原发性感染性心内膜炎的临床分型和外科处理

目的探讨原发性感染性心内膜炎的临床分型特点,分析影响手术近期预后的危险因素。方法对109例外科手术治疗的原发性感染性心内膜炎患者进行回顾性分析。根据手术前感染情况,分为感染活动型、感染静止型、和感染隐匿型,比较三组患者间围手术期临床特征和预后情况。结果感染活动型患者具有基础心脏病史比例显著低于感染静止型和感染隐匿型患者,而其血白蛋白、血白细胞等血液指标异常率、急诊手术治疗的比例和术后并发症发生率均显著高于感染静止型和感染隐匿型患者。三组患者手术死亡率无显著性差异。与生存组相比,死亡组患者中NYHA心功能Ⅲ~Ⅳ级、血沉异常、急诊手术及术后并发症的比例显著增高。结论不同临床分型的原发性感染性心内膜炎患者经早期诊断、正确选择手术时机和手术方法、以及良好的围手术期处理,均能获得较满意的手术疗效。     

关于我国胸心外科住院医师规范化培训制度的讨论

<正>随着人口老龄化及心血管疾病发病率增加,胸心外科服务需求日益增长。胸心外科医师培养周期长、就业晚、职业风险高、工作负荷大,即使在发达国家未来也面临胸心外科医师的短缺[1]。2014年国家卫计委正式公布《关于建立住院医师规范化培训制度的指导意见》和第一批住院医师规范化培训基地371家,2015年在全国全面启动住院医师规范化培训工作。如何结合我国胸心外科发展现状,预测未来需求,借鉴国际胸心外科住院医师规范化培训的     

体外循环心脏手术神经系统损伤对血清神经元特异性烯醇化酶浓度的影响

[目的]了解体外循环心脏手术神经系统损伤和神经元特异性烯醇化酶水平之间的关系，用以指导临床工作。[方法]随机抽取体外循环心脏术后有神经系统损伤患者20例，没有神经系统损伤患者20例，测量两组患者围术期不同时点NSE浓度，并纳入重复测量模型进行统计学分析。[结果]有神经系统损伤组患者末后各对点NSE水平均明显高于无神经系统损伤组。[结论]体外循环心脏术后有神经系统损伤时，NSE水平明显升高。     

模拟缺血再灌注后心肌细胞胰岛素抵抗机制的初步研究

Objective Recent.studies have found a strong association of insulin resistance, which might occur during ischemia reperfusion in vitro in the experimental dogs, with disturbed function of cardiomyocytes. Obvious acute insulin resistance, along with glucose dysmetabolism in the reperfused cardiomyocytes, was furher observed in the study performed with ischemia-reperfused ventric- ular myocytes of rats. We tried to investigate preliminarily the molecular mechanisms of insulin resistance in the cardiomyocytes after ischemia reperfusion. Methods An experimental model of insulin-stimulated ischemia reperfusion (SI/R) was created by isolating cardiomyocytes from adult rats. Glucose uptake of the cardiomyoctyes was evaluated with isotope-labeling technique. Glucose trans- porter 4 (GLUT4) translocation induced by insulin was investigated with Western blot analysis, and the intracellular level of free Ca2+ ([Ca2+]I) was measured quantitatively with Ca2+ indicator Fura-2. Results Insulin can stimulated glucose uptake by cardiomyo- cytes, indicating that these cells were insulin-sensitive. Cardiomyocytes were demonstrated notable acute insulin resistmce during reperfusion. Insulin-stimulated GLUT4 translocation in the cardiomyocytes 15 minutes after reperfusion was 72.2% of that in the con- trol group(P<0.05), in which the GLUT4 content in plasma membrane remained unchanged. The finding suggested that a disturbed GLUT4 translocation might happen in the cardiomyocytes during insulin-stimulated ischemia-reperfusion. Calcium overload was identi- fied in the cardiomyocytes with ischemia reperfusion. At 15 minutes of reperfusion, [Ca2+]I was significantly higher in the reperfused cardiomyocytes than that in the control cardiomyocytes[(318.66±23.06)vs(130.70±0.82) nmol/L, P<0.05], and kept at a higher level [(177.79±17.46) nmol/L] at 60 minutes of reperfusion (P<0.05, vs control). Partial correlation analysis revealed a negative correlation of[Ca2+]I with insulin-induced ghcose uptake in the cardiomyoctyes (r = -0.557,P=0.006). Conclusion Disturbed GLUT4 translocation and decreased intrinsic activity may be important molecular mechanisms for the development of insulin resistance in the cardiomyocytes of rat during insulin-simulated ischemia reperfusion,. [Ca2+]I overload may account for the de- creased intrinsic activity d GLUT4.     

