室间隔缺损合并肺动脉高压的体外循环管理

目的 总结室间隔缺损合并肺动脉高压的患者心内直视修补术中体外循环的管理.方法 选择2005年10月至2010年12月我院收治的室间隔缺损合并肺动脉高压患者65例,经诊断性治疗后54例患者在体外循环下行室间隔缺损修补术.结果 体外循环时间26～68 min,平均(46±12)min;主动脉阻断时间15～38 min,平均(26±8)min.手术死亡1例(1.8％),术后第5天死于低心排出量综合征.结论 对于室间隔缺损合并肺动脉高压患者,掌握好手术适应证、术中体外循环配合注重心肌保护、肺保护、酸碱和电解质平衡的纠正、扩血管药物以及超滤技术的应用,直接影响手术疗效.     

肺、体循环分别给药治疗体外循环后肺动脉高压危象的临床分析

目的 观察肺、体循环分别给药在治疗体外循环后严重肺动脉高压伴低心排综合征中的效果.方法 21例伴重度肺动脉高压的心脏病患者,在全麻体外循环下行心内直视手术.停体外循环时出现肺高压危象,经常规途径联合应用血管活性药物后无法脱离体外循环.在经肺动脉导管给予扩血管药物的同时,经主动脉根部置管输注去甲肾上腺素以对抗体循环低血压,以逐步脱机.结果 肺-体循环分别给药后,肺动脉压下降,桡动脉压逐渐上升,与给药前比较,差异有统计学意义;肺动脉压/桡动脉压比值以及肺循环阻力/体循环阻力比值降低,3 min后各时间点与用药前比较,差异有统计学意义.心脏指数逐渐上升,5 min后各时间点与0 min比较,差异有统计学意义.结论 肺一体循环分别输注酚妥拉明和去甲肾上腺素,可避免扩血管药物的体循环副作用,有助于体外循环后肺高压危象患者顺利脱机.     

心脏外科术后肺部氧摄取的临床观察与分析

目的：通过监测心脏外科需体外循环（CPB）手术的病人术后呼吸功能与动脉血气的变化。了解术后肺部氧摄取的能力。指导心脏外科术后的呼吸治疗。方法：对心脏外科房间隔缺损（ASD）、室间隔缺损（VSD）、风湿性心脏瓣膜病二尖瓣及主动脉瓣置换术后病人42例进行观察。其中肺动脉高压组患者18例，非动脉高压组24例，术后1h吸入氧浓度为50%时测呼吸功能和动脉血气值。结果：术后早期肺部氧摄取功能明显下降。术前合并肺术后1h吸入氧浓度为50%时测呼吸功能和动脉血气值。结果：术后早期肺部氧摄取功能明显下降，术前合并肺动脉高压的患者表现尤其突出。表现为PaO2下降，A-aDO2增大、Shunt%升高。气道阻力增高、静态及动态顺应性下降。结论：心脏外科术后氧摄取能力普遍下降，肺动静脉分流增大，胸肺总的静态顺应性降低，必须加强术后呼吸治疗。     

先天性心脏病肺动脉高压术后预防肺动脉高压危象临床观察

先天性心脏病肺动脉高压患者术前存在严重的肺血管病理改变。心内直视体外循环过程中，肺缺血再灌注损伤进一步加重肺泡组织、血管内皮细胞的损伤，导致肺泡气体交换功能下降，使血液氧合程度及肺组织供氧能力下降，肺血管收缩致肺动脉压增高，严重时引起肺动脉高压危象等多种严重的并发症.     

