原发性直立性低血压1例

1病例介绍患者,男,61岁,因反复晕厥4年加重1周入院。患者4年前在1次田间劳动时出现头晕后跌倒,神志不清,倒地后神志很快清醒,无抽搐和大小便失禁,醒后无特殊不适主诉。以后常在劳动或站立后有类似症状发作,头晕时下蹲或平卧后好转,无视物旋转。清晨症状最重,傍晚症状减轻。上述     

输尿管软镜术后SIRS发生的危险因素分析

目的：探讨逆行输尿管软镜钬激光碎石术（retrograde intrarenal surgery,RIRS）治疗肾及输尿管上段结石术后发生全身炎症反应综合征（systemic inflammatory response syndrome,SIRS）的危险因素。方法：回顾性分析2013年11月至2016年8月因肾及输尿管上段结石接受输尿管软镜治疗的890例患者的临床资料。将患者分为SIRS组（n=37）和Non-SIRS组（n=853）,通过单因素logistic回归分析和多因素logistic回归分析以确定RIRS术后发生SIRS的危险因素。结果：在890例患者（男性584例,女性306例）中,4.2%（37/890）术后出现SIRS。在单因素分析中,SIRS与术前使用免疫抑制剂、术前因结石发热、术前中段尿培养、术前尿白细胞计数、术中尿液浑浊、脓苔（P<0.05）等因素显著相关,与患者性别、年龄、体质量指数、糖尿病、高血压、术前血肌酐水平、手术时间、结石大小等因素无显著相关性（P>0.05）;在多因素回顾分析中,术前因结石发热（P=0.014,OR=4.228,95%CI=1.341～13.331）或术前尿白细胞计数≥544个/mL（P<0.001,OR=5.075,95%CI=2.350～10.959）或术中尿液浑浊、脓苔（P<0.001,OR=8.373,95%CI=2.773～25.279）与术后SIRS发生显著相关。结论：术前因结石发热、术前尿白细胞计数、术中尿液浑浊、脓苔为输尿管软镜碎石术后SIRS发生的危险因素。术前应予以充分治疗,必要时分期手术。     

Automatic modulation of refractoriness of His-Purkinje system during atrioventricular nodal reentrant tachycardia

Objective To illustrate the automatic modulation of refractoriness of His-Purkinje system during atrioventricular nodal reentrant tachycardia (AVNRT) and to discuss the possible mechanisms. Methods Programmed electrical stimulations were performed in high right atrium (HRA) in 8 patients with AVNRT before ablation to induce tachycardia and electrocardiagraphic recordings were done synchronically when AVNRT appeared. Results All the patients had 2∶1 atrioventricular (A-V) conduction when AVNRT began, 2 of whom were blocked below His bundle, 5 above His bundle and 1 unclear. After a duration of 14.03±10.03 s of 2∶1 A-V conduction, 1∶1 A-V conduction with bundle banch block appeared, 3 of which were right bundle branch block (RBBB), 3 left bundle branch block (LBBB), and 2 with both. Bundle branch block disappeared after a duration of 6.87±11.26 s. Conclusion Effective refractory period (ERP) of His-Purkinje system at the beginning of AVNRT was modulated automatically within less than 30-60 s and thus facilitated nodal-ventricular conduction. The mechanism of this is electrical remodeling.     

锁骨下静脉穿刺156例体会及并发症分析

目的 :探讨锁骨下静脉穿刺的方法 ,并发症及处理。方法 :对 15 6例锁骨下静脉穿刺的病例及其并发症进行分析 ,并提出有效防治对策。结果 :穿刺总成功率 97 4 % (15 2 15 6 )。气胸发生率占1 2 8% (2 15 6 ) ;纵隔血肿占 0 6 4 % (1 15 6 ) ,血气胸占 0 6 4 % (1 15 6 )。结论 :锁骨下静脉穿刺成功率高 ,并发症可控制在较低水平。术者要熟悉解剖结构 ,严格按照操作要求进行 ,熟知并发症发生的原因 ,并作出迅速的判断和正确的处理 ,一般不会造成严重后果     

