左室特发性室性心动过速的射频消融治疗

对 19例 IL VT患者进行射频消融治疗 ,在心动过速时标测最早出现的 P电位 ,并以此处为靶点进行消融。 19例中 ,心动过速起源于左室间隔面者 18例 ,左室流出道 1例 ;有 17例标测到 P电位 ,较体表心电图 QRS波群平均提前 2 4.7± 9.0 ms,均为起源于间隔部位者 ;另 2例标测到提前出现的 V波 ,分别提前 10 m s和 2 0 ms。射频消融治疗的总成功率为 95 .2 % ,复发率 5 %。采用激动标测寻找最早 P电位处为消融靶点是提高消融成功率的关键。     

标测浦肯野电位和舒张期电位在特发性左心室室性心动过速消融中的作用

目的探讨特发性左心室室性心动过速(ILVT)射频导管消融中标测浦肯野电位(Pur P)和舒张期电位(DP)的作用。方法44例患者,男性30例,女性14例,年龄9~74岁,无明显器质性心脏病证据,均有阵发性心悸史,ILVT时心电图表现为右束支阻滞伴心电轴左偏41例、右束支阻滞伴心电轴右偏3例。在ILVT时标测到最早Pur P或DP的部位进行消融。结果44例患者的ILVT均在左心室间隔左后分支(41例)或左前分支(3例)分布的范围内消融成功。25例和19例分别在标测到PurP(Pur P组)和DP(DP组)的部位消融成功,成功消融部位Pur P或DP分别提前体表心电图QRS波19~40(27±6)ms和26~60(41±10)ms(P<0.01)。在DP组的19例中,13例在标测到DP时可同时标测到Pur P,6例局部仅能标测到DP;12例首先在标测ILVT时较早的Pur P部位消融不能成功,后通过标测DP消融成功。成功消融ILVT的平均放电次数在Pur P组和DP组分别为4次和2次。DP组较Pur P组消融ILVT的成功部位在间隔部上移约0.5~2.0cm。成功消融ILVT后,窦性心律下体表心电图心电轴明显改变的发生率在Pur P组和DP组分别为44%和84%(P<0.05)。平均随访(23±12)个月,41例起源于左后分支的ILVT复发3例,均为Pur P组。结论ILVT通过标测室速时的Pur P和DP均可能消融成功,DP通常较Pur P有更早的激动时间,在标测到DP处消融有非常高的成功率和通常需要较少的消融次数。成功消融ILVT后,窦性心律下发生心电轴明显改变的发生率在DP组增高。     

窦性心律下非接触式标测指导线性消融治疗特发性左心室室性心动过速

目的 大多数特发性左心室室性心动过速(ILVT)是起源于左后分支(LPF)浦肯野纤维网的折返性心动过速,因而利用非接触式标测系统在窦性心律下标测LPF并经其导航系统指导线性消融治疗ILVT是可行的,现介绍此方法的安全性和有效性。方法 6例患者,1例既往接受3次射频导管消融术,临床呈无休止发作;1例为常规消融术后1个月复发;4例为常规首次接受射频导管消融术患者。其中男性5例,女性1例,平均年龄15～58(34.00±16.26)岁。常规电生理检查明确ILVT诊断后,将球囊电极导管经股动脉逆行送入至左心室心尖部,构建几何构形后建立窦性心律的等电位图。结果 窦性冲动沿希氏束向下传导,在间隔中部不到心尖处激动局部间隔心肌并很快激动整个左心室。局部虚拟电图显示,在间隔部激动的每个QRS波前均有高频、低幅的电位,该电位与QRS波之间的距离随激动的推移而逐渐缩短;心室激动爆发点处的局部电图呈QS型。在心室激动爆发点上方1 cm处于LPF区域作垂直于LPF激动方向的线性消融,消融后所有患者均出现不同程度的左后分支阻滞图形,线性消融的平均放电次数为4～8(5.66±1.50)次,消融完毕后心动过速均不能诱发。平均随访7～13(10.00±2.76)个月,所有患者均无心动过速复发。结论 窦性心律下标测LPF并指导线性消融治疗ILVT不仅安全有效     