肺动脉高压对同种原位心脏移植患者移植后早期血流动力学的影响

目的分析研究心脏移植患者术前不同程度的肺动脉高压对患者移植后早期血流动力学指标、超声心功能检查、围术期并发症和死亡率的影响。方法回顾总结2004年6月至2006年12月,阜外心血管病医院连续做的67例同种原位心脏移植手术患者。根据术前肺血管阻力将患者分为3组：Ⅰ组无肺动脉高压、肺血管阻力等于或低于2．5Wood单位15例;Ⅱ组轻到中度肺动脉高压、肺血管阻力大于2．5Wood小于5．0Wood单位42例;Ⅲ组严重的肺动脉高压、肺血管阻力等于或大于5．0Wood单位10例。连续监测并记录麻醉前、术后即刻、12、24及48h的CVP、MPAP、CO、Sv02、PAWP等指标;停体外循环后、术后第1、3、7d、1个月、3个月经超声测定左室舒张末径（LVEDD）、左室射血分数（EF）及二、三尖瓣的返流情况等;术后详细记录各种并发症、治疗情况及术后30d的死亡率。结果本研究患者均完成心脏移植手术,3组患者无手术死亡（术后30d内）。Ⅲ组患者的术前EF值与Ⅰ组比较,P〈0．05;3组患者的体外循环阻断时间、供体心脏热缺血、冷缺血时间无明显差别;Ⅲ组患者的体外循环时间明显长于Ⅰ组、Ⅱ组P〈0．05,术后带管时间Ⅲ组与Ⅰ组比较,P〈0．05。3组间麻醉前MPAP、PVR,P〈0．05,Ⅲ组患者麻醉前CI明显低于Ⅰ组、PCWP明显高于Ⅰ组P〈0．05;Ⅲ组术后各时间点MPAP、PVR明显低于麻醉前、特别是术后48h,P〈0．05,但仍表现为肺动脉压升高。术后并发急性肾功能衰竭3例（Ⅱ组1例、Ⅲ组2例）、急性右心衰竭6例（Ⅰ组1例、Ⅱ组2例、Ⅲ组3例）。超声检查除Ⅲ组2例患者术后早期显示三尖瓣中量返流外,未发现明显的心脏扩大、收缩功能降低等异常情况。结论术前严重肺动脉高压患者心脏移植后早期肺动脉压力明显降低,但术后易发生急性右心衰竭等并发症,经积极的强心、利尿等治疗措施恢复良好。供体心脏的保护、围术期特别是术中及术后早期右心功能的维护、抗感染及排异反应的监测等是保证手术成功的关键。     

动脉导管未闭的体外循环管理

目的总结动脉导管未闭（PDA）的体外循环管理方法及其经验。方法2000年2月-2009年4月我院心胸外科共收治动脉导管未闭患者10例,均采用深低温低流量体外循环管理,心肌保护为4∶1氧合血停搏液灌注,心脏停跳后即切开肺动脉堵住动脉导管开口,防止灌注肺的产生。结果本组病例体外循环时间在48-120 min,升主动脉阻断时间30-68 min,均心脏自动复跳,脱机顺利,痊愈出院。结论深低温低流量体外循环管理下动脉导管直视缝合术是一种安全有效的手术方法。     

体外循环心内直视手术后呼气末正压式机械通气（PEEP）治疗呼吸衰竭的护理体会

呼气未正压式机械通气（PEEP），使呼气末时仍保持呼吸道压力高于肺泡临界关闭压，能避免肺泡的早期闭合，增加功能残气量，提高动脉血氧，减少肺分流量，减少肺充血及肺水肿，并使一部分失去通气功能的肺泡扩张，增加氧的交换面积，从而提高氧分压，呼气未正压一般用0．5～1．5kPa。临床资料本组用例，男性12例，女性8例，年龄5～48岁，其中风湿性心脏瓣膜置换8例，法鲁氏四联症2例，室缺及房缺合并肺动脉高压7例，深低温微流量体外循环下闭合动脉导管3例，术后均发生不同程度的呼吸功能衰竭，患者动脉血氧分压均低于人8叭Pa，二氧化碳…     

