单消融导管与单环状标测电极导管指导环肺静脉电隔离术治疗心房颤动的随机对比研究

目的 比较单消融导管指导环肺静脉电隔离术与单环状标测电极导管指导环肺静脉电隔离术治疗心房颤动（房颤）的有效性和安全性.方法 122例房颤患者随机分为单消融导管指导环肺静脉电隔离组和单环状标测电极导管指导环肺静脉电隔离组.两组患者年龄、性别、房颤发作时间、合并器质性心脏病及左心房直径、左心室射血分数、CT所测双侧肺静脉血管直径差异均无统计学意义.其中阵发性房颤86例,持续性房颤36例.结果 两组患者平均总的消融时间为（158.0±29.5）min对（158.0±28.4）min（P=0.95）,平均透视时间为（41.4±9.9）min对（37.7±9.5）min（P=0.23）.所有患者随访9个月,房颤事件的复发率为32.5%对31%.两组患者随访期间无死亡事件发生,两种消融策略均未出现心脏压塞和肺静脉狭窄,与手术相关并发症发生率为3对2例.结论 单消融导管与单环状标测电极导管指导环肺静脉电隔离术治疗房颤具有同样的安全性和有效性.     

EnSite NavX指导下无肺静脉造影的阵发性心房颤动导管消融术

目的探讨不作肺静脉造影行阵发性心房颤动(房颤)环肺静脉电隔离术的有效性和可行性。方法 34例阵发性房颤患者分为无肺静脉造影组(n=18)和肺静脉造影组(n=16),无肺静脉造影组不作肺静脉造影,余步骤与肺静脉造影组相同,两组均在EnSiteNavX三维标测系统指导下重建左心房及肺静脉,再分别行左、右环肺静脉电隔离术,消融终点为肺静脉与心房完全电隔离。结果无肺静脉造影组消融术时间[(92.78±19.46)minvs.(106.44±20.18)min,P0.05]及X-线曝光时间[(11.47±4.32)minvs.(16.06±8.72)min,P0.05]少于肺静脉造影组,差异有统计学意义。两组左心房三维重建时间[(6.22±2.65)minvs.(6.31±3.00)min,P0.05]、左、右侧环肺静脉消融时间[(21.61±7.66)minvs.(20.50±8.09)min,P0.05;(17.33±10.22)minvs.(17.48±7.86)min,P0.05]及即刻消融成功率[100%(18/18)vs.100%(16/16),P0.05]比较,差异无统计学意义。结论不作肺静脉造影,仅在三维标测系统指导下行房颤消融治疗,可达到相同消融效果,可节省消融术及X-线曝光时间,减少手术步骤、耗材和费用。     

单纯三维电解剖标测系统指导与图像融合技术辅助下环肺静脉线性消融治疗心房颤动的临床对比分析

目的 评价三维电解剖(Carto)标测系统合并图像融合(Merge)技术指导下行环肺静脉线性消融术治疗心房颤动(房颤)的临床疗效,并与单纯用Carto系统治疗组比较.方法 回顾性分析2005年3月至2007年1月间接受导管射频消融术的连续68例房颤患者,其中单纯 Carto标测系统指导下手术患者11例(A组), Carto-Merge技术指导下手术患者57例.消融策略先行左房肺静脉电隔离,必要时加行左房碎裂电位消融 左房顶部、底部、峡部 右房三尖瓣峡部、上腔静脉、冠状静脉窦口部消融.结果 A组平均X线透视时间56.24±13.92 min,平均随访15.08±1.82个月,7例(57.14%)术后3个月生活质量明显改善,无房颤发作;其中阵发性房颤手术成功率为60%,2例接受第二次消融后治愈.B组平均X线透视时间33.32±13.84 min,平均随访8.97±6.28个月,51例(89.47%)术后3个月生活质量明显改善,无房颤发作;其中阵发性房颤手术成功率达95.12%;其X线透视时间,总体及阵发性房颤手术成功率均与A组有明显差异;B组中3例扩张型心肌病和1例肥厚型心肌病房颤消融成功,术后心功能明显改善.结论 在Carto-Merge技术指导下行环肺静脉线性消融术治疗房颤能提高手术效率及成功率,进一步减少X线曝光时间.左房肺静脉电隔离 左房碎裂电位消融 左房顶部、底部、峡部 右房三尖瓣峡部、上腔静脉、冠状窦口的消融可能通过改良心房基质而提高房颤手术成功率.     

