依托咪酯乳剂与丙泊酚在心脏瓣膜置换术麻醉诱导的对比

依托咪酯是新型催眠性静脉全麻药,起效快,平稳,对循环系统影响小和不引起组织胺释放等优点,适用于老年及心脏功能低下病人麻醉[1].心脏瓣膜置换术的患者大多病情危重,术前伴有不同程度的心功能损害和明显的血流动力学改变,使心血管储备功能明显受损,常难承受麻醉药对循环功能的影响,尤其当麻醉诱导集中给药时,可严重抑制循环功能,甚至发生意外,给麻醉诱导带来很大困难[2].因此,对比了依托咪酯乳剂与丙泊酚全麻诱导对心脏瓣膜置换病人血流动力学的影响,寻求安全,平稳的诱导方法.     

高原缺氧环境下硬膜外麻醉时胆心反射的临床研究

目的：观察高原缺氧环境下,硬膜外麻醉时行胆囊切除术中病人胆心反射的发生率、血流动力学变化对病人的影响;方法：择期胆囊切除术病人３０例,ＡＳＡⅠ级～Ⅱ级,肝肾功能正常,随机分为两组,对照（吸氧）组和观察（不吸氧）组,每组１５例,分别在入室后、麻醉后、牵拉分离胆囊、手术结束时,记录ＳＢＰ、ＤＢＰ、ＨＲ、ＳｐＯ２及ＥＣＧ的变化;结果：观察组的ＳＢＰ、ＤＢＰ、ＨＲ、ＳｐＯ２在牵拉分离胆囊时明显降低,与术前相比有显著性差异（Ｐ〈０．０５）,其中ＨＲ的减慢、ＳｐＯ２在降低有非常显著性差异（Ｐ〈０．０１）;结论在高原缺氧环境下,硬膜外麻醉时行胆囊切除术中,胆心反射的发生率较高（８０％）,心律失常的发生率较高（６０％）,血流动力学变化大,可危及病人生命安全。     

生脉液对大冠状动脉临界狭窄心脏血流动力学影响

在１２条麻醉开胸犬上，用微米狭窄器造成冠状动脉前降支临界狭窄。以平均动脉压（ＭＡＰ）、左心室收缩压（ＬＶＳＰ）、左心室舒张压（ＬＶＤＰ）、室内压最大上升速率（ｄｐ／ｄｔｍａｘ）。室内压最大下降速率（－ｄｐ／ｄｔｍａｘ）及心输出量（ＣＯ）等血流动力学指标，观察生脉液在冠脉临界狭窄基础上用药前后心脏功能的改变。结果表明：冠脉临界狭窄时，ＬＶＤＰ明显升高（Ｐ＜０．０５），ＬＶＳＰ、ｄｐ／ｄｔｍａｘ、－ｄｐ／ｄｔｍａｘ及ＣＯ明显降低（Ｐ＜０．０５），提示心功能减弱。而给药后，可使心肌缺血心脏功能的损害减轻，上述指标明显好转     

高压氧与一氧化氮对高原脱适应青年血流动力学的影响

目的：研究高压氧（ＨＢＯ）与一氧化氮（ＮＯ）对高原脱适应青年血流动力学的影响。方法：将海拔５０００ｍ以上居住１年返回海拔１４００ｍ的３６名青年随机分为：对照组;ＨＢＯ治疗组;ＮＯ治疗组。治疗前后分别用ＸＧⅢ型血液循环功能自动测试仪检测血流动力学。结果：对照组前后差别不显著（Ｐ＞０．０５）;ＨＢＯ组ＢＶ增加显著（Ｐ＜０．０５）,Ｐ、ＳＶ增加非常显著（Ｐ＜０．０１）,η降低非常显著（Ｐ＜０．０１）;ＮＯ组Ｐ、ＢＶ、ＳＶ、ｍＡＰ增加非常显著（Ｐ＜０．０１）,ＡＬＴ、ＰＡＷＰ降低显著（Ｐ＜０．０５）,ＴＰＲ、η降低非常显著（Ｐ＜０．０１）。结论：ＨＢＯ与ＮＯ对久居特高海拔返回后脱适应青年低排高阻性血流动力学有明显的增排降阻作用,吸入ＮＯ较ＨＢＯ效果更好     

