心房颤动的射频消融现状

查阅文献，了解当前国际上射频导管消融治疗心房颤动各种术式的现状。射频导管消融治疗心房颤动具有广阔的发展前景，其临床疗效尚待进一步研究和积累更多的临床资料。     

导管消融作为心房颤动一线治疗方案:进展与思考

心房颤动是临床上常见的心律失常，严重危害人类健康，早期有效控制房颤发作并减少并发症是治疗重点。鉴于导管消融是有创治疗手段，既往指南均推荐导管消融作为二线治疗策略。近年来随着导管消融技术的进步和优化，导管消融有望取代抗心律失常药物，成为心房颤动一线治疗方案。本文系统介绍了导管消融作为房颤一线治疗方案的探索，并探讨了有望成为房颤一线治疗的一些新技术。     

心房颤动经导管消融的方法学研究

20世纪90年代以来,通过对心房颤动电生理机制研究的不断深入,导管消融治疗心房颤动技术得到迅速发展,各种导管消融策略不断出现。已在临床上广泛推广的消融策略包括以下几种:节段性肺静脉电隔离术、三维标测系统引导下的左房线性消融术、三维标测系统引导下肺静脉前庭环形电隔离术和心腔内超声监测下肺静脉前庭环形电隔离术。各种方法治疗成功率均达90%以上,使心房颤动根治成为可能。本文对各种导管消融方法进行综述。     

心房颤动治疗的未来发展方向——混合消融

心房颤动是临床常见的心律失常,已有研究证明其与严重不良心脑血管事件(心力衰竭、脑卒中和心肌梗死)有关,目前全球心房颤动的患病人数超过了3 300万,预计未来40年内其患病率将增加1倍以上。多年来,医学相关人员在探究心房颤动的病理生理机制及开创改进其治疗方法等方面付出了大量努力。目前心房颤动的治疗管理仍是临床医学上的一个难题,尽管心房颤动治疗的手术消融和导管消融技术已逐渐趋于成熟,但对于心房颤动最佳的治疗方式、消融能量的选择尚无统一定论。导管消融通常需要多次手术且成功率低,而手术消融术后不良事件发生率较高。近年来,鉴于心脏外科医生和电生理学家之间的密切合作,结合导管及微创手术消融诞生了一种治疗心房颤动的新型策略——混合消融模式。混合消融克服了导管消融和微创手术消融的缺点,减少了不良结局,在治疗持续性心房颤动,尤其是长期持续性心房颤动上取得了可观的成效。本文主要通过回顾心房颤动消融的研究进展,对比分析目前混合消融模式治疗心房颤动的现有研究成果,归纳总结这种新型心房颤动治疗策略的优势与挑战,以期为临床心房颤动的治疗提供更多选择。     

预激综合征合并房颤患者的临床和射频消融治疗

目的：通过临床和射频导管消融治疗预激综合征合并心房颤动患者的急诊处理和导管消融预激旁道的研究，评价临床抗心律失常药物治疗、同步直流电复律、射频导管消融治疗预激综合症合并心房颤动患者的有效性与安全性。方法：28例经过心电图、动态心电图确诊的预激综合征合并心房颤动患者，经过临床抗心律失常药物、同步直流电复律等急诊复律治疗，随后接受射频导管消融治疗，消融预激旁道，达到根治或减少心房颤动，减少心律失常和猝死的风险。结果：28例患者接受药物及同步直流电复律，药物复律成功患者18例，同步直流电复律成功患者10例，无猝死事件发生；所有患者接受射频导管消融治疗，一次消融成功者24例，二次消融成功者3例，1例消融失败患者，拒绝再次手术，临床随访。结论：应用同步直流电复律，胺碘酮、普罗帕酮药物复律是治疗预激综合征合并房颤治疗的临床急诊处理的有效方法，导管射频消融预激旁道可以使患者长期获益。     

心房颤动导管消融术式的进展

心房颤动(房颤)的主要治疗手段有抗栓法、控制心室率法、电复律法和导管消融术等,其中导管消融术的应用为房颤的治疗提供了新的方式.随着对房颤产生机制及维持机制的深入探讨,导管消融术不断完善,发展出心房内线性消融、针对肺静脉触发灶的导管消融、心房复杂碎裂电位消融、房颤转子消融等多种术式.本文综述了目前房颤导管消融术不同术式的研究进展,为临床房颤的治疗提供参考.     

房颤导管消融术复发的危险因素

导管消融技术改变了心房颤动的治疗策略,且其疗效确切,手术创伤小。导管消融术治疗房颤结局显著 优于抗心律失常及控制心室率等药物的治疗方案,但其术后心房颤动的复发率高,其复发的影响因素包括年龄、性 别、体重指数、基础疾病、左心房体积、肺静脉容积、基因、房颤类型、手术方式等。针对这些因素进行相应调 整,对改善导管消融术后的临床疗效及预后至关重要。     

阵发性心房颤动的肺静脉电隔离治疗

目的 探索阵发性心房颤动的射频消融治疗方法及疗效。方法 对5例肺静脉起源的阵发性房颤患者，采用肺静脉内环状电极标测，温控导管对肺静脉电位进行射频消融，达到肺静脉完全电隔离。术后随访9～28个月，观察疗效。结果 5例患者电隔离治疗后，即刻成功率达100％；随访治愈2例，有效2例，无效1例，均无并发症发生。结论肺静脉电隔离治疗阵发性心房颤动是成功率较高，操作相对简单，比较安全的一种射频消融方法，有一定的发展前景。     

