="td40">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td42">
<p class="p5"><span class="s1">FS</span></p>
<p class="p5"><span class="s1">20~25%</span><span class="s4"> 軽度</span></p>
<p class="p5"><span class="s1">15~20%</span><span class="s4"> 中程度</span></p>
<p class="p2"><span class="s2">15%</span><span class="s1">以下 重度</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td43">
<p class="p3"><span class="s1">心タンポナーデ</span></p>
</td>
<td valign="middle" class="td44">
<p class="p2"><span class="s1">心嚢内圧上昇→心腔拡張障害</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">静脈圧上昇</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">うっ血肝、腹水、浮腫</span></p>
</td>
<td valign="middle" class="td45">
<p class="p2"><span class="s1">心房壁の虚脱</span></p>
<p class="p2"><span class="s1">心基底部周辺の腫瘤病変の精査</span></p>
</td>
<td valign="middle" class="td46">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td47">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td48">
<p class="p2"><span class="s2">CO(</span><span class="s1">心拍出量）</span></p>
<p class="p2"><span class="s2">SV(1</span><span class="s1">回拍出量）の測定</span></p>
</td>
<td valign="middle" class="td48">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td49">
<p class="p2"><span class="s1">心タンポナーデの原因疾患</span></p>
<p class="p2"><span class="s1">１漏出性 うっ血性心不全</span></p>
<p class="p2"><span class="s1"> 低アルブミン</span></p>
<p class="p2"><span class="s1"> 心膜横隔膜ヘルニア</span></p>
<p class="p2"><span class="s2">2</span><span class="s1">滲出性 感染性心膜炎</span></p>
<p class="p2"><span class="s1"> 非感染性心膜炎</span><span class="s2">(</span><span class="s1">特発性）</span></p>
<p class="p2"><span class="s2">3</span><span class="s1">出血性 外傷性 心臓腫瘍 特発性</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td50">
<p class="p3"><span class="s1">犬糸状虫症</span></p>
</td>
<td valign="middle" class="td51">
<p class="p2"><span class="s1">肺動脈の塞栓→肺血管抵抗の増大（肺高血圧）</span></p>
<p class="p2"><span class="s1">右室の後負荷上昇、求心性肥大</span></p>
</td>
<td valign="middle" class="td52">
<p class="p2"><span class="s1">④⑦肺動脈内に虫体</span></p>
<p class="p2"><span class="s1">①②</span><span class="s2">RA</span><span class="s1"> </span><span class="s2">RV</span><span class="s1">内に虫体がいないか</span></p>
<p class="p2"><span class="s2">RA</span><span class="s1">の拡大がないか</span></p>
<p class="p2"><span class="s1">右室壁の肥厚→肺高血圧</span></p>
</td>
<td valign="middle" class="td53">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td54">
<p class="p2"><span class="s1">肺動脈弁逆流 </span><span class="s2">TR</span><span class="s1">がないか</span></p>
</td>
<td valign="middle" class="td55">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td55">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td56">
<p class="p1"><br></p>
</td>
</tr>
<tr>
<td valign="middle" class="td8">
<p class="p4"><span class="s1">PDA</span></p>
</td>
<td valign="middle" class="td9">
<p class="p2"><span class="s1">大動脈⇒肺動脈の短絡</span></p>
<p class="p2"><span class="s1">左心の拡大→ＭＲの合併</span></p>
<p class="p2"><span class="s3">→</span><span class="s1">肺動脈⇒大動脈の短絡。</span></p>
</td>
<td valign="middle" class="td10">
<p class="p2"><span class="s1">①②左室の拡大がないか</span></p>
<p class="p2"><span class="s1">③真円状に拡張した左心室</span></p>
<p class="p2"><span class="s1">進行すると右心の円型化</span></p>
</td>
<td valign="middle" class="td11">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td12">
<p class="p2"><span class="s1">肺動脈弁以降の肺動脈内に広がるモザイク血流の観察</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td13">
<p class="p2"><span class="s1">連続的な血流で収縮期に最高値を示す血流を測定</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td14">
<p class="p2"><span class="s2">B</span><span class="s1">モード</span></p>
<p class="p2"><span class="s1"> 左心室が○型になる</span></p>
<p class="p2"><span class="s1">連続波ドプラ</span></p>
<p class="p5"><span class="s4"> 肺高血圧がない </span><span class="s1">4.0~5.5m/sec</span></p>
<p class="p2"><span class="s1"> 肺高血圧に進行 </span><span class="s2">4.0m/sec</span></p>
<p class="p2"><span class="s1"> 進行 収縮期性パターン</span></p>
<p class="p2"><span class="s1"> さらに進行 観察されなくなる</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td57">
<p class="p4"><span class="s1">VSD</span></p>
</td>
<td valign="middle" class="td58">
<p class="p2"><span class="s1">初期：左心系の容量負荷→ＭＲの併発、大動脈弁逆流</span></p>
<p class="p2"><span class="s1">中期：右心室圧の上昇→心室中隔の扁平化</span></p>
<p class="p2"><span class="s1">末期：さらに右心室圧上昇→右心室の肥大、拡大</span></p>
</td>
<td valign="middle" class="td59">
<p class="p2"><span class="s1">①②</span><span class="s2">LA</span><span class="s1">、</span><span class="s2">LV</span><span class="s1">の拡張がないか</span></p>
<p class="p2"><span class="s1">③</span><span class="s2">LV</span><span class="s1">が真円状に拡張</span></p>
</td>
<td valign="middle" class="td60">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td61">