急性等容血液稀释与术野血液回输用于颅脑血管手术的观察

目的：了解急性等容血液稀释与术野血液回输用于颅脑血管手术时对血液动力学的影响及术后血红蛋白的变化。方法：择期颅脑血管手术病人３６例,随机分成１组（对照组）、２组（血液稀释降压组）及３组（术野血液回输组）。比较三组病人血流动力学变化、出血量、输血量和术后血红蛋白。结果：１组、３组病人术中平均出血（１１８０±２３０）ｍｌ,２组病人术中平均出血（１０６０±１１５）ｍｌ,比１组、３组出血量减少１１．３％。２组、３组病人自体血液回输后,平均输库血量（３０５±８７）ｍｌ,与１组平均输库血（７５３±１８６）ｍｌ相比．减少了 １３０％左右。２组血液稀释后,ＭＡＰ虽有下降,但与１、３组相比,血液动力学无显著性差异（Ｐ＞０．０５）,术中实施控制性降压后,ＭＡＰ比 １、３组下降 １５～２０ ｍｍＨｇ,组间比较（Ｐ＜０．０５）。三组病人术后虽然仍有轻度贫血,但均在安全水平以上．组间比较无显著性差异（Ｐ＜０．０５）。结论：（１）急性等容血液稀释与术野血液回输可明显减少异体血的用量。（２）控制性降压能减少出血．并使术野清晰。     

慢性肾功能衰竭病人血浆ANP水平与心脏大小及血液透析的关系

探测３２例慢性肾功能衰竭病人的心脏内径，测定血液透析前后血浆ＡＮＰ、ＡＮＧ－Ⅱ，观察心脏改变及血液透析对血浆ＡＮＰ水平的影响。结果左心房内径增宽者血浆ＡＮＰ显著升高（Ｐ＜０．０１），左心室内径增宽者血浆ＡＮＰ水平无明显升高（Ｐ＞０．０５），而且左心房内径与血浆ＡＮＰ水平呈显著直线正相关（ｒ＝０．５０３２，Ｐ＜０．０１）。提示：慢性肾衰病人左心房扩大比左心室扩大更能刺激ＡＮＰ的释放。血液透析后病人ＡＮＰ、ＡＮＧ－Ⅱ水平都进一步升高（Ｐ＜０．０１），而血Ｎａ＋浓度及血压无变化（Ｐ＞０．０５）。表明ＡＮＰ的升高与血Ｎａ＋无关。可能是：（１）由血压介导的对ＡＮＧ－Ⅲ升高的一种对抗性反应；（２）心房容量受体对慢性高容量负荷的适应，使其缺乏对急性容量减少的反馈。     

非瓣膜房颤471例临床特点分析

目的：总结非瓣膜房颤患临床特点。方法：对１９９７年６月－２０００年６月在我院住院确诊为非瓣膜房颤的４７１例患进行回顾性分析,其中８６例行食道超检查,结果：根据三Ｐ分类分为Ａ组阵发房颤,Ｂ组持续房颤,Ｃ组永久房颤,Ｃ组心颤及栓塞发生率均高于高两组（Ｐ〈０．０５）,Ｃ组左心耳、左心室收缩功能低于前两组（Ｐ〈０．０５）,左心耳血栓发生率高于前两组（Ｐ〈０．０５）,Ａ,Ｂ两组之间无显差异（Ｐ〉０．０５）结论：永久性房颤患应积极控制心室率,改善心动功能,预防血栓栓塞,陈发及持续房颤病人应尽可能维持窦性心律。     

22例高原脑水肿患者血流动力学的观察

本文对喀喇昆仑山发病的２２例高原脑水肿患者血流动力学进行了检测。结果：Ｐ、ＴＰＲ、ＡＬＴ、ＡＲ、ＳＩ、ＶＰＥ、ＥＷＫ、ＨＯＩ、ｍＡＰ、Ｋ、ＰＡＷＰ、ＣＣＰ明显 高原健康对照组，ＢＶ、ＥＶＲ、ＡＣ明显低于对照组，差异非常显著（Ｐ〈０．００１或Ｐ〈０．０１）；η、ＳＶ高于对照组，ＥＴＫ低于对照组，差异显著（Ｐ〈０．０５）。高原脑水肿的血流动力学为高排主阻性病理性改变。     