华法林、达比加群酯和低分子肝素对心房颤动射频导管消融术中活化凝血时间达标情况及潜在血栓形成风险的影响

目的：评价目前心房颤动（房颤）射频导管消融术中抗凝方案的有效性和不同抗凝药对术中凝血状态的影响。方法：筛选2015年12月至2017年3月于我院行房颤射频导管消融术的患者163例,其中158例术前接受有效抗凝治疗的患者均纳入研究。根据患者服用不同药物分为三组：华法林组86例、达比加群酯组51例和低分子肝素（LMWH）组21例。分析患者房间隔穿刺后首剂肝素后活化凝血时间（ACT）达标率（First-ACT达标率）、穿间隔后1 h ACT达标率（1 h-ACT达标率）;比较三组间基础ACT值、First-ACT达标率、1 h-ACT达标率、ACT首次达标耗时、术中肝素总量情况。结果：158例患者中基础ACT结果：华法林组最接近有效范围,且三组间比较差异有统计学意义（P<0.001）;与达比加群酯组及LMWH组比较,华法林组的First-ACT达标率及1 h-ACT达标率明显升高,而ACT首次达标耗时和术中肝素总量明显减低,差异均有统计学意义（P均<0.05）;达比加群酯组及LMWH组比较差异无统计学意义（P>0.05）。结论：目前临床上参考体重和ACT监测给予肝素的术中抗...     

特发性流出道室性心律失常研究：基本原理和设计方案

背景 发生在无器质性心脏病的室性心律失常又称为特发性室性心律失常（IVA）,其中大多数起源于左心室或右心室流出道.目前关于特发性流出道室性早搏（IOTPVC）与非持续性室性心动过速（NSVT）的流行病学调查、预后以及临床干预均缺乏大样本的循证医学证据.基本原理 相关研究表明,不同负荷的IOTPVC/NSVT可能对患者的影响不同.IC类抗心律失常药物和β受体阻滞剂对IVA有效,导管消融是IVA的一线治疗措施.特发性流出道室性心律失常（IOTVA）研究将评估IOTPVC/NSVT对患者心功能的影响和不同干预方案对IOTPVC/NSVT负荷≥5％的患者的安全性与有效性.设计方案 IOTVA研究包括：①调查IOTVA在医院心内科门诊和住院患者中的构成比;②随访观察未经干预的IOTVA对患者心功能及预后的影响;③探讨与安慰剂对照的抗心律失常药物治疗IOTPVC患者的安全性;④比较抗心律失常药物与导管消融治疗IOTPVC/NSVT的安全性和有效性.在上述研究的基础上,探索IOTVA的临床治疗路径.患者的随访终点包括随访研究中PVC与NSVT出现次数及心脏功能变化等.本研究的次要终点包括脑钠肽（BNP）及生活质量的改善情况等.结论 IOTVA研究将明确我国IOTVA在门诊与住院室性心律失常患者中的构成比,抗心律失常药物和导管消融治疗的安全性与有效性.     

老年人心力衰竭的临床特点和治疗

将97例老年充血性心力衰竭患者与同期收治的88例老年前期心衰患者和145例年轻心衰患者的心脏病种类、发病诱因、临床特点进行对比分析。结果发现:老年心脏病以冠心病居多,占57.7％;诱因以呼吸道感染最常见,占68.0％。临床特点除了夜间阵发性呼吸困难和心前区疼痛外,神经系统功能障碍较为突出。窦性心动过缓和心房颤动是最常见的心律失常。并对治疗上值得注意的几个问题加以讨论。     