特发性左室室性心动过速非接触球囊导管系统的标测与消融

介绍非接触球囊导管标测系统 (EnSite 30 0 0系统 )指导难治性特发性左室室性心动过速的标测与射频消融的初步经验。 5例男性病人 ,年龄 33± 17(17～ 6 2 )岁 ,常规方法标测和导管消融失败 2 .4± 1.1(1～ 4)次。常规放置高位右房和右室电生理导管 ,运用置入左室的 6 4极球囊导管和大头电极 ,系统重建三维心内膜几何模型和等电势 ,经右室导管诱发VT ,心动过速周期为 32 3.8± 48.1ms。EnSite 30 0 0系统标测到VT的最早激动点分别位于左后间隔中下部、左侧间隔后下部左束支下方、后下间隔近心尖部、左室后壁近基底部和左后间隔中部。在最早激动点和关键峡部分别行点状、环状和线性消融。 2例患者在心动过速时放电、3例患者在窦性心律时消融 ,均获成功。成功消融靶点处的单极电图均为QS型。X线曝光时间为 2 5± 12min。随访 7.8± 4.6 (1～ 11)个月所有患者均未发作心动过速。结果表明 ,与常规方法比较 ,EnSite 30 0 0系统所建立的心腔三维模拟等电势图可直观地显示心动过速的起源点、传导途径和关键峡部 ,系统模拟的单极腔内电图的形态也有助于判断病灶起源部位及提高消融成功率 ,尤其适用于常规方法消融失败的室性心律失常的标测 ,其独特的导航系统可引导消融导管到达靶点部位指导射频消融 ,并可减少X?     

特发性室性心动过速的射频消融

目的特发性室性心动过速是临床较少见的心律失常,目前相关的较大系列临床资料并不多见.兹对多年来我院接收射频消融治疗的病例进行总结.方法共有190例患者(男性137例,女性53例),平均年龄(32.1±13.3)岁.特发性左心室心动过速(idiopathic left ventricular tachycardia,ILVT)113例;发生于右心室流出道(right ventricular ouutflow tract,RVOT)者为77例,其中36.4%(28/77)为反复发作的单形室性心动过速(repetitive monomorphic ventricular tachycardia,RMVT).所有患者均经药物治疗无效,在停服抗心律失常药物至少5个半衰期后进行心内电生理检查,在诱发出室性心动过速后进行射频消融治疗.术后平均随访(31±18)个月.结果ILVT患者平均年龄(35.9±12.8)岁而RVOT患者为(29.5±13.0)岁(P<0.05).同时,ILVT患者中男性占86.1%,而在RVOT患者中则只占51.4%.只有8例ILVT患者被发现有左心室假腱索,3例有二尖瓣脱垂,3例伴心动过速性心肌病.77例RVOT患者中有28例为RMVT.ILVT患者中除1例起源于左心室游离壁,4例位于室间隔高位,3例位于左冠状动脉窦下方之外,其余均位于室间隔左侧中、下部,消融时主要以激动顺序标测定位.接受了消融的起源于室间隔的102例ILVT患者中,90.2%可记录到浦肯野电位(Purkinie potential).而起源于右心室者则均以激动顺序结合起搏标测确定消融靶点.有7例患者在电生理检查时未能诱发VT.其余183例患者中有171例即时消融成功,消融成功率在LVT组为90.5%,RVT组为89.7%.18例在随访期内复发,其中8例再次消融成功.结论特发性室性心动过速多见于中青年患者,且与性别有关.射频消融可以较满意地根治特发性室性心动过速.     

特发性室性心动过速射频消融治疗的临床研究

目的 总结17例特发性室性心动过速射频消融方法和结果。方法 左室特发性室速(Idiopathic Left Ventricular Tachycardia,ILVT)16例,右室特发性室速(IdiopathicRight Ventricular Tachycardia,IRVT)1例,15例ILVT采用标测V波前最早浦肯野纤维电位(P电位)方法,1例因室速不能诱发的ILVT和1例IRVT采用起搏标测。射频消融按常规方法进行。结果 射频消融治疗ILVT成功率为87.5％,IL-VT均起源于左室间隔面,有效消融靶点处P电位较体表心电图QRS波起始点提前(29.6±11.2)ms(20～55ms)。IRVT1例射频消融成功,有效消融靶点处起搏时与心动过速时的12导联心电图QRS波形完全相同。无1例出现并发症。结论 射频消融术是治疗特发性室性心动过速的安全有效方法。     

