冠状动脉搭桥同期行瓣膜置换术近期疗效

目的探讨冠状动脉粥样硬化性心脏病(冠心病)合并心脏瓣膜病,风湿性心脏病合并冠心病同期行冠状动脉搭桥术(CABG)及瓣膜置换术的安全性及适应证。方法首都医科大学宣武医院心血管外科自2001年5月至2004年12月间,在中低温体外循环下完成12例冠心病合并瓣膜病变、风湿性心脏病合并冠心病同期施行冠状动脉搭桥和瓣膜替换手术。12例中男8例,女4例,年龄52~78岁,平均64.5岁。3例以多年风湿性心脏病、心功能不全为主诉,近年出现胸痛,手术前冠状动脉造影发现冠状动脉病变;9例以心肌缺血症状为主诉,同时合并瓣膜病变。冠状动脉造影提示单支病变1例,双支病变3例,3支病变8例。合并原发性高血压8例,糖尿病6例,心力衰竭病史5例,心房颤动7例。手术前左心室舒张末期内径(LVED)45~87 mm[(56.7±77)mm],左心室射血分数(LVEF)24%~67%(50.3%±11.7%)。心功能NYHAⅠ级1例,Ⅱ、Ⅲ和Ⅳ级分别为8、2和1例。12例患者中MVR(二尖瓣置换)+CABG 9例,AVR(主动脉瓣置换)+CABG 2例,DVR(双瓣置换)+CABG 1例。结果全组术后恢复顺利,随访3个月至2年无1例死亡。结论年龄超过50岁风湿性心脏病患者,无论有无心绞痛症状均需行冠状动脉造影检查,决定是否同期行CABG;冠心病合并二尖瓣中到重度反流及主动脉瓣严重钙化者,应同期行瓣膜置换术。对于冠状动脉病变与瓣膜病变同时存在的病例,2种手术同期进行可降低病死率,改善预后。     

球囊瓣膜成形术后二尖瓣瓣膜病变复发的外科治疗

目的总结球囊瓣膜成形术后二尖瓣瓣膜病变复发的外科治疗经验。方法回顾性分析我院1998年1月至2006年1月外科治疗的51例球囊瓣膜成形术后二尖瓣瓣膜病变复发患者的临床资料,并行二尖瓣置换术,就其病理改变、手术适应证及手术方法进行讨论。结果术中二尖瓣局部病理改变如下:交界硬化融合型3例,后瓣钙化卷缩型8例,交界钙化融合型34例,瓣膜与瓣下结构钙化型6例。术后早期死亡2例,死亡原因分别为低心排出量综合征和多脏器功能衰竭。46例患者术后获得6个月～7年的随访,随访率为90．2%,术后6个月随访时心功能均有不同程度改善。结论球囊瓣膜成形术后二尖瓣瓣膜病变复发以二尖瓣狭窄为主,外科治疗应以瓣膜置换术为宜,合并主动脉瓣及三尖瓣病变应同期积极手术纠正。     

心脏直视射频消融同期行左房减容手术治疗风湿瓣膜病合并心房纤颤

回顾性分析56例收缩末期的巨大左心房[内径为78~210(96.5±33.2)mm]行左房折叠术并同期行心房纤颤直视射频消融术及瓣膜置换手术的患者的临床资料,在合并心房纤颤的瓣膜病手术的同时对巨大左心房行左心房折叠术,并同期行改良直视射频消融术.术后恢复窦性心律比例较满意,心功能恢复效果良好.     