单纯碎裂电位指导心房颤动消融的初步临床观察

Objective To evaluate the feasibility of mdiofrequency catheter ablation of atrial fibrilla-tion (AF) guided by complex fractionated atrial electrograms (CFAEs). Methods Twenty-two patients with drug refractory and symptomatic AF(16 paroxysmal, 6 persisten) were enrolled. Using Carto, the left atrial or biatrial replica was created during spontaneous or induced AF, and areas associated with CFAEs were identi-fied. Radiofrequency ablation at the site with CFAEs was performed and the end points were to eliminate CFAEs or convert to sinus rhythm. Results Thirteen patients(59%)were converted to sinus rhythm, (7 cases conver-ted directly to sinus rhythm, and 6 via the intermediate atrial tachycardia(AT) or atrial flutter (AFL). The re-maining nine patients required cardioversion with D. C. shock or drug. Repeat ablation was performed in 6 pa-tients (5 AT/AFL, 1 paroxysmal AF). During(10.9 ±4.8) months follow-up, 16 patients (73%) were free of arrhythmia and symptoms. CFAEs were most commonly found along the left interatrial septum, pulmonary veins, left atrial roof. CFAEs ablation prolonged AFCL[(157 ± 18) ms vs (211 ± 32) ms, P < 0.05]. Only one patient had pericardial tamponade that required pericardiocentesis. Conclusion Radiofrequeney catheter abla-tion of atrial fibrillation (AF) guided by CFAEs is safe and effective.     

单纯碎裂电位指导心房颤动消融的初步临床观察

Objective To evaluate the feasibility of mdiofrequency catheter ablation of atrial fibrilla-tion (AF) guided by complex fractionated atrial electrograms (CFAEs). Methods Twenty-two patients with drug refractory and symptomatic AF(16 paroxysmal, 6 persisten) were enrolled. Using Carto, the left atrial or biatrial replica was created during spontaneous or induced AF, and areas associated with CFAEs were identi-fied. Radiofrequency ablation at the site with CFAEs was performed and the end points were to eliminate CFAEs or convert to sinus rhythm. Results Thirteen patients(59%)were converted to sinus rhythm, (7 cases conver-ted directly to sinus rhythm, and 6 via the intermediate atrial tachycardia(AT) or atrial flutter (AFL). The re-maining nine patients required cardioversion with D. C. shock or drug. Repeat ablation was performed in 6 pa-tients (5 AT/AFL, 1 paroxysmal AF). During(10.9 ±4.8) months follow-up, 16 patients (73%) were free of arrhythmia and symptoms. CFAEs were most commonly found along the left interatrial septum, pulmonary veins, left atrial roof. CFAEs ablation prolonged AFCL[(157 ± 18) ms vs (211 ± 32) ms, P < 0.05]. Only one patient had pericardial tamponade that required pericardiocentesis. Conclusion Radiofrequeney catheter abla-tion of atrial fibrillation (AF) guided by CFAEs is safe and effective.     

心肌梗死后骨髓间充质干细胞移植对心室肌细胞复极活动的影响

目的调查心肌梗死后植入骨髓间充质干细胞（mesenchymal stem cells，MSCs）对心室肌细胞复极活动的影响。方法10只健康幼猪作为正常对照组，23只幼猪通过球囊导管堵闭左冠状动脉前降支法建立心肌梗死模型并分别移植MSCs悬液（干细胞组，n=13）或等量生理盐水（梗死组，n=10），6周后行心肌组织免疫组化双染色、左心室血流动力学及左心室肌细胞复极活动的检查。结果（1）心肌组织免疫组化双染色示，MSCs源性细胞集中分布于梗死区，胞浆中出现了肌钙蛋白T（troponinT）；（2）干细胞组左心室射血分数、左心室收缩压和舒张末压虽未恢复正常（与对照组相比，P均〈0．01），但较梗死组均改善（P均〈0．05）；（3）梗死组和干细胞组动作电位复极90％的时间（APD90）、复极时间（RT）、APD和RT离散度值较对照组均延长（P均〈0．01），但干细胞组较梗死组显著缩短（P〈0．05—0．01）；（4）对照组APD重建曲线斜率〈1（正常），而干细胞组和梗死组APD重建曲线斜率均〉1（异常），但前者斜率明显小于后者；（5）干细胞组诱发APD交替的阈值周长虽高于对照组（P〈0．01），却低于梗死组（P〈0．05）。结论MSCs移植可减轻梗死心室复极紊乱，其机制可能与MSCs参与心肌组织修复、改善血流动力学水平有关。