采用心内非接触式标测的右心室流出道室性心动过速的射频消融

目的 右心室流出道(right ventricular outflow tract,RVOT)的解剖结构使得对该部位的室性心动过速(ventricular tachyeardia,VT,室速)标测定位的难度较大,远期成功率也较低,为此,采用心内非接触式标测指导导管消融。方法 20例患者(男性12例,女性8例),年龄14～59(35.1±12.3)岁。其中6例有晕厥或黑矇史,7例既往曾接受射频消融未获成功。全部患者均在RVOT内放置EnSite3000标测导管,在窦性心律下进行疤痕标测和心动过速时进行最早激动标测,并根据标测结果使用EnSite 3000导管的导航功能指导消融定位。消融前并进行起搏标测。结果 20例患者共诱发出22种RVOT室速,其中3例还伴其它起源的室性早搏(室早)。疤痕标测提示,13例患者有电学意义上的疤痕区域,且有11例室速起源于该疤痕区域。25个室速或室早起源点中1例起源于近肺动脉瓣口部,10个位于间隔侧,其余均偏游离壁,其中7个偏RVOT后壁中、下部,4个偏前壁中、下部,3个位于游离壁侧;病变基质的直径为6～42 mm,平均(16.8±9.2)mm。非接触式标测所确定的最早激动处电位平均领先体表20～62(41.0±13.8)ms;与自发的室性心动过速相比,起搏标测下14例的12个导联QRS形态完全一致,11/12个导联一致的为10例,1例有10/12导联一致。全部室速和室早均消融成功。在标测确定的     

特发性室性心动过速12例的电磁解剖标测系统标测和消融

目的评价电磁解剖标测系统(Carto)标测和指导射频消融在治疗特发性室性心动过速的临床应用价值。方法入选12例特发性室性心动过速患者,年龄(33±12)岁。心动过速周期(370±95)ms。室性心动过速持续发作时,7FNavi-Star在相关心室标测,实时重建心腔三维电解剖图,右心室室性心动过速在右心室流出道详细标测,根据激动图上最红色区域为较早激动部位,结合大头导管记录心室波最早、且起搏时体表12导联图形与心动过速一致处,作为消融靶点。左心室室性心动过速在间隔部细标,标识较体表QRS波及His束电位提前的P电位处,作为靶点。温控60℃放电消融。以基础态及静脉滴注异丙肾上腺素反复电生理检查.不可诱发室性心动过速作为成功消融终点。结果12例均成功消融,其中右心室室性心动过速7例,均位于右心室流出道前中间隔部,左心室室性心动过速5例,起源于左心室后中间隔4例、中下间隔近心尖部1例。1例左心室室性心动过速于心动过速在左心室后中间隔处标测时,室性心动过速终止,后标志此处作为靶点,放电消融成功。手术时间为(102±25)分钟,曝光时间为(11±7)分钟。随访6～18个月,无复发病例。结论Carto系统通过磁场标测定位,结合心内电图重建室性心动过速时心室电激动图,可有效快速寻找最早激动点或P电位处作为消融靶点,进行电解剖标测,并可在标测导管机械损伤终止室性心动过速处标志,结合起搏标测,作消融参考点指导消融,治疗特发性室性心动过速安全有效。     

特发性室性心动过速射频导管消融标测方法探讨

目的探讨特发性室性心动过速（IVT）的标测方法.方法对52例行射频消融的IVT患者进行标测.39例源于右心室的IVT采用消融导管右心室起搏标测法,以起搏时与室性心动过速（室速）发作时的12导联心电图QRS波形态与振幅完全相同的起搏部位为消融靶点.12例起源于左心室的IVT以发作时消融电极导管在左心室内标测到较体表心电图QRS波提前≥20 ms的最早高频低振幅电位为消融靶点（激动顺序标测法）,1例左心室室速采用起搏标测法.结果左心室IVT消融成功率100%（13/13）,右心室IVT消融成功率94.87%（37/39）.结论起源于左心室的IVT宜采用激动顺序标测法,起源于右心室的IVT宜采用起搏标测法.     

窦性心律下X线影像解剖定位与P电位标测相结合指导小儿左室特发性室性心动过速的射频消融治疗

目的探讨窦性心律(简称窦律)下X线影像解剖定位与P电位标测相结合的方法指导射频消融儿童特发性左室室性心动过速(ILVT)的可行性和有效性。方法窦律下X线解剖定位结合P电位标测方法 30例,激动顺序标测法(对照组)25例。比较两种标测方法射频消融的成功率和复发率。结果窦律下X线解剖定位结合P电位标测方法 30例,4例未能诱发ILVT,30例均消融成功,成功率100%。激动顺序标测方法 25例,2例未能诱发ILVT,23例(23/25)成功射频消融治疗,成功率100%。术后随访3个月至13年,前者复发1例(3.3%),后者复发3例(13.0%),两组差异有显著性(P<0.05)。复发病例再行射频消融获成功。全部患儿术后体表心电图均无左后分支阻滞。结论窦律下X线影像定位结合P电位标测方法指导射频消融治疗ILVT成功率高、复发率低且操作简单安全。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.