改良肺动脉灌注在发绀型先天性心脏病体外循环术中的应用

目的研究体外循环中经肺动脉灌注低温组胺酸-酮戊二酸-色氨酸灌注液(HTK)对发绀型先天性心脏病患儿的肺保护作用。方法 30例发绀型先天性心脏病患儿随机分为灌注组和对照组。灌注组体外循环期间肺动脉灌注低温HTK,对照组常规体外循环。围手术期检测血浆肿瘤坏死因子-α(TNF-α)。征得患儿家长同意,取右下肺组织活检,观察病理变化。检测围手术期动脉血气分析及体外循环(CPB)时间、主动脉阻断时间、呼吸机辅助时间、住监护室(ICU)时间、术后住院时间。结果 2组CPB时间、主动脉阻断时间及术后住院时间比较差异均无统计学意义(P>0.05)。灌注组呼吸机辅助时间、住ICU时间均显著低于对照组(P<0.05)。返回ICU后0、12、24和48 h,灌注组氧合指数均明显高于对照组,肺泡-动脉氧分压差明显低于对照组,差异有统计学意义(P<0.05)。体外循环前,灌注组血浆TNF-α与对照组比较差异无统计学意义(P>0.05);返回ICU后0、12、24和48 h灌注组血浆TNF-α与对照组比较明显降低,差异均有统计学意义(P<0.05)。肺组织病理学观察显示,灌注组体外循环术后肺泡轻度水肿,肺泡内炎症细胞浸润减少;对照组体外循环术后肺泡水肿,肺泡内见大量中性粒细胞浸润。结论改良肺动脉灌注低温HTK可以明显减轻发绀型先天性心脏病体外循环术后肺内炎症反应和改善肺功能。     

低温洗涤红细胞肺保护液对体外循环术后肺保护作用的研究

目的:探讨体外循环(cardiopulmonarybypass,CPB)术中采用低温洗涤红细胞肺保护液实施肺动脉灌注对肺的保护效果。方法:随机选取20例风湿性单纯二尖瓣病变合并中度肺动脉高压的患者,分为肺动脉灌注组和对照组(每组各10例)。灌注组在主动脉阻断后,经肺动脉根部间断灌注低温洗涤红细胞肺保护液,测定两组患者围术期的机械通气时间、肺血管阻力、白细胞比值(静脉血/动脉血)、肺循环血浆MDA含量。结果:体外循环术后灌注组机械通气时间显著低于对照组(P<0.05);各时点肺血管阻力、白细胞比值(静脉血/动脉血)、肺循环血浆MDA含量均显著低于对照组(P<0.01)。结论:低温洗涤红细胞肺保护液肺动脉灌注对体外循环术后肺损伤有明显的保护作用.     

不同途径中和肝素对先天性心脏病合并肺动脉高压术后肺循环的影响

目的探讨不同途径输注鱼精蛋白对非紫绀型先天性心脏病合并肺动脉高压患者体外循环术后肺循环的影响。方法选择手术治疗非紫绀型先天性心脏病患者80例,根据不同给药途径(主动脉、中心静脉)及有无肺动脉高压分为4组,每组20例:A1组(无肺动脉高压、主动脉给药)、A2组(无肺动脉高压、中心静脉给药)、B1组(肺动脉高压、主动脉给药)、B2组(肺动脉高压、中心静脉给药)。记录术前(T0)、输注鱼精蛋白之前(T1)、输注后1min(T2)、3min(T3)、5min(T4)、10min(T5)、15min(T6)、25min(T7)各时间点肺动脉压(PAP)、肺静脉压(PVP)、中心静脉压(CVP)、气道峰压(Ppeak)、平均气道压(Pmean)等参数,并采静脉血测血清中各时间点血栓素B2(TXB2)的水平。结果输注鱼精蛋白后,经中心静脉给药A2组及B2组PAP、PVP、CVP、Ppeak、Pmean均高于经主动脉给药的A1组及B1组(P<0.05);给药后(T2~T7)4组患者血中TXB2浓度较术前(T0)均明显升高(P<0.05),经中心静脉给药的A2组及B2组较主动脉给药的A1组及B1组升高更为显著(P<0.01)。结论心脏直视术后输注鱼精蛋白经主动脉给药较中心静脉给药可明显减少TXB2的释放,可避免鱼精蛋白直接进入肺循环刺激肺血管和气管平滑肌产生强烈痉挛,对体外循环术后患者的肺循环影响较小,特别是合并有肺动脉高压的患者。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.