药物洗脱支架和金属裸支架对高龄患者安全性和效果的研究

目的:对比评价药物洗脱支架和金属裸支架对75岁以上高龄患者的安全性和有效性.方法:2005-11至2006-12我院75岁以上接受冠状动脉支架置入术的患者269例,年龄在75～87岁;其中,药物洗脱支架组140例,金属裸支架组129例.30天、6～12个月进行临床随访,对比2组全因死亡和主要不良心脏事件(MACE,包括心脏性死亡,非致死性心肌梗死和靶病变血运重建的发生率).结果:药物洗脱支架组支架直径显著小于金属裸支架组(P＜0.05),支架长度显著大于金属裸支架组(P＜0.05).30天MACE药物洗脱支架组与金属裸支架组差异无统计学意义(P＞0.05).术后6～12月随访,两组只有靶病变血运重建率在药物洗脱支架组显著低于金属裸支架组(P＜0.001),在总随访率、造影复查率、造影复查时间、MACE和全因死亡率等之间均无显著差异(P均＞0.05).药物洗脱支架组晚期血栓发生率为1.4%,金属裸支架组未见晚期血栓发生.结论:药物洗脱支架和金属裸支架对75岁以上的高龄患者具有同样的疗效和安全性,并且MACE有减少的趋势,但药物洗脱支架有发生晚期血栓的可能性.     

经胸骨正中小切口行心脏瓣膜手术130例临床经验总结

目的　探讨经胸骨正中小切口行各种心脏瓣膜手术的适应证和手术方法 ,并报告 130例临床结果。　方法　 4例单纯主动脉瓣置换采用胸骨上段切口 ,其余手术均经胸骨下段切口。胸骨上段切口自胸骨上凹至第三肋间并向两侧横断胸骨 ,皮切口长度 5cm～ 7cm ;胸骨下段之皮切口自第三胸肋关节水平至剑突根部 ,长度 9cm～13cm ,自下而上纵行劈开胸骨至第二或第一肋间处向右侧横断。手术采用常规体外循环 ,共行二尖瓣置换 6 6例 ,主动脉瓣置换 2 0例 ,主动脉瓣及二尖瓣双瓣置换 32例 ,二尖瓣成形 11例 ,单纯三尖瓣成形 1例。同期行左心房血栓清除 2 2例及三尖瓣DeVega环缩 35例。　结果　无手术死亡。平均主动脉阻断、体外循环和手术时间分别为 6 3分± 2 9分、92分± 32分和 191分± 4 7分 ;平均气管插管 12小时± 5 2小时 ;平均住院 14天± 6 8天。术后胸液量平均 345ml± 197ml(5 0ml± 170 0ml) ,有 82例患者 (6 3% )未输血。　结论　正中经胸骨小切口行心脏瓣膜手术安全可靠 ,美观 (胸骨下段入路 ) ,创伤小 ,出血少 ,保留了胸廓的连续性 ,早期结果满意。     

腺苷负荷试验心肌灌注显像诊断冠心病的临床价值

目的　评价腺苷负荷试验心肌灌注显像诊断冠心病的准确性。方法　对 89例临床疑诊冠心病患者 ,分别静脉注射腺苷 ,剂量为 14 0 μg·kg-1·min-1,用药时间 6min(总剂量为 0 8mg/kg) ,注射过程中 ,行心电监测 ,观察患者的症状、血压和心率 ,于注射腺苷 3min末 ,静脉注射核素显像剂99mTc MIBI 92 5MBq ,1h后行心肌灌注断层显像 ,若显像异常 ,次日行静息心肌显像。所有患者行冠状动脉造影。结果　在 89例患者中 ,31例冠状动脉造影显示明显的冠状动脉狭窄病变 ,其中单支病变 10例 ,二支病变 11例 ,三支病变 10例。累及左前降支 2 8支 ,左回旋支 18支 ,右冠状动脉 16支 ,左主干 2支。腺苷负荷试验心肌灌注显像诊断冠心病的敏感性为 71%、特异性为 91%、阳性预测值81%、阴性预测值 84 %、准确性为 84 %。诊断单支、二支和三支冠状动脉病变患者的敏感性分别为5 0 %、73%、90 %。腺苷负荷试验心肌灌注显像判断血管病变的敏感性 77%、特异性 96 %、准确性 92 %。结论　腺苷负荷心肌灌注显像诊断冠心病敏感性及特异性均较高 ,具有重要的临床应用价值。     