海拔4300m世居藏族与移居汉族青年血流动力学对比观察

目的：研究高原世居者与移居者血流动力学的不同特点。方法：在海拔４３００ｍ对２５名世居藏族青年和２５名移居汉族青年分别用ＸＧ－Ⅲ型血液循环功能自动测试仪检测血流动力学指标。结果：世居藏族产移居汉族 效血容量、每搏心搏量、心脏指数高,微循环半更新时间短,但差异不显著（Ｐ〉０．０５）;总周围阻力、平均动脉压、肺动脉楔压低,差异显著（Ｐ〈０．０５）;心率、全血粘度、冠状动脉灌注压低,差异非常显著（Ｐ〈０．     

心肌缺血预适应对初次心肌梗塞面积及左室功能的影响

目的 评价首次急性心肌梗塞（ＡＭＩ）前４８小时内发生的心绞痛（ＡＰ）对梗塞面积和心功能的影响。方法 根据ＡＭＩ前４８小时内有无Ａ安作民政部进行分组。无ＡＰ组（２２例）及ＡＰ组（２９例）。比较两组病人严重心功能障碍发生率及严重心律失常用核素门控心室显像测得左室功能参数。结果 无ＡＰ组及ＡＰ组严重心功能障碍发生率分别为２７．３％（６例）及６．９％（２例），两组病人差异有显著性（Ｐ〈０．０５）；严重心律     

比较心脏不停跳与停跳行二尖瓣置换术心肌酶谱及线粒体的变化

目的比较心脏不停跳与停跳行二尖瓣置换术心肌保护的效果。方法将12例浅低温心脏不停跳二尖瓣置换术(BH)与12例冷晶体灌注心脏停跳下二尖瓣置换术(CCP)做比较,在麻醉后10 min,术后42、4、48、72 h这5个时点抽取周围静脉血测定血清CK、CK-MB、cTnI,MYO的变化。其中随机在BH组及CCP组各抽取10例,分别于体外循环(CPB)前和体外循环后取右心房心肌标本,在透射电子显微镜下观察线粒体形态并进行量化计分。结果 BH组术后各项指标虽较麻醉后增高,但增高幅度小于CCP组,在术后24 h均开始下降,72 h已基本接近正常。CCP组在术后24 h时各项指标除MYO外仍持续增高,72 h尚未恢复。体外循环后CCP组肌线粒体计分均高于BH组(P<0.01),BH组心肌超微结构优于CCP组。结论浅低温心脏不停跳较冷晶体灌注心脏停跳下行二尖瓣置换术具有更好的心肌保护效果。     

国产新型双叶机械人造心脏瓣心输出量的测定

目的观察国产新型双叶机械人造心脏瓣(久灵瓣)植入动物体和人体后的心输出量。方法1)动物实验测定:手术中对置换21mm型号二尖瓣的6只羊用导管法测定心输出量;对2只术后存活30个月的羊先用超声法,然后用导管法并在多巴酚丁胺负荷下作心输出量测定。2)临床患者测定:对14例主动脉瓣和10例二尖瓣置换术患者术中用导管法测定,术后12个月用超声法测定心输出量。结果1)动物实验:术中6只羊用导管法测定平均心输出量为2.5L/min;2只羊术后30个月用超声法测定平均心输出量为3.0L/min,用导管法测定为2.9L/min。2)临床应用:4例21mm瓣置换患者用导管法测定平均心输出量指数为(2.55±0.27)L/(min.m2);术后12个月用超声法测定平均心输出量指数为(2.84±0.13)L/(min.m2)。结论动物体和人体进行该国产新型机械瓣移植后心脏功能恢复正常,瓣膜具有良好的血流动力学性能。     