心房颤动患者射频导管消融治疗的疗效观察

目的研究宁波市第一医院心脏中心心房颤动患者经导管射频消融治疗的有效性及安全性。方法回顾性分析了在宁波市第一医院心脏中心接受经导管射频消融治疗的90例心房颤动患者术后并发症,并通过随访观察了解经导管射频消融术治疗房颤的总体有效率。结果 90例患者平均随访（16±4.2）个月,76例（84.4%）术后3个月维持窦性心律无心房颤动复发,其中3例扩张型心肌病消融成功,术后心功能明显改善;66例（73.3%）术后12个月维持窦性心律,生活质量明显改善。90例患者术中发生心包填塞1例,术后发生中等量心包积液1例,少量心包积液2例,迷走反射2例,心房扑动2例,房性心动过速1例;严重并发症发生率1.1%,总体并发症发生率10%。结论宁波市第一医院心脏中心经导管射频消融治疗心房颤动手术有效性和安全性均在可接受范围。     

射频消融术治疗心房颤动相关并发症的观察及护理

目的探讨射频消融治疗心房颤动（AF）相关并发症护理及临床治疗效果。方法对30例经导管射频消融治疗心房颤动患者护理措施及疗效进行分析。结果30例患者经射频消融治疗后均治愈,未见明显并发症。结论射频消融术治疗心房颤动其治愈率高,并发症较少,且良好的护理工作是治疗成功重要保障。     

APPLICATION OF LORNOXICAM TO PATIENT-CONTROLLED ANALGESIA IN PATIENTS UNDERGOING ABDOMINAL SURGERIES

FOR anesthesiologis s ,treatingpostoperativepainhas alwaysbeen a problem.Althoughopioidshave been provedtobe effective,theirsideeffectscouldnotbeignored.With thedevelopmentofscienceand pharmacology,many drugs with aspectsof satisfactoryanalgesicefficacyand couldbe welltoleratedby patientshave been developed.And lornoxicamisone of them, which isa non-steroidalanti-inflammatorydrug (NSAID ), with analgesic, anti-infl-ammatory,andantipyreticproperties.Itseliminationhalf-time(3 to 5 hours) isle…     

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.     

Acupuncture Combined with Spinal Tui Na for Treatment of Primary Dysmenorrhea in 30 Cases

Objective: To observe the therapeutic effects in acupunture treatment of primary dysmenorrhea combined with spinal Tui Na, and study its mechanism. Methods: Thirty cases of the treatment group were treated by acupuncture combined with spinal Tui Na, and thirty cases in the control group were treated by routine acupuncture. Results: The total effective rate was 93.3% in the treatment group, and 73.3% in the control group, with a significant difference between the two groups (P<0.05). Conclusions: Acupuncture combined with spinal Tui Na has good prospects for treatment of primary dysmenorrhea.     

Luo Lingjie's Experience in Treating Chronic Nephropathy

In treating chronic nephropathy,Luo Lingjie,a chief physician,pays attention to regulating the balance between yin and yang,treating infection if present,and removing pathogenic factors.He prescribes gentle drugs and uses carefully strongly warming-tonifying ones,emphasizes the importance of persuading the patient to persist in treatment with medication and nurse one's health for recuperation,and is good at combined use of TCM and western medicine therapy and brings the merits of various therapies into full play,with obvious theraoeutic effects.     

Dr.Zhang Ren's Experience in the Acupuncture Treatment of Different Diseases with the Same Therapeutic Principle

Dr.Zhang Ren,the chief physician,is the chairman of Shanghai Acupuncture and Moxibustion Association.Having been engaged in medicine for about 40 years,he is experienced in treating various intractable diseases.In his long years of clinical practice,he advocates taking the TCM differentiation as the basis to seek for the acupuncture method for treatment of modern intractable diseases.The author of this essay had the fortune to follow Dr.Zhang in study.The following is a summary of Dr.Zhang's experience in the acupuncture treatment for different intractable diseases with the same therapeutic principle.     

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.     

猪肺磷脂注射液联合经鼻持续气道正压通气对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性的影响

目的 探讨猪肺磷脂注射液联合经鼻持续气道正压通气(NCPAP)对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性(CK-MB)的影响.方法 选取呼吸衰竭早产儿80例,分为观察组和对照组各40例.对照组采用NCPAP给氧治疗,观察组给予NCPAP给氧联合猪肺磷脂气管内给药.观察两组患儿治疗前及治疗12h、24 h后PaO2、PaCO2、血氧饱和度(SaO2)、pH的变化情况,检测治疗前及治疗5d后血清CK-MB水平;评估两组患儿的临床治疗效果.结果 两组患儿PaO2、PaCO2、SaO2、pH比较,差异均有统计学意义(P＜0.05),其中观察组治疗后的PaO2、SaO2、pH均高于对照组,PaCO2则低于对照组.两组的PaO2、SaO2、pH均随观察时间延长而升高(P＜0.05),PaCO2均随观察时间的延长而降低(P＜0.05).观察组治疗有效率为87.5％,显著高于对照组的70.0％ (P ＜0.05).治疗5d后两组患儿血清CK-MB水平均较前降低(P＜0.05),且观察组明显低于对照组(P＜0.05).结论 猪肺磷脂注射液气管内给药联合NCPAP可以显著降低呼吸衰竭早产儿CK-MB的含量,提高治疗有效率,起到很好的呼吸循环支持作用.