影响慢性心力衰竭患者心脏再同步化治疗效果的因素分析

目的 观察慢性心力衰竭患者心脏再同步化治疗(cardiac resynchronization therapy,CRT)的临床疗效,比较CRT有反应和无反应患者的临床特征,分析不同因素对CRT反应及预后的影响.方法 选取在浙江大学医学院附属第二医院心血管内科成功置入CRT-P/D的慢性心力衰竭患者204例,收集术前临床资料、手术资料及术后随访资料,结合手术前后临床症状及超声心动图参数的改善,评估CRT疗效.比较有反应和无反应患者的临床特征,并通过多因素回归分析及生存分析比较不同因素对CRT反应及预后的影响.结果 纳入研究者共204例,其中男性130例,女性74例,平均年龄(64.8±11.9)岁,随访6～60个月.CRT有反应者125例(61.3％).有反应的患者中,女性、QRS波时限≥150 ms及QRS波形态呈完全性左束支传导阻滞(CLBBB)者所占比例分别为41.6％ (52/125)、58.4％(73/125)、65.6％(82/125),明显高于CRT无反应的患者(P＜0.05).多因素回归分析显示,QRS波时限≥150 ms是CRT有反应的唯一独立预测因子.Kaplan-Meier法分析显示CRT有反应的患者生存率高于无反应的患者(P＜0.001).结论 临床特征,包括女性、QRS波时限≥150 ms及CLBBB,与CRT反应密切相关,其中QRS波时限≥150 ms能独立预测CRT有反应.CRT有反应的患者预后优于无反应的患者.     

血浆大内皮素1对心脏再同步治疗反应性的预测价值

目的 评价血浆大内皮素l(big ET-1)预测心脏再同步治疗(CRT)反应性的临床价值.方法 本研究回顾性分析了2009年1月至2011年12月间在阜外心血管病医院植入心脏再同步治疗起搏器和/或心脏再同步治疗除颤器(CRT-P/D)的患者.酶联免疫吸附试验(ELISA)测定基线big ET-1及氨基末端B型脑钠肽前体(NT-proBNP)水平,采集基线及随访期心功能(NYHA分级)和超声心动图指标,用Simpson法测定左心室射血分数(LVEF).心功能降低Ⅰ级同时LVEF提高≥0.05定义为有反应;LVEF提高2倍或绝对值≥0.50同时心功能改善至Ⅰ或Ⅱ级定义为超反应.结果 共93例患者入组研究,其中男60例,女33例,平均年龄(60.8±11.0)岁.随访12～50(27±11)个月,无反应34例,有反应24例,超反应35例.3组患者血浆big ET-1水平分别为(1.2±0.9)pmol/L、(0.8±0.4) pmol/L、(0.8±0.6)pmol/L(P=0.003),差异有统计学意义.相关性分析显示血浆big ET-1浓度与NT-proBNP浓度相关(r=0.469,P=0.001).血浆big ET-1水平与CRT反应性相关(r=-0.237,P=0.022).结论 血浆big ET-1与心力衰竭严重程度相关.它是慢性心力衰竭患者CRT反应性的预测指标,与CRT反应呈负相关.big ET-1高预示患者对CRT无反应.     

经组织多普勒筛选的右束支传导阻滞心力衰竭患者行心脏再同步化治疗的疗效

目的观察经组织多普勒(TDI)筛选的右束支传导阻滞(RBBB)的心力衰竭患者行心脏再同步化治疗(CRT)的效果。方法 8例心力衰竭合并RBBB患者接受了CRT,其中5例并发左侧束支的部分阻滞(LHB),3例为单纯RBBB,所有患者符合CRT治疗的I类适应证,并在CRT治疗前应用TDI进行了严格筛选,所有患者均存在心室间及室内收缩不协调,左室电极尽量放置在收缩最延迟处,观察患者术后症状及超声指标改善情况。结果 CRT术后6个月随访,所有患者均存活,其中5例并发LHB患者及1例单纯RBBB患者NYHA心功能分级改善至少1级,射血分数改善大于5%,其余2例单纯RBBB患者对CRT治疗无反应,NYHA心功能分级未改善,射血分数改善小于5%。结论经TDI筛选的RBBB心力衰竭患者可从CRT治疗中获益,但获益的患者多数合并有LHB,而只有较少单纯RBBB患者从CRT获益。     

心力衰竭合并右束支传导阻滞患者心脏再同步化治疗现状

心脏再同步化治疗(CRT)已成为中重度心力衰竭患者的一线治疗方法。然而,CRT治疗对于合并右束支传导阻滞(RBBB)的患者疗效不佳。这可能与RBBB患者心脏病变更为严重有关。不过,RBBB患者也可能存在左室激动延迟,因此有可能从CRT治疗中获益。应用临床和超声学指标筛选CRT植入者有助于改善其反应率。     