升高高密度脂蛋白胆固醇药物的相关研究进展

目前已有流行病学资料明确提示,高密度脂蛋白胆固醇(HDL-C)水平与冠心病危险性呈负相关,低水平的HDL-C已被公认为动脉粥样硬化性疾病的独立危险因素之一。通过药物使HDL-C升高能否进一步降低心血管疾病的发病风险已成为近些年来临床试验关注的焦点。本文对目前已应用于临床或正在研究的具有升高HDL-C作用的四类药物,即他汀类、贝特类、烟酸及胆固醇酯转运蛋白(CETP)抑制剂的主要作用机制、临床研究进展等进行归纳和总结。其中,烟酸及CETP抑制剂升高HDL-C作用显著,尽管目前针对这两类药物的临床证据仍然较为匮乏,但有理由相信正在进行的几项国际大规模临床试验将为此提供重要的询证医学证据,其结果值得期待。     

微小RNA在大鼠心脏逆重构中的变化

目的 构建大鼠心脏肥厚及移植模型来模拟临床心脏重构及逆重构过程,检测该过程中心脏胶原、转化生长因子-β(TGF-β)及微小RNA(miRNA)的改变,阐述TGF-β胶原轴在该过程中的变化并筛选部分可能参与该过程的miRNA.方法 实验Lewis大鼠分为4组,分别为假手术组、心脏肥厚组、肥厚移植组及单纯移植组.以动物超声心动图、免疫组织化学、心肌细胞横截面积检测、实时荧光定量逆转录聚合酶链反应(qRT-PCR)检测等方法对模型心肌细胞、心脏胶原和TGF-β的表达进行检测.miRNA芯片检测各组心脏组织miRNA的变化,对其中部分有意义的miRNA进行qRT-PCR验证,并通过miRNA靶点数据库分析其功能.结果 心脏肥厚组大鼠心脏重量、左心室重量、心室壁厚度和心肌横截面积均高于假手术组,而肥厚移植组均低于心脏肥厚组.单纯移植组心脏重量及心脏与整体重量比值均低于假手术组.心脏肥厚组胶原及TGF-β表达均高于假手术组,肥厚移植组中其表达高于心脏肥厚组.经基因芯片检测发现有82个miRNA在4个实验组中发生了2倍以上的变化,心脏肥厚组有1个miRNA高于假手术组,9个miRNA低于假手术组;肥厚移植组有26个miRNA高于心脏肥厚组,6个低于心脏肥厚组;单纯移植组有29个miRNA高于假手术组,11个低于假手术组.对其中6个miRNA进行验证,结果发现各组均发生了显著性变化,各组间△△CT差大于2倍,差异有统计学意义(P＜0.05).结论 大鼠心肌肥厚及卸负荷模型能较好的模拟心脏重构及逆重构过程.胶原和TGF-β在心脏肥厚模型中增加,且经卸负荷处理后增加更多.较多miRNA在肥厚过程中发生了改变,经对部分miRNA作用靶点的查找发现,miRNA可能通过不同的机制影响心脏重构及逆重构过程.

Abstract：

Objective To establish a reverse remodeling heart model in rats and observe collagen and TGF-β expression and relevant rmicroRNAs changes during reverse remodeling. Methods Lewis rats were divided into four groups including sham(NL, n = 10), abdominal aortic constriction(AAC, n = 10),heterotopic transplantation of abdominal aortic constriction(AAC-HT, n = 9)and heterotopic transplantation of normal heart(HT, n = 8). Left ventricular wall thickness and LV cavity were measured by echocardiography. The cardiomyocyte cross-sectional area(CSA)was determined on HE stained sections.Immunohistochemical and qRT-PCR were used to detect collagen and TGF-β expressions. miRNAs were detected by MicroRNA microarray. Results Heart weight, left ventricular wall thickness and CSA were significantly increased in AAC hearts compared to those in the NL and AAC-HT hearts. The collagen and TGF-β were increased in AAC hearts and further increased in AAC-HT hearts. miRNA microarray evidenced more than two folds changes on 82 miRNAs compared to NL(10 in AAC, 32 in AAC-HT and 40 in HT).Conclusion Rat abdominal aortic constriction and heterotopic transplantation could be used as a reverse remodeling heart model and significant collagen and TGF-β as well microRNA expression changes were evidenced in this model.     

芍药苷对心脏钾通道电生理功能的影响

目的研究芍药苷对内向整流钾电流(IK1)、瞬时外向钾电流(Ito)以及延迟整流钾电流(IKs和IKr)的作用。方法用全细胞膜片钳技术记录大鼠心室肌细胞的Ito和IK1电流。而IKs和IKr电流在转染相应质粒的HEK293细胞上记录。对比芍药苷使用前后的电流图,观察芍药苷对各种离子通道电流的影响。结果在-100mV测试电压下,100μmol/L的芍药苷能使IK1峰值密度从(-25.26±8.21)pA/pF降至(-17.65±6.52)pA/pF,平均抑制率为30.13%(n=6,P<0.05),但对其反转电位以及内向整流特性无影响。此外,100μmol/L芍药苷对Ito、IKs和IKr电流无明显作用。结论芍药苷对IK1电流具有明显的抑制作用,而对Ito、IKs及IKr无明显作用。     