再次心瓣膜置换术32例

目的总结既往有心脏瓣膜手术史的患者再次或第3次瓣膜手术治疗的经验。方法胸骨正中切口29例,右前外侧切口2例,左后外侧切口1例,行二尖瓣置换术23例,二尖瓣和主动脉瓣置换术5例,主动脉瓣置换术2例,左心室内细菌赘生物清除1例,瓣周漏修补1例。结果无1例住院死亡,住院9~24 d,出院时心功能改善至Ⅰ级28例,Ⅱ级4例。结论适时再次心瓣膜置换术能有效改善患者预后。     

儿童瓣膜性心脏病的外科治疗

报道87例儿童瓣膜性心脏病患者的外科治疗。其中男58例,女29例,年龄4－14（平均10．2）岁,其中二尖瓣置换36例,主动脉瓣置换13例,二尖瓣和主动脉瓣双瓣置换6例,主动脉瓣成形13例,二尖瓣成形19例。所用心脏瓣膜均为机械瓣。同期处理三尖瓣关闭不全41例,室间隔缺损23例,房间隔缺损9例,佛氏窦瘤破裂8例,动脉导管未闭3例。术后早期并发症包括：低心排综合征7例,呼吸衰竭3例,心律失常5例。早期死亡4例,病死率4．60％。随访0．5－14．5（平均6．51）年,晚期死亡3例,病死率3．61％。儿童瓣膜性心脏病手术治疗时,首先应尽量选择瓣膜成形术;对人工心脏瓣膜替换术者,瓣膜尽量选用成人型号,术后常规行华法林抗凝治疗,并要重视对患儿术后风湿活动的治疗。     

复发性心脏瓣膜病的多次手术治疗(附28例报告)

目的 总结复发性心脏瓣膜病行多次心脏瓣膜手术治疗的经验.方法 回顾性分析2004年6月-2015年6月行3次或以上瓣膜手术的28例复发性心脏瓣膜病患者的病例资料,其中男15例,女13例,年龄55.6±6.5(44~67)岁,均有2次或以上二尖瓣和(或)主动脉瓣置换或成形手术史,均行再次心脏瓣膜手术,其中二尖瓣置换18例,三尖瓣置换10例.二尖瓣置换在中低温心脏停搏下进行,均同期行三尖瓣成形;三尖瓣置换在体外循环心脏跳动下进行.10例采用股动静脉结合上腔静脉插管,其余18例均常规行动静脉插管.对心脏停搏患者采用主动脉根部灌注停跳液进行心肌保护.结果 全组患者体外循环时间65~300min,平均125min;18例二尖瓣置换患者主动脉阻断时间55~107min,平均80min.全组死亡2例,死因均为严重低心排综合征.术后早期主要并发症包括呼吸衰竭3例,严重低心排综合征2例,因纵隔出血行二次开胸探查止血2例,重症感染性休克1例.随访6~36个月,患者心功能明显改善,置入瓣膜未发现异常.结论 复发性心脏瓣膜病行3次或以上瓣膜手术虽然具有较高的手术风险,但只要准确把握手术时机、采用正确的手术技术及妥善的围术期处理,仍然能取得满意的手术效果.     

ω-3多不饱和脂肪酸对心脏瓣膜置换术围术期炎性反应的影响

 目的 探讨ω-3多不饱和脂肪酸对体外循环下心脏瓣膜置换术围术期患者炎性反应的影响。方法 选择解放军第305医院收治的需要行心脏瓣膜置换手术的患者62例,随机分为两组,每组31例。加用ω-3多不饱和脂肪酸[(尤文,0.2 g/(kg·d)],对照组给予等量生理盐水,并分别测定手术开始前,升主动脉阻断后0.5 h,体外循环结束后2 h,手术后12、24、48 h等时间点血浆中IL-6、TNF-α、IL-10的浓度。结果 与手术开始前(T₀)比较,其余各时间点两组患者血中 TNF-α、IL-6、IL-10水平均升高,差异有统计学意义(P<0.05);与对照组比较,试验组其余各时间点血中TNF-α及IL-6水平均较低,IL-10水平则升高,差异有统计学意义(P<0.05)。结论 ω-3多不饱和脂肪酸对心脏瓣膜置换手术围术期炎性反应有一定程度的抑制作用。     