我院心脏再同步化治疗患者临床及预后分析

目的回顾性分析我院接受心脏再同步化治疗(Cardiac Resynchronization Therapy,CRT)患者的临床及预后情况。方法收集2001年至2013年在我院植入CRT-P/D(起搏/除颤)的心力衰竭(心衰)患者基线及长期随访资料。根据左室功能和重构指标,将CRT应答分为无反应、有反应和超反应组,分析三组在临床及预后方面的差异。结果 CRT术后患者长期随访92例,三组分别为28,37和27例,无反应组的心房纤颤(房颤)患者比例为57.1%,明显高于有反应组及超反应组(P=0.004)。有反应组及超反应组,CRT术后的客观指标:左室射血分数(LVEF),左室舒张末内径(LVEDD),6分钟步行距离(6MWD),左室收缩末容量(LVESV)及主观指标(NYHA分级)均较术前改善(P0.05),术后QRS时限明显缩短(P0.05);而无反应组患者,仅NYHA分级有一定程度的提高(P0.05),其他指标无明显变化。结论CRT-P/D可改善心衰患者的症状及预后。房颤是导致误放电、起搏比例偏低的重要因素,可能是降低术后应答的重要原因。     

氨基端脑钠素原对心脏再同步治疗远期疗效的预测价值

目的评价心脏再同步治疗（CRT）对血浆氨基端脑钠素原（NT-proBNP）的影响,以及NT—proBNP水平变化对CRT远期疗效的预测价值。方法44例首次植入CRT的心力衰竭患者入选,男性34例,女性10例,平均年龄（58±13）岁,心功能（3．3±0．5）级（NYHA分级）,QRS时限（150±14）ms。最初3个月随访期间,所有患者药物治疗稳定。分别在CRT植入术前和植入术后3个月时测定血浆NT-proBNP水平,同时在每次门诊随访时评估患者超声心动图和运动耐量的变化。结果平均随访（16．3±5．5）个月,11例为CRT无反应者（心功能无改善8例,心力衰竭再住院2例,心力衰竭死亡1例）。CRT反应者NT—proBNP水平明显降低[（1697．8±1279．8）fmol／ml对（1075．O±874．6）fmol/ml,P〈0．001],但CRT无反应者NT—proBNP水甲无明显改善【（1834．9±1159．9）fmol／ml对（1782．4±1070．4）fmol／ml,P=0．21]。取血浆NT—proBNP水平下降12．9％为预测CRT反应者和无反应者的最佳闽值点。结论心力衰竭患者接受CRT3个月后血浆NT—proBNP水平明显降低。血浆NT—proBNP可能是预测CRT远期疗效的有效指标。     

心脏再同步治疗术后患者死亡原因分析

目的探讨心力衰竭患者心脏再同步治疗（CRT）术后的死亡原因及相关影响因素。方法对110例行CRT的心力衰竭患者[其中7例植入带有心脏再同步治疗除颤器（CRT—D）]进行长期随访,观察患者术后的转归情况,以及死亡患者的死亡原因、生存时间和相关影响因素。结果110例患者中有92例患者完成随访研究,随访1～132（48±28）个月,共死亡30例,死亡率为32．6％,5年生存率为66．9％±5．8％。24例为心脏性死亡,占总体死亡的80％,其中包括11例为心力衰竭恶化导致的死亡,13例为心脏性猝死（SCD）,其余6例为非心脏性死亡。14例行CRT的持续性心房颤动（房颤）患者中有8例死亡;71例行CRT的窦性心律患者中死亡22例;前组的中位生存时间短于后组（50比87,P=0．013）;7例植人CRT—D的患者均无死亡;3组患者的死亡率差异有统计学意义（P=0．01）。合并慢性肾功能衰竭的CRT患者死亡率（66．7％）较无肾功能不良者（20．6％）高（相对危险度：3．24,95％CI1．88～5．59,P〈0．001）。结论CRT患者的主要死亡原因是心脏性死亡,其中包括心力衰竭恶化和SCD。CRT—D和CRT两组患者之间的死亡率差异有统计学意义,接受CRT的窦性心律患者较持续性房颤患者有显著的生存获益。合并慢性肾功能衰竭的CRT患者预后较差。对于合并持续性房颤的CRT患者同时给予房室结消融有可能进一步提高生存率。     

心脏再同步治疗不同反应者对心律失常的影响

目的 根据扩张型心肌病(DCM)患者对心脏再同步治疗(CRT)不同的反应性,对其心律失常的性质与数最进行临床观察.方法 随机选取近年来90例随访资料完整的心脏再同步治疗起博器(CRT-P)或心脏再同步治疗除颤器(CRT-D)纳入分析,根据其反应性分为超反应组、有反应组及无反应组.并在CRT术后第6个月及1年随访时,进行临床评估、动态心电图及超声心动图评价.结果 各组患者在基线状态除QRS时限、心力衰竭症状出现时间有明显差别外,其余参数在基线状态无明显区别.6个月及1年随访时超反应组的室性心律失常及房性心律失常均明显改善,无反应组则无明显变化.结论 CRT能改善患者室性及房性心律失常的发生,特别是对于超反应者效果更明显.     