二尖瓣副瓣及主动脉瓣下隔膜共同导致左室流出道梗阻外科治疗一例

左室流出道梗阻在先天性心脏病中发病率相对较低,本文报道一例二尖瓣副瓣及主动脉瓣下隔膜共同导致左室流出道梗阻的罕见病例。13岁男性被发现二尖瓣副瓣起自主动脉二尖瓣幕帘,呈囊袋状,并有独立腱索连接至前外侧乳头,左室收缩期与主动脉瓣下隔膜共同导致左室流出道重度狭窄。通过手术切除二尖瓣副瓣及主动脉瓣下隔膜,梗阻成功解除,术后复查手术效果良好。     

Adverse Outcomes Associated With Inpatient Administration of Beers List Medications Following Total Knee Replacement

PurposeBeers List drugs are potentially harmful in older adults and are grouped by level of risk. Over 9000 total knee arthroplasties (TKAs) are performed each year Veterans Affairs (VA) hospitals, primarily on older adults. Minimal data on the administration of Beers List drugs following arthroplasty currently exists in the literature. Our goal was to quantify the risks of these drugs following TKA. We hypothesized that increasing doses of Beers List drugs would be associated with increased risks for readmission, reoperation, emergency department (ED) visits, and mortality.MethodsIn this retrospective cohort study, data from TKAs performed in VA hospitals from 2010 to 2014 were examined, with complicated or bilateral procedures excluded. The data were obtained from the VA Corporate Data Warehouse. The outcomes examined were readmission, postoperative ED visits, reoperation on ipsilateral knee, and mortality. Beers List drugs were divided into 3 categories: medications to use with caution (Beers 0); medications to avoid in older adults (Beers 1); and medications to avoid in certain disease states (Beers 2). Beers 2 was not included in the final analysis due to an inability to verify appropriate diagnostic criteria without manual chart review. Logistic regression was performed looking at the total number of doses in the first 48 h after surgery compared to the above-mentioned outcomes.FindingsData from 12,639 TKAs were analyzed; the mean age of the patients was 65.06 years, and 77.8% of patients received Beers List drugs while admitted. The most frequently administered Beers List drugs were proton pump inhibitors, NSAIDs, insulin, α-blockers, benzodiazepines, antihistamines, muscle relaxants, and antipsychotics. There was a dose-dependent increase in readmission and ED visits in the Beers 1 group. The odds ratios were 1.03 for 30-day readmission and 1.02 at 90 days. The odds ratios for ED visits were 1.05 for 72-h ED visits and 1.04 for ED visits within 7 and 30 days. The odds ratios were set at 1-unit dose intervals. All results were found after control for VA facility, sex, age, American Society of Anesthesiologists class, Charlson score, case length, and body mass index.ImplicationsThe group of medications to avoid (Beers 1) from the 2015 Beers List showed associations with increased frequency of readmission and postoperative ED visits. Reinforcement of the need to avoid those drugs during surgical care will hopefully reduce such complications. Limitations included not controlling for overall discharge drug count and reliance on the outpatient problem list for outpatient diagnoses. Additional subgroup analysis will be performed to see whether specific drugs pose a higher than risk others.     

静脉注射艾司洛尔治疗急性心肌梗死并发急性心力衰竭的疗效及安全性

目的探讨静脉注射艾司洛尔治疗急性心肌梗死(AMI)并发急性心力衰竭(AHF)的临床疗效。方法入选11例AMI患者并发AHF、心功能KillipⅡ～Ⅲ级,在常规标准抗缺血、抗心力衰竭治疗效果欠佳,且伴有血压和心率较基线水平升高的条件下,给予静脉注射艾司洛尔(负荷剂量0.5 mg/kg 1 min内静脉注射,继之0.05 mg.kg-1.min-1持续静脉泵入),观察患者治疗前后生命体征、临床表现及X线胸片肺淤血程度的变化。结果 (1)与治疗前比较,11例患者接受静脉注射艾司洛尔治疗(中位给药时间38.5 h)后,收缩压降低[(109±16)mm Hg比(136±18)mm Hg]、舒张压降低[(61±8)mm Hg比(77±11)mm Hg]、心率减慢[(71±11)次/min比(96±31)次/min],差异均有统计学意义(均为P<0.05);(2)11例患者经治疗后,心力衰竭症状均明显缓解,肺部啰音均明显减少,X线胸片肺淤血程度均明显减轻;(3)11例患者治疗过程中均未发生低血压、严重缓慢性心律失常等不良反应。结论对于AMI患者,若病程中发生以缺血为诱因的AHF且伴有血压、心率较基础水平升高,可在常规治疗基础上,加用静脉注射艾司洛尔,可以获得良好的临床疗效,并且无明显不良反应。