缺血性心肌病OPCAB治疗患者中辅助应用主动脉内球囊反搏治疗的价值及安全

目的:分析缺血性心肌病非体外循环冠状动脉旁路移植术(Off pump coronary artery bypass grafting,OPCAB)治疗中辅助应用主动脉内球囊反搏(Intra aortic balloon counterpulsation,IABP)治疗的价值及安全性.方法:于我院(2018年9月至2020年9月)收治的缺血性心肌病患者中,抽取82例,随机分为对照组、观察组,每组41例,两组均行OPCAB治疗,在此基础上,对照组行常规处理,观察组行IABP治疗,对比两组治疗效果、围术期临床指标、肌酸激酶同工酶(Creatine kinase isoenzyme,CK-MB)及肌钙蛋白(Cardiac troponin I,cTnI)水平、并发症发生率及预后.结果:观察组的治疗效果、各项手术指标、左室舒张末内径均优于对照组(P<0.05);治疗后,两组CK-MB、cTnI水平均降低,且研究组降低得更显著(P<0.05);观察组并发症发生率低于对照组(P<0.05);术后持续对患者随访半年,两组心功能均明显改善(P<0.05),术后1个月、半年内观察组复发率低于对照组,但差异无统计学意义(P>0.05).结论:缺血性心肌病OPCAB治疗中应用IABP效果显著,安全性高.     

非体外循环冠状动脉旁路移植术在老年冠心病患者中的应用

目的探讨非体外循环冠状动脉旁路移植术治疗老年冠心病患者的临床疗效,分析其可行性及安全性。方法我院2007年1月至2012年1月收治248例60岁以上的冠状动脉硬化性心脏病患者,术前均拟定行非体外循环冠状动脉旁路移植术。将患者按照年龄分为60~70岁组(92例)和70岁以上组(84例),观察2组移植血管数量、主动脉内球囊反搏的使用、呼吸机辅助时间、术后住院时间、术后输血量、术后并发症、术后病死率等情况。结果与60~70岁组比较,70岁以上组呼吸机辅助时间明显较长、术后输血量较大,2组比较差异具有统计学意义(P0.05),2组移植血管数量、主动脉内球囊反搏使用率、术后住院时间、并发症发生率及病死率等比较差异无统计学意义(P0.05)。结论非外循环冠状动脉旁路移植术应用于老年冠心病患者的治疗中是安全可行的,老年并不能作为该术式的禁忌证。     

主动脉球囊反搏术在再次冠状动脉旁路移植术中的应用

观察主动脉球囊反搏术(IABP)在再次冠状动脉旁路移植术中的应用价值.收集再次冠状动脉旁路移植术应用IABP的患者21例,观察其IABP前后的连续心输出量(CCO)、混合静脉血氧饱和度(SVO2)、有创动脉收缩压(SABP)、有创平均动脉压(MABP)、心指数(CI)、肺毛细血管楔压(PCWP)等血流动力学指标和临床恢复情况.并行统计学分析.在21例IABP中.术前使用3例,术中使用6例,术后使用12例;15例患者恢复良好,死亡6例.死者中有3例因经济原因放弃治疗,2例死于围术期心肌梗死.1例是死于肺功能衰竭.3例出现球囊破裂,1例出现感染.平均IABP时间(98.4±43.7)h,在使用IABP期间,升压药单纯用多巴胺即可,剂量平均(5.2±3.6)μg/kg·min-1,在6例症状改善不明显的患者中,合用了肾上腺素或者间羟胺.平均呼吸机辅助时间(33.6±12.9)h,ICU监护时间(5.7±1.6)d,辅助用药时间(48.7±23.8)h.血流动力学指标:术后CCO、CI、SABP、MABP、SVO2较术前明显升高(P<0.05),而PCWP较术前明显降低(P<0.05).在再次冠状动脉旁路移植术中应用主动脉球囊反搏能明显改善患者心功能,降低死亡率.     

