Pattern of cardiac diseases in children in Pokhara, Nepal

Objective: The objective of the study was to point out the relative public health problems of cardiac diseases in childhood. Material and methods: A study of the cardiac diseases in children attending the Paediatric OPD of Manipal Teaching Hospital, Pokhara, Nepal was done over a period of 2 years. The idea was to see the pattern of diseases, as being a developing country, these diseases would be a large public health problem. 107 cases had been studied and it was found that 52% were congenital heart diseases and 25% were rheumatic heart diseases. Other cases included dilated cardiomyopathy, Pericardial diseases and a few cases of hypertension. All the cases were investigated by ECG, X-ray and echocardiographic studies. These cases are under follow up and some have undergone surgical treatment. Results: In this study in a short period of 2 years we had 107 cases of heart diseases of which 51% were CHD, 25% RHD and others were pericardial disease, DCM, hypertension and some had no demonstrable lesions. All the cases of RHD are being followed by regular Penicillin prophylaxis. Among them one has had mitral valve replacement done and 2 had mitral valvotomy. Of the CHD cases 5 cases have had VSD operated upon, one PDA also had surgery and one case of Fallot's is shortly going to undergo corrective surgery. Conclusion: Heart disease in neonates could be benign or very significant and a high level of suspicion and knowledge of physiology will differentiate between the two. Early recognition of CHD will help to treat the child and if possible get corrective surgery done. Similarly a history of rheumatic fever is important and all children need to be followed up till at least 18 years of age. Key words: CHD-congenital heart diseases, RHD- rheumatic heart diseases, DCM- dilated cardiomyopathy, VSD-Ventricular septal defect, ASD-atrial septal defect, PDA-patent ductus arteriosus.     

风湿性心脏瓣膜病肝脏病理改变的临床意义

目的：探讨风湿性心脏瓣膜病（简称风心病）肝脏病理改变的临床意义。方法：选择风心病41例,其中合并三尖瓣关闭不全患30例,施行心脏瓣膜置换术,在体外循环建立前取肝组织活检,采用光学显微镜及H－800透视电镜检查。结果：风心病合并三尖瓣关闭不全,且有一定反流量患的肝脏典型病理改变主要表现为：（1）肝细胞间质改变：肝窦状隙淤血、扩张,肝纤维组织增生;（2）肝细胞改变：肝细胞肿胀,线粒体肿胀,嵴消失、肝细胞坏死。而且,本组患肝脏病理改变程度与三尖瓣反流量有关,反流量越大病理损伤越严重。结论：强调风心病合并三尖瓣关闭不全患应尽早手术,术中积极矫正三尖瓣关闭不全,是改善和恢复肝脏病理改变的重要措施。     

手术治疗风湿性心脏病合并心房颤动术后出血的护理

目的总结人工机械瓣膜置换术同期双极射频消融治疗风湿性心脏病合并心房颤动患者术后出血的护理要点。方法 2004年1月至2011年3月我科收治56例风湿性心脏瓣膜病合并心房颤动患者,给予人工机械瓣膜置换术同期双极射频消融术,术后对出血给予针对性观察及护理。结果 1例出现微量心包积液,17例出现少量心包积液,1例出现中量心包积液,其余患者经处理均康复出院。结论人工机械瓣膜置换术同期双极射频消融术可有效改善患者风湿性心脏瓣膜病合并心房颤动;术后提供严密观察和护理,能及时发现患者病情变化,给予有效的处理措施,能降低术后出血并发症的发生率。     

二尖瓣置换术治疗风湿性心脏病的安全性及与心功能的相关性研究

目的 探究二尖瓣置换术治疗风湿性心脏病（rheumatic heart disease,RHD）的安全性及与患者心功能的相关性。方法 选取2018年1月至2022年4月榆林市第二医院和西安交通大学第一附属医院收治的170例RHD患者的临床资料,根据是否发生术后并发症将RHD患者分为并发症组和对照组。通过单因素分析及多因素Logistic回归比较并发症组和对照组患者的相关资料,分析影响RHD患者术后并发症发生的危险因素。使用ROC曲线分析心功能指标对RHD患者术后并发症的预测价值。结果 149例RHD患者中,15例发生并发症,并发症发生率10.07%。对比两组患者的病程、心房纤颤发生率、左心室舒张末内径（left ventricular end-diastolic dimension,LVEDD）、左心室质量指数（left ventricular mass index,LVMI）,并发症组均明显高于对照组,差异有统计学意义（P<0.05）。病程、心房纤颤、LVEDD、LVMI均为RHD患者二尖瓣置换术后并发症发生的独立危险因素（P<0.05）。LVEDD和LVMI对RHD患者术后并发症发生均具有较好的预测价值。结论 RHD患者二尖瓣置换术后的并发症发生风险较高,其中病程长、合并有心房纤颤、LVEDD和LVMI较高的患者为术后并发症发生的高风险人群。     