左心室室壁瘤外科治疗体会

目的总结左心室室壁瘤外科治疗经验。方法43例左心室室壁瘤,在全麻下行闭式折叠缝合术2例,标准线性修补术24例,心室内补片成形术17例,同期行冠状动脉旁路移植术(CABG)40例、二尖瓣成形术2例、二尖瓣置换术2例,室间隔穿孔修补术2例。术中预防性植入主动脉内球囊反搏(IABP)2例。结果术后1个月随访显示:左心室舒张末期内径从术前68.7±10.6mm缩小到术后62.2±9.7mm,差异有显著意义(P<0.05);NYHA心功能分级从术前2.5±0.8级提高到1.6±0.6级,差异也有显著意义(P<0.05);左室射血分数(LVEF)较术前有所增加但差异不显著(P>0.05)。术后并发症:低心排5例,室性心律失常5例,肺部并发症3例,脑梗死1例。术后死亡3例,2例死于重度低心排,1例死于术后大面积脑梗死合并肺部感染。结论标准线性修补术和心室内补片成形术手术安全、可靠,效果良好。同期完全再血管化可以提高手术远期效果。对于LVEF低下患者植入IABP可预防低心排发生。     

99例巨大左室患者心脏瓣膜置换术分析

目的 总结巨大左室患者瓣膜置换术的经验,探讨提高外科治疗效果的方法.方法 回顾性分析99例巨大左室心瓣膜病手术患者的临床资料.二尖瓣置换36例,主动脉瓣置换29例,二尖瓣 主动脉瓣双瓣置换34例,同期行心脏其他合并畸形矫治11例.同时建立多因素Logistic回归分析模型评价围术期各影响因素对于术后病死率的作用大小.结果 本组早期死亡9例,病死率为9.1%,并发症发生率54.5%.主要死亡原因为多脏器功能不全综合征(MODS)、严重低心输出量综合征和室颤.经过分析,发现年龄≥55岁、术前心功能分级和术后使用GIK液对巨大左室心瓣膜病患者手术病死率的影响具有统计学意义.Hosmer-Lemeshow goodness-of-fit系数:0.983.结论 与巨大左室心瓣膜病患者手术病死率的关系密切的危险因素为年龄≥55岁、术前心功能分级;术后使用GIK有利于巨大左室心瓣膜患者术后的恢复.加强国术期综合处理可有效地提高巨大左室心瓣膜患者瓣膜替换术的治疗效果.     

少儿心脏瓣膜置换手术方法和效果的回顾分析

目的　总结我院 79例 18岁以下少儿心脏瓣膜置换术经验 ,探讨少儿瓣膜置换术的方法和效果。方法　回顾性分析我科从 1982年 4月至 2 0 0 2年 8月间 79例接受瓣膜置换术的少儿患者临床治疗资料。年龄 9～ 18( 12 .5± 4.4)岁 ,<14岁 2 4例。先天性 2 2例 ( 2 7.8% ) ,心内膜炎 6例 ( 7.6% ) ,有合并畸形者 2 0例 ( 2 5 .3 % ) ,风湿性 5 1例 ( 64 .6% )。二尖瓣置换 5 0例 ,主动脉瓣置换 15例 ,三尖瓣置换 6例 ,二尖瓣和主动脉瓣双瓣置换 8例。生物瓣置换 2例 ,机械瓣置换 77例。所有机械瓣置换病人均长期口服华法林抗凝。结果　早期死亡 3例 ( 3 .8% ) ;随访 3～ 2 4( 12 .6± 6.4)个月 ,晚期死亡 1例 ( 1.3 % )术后 2年死于感染性心内膜炎 ;其余患者恢复良好。结论　少儿心脏瓣膜置换手术对于瓣膜病变严重 ,不能进行成形手术的患儿是一种安全有效的治疗方法。选择合适的手术方式、同期处理合并畸形、正规的抗凝治疗是提高儿童瓣膜置换手术效果的关键     

