42例心脏手术后新发快速心房颤动的治疗体会

【摘要】 目的 总结42例心脏手术后新发快速心房颤动的治疗经验。方法 2002年8月至2012年8月,我科施行的395例术前为窦性心律的心脏手术患者中,有42例患者术后新发快速心房颤动,其中冠心病18例,心脏瓣膜病15例,冠心病合并心脏瓣膜病3例,先天性心脏病6例。患者术后新发快速房颤时,在心电监护下静脉使用胺碘酮,首先控制心室率,争取转复为窦性心律,并行抗凝治疗,同时口服胺碘酮治疗。术中安置了临时起搏导线的患者,术后开启临时起搏器,设置保护心率70~90次/分。房颤发作前已使用β受体阻滞剂的患者,不停用。结果 24小时内有32例患者转为窦性心律,其余患者5天内转复为窦性心律。无死亡病例,无脑梗塞病例发生。结论 采用胺碘酮,可将心脏术后新发的心房颤动转复为窦性心律;胺碘酮与β受体阻滞剂合用时,要注意调整好两者的用量,避免心率过慢的发生,同时要注重房颤诱因的治疗。     

非心脏手术围术期心脏事件危险评估与保护性干预

围术期心脏事件是非心脏手术围手术期严重并发症和死亡的重要原因。在临床广泛应用的修订心脏风险指数及ACC／AHA制定的非心脏手术围术期评估指南．可协助临床医生评价非心脏手术心脏风险并做出围术期诊治决策。β受体阻滞剂和他汀类药物可减少高危患者非心脏手术围术期心脏事件及死亡的发生,术前血管重建治疗对于严重冠心病患者是必要和有益的。     

β受体阻滞剂与非心脏手术围术期心脏并发症

β受体阻滞剂越来越多地在围术期得到预防性应用,现就β受体阻滞剂临床应用现状、作用机制、应用标准、注意事项以及对非心脏手术患者围术期心脏并发症的影响等方面作一综述。     

术后心脏事件的高危患者围术期β-受体阻滞剂的应用

围术期应用β-受体阻滞剂可以降低高危患者术后心脏事件的发生率，但目前接受其治疗的患者比例仍然较低：此文阐述了其同术期广泛应脂的主要障碍，包括：①它的有效性可能并不足够；②对它的副作用和禁忌症有顾虑；③用药经验有限；④治疗策略的可行性，以说明高危患者围术期接受β-受体阻滞剂治疗是有效的、安全的、可行的。     

风湿性瓣膜病术前并发心室电风暴的急诊外科手术治疗

目的探讨成人风湿性心脏瓣膜病术前并发心室电风暴(恶性室性心动过速、心室颤动)行急诊手术的疗效及体会。方法回顾性分析2004年10月至2014年10月我院成人心脏瓣膜入院后突发恶性室性心动过速、心室颤动的患者6例,其中男2例,女4例,年龄35.0~64.0岁,平均49.8岁。6例患者均为风湿性心脏瓣膜病,二尖瓣中重度狭窄并主动脉瓣及三尖瓣中重度关闭不全2例,二尖瓣中重度关闭不全并三尖瓣中重度关闭不全4例,恶性心律失常发作后立即予艾司洛尔等药物控制,病情基本稳定后急诊手术。其中,行双瓣膜置换+三尖瓣成形术2例,行二尖瓣置换+三尖瓣成形术4例。结果无围术期患者死亡,术后无心功能显著恶化、无多脏器功能衰竭、无恶性室性心律失常。术后1~2周24 h动态心电图提示室性早搏大于1 000次的2例,室性早搏500~1 000次1例,小于500次的患者3例,短阵室性心动过速2次的患者2例,短阵室性心动过速3次的患者1例。所有6例患者均安全出院,随访6个月至10年,无患者死亡。结论急诊外科手术联合β受体阻滞剂在治疗成人心脏瓣膜疾病术前突发的反复恶性室性心动过速、心室颤动安全有效。     

β受体阻滞剂在非心脏手术患者围术期的应用

背景 多项临床试验结果显示,非心脏手术患者围术期应用β受体阻滞剂可降低术后心脏不良事件的发病率和死亡率.然而针对不同患者人群,各试验结果并不完全一致.目的 为进一步的临床试验及研究提供依据.内容 探讨β受体阻滞剂在临床应用时的适应证、药物选择、治疗时机、持续时间及存在的问题与争议.趋向 随着对β受体阻滞剂认识的深入,其临床应用必将得到进一步的拓展,但目前各项研究中存在的分歧,仍需大样本,多中心,随机,对照试验来证实.     