Dilemmas in the management of rheumatic heart disease

Rheumatic heart disease (RHD) is a major health care problem in India and will continue to be so for few more decades. As there is no vaccine against RHD, it is difficult to control the disease. Besides RHD, most children have other preventable ailments as well. Hence the schools, specially for the poor, must act as primary and preventive health care centres. Prevention of RHD starts with school prophylaxis. Primary, secondary and tertiary prophylaxis play their roles afterwords. After the heart valves have been damaged, tertiary prevention might minimise further damage. For mitral stenosis, closed mitral valvotomy (CMV), open mitral valvotomy (OMV) and interventional mitral valvotomy (IMV) are the different options but none is curative. Valve replacement poses many problems and therefore valvotomy is deferred as far as possible. Mild or moderate mitral regurgitation (MR) is best treated medically. For more advanced disease repair or replacement is the option. For aortic stenosis (AS), valvotomy may be preferred to replacement wherever feasible and for aortic regurgitation (AR) repair is not yet well established. In combined mitral and aortic valve disease it is important to assess both the valves carefully and try to repair one or both the valves and to avoid double valve replacement as far as possible. Once the heart valve is damaged any treatment is palliative, hence all efforts should be directed towards prevention of RHD. Indian Medical Association can play a major role in this endeavour and help children in India to grow up free from RHD.     

国产GK-2型人造心脏瓣膜20年临床应用的随访观察

目的总结20年间应用413枚GK2型人造心脏瓣膜的治疗效果,评价国产GK2型单叶式机械瓣膜的远期疗效。方法对1985年初至2004年间施行的327例心脏瓣膜替换术患者进行随访观察,男123例,女204例。年龄1.6～68岁(38.62岁±10.14岁)。心功能Ⅱ级21例,Ⅲ级216例,Ⅳ90例。术式为二尖瓣置换(MVR)205例(62.69%),二尖瓣及主动脉瓣置换(DVR)86例(26.30%),主动脉瓣置换(AVR)31例(9.48%),三尖瓣置换(TVR)5例(1.52%)。共使用GK2型二尖瓣296枚,主动脉瓣117枚。随访0.5～19.6年(9.05年±4.59年),总随访人年数为2440.7患者年。结果早期死亡11例,死亡率为3.36%(11/327)。远期死亡24例,死亡率0.98%患者年。5年、10年、15年生存率分别为93.31%±0.03%、89.59%±2.1%及83.61%±6.09%。12例发生出血事件(0.49%患者年),7例发生瓣膜血栓形成或栓塞(0.29%患者年)。91.98%的患者(241/262)心功能恢复至(NYHA)I、II级。结论连续20年的临床应用和长期随访表明,该型瓣膜具有多项优点,瓣膜相关事件发生率处于较低水平,远期效果满意。     

单中心130例再次心脏瓣膜手术病因及围术期风险因素分析

目的 回顾性分析复旦大学附属中山医院再次心脏瓣膜手术病例并探究病因及术后恢复的影响因素。方法 分析2015年5月至2017年10月在复旦大学附属中山医院心外科施行再次心脏瓣膜手术患者130例,年龄15~83岁,其中男性62例（47.7%）,女性68例（52.3%）。收集患者的临床资料,包括术前合并症、术前心功能、初次手术方式、两次手术间隔时间、再次手术原因及手术类型、主动脉阻断时间及体外循环时间、术后并发症、术后重症监护时间等。对再次瓣膜手术病例做Logistic回归,分析其严重并发症的影响因素。结果 再次手术前合并高血压、糖尿病、肺动脉高压、房颤等疾病者114例（87.7%）,术后死亡8例（6.2%）,主要死亡原因包括心功能不全（7例）、呼吸功能不全（6例）和肾功能不全（6例）等。而再次手术的原因主要包括瓣膜赘生物、瓣周漏、三尖瓣关闭不全和大血管病变等;多因素Logistic回归分析结果显示,患者术前合并肺动脉高压（P=0.039,OR=2.268）和高血压病（P=0.048,OR=7.935）是导致患者术后死亡的危险因素;剔除35例术前心功能严重减低的病例后,多因素回归分析发现,术前合并肺动脉高压（P=0.040,OR=1.682）和风湿性心脏病（P=0.013,OR=4.995）与术后新发心功能不全显著相关,而单因素回归分析仅发现术前肾功能不全（P=0.048,OR=6.727）与术后新发呼吸功能不全显著相关,未行多因素分析。结论 心、肺、肾功能异常是导致再次瓣膜手术风险升高的重要因素,着重评估术前的主要器官功能并予积极保护,对提高患者的预后十分重要。     