冠心病合并室壁瘤及瓣膜病变的同期手术治疗

目的:探讨同期处理室壁瘤和瓣膜病变在冠心病外科治疗中的临床经验和手术效果。方法:对95例冠心病合并室壁瘤或(和)瓣膜病变患者在体外循环下同期实施冠状动脉旁路移植术、左室成形术及瓣膜置换(成形)术,比较术前、术后早期及晚期心功能。32例室壁瘤均采用Dor术治疗,二尖瓣成形术8例,二尖瓣置换术46例,主动脉瓣替换术16例,三尖瓣成形术18例,移植旁路血管2-4支/例。结果:全组手术后围术期死亡2例(2.1%),死于低心排综合征1例,多器官功能衰竭1例,其他93例患者痊愈出院。术后随访86例,随访(50.6±19.2)月,死亡2例,失访7例。心功能NYHA分级从术前(3.05±0.55)级改善到术后早期(1.73±0.65)级、远期(1.61±0.67)级;左室射血分数(LVEF)从术前(46.75±8.32)%提高到术后早期(55.09±6.72)%、远期(55.86±6.94)%。左室舒张末内径(LVEDD)由术前(60.53±8.14)mm减小至术后早期(52.79±6.61)mm、远期(54.37±6.23)mm,以上比较均为P<0.05,有统计学差异。结论:对左心室腔、冠脉血管及瓣膜病变的同期干预能较好的改善心功能,近远期疗效显著,是冠心病合并室壁瘤及瓣膜病变外科治疗中非常有效的方法。     

心脏生物瓣膜置换术120例临床分析

目的总结心脏生物瓣膜置换术的手术方法和临床效果,为临床应用提供依据。方法对2009年6月至2012年6月的120例心脏瓣膜病生物瓣膜置换术患者的临床资料进行分析。其中单纯主动脉瓣或二尖瓣生物瓣置换术102例,二尖瓣主动脉瓣联合生物瓣膜置换术18例。同期行血栓清除术15例,三尖瓣成形术22例,冠状动脉旁路移植术6例,左心房折叠术5例,房颤射频消融2例。结果术后共有5例患者死亡,115例患者术后恢复良好出院,术后生活质量提高,无明显瓣膜损坏、心脑血管意外、抗凝意外等发生。结论心脏生物瓣膜置换术安全性大,并发症少,效果良好。     

合并巨大左室的重症风湿性瓣膜病的外科治疗

目的总结瓣膜置换术治疗合并巨大左室的重症风湿性瓣膜病39例的经验.方法 1994年6月～2004年6月的39例重症风湿性瓣膜病巨大左室病人施行心脏瓣膜置换术.其中二尖瓣置换术6例,主动脉瓣置换术4例,主动脉瓣和二尖瓣双瓣置换术29例;同时行三尖瓣成形术21例,左房折叠术10例.结果治愈好转34例(87.2%),术后早期死亡5例(12.8%),术后室颤和严重低心排综合征、肾功能衰竭是主要的死亡原因.结论瓣膜置换术是治疗合并巨大左室重症风湿性瓣膜病的优选方法,良好的心肌保护以及加强围术期的处理是手术成功的关键.     

60岁以上老年人心脏手术的围术期治疗及影响因素

目的总结60岁以上老年人心脏手术的围术期治疗体会,提高老年人心脏手术治疗水平。方法老年心脏病患者52例,单纯冠状动脉病变35例,冠状动脉病变合并瓣膜病变3例,单纯瓣膜病变11例,左心房黏液瘤1例,升主动脉瘤2例。38例冠状动脉搭桥术(CABG)中,有2例同期行二尖瓣置换术,1例同期行二尖瓣、主动脉瓣置换术。单纯二尖瓣置换2例,二尖瓣合并主动脉瓣置换9例,黏液瘤切除术1例,Bentall术2例。27例体外循环时间平均为(120.00±33.47)min,主动脉阻断时间平均(82.26±38.17)min。结果在52例手术中,术后出现严重并发症8例(15.4%),其中低心排综合征3例;肺功能不全致低氧血症3例,其中格林-巴利综合征1例;肾功能衰竭1例;脑血栓1例。围术期死亡4例(7.7%)。结论60岁以上老年人心脏手术,围手术期出现低心排综合征,肺功能不全和肾功能衰竭是影响手术效果的主要因素。     

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.     

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.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.