射频消融肺静脉电隔离术治疗阵发性房颤20例

目的观察电生理标测指导下肺静脉电隔离术治疗阵发性房颤的临床疗效.方法阵发性房颤患者20例,环状电极指示下对肺静脉行射频消融电隔离术.结果20例患者共接受心脏大静脉电隔离治疗28次(6例进行了第2次,1例进行了第3次),隔离静脉68根,肺静脉62根,上腔静脉6根,在房颤心律下消融58根,62根肺静脉中54根达到消触终点.平均操作时间和X线透视时间分别为(120±18)min和(32±9)min.平均随访(5.0±2.3)个月,示13例无房颤发作、2例房颤发作明显减少,总有效率达75%.结论肺静脉电隔离术治疗阵发性房颤具有较好临床疗效.     

双Lasso导管和三维标测指导下环肺静脉线性隔离术治疗心房颤动

目的在双Lasso导管和三维标测指导下环肺静脉线性消融并彻底隔离肺静脉以治疗心房颤动(简称房颤)。方法28例房颤患者接受射频消融治疗,其中阵发性房颤12例,持续性房颤16例。所有患者首先利用三维电解剖标测系统(CARTO)进行左房重建,然后将两根Lasso导管同时置入右(左)上下肺静脉内,在肺静脉口外0.5~1cm左右行环肺静脉线性消融,消融终点为左房-肺静脉完全性传导阻滞。结果28例均电隔离成功,肺静脉完成隔离后,共86.6%(97/112)的肺静脉内可见缓慢自律性电活动。手术时间205±67min,X线透视时间27±16min,无并发症发生。术后随访8.5±3.7个月,23例无房颤复发,总成功率82.1%。结论双Lasso导管和三维标测指导下有明确电学隔离指标的环肺静脉线性消融术治疗房颤安全而有效。     

以双向阻滞作为阵发性心房颤动肺静脉电隔离终点的临床研究

目的 评价以左心房-肺静脉电联系双向阻滞作为环肺静脉消融电隔离术终点对阵发性心房颤动(房颤)导管消融疗效的影响.方法 在76例阵发性房颤患者导管消融达到左心房-肺静脉传入阻滞后,分别于每根肺静脉内起搏评价肺静脉-左心房传导情况.据此分为双向阻滞组(传入与传出均阻滞)和传入阻滞组,随访观察房颤导管消融的临床疗效.结果 76例均完成导管消融术,306根肺静脉(2例患者存在右中肺静脉)均达到左心房-肺静脉电学传入阻滞之传统终点.18例消融术后左心房-肺静脉传导呈双向阻滞,58例仅传入阻滞.平均随访(6.85±1.08)个月,1次消融成功率为77.63％.其中,双向阻滞组为83.33％,传入阻滞组为75.86％,两组相比差异无统计学意义(P＞0.05).术后房性心动过速发生率5.26％(4/76),无心脏压塞、脑栓塞、左心房食管瘘等并发症以及死亡发生.结论 以左心房-肺静脉传导双向阻滞为房颤导管消融终点治疗阵发性房颤的策略似乎临床疗效较好.     

经导管射频消融治疗阵发性心房颤动的疗效和安全性

目的 探讨经导管射频消融治疗阵发性心房颤动(简称房颤)的有效性与安全性.方法 42例阵发性房颤患者采用节段性消融肺静脉电隔离术或三维标测系统指导下环肺静脉电隔离术两种不同方法进行经导管射频消融治疗,术后进行随访,观察其疗效和安全性.结果 42例患者中,25例(59.52%)经导管消融成功.4例(9.52%)有效,13例(30.95%)无效,4例(9.52%)出现并发症,无死亡病例.节段性消融肺静脉电隔离术平均手术时间为(235.50±38.01)min,X曝光时间为(74.35±12.73)min;三维标测系统指导下环肺静脉电隔离平均手术时间为(163.18±24.76)min,X曝光时间为(36.90±8.06)min.结论 经导管射频消融治疗阵发性房颤对大部分患者是有效的,三维标测系统指导下环肺静脉电隔离术的手术时间和X曝光时间短于节段性消融肺静脉电隔离术.     

冷冻直导管行肺静脉节段消融治疗心房颤动的短期效果

目的 探讨使用冷冻直导管节段消融肺静脉治疗心房颤动(房颤)的可行性和短期治疗效果.方法 选择临床确诊阵发性房颤患者11例,采用6 mn冷冻直导管、Lasso导管标测肺静脉电位,节段消融电隔离肺静脉,肺静脉电位消失30 min为消融隔离成功.结果 平均消融术时间(252.55±51.99)min,曝光时间(35.65±9.88)min.共隔离36根肺静脉,平均每根静脉冷冻(7.9±4.1)次.消融即刻成功率100%.平均随访(8.73±4.15)个月,短期成功率81.8%.结论 冷冻直导管节段消融肺静脉治疗房颤的短期效果较好.     

心房颤动射频消融术后无症状性心包积液的危险因素分析

目的:探讨心房颤动(房颤)射频消融术后出现无症状性心包积液的危险因素。方法:选择首次接受房颤射频消融治疗的患者166例,术中根据房颤类型、肺静脉隔离情况,实施环肺静脉电隔离或肺静脉电隔离+左房消融径线的消融术式。术前及术后24 h常规行经胸心脏彩超检查,术后筛选出少量心包积液且无症状的患者,将心包积液与各危险因素进行统计分析。结果:房颤射频消融术后出现无症状性心包积液31例(心包积液组),无心包积液135例(非心包积液组)。心包积液组中阵发性房颤、非阵发性房颤分别为13例、18例,非心包积液组中分别为101例、34例(P=0.001)。心包积液组手术时间为(183.06±78.07)min,非心包积液组为(149.11±51.29)min,差异有统计学意义(P=0.005)。心包积液组术中电复律19例,非心包积液组37例(P=0.001)。消融术式:心包积液组中肺静脉电隔离术、肺静脉电隔离术+左房消融径线分别为6例、25例,非心包积液组中分别为61例、74例(P=0.003)。心包积液组的左房直径为(45.03±5.69)mm,非心包积液组为(41.41±6.59)mm,差异有统计学意义(P=0.005)。多因素Logistic回归分析显示,手术持续时间是房颤射频消融术后出现无症状性心包积液的独立危险因素[β=0.009,Exp(β)=1.009,Exp(β)的95%CI为:1.001～1.017,P=0.027]。结论:房颤射频消融手术持续时间长的患者中,术后易出现无症状性心包积液。     

使用海星状电极快速解剖建模联合压力导管在心房颤动肺静脉隔离术中的优势

目的探讨海星状电极(Pentaray)导管对左房进行高密度标测快速解剖建模(FAM),联合使用压力导管在心房颤动(简称房颤)肺静脉电隔离术中的优势。方法序贯入组2015年7月1日到2016年5月30日在华山医院心内科确诊房颤、拟行环肺静脉电隔离术的患者,在Carto3系统下用环状电极(Lasso)或者Pentaray,以FAM法建立左房三维模型,根据使用的建模导管将患者分为Lasso组(L组)和Pentaray组(P组),两组患者均使用SmarttouchTM压力监测导管进行环肺静脉消融,术后在窦性心律下通过肺静脉与左房的双向起搏,以传导阻滞为手术终点。记录患者的一般情况,手术时间以及消融点的平均压力等参数,术后3个月、6个月随访24h动态心电图,并记录患者用药情况,分析消融效果。结果共纳入符合要求的患者52例,其中L组30例,P组22例。所有患者中,阵发性房颤43例,男性占73%。手术均能达到肺静脉电隔离的终点。两组建模时间为:L组(18.3±2.43)min,P组(13.3±3.63)min(P<0.001);L组和P组总消融时间分别为:(157.1±13.55)min和(138.9±11.30)min(P<0.001),两组患者肺静脉隔离使用时间分别为L组(98.6±12.26)min和P组(95.9±11.56)min,(P=0.427)。术后6个月房颤复发率L组为22.7%,P组为23.3%(P=0.752)。结论使用Pentaray进行心房高密度标测快速建模联合压力导管,可以在保证安全性的前提下,缩短房颤肺静脉电隔离的时间,提高手术成功率。     

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.     

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.     

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.     

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.