围术期β肾上腺素受体阻滞剂的应用

β肾上腺素受体阻滞剂为临床上常用的心血管药物,在围术期可用于防治高血压、控制心律失常、治疗慢性心衰、保护和改善心肌功能,从而增强手术耐受力,提高术后生存率。现就β肾上腺素受体阻滞剂在围术期的应用作一探讨。     

围术期β肾上腺素受体阻滞剂的应用

β肾上腺素受体阻滞剂为临床上常用的心血管药物，在围术期可用于防治高血压、控制心律失常、治疗慢性心衰、保护和改善心肌功能，从而增强手术耐受力，提高术后生存率。现就β肾上腺素受体阻滞剂在围术期的应用作一探讨。     

外科治疗心脏电风暴三例

心脏电风暴是指24h内反复发生2次或2次以上的快速室性心律失常.我院于2010年3月至2012年5月通过冠状动脉旁路移植术(CABG)成功救治3例心脏电风暴患者,现总结其治疗经验,以供临床参考. 1 临床资料与方法 1.1一般资料全组共3例,均为男性急性心肌梗死患者,年龄46～65岁,患高血压病3例,糖尿病2例,心电图提示ST抬高型心肌梗死,心肌酶谱、肌钙蛋白明显升高,心脏超声心动图提示,射血分数(EF) 40％～45％,冠状动脉造影显示为3支血管病变. 1.2治疗方法 患者心肌梗死后血流动力学极不稳定,并反复出现室性心动过速、心室颤动等恶性心律失常,即所谓心脏电风暴.应用呼吸机辅助呼吸,反复多次电击除颤,静脉应用艾司洛尔、胺碘酮及利多卡因等多种抗心律失常药物.治疗过程中出现Q-T间期延长者,将胺碘酮减量或停药;血压不稳定者,减小艾司洛尔剂量,不应用肾上腺素,因肾上腺素加快心率,可能诱发心脏电风暴.     

良性前列腺增生合并糖尿病TUVP的围手术期处理(附37例分析)

目的 探讨提高良性前列腺增生合并糖尿病围手术期安全性的措施。方法 回顾性分析37例良性前列腺增生合并糖尿病患者经尿道前列腺汽化术（TUVP）的围手术期处理。结果 35例排尿满意，2例口服α受体阻滞剂达到满意排尿，2例并发前列腺电切综合症（TURS），1例脑血栓，2例冠心病心绞痛发作，未发生低血糖反应、糖尿病高渗性昏迷及酮症酸中毒。结论 良性前列腺增生合并糖尿病患者在围手术期密切监测其血糖，应用胰岛素严格控制血糖，TUVP术是安全有效的。     

心脏瓣膜置换同期双极射频消融的围术期护理体会

目的探讨心脏瓣膜病合并房颤的患者,在行瓣膜置换的同时联合进行双极射频消融术时,在围术期各阶段所采取的护理措施。方法我科从2012年6月至2013年4月对80例风湿性心脏瓣膜病合并房颤的患者,实施了心脏瓣膜置换联合双极射频消融术,其中二尖瓣置换＋双极射频消融术17例,二尖瓣置换＋三尖瓣成形术＋双极射频消融术31例,主动脉瓣置换＋二尖瓣置换＋双极射频消融术9例,主动脉瓣置换十二尖瓣置换＋三尖瓣成形术＋双极射频消融术23例。结果本组共11例患者出现心律失常,其中7例为室上速,4例口服可达龙后心率维持在100~／min左右,3例经静脉泵入后心率维持在100～120~／min,上述患者出院时心率基本正常,嘱患者出院后继续口服可达龙;另有4例出现窦性心动过缓,心率50～60次／min,经过停用可达龙,1例心率恢复正常,2例给予异丙肾上腺素0．01—0．05斗∥（kg·min）微量泵泵入,2～7d后心率恢复正常,1例使用心表临时起搏器,2周后顺利停用,恢复正常心率。所有患者均康复出院,出院时维持窦性心律。出院后随访3—12个月,均维持窦性心律,未见心脑血管意外等并发症。结论心脏瓣膜病合并房颤的患者,在行瓣膜置换的同时联合进行双极射频消融术,具有安全、疗效显著、远期复发率低等优点。在围术期各阶段采取正确、有针对性的护理措施,有利于促进患者更快的恢复,并有效防止远期并发症的发生。     

A case of electrical storm in a liver transplant patient

Electrical storm has not been well described in liver transplant patients. We present a case of sympathetically mediated recurrent ventricular fibrillation in a young patient transplanted for acute Wilson's disease. This case highlights the role of the sympathetic nervous system in causing electrical storm and it demonstrates the ability of beta-blocking agents to terminate the event. In young liver transplant patients, beta-blocking agents should be considered for therapy of perioperative electrical storm if there is no known structural or coronary heart disease and when there are no risk factors for, or evidences of, torsades de pointes.     