急性A型主动脉夹层手术主动脉断端加固方法的改进

目的改进急性主动脉夹层手术中对主动脉断端加固处理的方法,探讨该方法的有效性。方法华西医院胸心血管外科在主动脉夹层手术中对主动脉夹层断端加固方法在传统＂三明治＂法的基础上进行了改良,2006年1月至2008年12月对28例急性A型主动脉夹层患者采用改良主动脉夹层断端加固法施行手术。其中10例用外膜向内翻转折迭加固断端,另18例在夹层中（内外膜之间）和内膜内侧放置条形毛毡或心包条,缝线加其固定加固夹层断端;并观察吻合口出血情况和术后早期转归。结果全组患者无出血并发症;手术死亡2例,1例为术中、术后出现严重低心排血量综合征,另1例于术后1周死于多器官功能衰竭。术后仅2例患者出现苏醒延迟,其他均无神经系统并发症,无胸骨和手术切口相关并发症。26患者经治疗后痊愈出院。结论改良主动脉断端加固方法除了能达到加固夹层断端的目的外,还可以很清楚地发现吻合口上的出血点,从而施行有效的缝合止血。该方法实施方便、有效,值得在临床推荐应用。     

房间隔缺损经皮封堵治疗后封堵器移位外科治疗1例

患者男,63岁.16年前体检发现心脏杂音,诊断“先天性心脏病,房间隔缺损”,未处理.9年前外院行经皮房间隔缺损封堵术,具体情况不详,术后症状缓解.3年前患者开始偶感胸闷、心悸,无明显诱因,可自行缓解,未进一步诊治.1年前患者发生过黑朦、意识模糊,于当地医院对症处理后缓解.之后常感心悸,每日2次口服倍他乐克12.5 mg至今,服药后心悸症状有所缓解.患者房间隔缺损封堵术后一直未行超声心动复查.1个月前患者因心悸于我院就诊,超声心动检查示“房间隔封堵伞移位,三尖瓣反流(中度)”.     

心脏机械瓣膜置换术后妊娠妇女低强度华法林抗凝治疗56例

目的 探讨心脏机械瓣膜置换术后妊娠妇女低强度抗凝治疗的方法,以及抗凝药物对孕妇和胎儿的影响.方法 随访56例心脏机械瓣膜置换术后妇女妊娠、分娩期抗凝治疗情况.结果 56例(61例次)妊娠全程均口服华法林行抗凝治疗,42例用国产华法林(3.02±0.85)mg/日,14例用进口华法林(2.84±0.57)mg/日,国际标准比值(INR)均值为1. 67±0.58.所有孕妇均无严重出血及栓塞等并发症发生,仅11例次有一般性出血现象.本组足月妊娠47例,早产7例,自然流产6例,死产(畸胎)1例;低体重儿6例.新生儿均无畸形发生.结论 心脏机械瓣膜置换术后妇女妊娠全程服用较小剂量华法林(＜5 mg/日)行低强度抗凝治疗(INR=1.5～2.0)对孕妇安全、方便,且胎儿并发症发生率较低.