艾司洛尔用于OPCAB手术cTnI水平变化的临床研究

有文献提示 ,非体外循环下冠状动脉旁路移植术 (offpumpcoronaryarterybypass,OPCAB)中静脉输注艾司洛尔有助于手术成功[1 ] ,本文目的是通过检测患者心肌肌钙蛋白I(cTnI)、肌红蛋白 (myoglobin)、心肌型肌酸激酶同功酶 (CK -MB)水平 ,监测艾司洛尔用于OPCAB手术心肌损伤程度 ,以便更好使用艾司洛尔用于OPCAB。资料和方法一、一般资料 :择期行OPCAB的患者 6 0例 (男 4 9,女 11) ,年龄 4 2～ 76岁 ,平均 6 7岁。其中心功能Ⅱ级 4 3例 ,Ⅲ级 17例。再随机分成对照组和试验组各 30例。患者除合并糖尿病外都有口服倍他乐克史 ,心电图…     

主动脉内球囊反搏治疗心脏瓣膜置换术后低心排综合征的疗效比较

目的 比较主动脉内球囊反搏(IABP)治疗单纯主动脉瓣狭窄及其他心脏瓣膜病换瓣术后低心排综合征疗效的差异,探讨提高心脏瓣膜病IABP治疗效果的可行途径.方法 回顾性分析2004年6月至2009年1月本科室心脏瓣膜置换术后出现低心排综合征21例患者的临床资料,均采用经皮股动脉穿刺法行IABP治疗.其中单纯主动脉瓣狭窄患者10例,其他瓣膜病患者11例,比较2组IABP治疗的成功率.因低心排综合征致无法脱离体外循环术中紧急置入IABP 10例,其余11例均为术后在重症监护病房(ICU)紧急置入,比较2组IABP治疗的成功率.结果 21例换瓣术后低心排综合征患者IABP治疗成功11例.IABP对单纯主动脉瓣狭窄患者及其他心脏瓣膜病患者换瓣术后低心排综合征的治疗成功率分别为90.0%(9/10)和18.2%(2/11),前者明显高于后者(P＜0.05).术中和术后IABP置入的成功率分别为80.0%(8/10)和27.3%(3/11),术中IABP置入的成功率明显高于术后(P＜0.05).结论 针对性地尽早应用IABP有望提高其对心脏瓣膜置换术后低心排综合征的疗效.     

非体外循环心脏不停跳冠状动脉旁路移植术的临床应用

目的 :分析并讨论微创冠状动脉旁路移植术 (OPCAB)临床应用的效果。方法 :使用心脏稳定器 ,在心脏不停跳的情况下完成冠状动脉搭桥术。结果 :本组 6例手术效果良好 ,无死亡及重大并发症。ICU时间 12h～ 4 8h ,住院时间 10d～ 12d。术后随访心绞痛消失 ,心功能恢复至Ⅰ～Ⅱ级。结论 :微创非体外循环心脏不停跳冠状动脉搭桥术临床应用效果良好 ,创伤小、并发症少、恢复快、死亡率低 ,住院时间、出血及输血量较常规CABG明显减少。尤其对搭桥高危病例手术优越性显著 ,随着手术指征的扩大 ,可适合大多数冠心病例 ,临床应用前景广阔     

胸腺肽α1围手术期应用对肝癌患者T细胞亚群的作用

目的:探讨胸腺肽α1围手术期应用对肝癌患者细胞亚群的影响。方法:选取45例可切除肝癌患者,按手术大小分为治疗组(23例)和对照组(22例),治疗组术后当天、第3、第5d皮下注射胸腺肽α14mg,观察两组术前、术后第1、4、7d外周血T淋巴细胞CD3 、CD4 、CD8 、CD4 /CD8 分子的变化。结果:对照组术后CD3 、CD4 、CD4 /CD8 降低(CD4 、CD4 /CD8 术后1、4、7d与术前相比P<0.05),CD8 升高(术后1、4、7d与术前相比P<0.05),以第4d明显。治疗组CD3 、CD4 /CD8 术后第1、7d比较有统计学差异(P<0.05)。两组间比较,CD4 、CD4 /CD8 治疗组大于对照组(术后第1、4、7d均P<0.05),CD8 试验组小于对照组(术后第1、4、7d均P<0.05);CD3 试验组大于对照组(术后第4、7dP<0.05)。结论:手术对肝癌患者术后T淋巴细胞免疫功能抑制,胸腺肽对T淋巴细胞免疫功能有较好的保护作用。     