小剂量胺碘酮预防冠状动脉旁路移植术后心房纤颤

目的 评价小剂量胺碘酮对冠状动脉旁路移植术后心房纤颤的预防效果、耐受性和安全性。方法 对1998至1999年235例冠状动脉旁路移植术后病人进行回顾性研究分析，其中对照组155例予常规药物，试验组80例合用小剂量胺碘酮。结果 常规药物治疗组21．93％出现心房纤颤，而小剂量胺碘酮预防用药组10％出现心房纤颤(P=0．024)。小剂量胺碘酮致心律失常3例，无甲状腺及肺部并发症发生。结论 预防应用小剂量胺碘酮能明显降低术后心室率，减少心房纤颤发生率，延迟发作，缩短持续时间，促进心房纤颤转复，同时改善心功能。小剂量胺碘酮毒副作用低于大剂量胺碘酮，尤其适用于缺血性心脏病合并心肌梗死及左心功能不全者。     

Antiarrhythmika

The goal of the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) was to create valid, widely accepted international resuscitation guidelines based on international science. The International Guideline 2000 Conference has dramatically changed the recommended approach to the treatment of life-threatening tachyarrhythmias. The experts advocate a new emphasis on existing hemodynamic instability and on the degree of impaired ventricular function. Patients with clinical congestive heart failure or depressed left ventricular function should be treated very cautiously with antiarrhythmic drugs. In comparison with other antiarrhythmic agents, amiodarone causes less proarrhythmic effects and the least additional impairment of left ventricular function. Because of its broad antiarrhythmic spectrum and minor negative inotropic effects, amiodarone now dominates the management of ventricular tachyarrhythmias. If amiodarone or other antiarrhythmic treatment fail to produce the desired response, the preferred next intervention is to attempt early electrical cardioversion. In the treatment of shock-refractory cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia evidence supports the use of intravenous amiodarone.     

Amiodaron zur Therapie perioperativer kardialer Rhythmusstörungen

Cardiac arrhythmias are a common problem in the perioperative period. The incidence found in the current literature varies depending on the population studied and the definition of arrhythmia used. Overall supraventricular arrhythmias, namely atrial fibrillation, are the most common form. Because of its broad spectrum amiodarone is often used to suppress supraventricular and ventricular arrhythmias. It is believed to be safe for treating patients with severe cardiac disease and it has less proarrhyhmogenic potential than many other antiarrhythmic drugs. However, the use of amiodarone is limited by its cardiac and non-cardiac adverse effects, such as life-threatening bradycardia, pulmonary fibrosis or thyrotoxicosis. According to the guidelines of the American Heart Association, amiodarone can be used to treat atrial fibrillation. Because spontaneous conversion rates in the perioperative setting are high and the advantage of a rhythm control strategy over rate control is questionable, a rate control strategy using less toxic drugs like beta blockers or calcium channel blockers should be preferred in hemodynamically stable patients. The current guidelines of the European Resuscitation Council (ERC) recommend amiodarone to treat hemodynamically stable ventricular tachycardia and in this setting ajmaline is also highly effective. Amiodarone should be administered to patients with cardiac arrest if ventricular tachycardia or ventricular fibrillation persists after three attempts at defibrillation. Dronedarone is a derivate of amiodarone with a similar mechanism of action but with less non-cardiac side effects and is currently being tested in clinical trials. The use of the atrial-specific potassium channel blockers AZD7009 and vernakalant are also being investigated. Furthermore, the role of statins, ACE inhibitors and angiotensin receptor blockers in the prevention of atrial fibrillation has to be evaluated.     

Early outcome of initiating amiodarone for atrial fibrillation in advanced heart failure.

BACKGROUND: Little information exists about the early outcomes of initiating amiodarone for atrial fibrillation in patients with advanced heart failure. This study assessed the initial rate of success and complications of amiodarone therapy initiated for patients with atrial fibrillation during hospitalization for heart failure. METHODS: We reviewed medical records for 37 consecutive patients with left ventricular ejection fractions 相似文献   

Comparative study between landiolol and amiodarone for therapeutic efficacy after open heart surgery

Tachyarrhythmia, especially atrial fibrillation, remains as a common complication after open heart surgery and sometimes leads to fatal condition. Many reports showed that landiolol (ultra short-acting beta one blocker) and amiodarone were effective against postoperative atrial fibrillation (POAF). However, there were few comparative studies between these 2 drugs as prophylactic agents, and no report mentioned the therapeutic efficacy. Our study suggests that landiolol be the 1st choice for rate control of tachyarrhythmia because of easy dose adjustment and mild side effects. Amiodarone may be useful for the patients whose left ventricular function is poor.     

Surgical Ablation of Ventricular Tachycardia in the Normothermic Heart

Nineteen patients with ventricular tachycardia were subjected to surgery using a normothermic map-guided approach. Surgical ablation was performed by endocardial resection and cryoablation. Eleven patients had multiple distinct morphologies, and eight patients needed concomitant coronary artery bypass surgery. Seventeen patients survived the perioperative period, and all but one patient had a successful surgical ablation of all documented morphologies. Ventricular tachycardia surgery can be accomplished with the sequential map-guided approach on the normothermic beating heart, and in this era of the implantable defibrillator should remain a mainstay of the surgical treatment for ventricular tachycardia.