<p class="p2"><span class="s1">①</span><span class="s2">LV</span><span class="s1">から</span><span class="s2">RV</span><span class="s1">に噴出する血流を確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">収縮期に噴出する</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">三尖弁狭窄、肺動脈弁逆流と類似するので注意</span></p>
</td>
<td valign="middle" class="td62">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td62">
<p class="p2"><span class="s1">①収縮期性の波型を確認する</span></p>
</td>
<td valign="middle" class="td63">
<p class="p5"><span class="s4">肺高血圧なし </span><span class="s1">5.0~6.0m/sec</span></p>
<p class="p5"><span class="s4">中期 </span><span class="s1">4.5m/sec</span><span class="s4">以上</span></p>
<p class="p2"><span class="s1">末期 血流なくなる</span></p>
<p class="p2"><span class="s2">※MR</span><span class="s1">、</span><span class="s2">AR</span><span class="s1">が付随している場合は早期の対策が必要</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td64">
<p class="p4"><span class="s1">ASD</span></p>
</td>
<td valign="middle" class="td65">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td66">
<p class="p5"><span class="s4">①</span><span class="s1">RA,RV</span><span class="s4">が拡張</span></p>
<p class="p2"><span class="s1">③</span><span class="s2">RV</span><span class="s1">が拡張</span></p>
<p class="p2"><span class="s1">④</span><span class="s2">PA</span><span class="s1">に異常がなければ</span><span class="s2">ASD</span><span class="s1">の疑いを持つ</span></p>
</td>
<td valign="middle" class="td67">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td68">
<p class="p2"><span class="s1">②</span><span class="s2">LA</span><span class="s3">→</span><span class="s2">RA</span><span class="s1">に流入する血流を確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">モザイクではなく層流で観察されることが多い</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">後大静脈からの還流血流との鑑別が大事</span></p>
</td>
<td valign="middle" class="td69">
<p class="p2"><span class="s1">②④⑥短絡血流</span><span class="s2">2m/sec</span><span class="s1">以下</span></p>
<p class="p1"><br></p>
</td>
<td valign="middle" class="td69">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td70">
<p class="p2"><span class="s2">ASD</span><span class="s1">を診断した後は必ず両房室弁機能の評価を行う</span></p>
<p class="p2"><span class="s2">MR</span><span class="s1">、</span><span class="s2">TR</span><span class="s1">が認められる場合は早期治療が必要</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td71">
<p class="p4"><span class="s1">PS</span></p>
</td>
<td valign="middle" class="td72">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td73">
<p class="p2"><span class="s1">①②右心室の求心性肥大</span></p>
<p class="p2"><span class="s1">右心室壁厚の肥大</span></p>
<p class="p2"><span class="s1">③平坦化した心室中隔</span></p>
<p class="p2"><span class="s1">④⑦流出路、肺動脈弁の形状確認</span></p>
<p class="p2"><span class="s2">※</span><span class="s1">運動性の異常、高輝度</span></p>
</td>
<td valign="middle" class="td74">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td75">
<p class="p2"><span class="s1">④⑦収縮期に右室→肺動脈に噴出するモザイク血流を確認</span></p>
</td>
<td valign="middle" class="td76">
<p class="p2"><span class="s1">血流速計測</span></p>
<p class="p5"><span class="s4">軽度 ＜</span><span class="s1">3.5m/sec</span></p>
<p class="p5"><span class="s4">中程度</span><span class="s1">3.5~5.0m/sec</span></p>
<p class="p5"><span class="s4">重度 ＞</span><span class="s1">5.0m/sec</span></p>
</td>
<td valign="middle" class="td76">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td77">
<p class="p2"><span class="s1">合併症（</span><span class="s2">TR,ASD</span><span class="s1">、</span><span class="s2">VSD</span><span class="s1">）の確認を行う</span></p>
</td>
</tr>
<tr>
<td valign="middle" class="td36">
<p class="p4"><span class="s1">AS</span></p>
</td>
<td valign="middle" class="td37">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td38">
<p class="p2"><span class="s1">②③左心室壁の求心性肥大</span></p>
<p class="p2"><span class="s1">①異常な大動脈弁下構造</span></p>
</td>
<td valign="middle" class="td39">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td40">
<p class="p2"><span class="s1">①⑥収縮期大動脈遠位モザイク血流</span></p>
</td>
<td valign="middle" class="td41">
<p class="p2"><span class="s1">大動脈血流</span><span class="s2">2.0m/sec</span><span class="s1">以上で診断</span></p>
<p class="p5"><span class="s4">軽度＜</span><span class="s1">3.8m/sec</span></p>
<p class="p5"><span class="s4">中程度</span><span class="s1">3.8~5.0m/sec</span></p>
<p class="p5"><span class="s4">重度</span><span class="s1">5.0m/sec</span><span class="s4">以上</span></p>
</td>
<td valign="middle" class="td41">
<p class="p1"><br></p>
</td>
<td valign="middle" class="td42">
<p class="p2"><span class="s1">不整脈、</span><span class="s2">MR</span><span class="s1">の確認</span></p>
</td>
</tr>
</tbody>
</table>
<p class="p1"><br></p>
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