肌酸激酶同功酶肌钙蛋白Ⅰ肌红蛋白的变化

目的射频消融术(RFCA)可造成微小心肌损伤,本文旨在通过对血清肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)、肌红蛋白(Mb)的检测,进一步探讨其对RFCA所致心肌损伤的诊断价值.方法选择30例室上性心动过速患者,分别于RFCA前、电生理检查后、术后即刻、术后1天、2天采外周静脉血,采用美国德普公司自动免疫化学发光分析仪分别测定血清CK-MB、 cTnI、Mb.结果 CK-MB术后1天较术前增高(P<0.01);cTnI与术前相比术后1天、2天明显增高(P<0.05);与术前相比术后即刻Mb明显增高(P<0.01).结论 RFCA所造成心肌损伤属微小心肌损伤,可使血清心肌损害标志物有不同程度的升高,CK-MB 、cTnI、Mb可用于RFCA对心肌损伤的监测.     

星状神经节阻滞对双侧局部脑氧饱和度及对术后认知功能的影响

本研究旨在观察星状神经节阻滞对冠状动脉旁路移植术老年患者术中双侧局部脑氧饱和度(rSO2)及术后认知功能的影响。研究纳入体外循环下冠状动脉旁路移植术患者80例,随机分为超声引导星状神经节阻滞组和生理盐水对照组,比较术中双侧rSO2,采用简易精神量表(MMSE)、视觉语言学习测试(VVLT)、数字广度测试(DST)评估认知功能。结果发现:1术后第7天星状神经节阻滞组术后认知功能障碍发生率明显低于对照组(P0.05);2阻滞组阻滞侧rSO2在体外循环复温前显著高于星状神经节阻滞前(P0.05),体外循环开始前显著高于非阻滞侧(P0.05),体外循环开始前和体外循环停机后显著高于对照组(P0.05);阻滞组非阻滞侧rSO2在麻醉诱导前显著低于阻滞前和对照组(P0.05)。研究显示超声引导星状神经节阻滞可明显增加术中阻滞侧rSO2,明显减少术后认知功能障碍的发生。     

缺血预处理对心瓣膜置换术中心肌细胞Bcl-2及线粒体的影响

目的:研究体外循环下(CPB)心瓣膜置换术中缺血预处理(IP)对心肌细胞Bcl-2及线粒体的影响。方法:取2004年4月-2004年12月我院接受心脏瓣膜置换手术治疗的患者54例,随机分成2组,IP组(n=22):主动脉阻断前实行单次缺血2min和开放3min的IP方案,阻断主动脉后采用冷晶体心脏停搏液心肌保护进行手术;对照组(n=32):未进行IP方案,余步骤同IP组。比较2组术前和术后射血分数(EF)、短轴缩短百分率(FS)及每搏心输出量(SV)变化,观察肌钙蛋白T(c-TnT)、Bcl-2蛋白表达以及电镜下心肌细胞线粒体的改变。结果:对照组术后EF、FS及SV均较术前降低,P0.05;IP组术前后EF、FS及SV变化不明显,IP组术后6h、24h、48h、72h及第5dc-TnT水平均低于对照组,且随时间呈下降趋势;2组术前Bcl-2表达无显著差异(P0.05),术后IP组为19.85±5.88,较术前显著上升(P0.05);对照组为14.17±3.39,与术前无明显差别(P0.05)。术后2组Bcl-2表达具有显著差异(P0.05)。电镜观察:对照组心肌细胞线粒体肿胀,线粒体膜模糊不清,部分线粒体膜破裂;线粒体嵴明显疏松溶解,大量空泡形成;IP组心肌细胞线粒体膜基本完整,线粒体嵴密集,电子密度增高,无空泡形成。结论:IP可能上调心肌抗凋亡蛋白Bcl-2的表达,对心肌细胞线粒体起保护作用,减轻缺血再灌注对心肌细胞的损伤作用,一定程度上维护心脏功能。     

Variant of the left coronary artery with an unusual origin and course: Anatomic and postmortem angiographic findings

This study demonstrates anatomic and postmortem angiographic findings characterizing the origin of the left coronary (LC) artery arising in common trunk with the right coronary (RC) artery from the right aortic sinus and its course via the ventricular septum (VS) to the left heart. This anomaly was a single finding observed among 388 angiographies and 60 corrosion castings. The course of the LC was divided in four segments. The first three form a curve that is upward concave. Large branches to the septomarginal trabecula (ST), VS, diagonals (DS), and the small anterior interventricular (anterior descending) artery originated from the outer part of this curve. In the anteroposterior x-ray, the above curve resembles a deep-bottom pot with a handle corresponding to the fourth segment. In the right anterior oblique, the first and second segments form a large erect angle. The third segment occupies the lower part of the absent proximal anterior interventricular artery, and the fourth crosses the outflow tract and the first segment in the middle. The course of these four segments of LC resembles the shape of the number 6. These findings are important for interpreting coronary angiographies in patients with this anomaly. Clin. Anat. 11:367–371, 1998. © 1998 Wiley-Liss, Inc.     