Einsatz der Dual-source-Computertomographie in der prä- und postoperativen kardiochirurgischen Diagnostik

PURPOSE: The aim of this study was to evaluate the clinical potential of dual-source computed tomography (DSCT) in pre- and postsurgical diagnostics in the field of cardiac surgery. MATERIAL AND METHODS: A total of 20 patients underwent DSCT of the heart. This CT system with two rotating X-ray tubes (Somatom Definition, Siemens Medical Solutions, Forchheim, Germany) achieves a temporal resolution of 83 ms and a spatial resolution of 0.4 x 0.4 x 0.4 mm. The patient cohort consisted of two subgroups. In a group of ten patients with known coronary artery disease (CAD), scheduled for bypass surgery (i.e., high pretest likelihood for having significant CAD), the results of DSCT coronary angiography (CTA) and invasive quantitative catheter angiography (QCA) were compared to assess the diagnostic accuracy of DSCT in the detection of significant coronary artery stenoses (>50%). In a second group of ten patients with previous aortic valve replacement (homografts), the valve opening area of the transplanted aortic valve graft was measured by DSCT and compared with echocardiography as a standard of reference to exclude postsurgical restenosis of the valve. RESULTS: Of 150 coronary artery segments depicted by CT, 144 (96%) were classified as "assessable." A significant CAD was known in all patients, and altogether 43 significant stenoses were present according to the results of QCA. Blinded to these results, DSCTA reached a sensitivity and specificity of 95% (41/43) and 93% (103/111), yielding a positive and negative predictive value (PPV, NPV) of 79% (31/39) and 98% (103/105), respectively. In patients with aortic valve homografts, all DSCT datasets were considered as being of diagnostic image quality concerning valve depiction. The planimetric evaluation of the CT data as compared to results of echocardiography showed a significant correlation of the results (r=0.64, p=0.0467). A high-grade valve stenosis (opening area <1.0 cm(2)) could be correctly excluded by DSCT in all patients. CONCLUSIONS: Dual-source CT shows great diagnostic potential in patients before or after cardiac surgery. DSCT provides a high diagnostic accuracy for detection of coronary artery stenosis before bypass surgery. DSCT also proved to be accurate in the assessment of patients who received aortic valve replacement.     

Automated quantification of mitral valve geometry on multi-slice computed tomography in patients with dilated cardiomyopathy – Implications for transcatheter mitral valve replacement

ObjectivesThe primary aim of this study was to quantify the dimensions and geometry of the mitral valve complex in patients with dilated cardiomyopathy and significant mitral regurgitation. The secondary aim was to evaluate the validity of an automated segmentation algorithm for assessment of the mitral valve compared to manual assessment on computed tomography.BackgroundTranscatheter mitral valve replacement (TMVR) is an evolving technique which relies heavily on the lengthy evaluation of cardiac computed tomography (CT) datasets. Limited data is available on the dimensions and geometry of the mitral valve in pathological states throughout the cardiac cycle, which may have implications for TMVR device design, screening of suitable candidates and annular sizing prior to TMVR.MethodsA retrospective study of 15 of patients with dilated cardiomyopathy who had undergone full multiphase ECG gated cardiac CT. A comprehensive evaluation of mitral valve geometry was performed at 10 phases of the cardiac cycle using the recommended D-shaped mitral valve annulus (MA) segmentation model using manual and automated CT interpretation platforms. Mitral annular dimensions and geometries were compared between manual and automated methods.ResultsMitral valve dimensions in patients with dilated cardiomyopathy were similar to previously reported values (MA_area Diastole: 12.22 ± 1.90 cm²), with dynamic changes in size and geometry between systole and diastole of up to 5%. The distance from the centre of the MA to the left ventricular apex demonstrated moderate agreement between automated and manual methods (ρ_c = 0.90) with other measurements demonstrating poor agreement between the two methods (ρ_c = 0.75–0.86).ConclusionsVariability of mitral valve annulus measurements are small during the cardiac cycle. Novel automated algorithms to determine cardiac cycle variations in mitral valve geometry may offer improved segmentation accuracy as well as improved CT interpretation times.     