Abstract：

Objective To evaluate the method of low-intensity anticoagulation therapy in the pregnant women who had received mechanical heart valve replacemant, and the effects of warfarin on the pregnant women and their fetus. Methods This retrospective study involved 56 pregnant women( 61 pregnancies)who had received mechanical heart valve replacement.Their pregnant status, delivery, and anticoagulation therapy were observed and followed-up between May 1986 and November 2009 at West China Hospital of Sichuan University. Results All patients took oral anticoagulant (warfarin) throughout pregnancy. The dose of domestic warfarin was ( 3.02 ± 0.85 ) mg/d ( in 42 cases), and the dose of imported warfarin was (2.84 ± 0.57 )mg/d (in 14 cases). The mean INR value of 401 samples from patients was 1.67 ±0.58. No thromboembolism or major hemorrhagic complications occurred. Minor bleeding occurred in 11 pregnancies. Forty-seven patients had term delivery, 7 had premature birth, 6 had spontaneous abortion, and 1 had intrauterine fetal death. Six newborns were born with low birth weight (2.3 ± 0. 5 ) kg, and no abnormal fetus was observed. Conclusion The low-intensity anticoagulation therapy with warfarin (at a dose of less than 5 mg/d) and a INR target of 1.5 to 2.0 was safe and convenient for the pregnant women,who had received mechanical heart valve replacement. The abnormalities rate of fetus was low.     

二尖瓣、主动脉瓣机械瓣置换术后二尖瓣机械瓣血栓形成一例

患者女,56岁。因二尖瓣、主动脉瓣机械瓣置换术后3.5年,反复发生心累、气促5个月余入院。患者3.5年前因风湿性心脏病,二尖瓣、主动脉瓣双瓣膜病变而行二尖瓣、主动脉瓣机械瓣置换术。所使用瓣膜为St.Jude机械瓣,二尖瓣机械瓣25 mm。     

二尖瓣狭窄下游湍流强度体内多普勒超声定量研究

目的以无创的多普勒超声检测方法了解二尖瓣狭窄下游血流不同部位湍流强度特点,探讨湍流剪应力(turbulent shear stress, TSS)、相对扰动强度(relative turbulent intensity, Irel) 与狭窄病变间的相互关系,为深入研究瓣膜疾病发生发展机制与人工心瓣血流动力学提供前期基础和科学依据. 方法应用与计算机图像分析技术相结合的多普勒超声,对一组不同程度二尖瓣狭窄病人二尖瓣下游跨瓣血流不同部位湍流强度进行定量描述. 结果二尖瓣狭窄下游射流区TSS与Irel均明显低于射流周围湍流区.射流区TSS与Irel在不同狭窄程度组间差异均无显著性(p>0.05),而湍流区TSS与 Irel在不同狭窄程度组间差异均存在显著性(p<0.05),并且,T SS和Irel均与有效瓣口面积(effective orifice area, EOA)成明显负相关(r各为-0.84和-0.82).超声显示,绝大部分患者瓣尖部位病变的严重程度远高于瓣膜的其它部分. 结论二尖瓣狭窄下游射流周围湍流区湍流强度远高于射流区,狭窄病变越重,湍流强度越大,而射流区湍流强度与狭窄程度无关.TSS集中分布于湍流区与瓣膜病变的空间对应关系提示,TSS是导致瓣膜病变进行性加重不容忽视的重要因素,其具体作用机制有待进一步研究加以阐明.此外,生物心瓣(bioprosthetic heart valve, BHV)的衰败很可能还与其下游长期存在的TSS有关,值得深入研究.     

主动脉瓣置换术105例临床分析

目的 :总结 10 5例主动脉瓣置换术的临床经验。方法 :自 1991年 1月至 2 0 0 0年 6月共行主动脉瓣机械瓣置换术 10 5例。结果 :体外循环时间 5 5～ 2 19分 (112± 30分 ) ,升主动脉阻断时间 30～ 15 0分 (6 4± 19分 ) ,手术时间 190～ 5 40分 (2 6 4± 6 3分 )。术后发生低心排血综合征 8例 (7 6 % ) ,严重室性心律失常 10例 (9 5 % )。死亡 8例 ,死亡率 7 6 %。结论 :如病例选择适当 ,主动脉瓣置换术安全可行且效果好 ,室性心律失常是术后最常见的并发症 ,也是术后死亡最常见的原因。