Changes in Coronary Perfusion after Occlusion of Coronary Arteries in Kawasaki Disease

Purpose

Myocardial infarction in children with total occlusion of a coronary artery after Kawasaki disease is rare due to multiple collateral vessels. We aimed to investigate the changes in coronary perfusion associated with coronary artery occlusion after Kawasaki disease.

Materials and Methods

Eleven patients with coronary artery occlusion after Kawasaki disease were investigated. Serial coronary angiographies after total occlusion of a coronary artery were reviewed and the changes were described in all patients with additive information collected.

Results

The median age at the occlusion was 5.9 years old. The interval to occlusion was 6.2±6.9 years. Four left anterior descending coronary artery total occlusions and 10 right coronary artery total occlusions were detected. Immediate coronary artery bypass graft for left anterior descending coronary artery total occlusion made right coronary total occlusion occurred in all except one patient and the intervals thereof were 1 year, 1.8 years, and 4 years. Collaterals to the left coronary artery regressed after recanalization, while new collaterals to the right coronary artery developed. In three, collaterals to the right coronary artery decreased without recanalization without clinical signs.

Conclusion

The right coronary artery should be followed up carefully because of possible occlusion of new onset or changes in collaterals.     

Rapid progression of nonculprit coronary lesions six weeks after successful primary PCI in culprit artery： a case report

We report a case of a 49-year-old man who was admitted with a 3-hour history of sudden onset of substemal chest pain. Coronary angiography revealed that the left circumflex artery （LCX） was acutely and totally occluded at the mid-portion. In addition, the proximal and mid-portion of the right coronary artery （RCA） had a 60% occlusion. We inferred that the LCX was the culprit artery and primary PCI was successfully performed. Six weeks later, the patient had an eventful course with recurrence of chest pain. Coronary angiography showed no significant ste- nosis in the previous LCX lesion, while the proximal and middle potion of the RCA had a 90% occlusion. Our case demonstrates the systemic nature of acute coronary syndromes and highlights the inherent instability of coronary artery disease.     

冠脉CT与冠脉造影诊断心肌桥的临床价值比较

目的:比较冠脉CT与冠脉造影诊断心肌桥的临床价值。方法:收集2015年7月~2020年7月苏州大学第二附属医院心内科收治的107例疑似冠心病患者临床资料。依次进行冠脉CT和冠脉造影检查,计算壁冠状动脉（MCA）狭窄程度,观察前降支、对角支、钝缘支、后降支和回旋支冠脉分布走行以及与心肌的关系,测量心肌桥长度和厚度。比较两种检查方法图像质量优良率、心肌桥检出率以及心肌桥测量指标。分析两种检查方法显示MCA狭窄程度和诊断心肌桥的一致性。以冠脉造影为金标准,计算敏感度、特异度、准确度、阳性预测值、阴性预测值,评估冠脉CT判断MCA中重度狭窄和诊断心肌桥的价值。结果:两种检查方法图像质量优良率均较好,冠脉CT心肌桥检出率显著高于冠脉造影（25.23% vs 14.02%, P<0.05）;冠脉CT测得心肌桥长度大于冠脉造影,MCA狭窄程度低于冠脉造影,差异具有统计学意义（P<0.05）;冠脉CT和冠脉造影显示MCA狭窄程度的一致性较好（Kappa=0.832, P<0.05）;与冠脉造影比较,冠脉CT判断MCA中重度狭窄的敏感度、特异度、准确度、阳性预测值、阴性预测值分别为90.63%、86.67%、74.36%、95.59%、87.85%;冠脉CT和冠脉造影诊断心肌桥的一致性较好（Kappa=0.815, P<0.05）;与冠脉造影比较,冠脉CT诊断心肌桥的敏感度、特异度、准确度、阳性预测值、阴性预测值分别为64.29%、73.33%、69.23%、68.75%、68.97%。结论:冠脉CT与冠脉造影对心肌桥诊断均具有一定价值,而冠脉CT具有无创性、图像质量优良率高,且对心肌桥位置及分布显示佳,并对MCA狭窄具有较高敏感度和特异度,更具临床应用优势。     