16-detector row computed tomographic coronary angiography in patients undergoing evaluation for aortic valve replacement: comparison with catheter angiography

AIM: To evaluate the diagnostic accuracy of 16-detector row computed tomography (CT) in assessing haemodynamically significant coronary artery stenoses in patients under evaluation for aortic stenosis pre-aortic valve replacement. SUBJECTS AND METHODS: Forty consecutive patients under evaluation for severe aortic stenosis and listed for cardiac catheterization before potential aortic valve replacement underwent coronary artery calcium (CAC) scoring and retrospective electrocardiogram (ECG)-gated multi-detector row computed tomographic coronary angiography (MDCTA) using a GE Lightspeed 16-detector row CT within 1 month of invasive coronary angiography (ICA) for comparative purposes. All 13 major coronary artery segments of the American Heart Association model were evaluated for the presence of > or =50% stenosis and compared to the reference standard. Data were analysed on a segment-by-segment basis and also in "whole patient" terms. RESULTS: A total of 412/450 segments from 35 patients were suitable for analysis. The overall accuracy of MDCTA for detection of segments with > or =50% stenosis was high, with a sensitivity of 81.3%, specificity 95.0%, positive predictive value (PPV) 57.8%, and negative predictive value (NPV) 98.4%. On a "whole-patient" basis, 100% (19/19) of patients with significant coronary disease were correctly identified and there were no false-negatives. Excluding patients with CAC >1000 from the analysis improved the accuracy of MDCTA to: sensitivity 90%, specificity 98.1%, PPV 60%, NPV 99.7%. CONCLUSION: Non-invasive 16-detector row MDCTA accurately excludes significant coronary disease in patients with severe aortic stenosis undergoing evaluation before aortic valve replacement and in whom ICA can therefore be avoided. Its segment-by-segment accuracy is improved further if CAC>1000 is used as a gatekeeper to MDCTA.     

Cardiac systolic rotation and contraction before and after valve replacement for aortic stenosis: a myocardial tagging study using MR imaging

OBJECTIVE: Aortic stenosis leads to the derangement of cardiac function and contraction mode because of chronic pressure overload that is relieved after surgical valve replacement. The purpose of this study was to determine the changes in left ventricular systolic rotation and contraction using MR tagging in patients with aortic stenosis before and after surgical valve replacement compared with age-matched healthy volunteers. MATERIALS AND METHODS: Twelve patients with aortic stenosis were examined with an electrocardiographically triggered two-dimensional tagging sequence at 1.5 T before and 12 months after surgical valve replacement for the evaluation of wall function of the apical, mid ventricular, and basal levels. Eight healthy volunteers in the same age group served as the control group. RESULTS: Before surgery, all patients showed a significant increase of apical rotation (22.2 degrees +/- 5.9 degrees vs 10.3 degrees +/- 2.5 degrees, p < 0.0001) and overall left ventricular torsion (25.1 degrees +/- 6.6 degrees vs 14.5 degrees +/- 3.7 degrees, p < 0.001); basal rotation was not significantly different (-2.9 degrees +/- 2.1 degrees vs -4.2 degrees +/- 1.9 degrees, p = not significant) compared with the volunteer group. Apical rotation and torsion were negatively correlated with left ventricular mass (r = -0.73, p < 0.01, and r = -0.61, p < 0.05, respectively) and end-diastolic volume (r = -0.73, p < 0.01 and r = -0.64, p < 0.03, respectively). One year after surgery, basal rotation was reduced in the patients with aortic stenosis compared with the patients in the control group (-1.9 degrees +/- 1.8 degrees, p < 0.01). In comparison with preoperative values, apical rotation (14.2 degrees +/- 3.6 degrees, p < 0.01) also decreased but was still elevated, and this resulted in a normalization of left ventricular torsion (16.1 degrees +/- 3.7 degrees, p < 0.01). CONCLUSION: Surgical valve replacement for aortic stenosis leads to normalization of the left ventricular torsion 1 year after surgery. Pressure overload before surgery is associated with an increase of systolic left ventricular wringing motion, possibly serving as a compensatory mechanism. This mechanism declines with increasing left ventricular hypertrophy and dilatation.