左心室瘢痕负荷SPECT相位分析法检测及其对心脏再同步治疗疗效的影响

目的 观察慢性心力衰竭患者心脏再同步治疗(CRT)后有反应和无反应者之间左心室瘢痕负荷的差异性,评价左心室瘢痕负荷对CRT疗效的影响.方法 对30例2006年至2010年因慢性心力衰竭在南京医科大学第一附属医院接受CRT的患者进行静息核素心肌显像检查,应用相位分析技术检测左心室瘢痕负荷、收缩期相位时间标准差( phase S D)和带宽(BW)并用来评价心脏同步性.以术后6个月超声心动图的检测结果及随访6个月内是否因心力衰竭住院作为分组标准,左心室射血分数(LVEF)提高≥0.05且无因心力衰竭住院的患者入选反应组,LVEF提高＜0.05或者入院1次以上的患者入选无反应组,观察两组之间左心室瘢痕负荷和同步性指标之间的差异.结果 30例患者中反应组19例(男8例),无反应组11例(男8例).两组之间术前临床资料相似,年龄、性别均差异无统计学意义;有反应组术前QRS时限显著大于无反应组[(163.0±7.7)ms对(134.6±11.8) ms,P＜0.05];两组术前LVEF差异无统计学意义,但术后有反应组显著高于无反应组(0.49±0.02对0.33±0.15,P＜0.01).两组患者左心室瘢痕负荷和CRT术后左心室同步性差异具有统计学意义,有反应组患者的左心室瘢痕负荷明显低于无反应组(24.6％±3.6％对36.5％±3.9％,P=0.022);有反应组左心室同步性较好,收缩期相位时间标准差明显小于无反应组(28.1°±4.4°对56.1°±6.9°,P＜0.01),收缩期带宽明显小于无反应组(88.0°±13.9°对170.1°±24.4°,P＜0.01).左心室瘢痕负荷和心脏同步性对CRT疗效具有明显的影响.结论 接受CRT的慢性心力衰竭患者,左心室瘢痕负荷和CRT术后心脏同步性与CRT疗效密切相关.     

束支阻滞类型对心脏再同步治疗效果的影响

目的 探讨不同类型束支阻滞对心脏再同步治疗(CRT)效果的影响.方法 159例难治性心力衰竭患者接受CRT治疗,其中6例已植入永久起搏器,其余153例患者根据体表心电图QRS波形态分为左束支阻滞(LBBB)、右束支阻滞(RBBB)、非特异性室内阻滞(IVCD)、右束支伴左侧分支阻滞(RBBB伴LHB)及室内伴左侧分支阻滞(IVCD伴LHB)5组,比较植入术前及术后6个月心功能(NYHA分级)、QRS时限、左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)等指标的差异.结果 153例患者年龄21～ 84(61.43±12.54)岁,其中男118例,女35例.LBBB组治疗后心功能(3.13±0.55对2.84±0.65)、QRS时限[173.37±28.54)ms对(156.29±22.25)ms]及LVEF[(0.31±0.07)对(0.39±0.09)]、LVEDD[(73.09± 10.81) mm对(68.18± 11.36) mm]、LVESD[(61.38±11.60)mm对(55.20±13.25)mm]等均明显改善(P＜0.01).RBBB组治疗后各项指标未得到显著改善(P＞0.05),IVCD组与RBBB伴LHB组治疗后LVEF显著提高,LVEDD缩小(P＜0.05),而IVCD伴LHB组除QRS时限外,心功能、LVEF、LVEDD、LVESD等指标均得以改善(P＜0.05).此外,RBBB组与IVCD组超声心动图指标的改变不及LBBB组(P＜0.05),而RBBB伴LHB组及IVCD组超声心动图指标改善程度与LBBB组相近(P＞0.05).应用Cox回归分析显示LBBB者较其他束支阻滞类型生存期长(风险比0.30,95％可信区间0.12～0.77,P＜0.01).结论 LBBB者对CRT的反应性优于RBBB者,IVCD者疗效可能介于两者之间,而RBBB伴LHB或IVCD者疗效优于单纯RBBB或IVCD者.     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Language of CTO interventions – Focus on hardware

The knowledge of variety of chronic total occlusion (CTO) hardware and the ability to use them represents the key to success of any CTO interventions. However, the multiplicity of CTO hardware and their physical character and the terminology used by experts create confusion in the mind of an average interventional cardiologist, particularly a beginner in this field. This knowledge is available but is scattered. We aim to classify and compare the currently used devices based on their properties focusing on how physical character of each device can be utilized in a specific situation, thus clarifying and simplifying the technical discourse.