Animal models of coronary heart disease

Cardiovascular disease, predominantly coronary heart disease and stroke, leads to high morbidity and mortality not only in developed worlds but also in underdeveloped regions. The dominant pathologic foundation for cardiovascular disease is atherosclerosis and, as to coronary heart disease, coronary atherosclerosis and resulting lumen stenosis, even total occlusions. In translational research, several animals, such as mice, rabbits and pigs, have been used as disease models of human atherosclerosis and related cardiovascular disorders. However, coronary lesions are either naturally rare or hard to be fast induced in these models, hence, coronary heart disease induction mostly relies on surgical or pharmaceutical interventions with no or limited primary coronary lesions, thus unrepresentative of human coronary heart disease progression and pathology. In this review, we describe the progress of animal models of coronary heart disease following either spontaneous or diet accelerated coronary lesions.     

Giant coronary sinus aneurysm secondary to right coronary arteriovenous fistula leading to pseudo-mitral stenosis

We herein report a case in which a right coronary to coronary sinus arteriovenous fistula determined progressive aneurysmatic dilatation of the coronary sinus. Severe compression of the left atrium ensued. This led to a clinical and instrumental picture similar to that observed in severe mitral stenosis.     

Comparing mortality and myocardial infarction between coronary artery bypass grafting and drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis

Introduction

We aim to compare the midterm outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in diabetic patients who had multivessel coronary artery diseases (CAD).

Material and methods

A comprehensive literature search was conducted to identify the related clinical studies with a follow-up for 1 year at least. The endpoints were death, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE).

Results

Finally, the analysis of ten studies involving 5,264 patients showed that patients with CABG had worse baseline characteristics, a higher rate of stable angina pectoris, a higher percentage of triple-vessel disease, higher incidence of chronic total occlusion and a higher SYNTAX score. However, there was no significant difference in mortality between the two groups. Additionally, the rates of myocardial infarction and MACCE were markedly decreased in the CABG group.

Conclusions

The strategy of CABG is better than PCI for diabetic patients with multivessel CAD. The CABG can significantly reduce the rates of myocardial infarction and MACCE and is comparable in mortality despite the worse baseline characteristics.     

右冠状动脉起源于左主干5例临床分析

目的：分析右冠状动脉起源于左主干的临床特征，探讨其与心肌缺血的关系。方法：回顾分析5例右冠状动脉起源于左主干的临床资料及相关文献。结果：（1）本组5例患者中，女性1例，男性4例，年龄27～70岁。（2）临床表现主要为胸痛、胸闷等心绞痛症状，除1例老年患者外，其余4例病人都有典型的心绞痛症状和缺血心电图变化。（3）冠状动脉造影示3例合并严重冠状动脉粥样硬化，给予冠状动脉搭桥术，术后随访2月～6年无明显不适；另2例冠状动脉无明显病变，药物治疗后仍有劳累性心绞痛发作，其中1例半年后猝死。结论：右冠状动脉起源于左主干是一种罕见的冠脉畸形，对存在严重心肌缺血的患者应进行预防性冠状动脉搭桥术或介入治疗，预防不良事件的发生。     

老年冠心病慢性闭塞病变的介入治疗探讨

目的探讨老年冠心病患者采用经皮冠状动脉介入(PCI)治疗的中短期疗效。方法对102例住院老年患者采用股动脉穿刺后,行球囊扩张,造影显示扩张满意后植入合适支架。术后随访6-32个月。结果102例患者术后临床症状均完全或基本完全缓解。本组患者有19例多支病变患者至少有一支慢性完全闭塞血管经努力而未能开通,无法植入支架。102例患者通过随访6-32个月,其中32例患者接受了冠脉造影复查,有17例患者分别于术后6个月至16个月又出现胸痛、胸闷症状。超声心动图检查射血分数(EF),心功能术后较术前明显改善,P<0.05。结论对冠状动脉慢性完全闭塞的老年患者,无论核素或超声检查是否存在存活心肌,均应尽量进行闭塞病变的介入治疗,以期改善患者的远期预后。     

Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment.