交感风暴发生机制及治疗

交感风暴指24 h内自发≥3次的伴血流动力学不稳定的室性心动过速和(或)心室颤动,通常需要电转复和电除颤紧急治疗.电生理研究逐步深化了对室速或室颤机制的认识;在治疗上临床实践也进行了诸多有益探索.药物治疗是基石,植入式心律转复除颤器(ICD)仍是降低由室性心律失常所致心源性猝死的最好方法,但ICD植入不能改变致心律失常的潜在基质,相当部分ICD患者可能仍要经历电风暴.对于顽固性电风暴治疗,导管射频消融可能是一个重要的治疗策略.该文对交感风暴的机制及目前的治疗作一综述.     

经导管射频消融心律转复除颤器植入后电风暴

目的报道3例心律转复除颤器（ICD）植入后抗心律失常药物治疗无效的室性心律失常电风暴患者经导管射频消融的结果。方法2名男性与1名女性患者,年龄为75、55、37岁,分别患有陈旧性前壁心肌梗死、致心律失常性右心室心肌病、左心室心肌病。均在ICD植入后发生抗心律失常药物治疗无效的电风暴。应用Carto电解剖标测系统引导盐水灌注射频导管标测和消融室性心动过速（VT）。对可标测VT（持续性、血流动力学稳定）行激动和拖带标测;对不可标测VT,则在基质标测的基础上行起搏标测和／或短时间的拖带标测。结果3例患者中共诱发出5种形态的VT,4种血流动力学较稳定VT和1种血流动力学不稳定VT。成功消融了所有形态的VT,抑制了电风暴的急性发作。消融后随访的6、19和36个月中,仅1例患者出现1次ICD放电。结论在电解剖标测的基础上,应用盐水灌注射频导管消融ICD植入后抗心律失常药物治疗无效的电风暴有很好的疗效。     

射频消融治疗植入型心律转复除颤器术后电风暴

植入型心律转复除颤器（ICD）已经成为威胁生命的室性心律失常治疗首选方法。但一些患者术后由于无休止室性心动过速（室速）接受多次电除颤治疗,即ICD电风暴^[1]。射频消融在电风暴治疗中越来越受到重视。本文回顾了近两年本中心ICD及心脏再同步治疗除颤器（CRT—D）术后电风暴患者射频消融治疗的经验。     

心律失常的非药物治疗

心律失常的非药物治疗是当前心血管病领域最活跃的一个方面 ,概括起来可分为 :外科手术、导管射频消融 (RFCA)、心脏起搏器和植入型心律转复除颤器 (ICD)。一、外科手术心律失常的外科介入 ,主要对冠心病室性心动过速 (VT)和心房颤动 (AF)。1 VT :特别是冠心病、心肌梗死后室壁     

植入埋藏式心脏转复除颤器患者室性心律失常发生的多因素分析

目的探讨植入埋藏式心脏转复除颤器(ICD)患者术后发生室性心动过速/心室颤动(简称室速/室颤)的危险因素。方法回顾分析植入ICD/心脏再同步化治疗除颤(CRTD)的患者51例,随访(39.4±22.3)个月,19例ICD/CRTD记录到持续性室速和或快室速、室颤,为室性心律失常组;32例ICD/CRTD未记录到持续性室速和或快室速、室颤事件,为非室性心律失常组。分析ICD/CRTD植入患者发生室性心律失常的临床因素以及两组患者临床事件的发生情况,并作logistic回归分析。结果对51例ICD/CRTD植入患者月随访中,发现有19例(37.3%)ICD/CRTD记录到室速/快室速/室颤,而且ICD/CRTD给予恰当治疗(ATP或电击),其中3例经历了室速电风暴。对ICD/CRTD植入患者术后室性心律失常和临床事件发生作多因素分析发现,室性心律失常的发生与术后12个月的左室射血分数(LVEF)值显著相关(r=0.149,P=0.047),ICD/CRTD术后住院/死亡的发生与缺血性心肌病(r=17.643,P=0.045)、可达龙(r=14.672,P=0.013)、室性心律失常(r=21.561,P=0.046)显著相关。结论术后12个月LVEF值的显著提高可减少室性心律失常的发生。缺血性心肌病及术后室性心律失常的发生会增加ICD/CRTD植入患者术后住院/死亡的发生,而可达龙可有效降低住院/死亡率。     

心力衰竭与室性心律失常

心力衰竭(心衰)是多种心脏疾病的终末期结果,心衰患者发生室性心律失常的比例高达30%。发生室性心律失常的心衰患者生存率较无室性心律失常患者低。心衰与室性心律失常互相恶化,恶性循环。发生室性心律失常的心衰患者,需根据指南推荐选择适当的治疗方法。对左室射血分数减小的心衰患者,建议植入ICD,导管消融治疗植入ICD的患者需早期干预。必要时可进行去交感神经节治疗。     

远程数据传输在植入型心律转复除颤器电风暴急救时的应用一例

自20世纪90年代国内开展第一台植入型心律转复除颤器(ICD)技术以来,越来越多的恶性心律失常患者得到了及时救治.但ICD植入后也会有一系列问题让患者和医生感到无奈和恐慌.ICD电风暴就是值得关注的问题之一[1],特别是在ICD植入后1年内,植入ICD作为心脏性猝死二级预防是电风暴发生的独立危险因素[2].ICD电风暴是指患者在植入ICD后,24h内出现3次或3次以上需ICD干预的室性心动过速或心室颤动(室速/室颤),是植入ICD后所特有的现象[3].ICD对这种恶性心律失常的转复治疗过程会自动保存在脉冲发生器中,在程控仪调取时医生会回顾性地看到事件的记录.自从"家庭监测"功能应用到临床后,ICD在抗心动过速起搏(anti-tachycardia pacing,ATP)或者电除颤后,能立即传输当时的腔内心电图等资料,让医生及时了解到发生的事件情况,使对植入ICD患者的病情监测迈上了一个新的台阶.以下,通过ICD电风暴患者经家庭监测实时传输数据资料,进而完成远程会诊、协助治疗的实例,总结远程数据传输在ICD电风暴抢救时的经验.     

联合埋藏式心律转复除颤仪及射频消融治疗室性心律失常有效性的荟萃分析

目的:对已发表的随机对照研究以及队列研究进行荟萃分析,验证联合植入埋藏式心律转复除颤仪(implantable cardioverter-defibrillator,ICD)及射频消融的治疗方法是否有效。方法:使用MEDLINE及EMBASE搜索引擎搜索相关临床研究文献,时间截止至2018年12月21日。对搜索到的文献浏览其引用文献列表以防止遗漏。文献入选标准为报告了ICD风暴、ICD电击次数、ICD事件、室性心律失常复发率、每月ICD治疗次数等终点的随机对照研究和队列研究。荟萃分析的合并效应量采用随机效应模型。结果:共有12项研究被纳入本荟萃分析。纳入的总病例数为667例。与单纯植入ICD组相比,ICD植入联合射频消融组的终点事件风险更低。各终点合并风险比:ICD风暴为0.61(95%CI 0.36～1.03),ICD电击次数为0.37(95%CI 0.22～0.63),ICD事件为0.39(95%CI 0.25～0.61)以及死亡为0.80(95%CI 0.45～1.44)。各研究合并的室性心律失常复发率为34%(95%CI 0.26～0.41),合并的每月ICD治疗次数为0.05(95%CI-0.03～0.13)。结论:与单纯植入ICD相比,ICD植入联合射频消融可成为室性心律失常且(或)合并有结构性心脏病患者的更好治疗选择,体现在可明显减少ICD事件以及ICD电击次数,但并不能减少ICD风暴和死亡的风险。     

植入型心律转复除颤器植入后电风暴研究进展

目前,植入型心律转复律除颤器(ICD)已成为治疗致命性室性心律失常和预防心脏性猝死的首选方法.伴随ICD的广泛应用,其相关并发症的报道日益增多,其中ICD电风暴以其发病迅急,症状严重,需要紧急处理而倍受关注.鉴于此,本文对近年来有关ICD电风暴的研究进展做一综述.     

导管消融室性心律失常的现状和未来

运用导管消融的方法治疗室性心律失常已经广泛用于临床。术前运用心电图、心脏超声、计算机断层摄影术(CT)和磁共振成像(MRI)等辅助检查手段和起搏标测、激动标测、基质标测、电压标测和起搏拖带等标测方法,对判断室性心律失常的发生机制、起源点位置和制定合理的室性心律失常导管消融策略具有很大的帮助。导管消融治疗特发性室性心律失常,成功率高、风险和并发症发生率低,目前已成为一线治疗。而对于疤痕介导性室性心律失常,导管消融只是药物治疗和植入型心律转复除颤器(ICD)治疗的辅助手段。目前导管消融治疗室性心律失常的临床终点和对患者的临床长期受益,还需要进行前瞻性、随机的多中心研究。     

肿瘤病人弓形虫感染分析

在肿瘤的发生和发展进程中 ,多伴有免疫功能低下或缺陷 ,从而极易遭受各种感染。弓形虫是机会感染因子 ,当患者免疫功能受损时 ,易于感染 ,还会使隐性感染激活 ,引起低热不退、淋巴结肿和脑神经系统的反应 ,此现象尚未引起临床医师的重视。近年来 ,我们对 4 0 9例肿瘤病人进行了弓形虫感染及弓形虫病的分析观察 ,报告如下 :1　材料与方法1 1　材料　 30 4例病人血清取自江西省肿瘤医院住院或门诊病人 ,随机抽样后低温保存待检 ,10 5例取自其他医院送检样品 ,有急性症状者随到随检 ,以便及时做病原学检测。1 2　弓形虫病诊断方法1 2 1　免疫…     

A patient with rectal ulcer with severe stenosis presenting with perforated peritonitis

We report a patient with rectal ulcer with severe stenosis, who underwent urgent surgical treatment for perforated peritonitis. The 54-year-old man suddenly developed cramping abdominal pain and fever while hospitalized, with signs of peritoneal irritation. An emergency laparotomy was performed, and severe stenosis of the rectum and a perforated lesion on the oral side approximately 10 cm distant from the stenosis were found, with massive abdominal purulent fluid. He was treated by rectosigmoid colon resection with transverse colon loop colostomy. Histopathologically, the stenosis was caused by ulceration extending to all muscular layers of the rectum, with inflammatory changes. Benign rectal stenosis is so rare that differential diagnosis from malignancy may be difficult when there are inflammatory changes in the surrounding tissues. However, it is necessary to keep in mind the likelihood of this disease in differentiation from rectal cancer. Received: December 21, 1998 / Accepted: May 28, 1999     

Infection with Rhodococcus equi in a patient with sarcoidosis treated with corticosteroids

A 51-year-old female farmer was diagnosed as having sarcoidosis. During 4 years of observation, slow radiological progression was observed. Cough then developed, necessitating treatment with corticosteroids. After 28 months of continuous treatment with prednisolone in low doses (5-7.5 mg daily), she suffered fever episodes, recurrent haemoptyses, general malaise and loss of weight. A chest roentgenogram showed a left upper lobe infiltrate, which progressed and finally cavitated, and rib destruction. Despite efforts, including a thoracotomy, 22 months passed before a diagnosis could be made. Blood and sputum cultures and cultures from the destroyed rib showed growth of Rhodococcus equi, a common soil organism which can cause infections in foals and other animals. Treatment with rifampicin and erythromycin was successful. R. equi has been reported to cause infection in patients with neoplastic disease and/or immunosuppression, but the disease might be more common than is suggested by the sparse case reports in the literature, owing to lack of familiarity with the organism, which will tend to be overlooked as a contaminant.     

Evaluation of atrial vulnerability with transoesophageal stimulation in patients with atrioventricular junctional: Comparison with patients with ventricular pre-excitation and with normal subjects

The aim of our work was to evaluate the inducibility of atrialfibrillation in a group of patients with atrioventricular junctionalreentrant tachycardia and to compare it with that of patientswith a Kent-type ventricular pre-excitation (Wolff-Parkinson-Whitesyndrome) and a control group. One hundred and twenty-five subjects were separated into groups.Group 1 comprised 49 Wolff-Parkinson-White patients, with amean age of 26.4, range 10.66 years; group 2, 51 patients withatrioventricular junctional reentrant tachycardia inducibleby transoesophageal atrial stimulation andlor clinically documented,with a mean age of 43.4, range 16–78 years; group 3, 25control subjects with a mean age of2.64, range 13–76 years. Each subject underwent atrial transoesophageal stimulation withthe following protocol: programmed atrial stimulation with 1and 2 stimuli during atrial pacing of 100. min^–1 and 150.min^–1; atrial stimulation for 10 s at a rate of 200–300–400–500–600.min^–1 with intervals of 10 s between stimulations, fivesuccessive ‘ramp-up’ atrial stimulations for 9 swith the rate increasing from 100 to 800. min^–1 with intervalsof 10 s between stimulations. The end point was the completionof the protocol or induction of sustained atrial fibrillation(>1 min). The chi-square test was used for statistical analysis. Our resultsshowed that in group 1 atrial fibrillation was induced in 27149patients (55.1%); this was sustained in 13149 (26.5%) and non-sustainedin 14149 (28.5%); in group 2, atrial fibrillation was inducedin 22151 patients (43.0%); it was sustained in 7151 (13.7%)and non-sustained in 15151 (29.4%); in group 3, sustained atrialfibrillation was not induced in any subject and in only onesubject was a non-sustained atrial fibrillation (4 s) induced. The chi-square test showed that group 2 vs group 1 were non-significant,while group 2 vs group 3 and group 1 vs group 3 were significant(P<0.003 and P<0.0007, respectively). Therefore group 2 patients showed a greater atrial vulnerabilityin comparison to the control subjects and a similar vulnerabilityto group 1 patients. It is possible that the greater atrialvulnerability in the patients of group 2 was due to the doublenodal pathway.     

Treating patients with lupus with B-cell depletion

A new era in the treatment of systemic lupus erythematosus has dawned with the increasing introduction of monoclonal antibodies and other approaches, that target the key molecules involved in the pathogenesis of the disease. At present the ability to block the CD20 molecule on those B cells that carry this marker has proved the most effective way to treat patients resistant to conventional immunosuppressive drugs. However, these studies have all been open label and the results of double blind controlled studies are eagerly awaited.