老年人风湿性心脏病50例临床分析

本文报告了老年人风湿性心脏病50例,占同期住院风心病患者总数的5.7％。其中5例(10％)住院期间死亡,6例(12％)入院时误诊。36例(72％)并发心力衰竭,25例(50％)并发心房纤颤,10例(20％)合并冠心病,3例(6)合并肺心病。本文就老年人风心病的临床特点、并发症及误诊原因等问题进行了探讨。     

心脏瓣膜置换手术围手术期相关危险因素分析

目的 分析及评价心脏瓣膜病行瓣膜置换手术,探讨风湿性心脏病行瓣膜置换手术的围手术期相关的危险因素。方法 收集四川大学华西医院2012年8月至2015年1月行瓣膜置换手术患者（2 696例）临床资料。所有危险因素经Spearman相关性分析筛选,再采用多因素logistic回归分析筛选最终得到与终点事件明显相关的危险因素。结果 当终点事件为院内死亡时,与体外循环时间〔标准偏回归系数（ B’）=0.418）〕、心功能分级（ B’=0.344）和肺动脉高压（ B’=0.285）有关。当终点事件为术后并发症（以呼吸机带机时间延长为表征）时,心功能分级（ B’=0.520）、肺动脉高压（ B’=0.365）、体外循环时间（ B’=0.306）、糖尿病（ B’=0.129）、左室内径（ B’=0.118）和肺动脉瓣关闭不全（ B’=0.071）是其主要危险因素。在风湿性心脏病行瓣膜置换术的患者中,心功能分级（ B’=0.578）、肺动脉高压（ B’=0.401）、体外循环时间（ B’=0.305）和糖尿病（ B’=0.143）则是风湿性心脏病行瓣膜置换手术术后并发症（以呼吸机带机时间延长为表征）的主要危险因素,而左室射血分数这一常见危险因素首次报阴。结论 高心功能分级和存在肺动脉高压是患者瓣膜置换手术死亡的主要危险因素,也是因心脏瓣膜疾病（包括风湿性心脏病）行瓣膜置换手术的患者术后并发症共同的危险因素。     

Radiation therapy for clinically localized prostate cancer: a multi-institutional pooled analysis

CONTEXT: Prostate-specific antigen (PSA) evaluation leads to the early detection of both prostate cancer and recurrences following primary treatment. Prostate-specific antigen outcome information on patients 5 or more years following treatment is limited and available mainly as single-institution reports. OBJECTIVES: To assess the likelihood and durability of tumor control using PSA evaluation 5 or more years after radical external beam radiation therapy and to identify pretreatment prognostic factors in men with early prostate cancer treated since 1988, the PSA era. DESIGN AND SETTING: Retrospective, nonrandomized, multi-institutional pooled analysis of patients treated with external beam radiation therapy alone between 1988 and 1995 at 6 US medical centers. Follow-up lasted up to a maximum of 9 years. Outcome data were analyzed using Cox regression and recursive partitioning techniques. PATIENTS: A total of 1765 men with stage T1b, T1c, and T2 tumors treated between 1988 and 1995 with external beam radiation. The majority (58%) of patients were older than 70 years and 24.2% had initial PSA values of 20 ng/mL or higher. A minimum of 2 years of subsequent follow-up was required for participation. MAIN OUTCOME MEASURE: Actuarial estimates of freedom from biochemical failure. RESULTS: The 5-year estimates of overall survival, disease-specific survival, and the freedom from biochemical failure are 85.0% (95% confidence interval [CI], 82.5%-87.6%), 95.1% (95% CI, 94.0%-96.2%), and 65.8% (95% CI, 62.8%-68.0%), respectively. The PSA failure-free rates 5 and 7 years after treatment for patients presenting with a PSA of less than 10 ng/mL were 77.8% (95% CI, 74.5%-81.3%), and 72.9% (95% CI, 67.9%-78.2%). Recursive partitioning analysis of initial PSA level, palpation stage, and the Gleason score groupings yielded 4 separate prognostic groups: group 1, included patients with a PSA level of less than 9.2 ng/mL; group 2, PSA level of at least 9.2 but less than 19.7 ng/mL; group 3, PSA level at least 19.7 ng/mL and a Gleason score of 2 to 6; and group 4, PSA level of at least 19.7 ng/mL and a Gleason score of 7 to 10. The estimated rates of survival free of biochemical failure at 5 years are 81 % for group 1, 69% for group 2, 47% for group 3, and 29% for group 4. Of the 302 patients followed up beyond 5 years who were free of biochemical disease, 5.0% relapsed from the fifth to the eighth year. CONCLUSIONS: Estimated PSA control rates in this pooled analysis are similar to those of single institutions. These rates indicate the probability of success for subsets of patients with tumors of several prognostic category groupings. These results represent a multi-institutional benchmark for evidence-based counseling of prostate cancer patients about radiation treatment.     

口服华发林抗凝治疗中出血并发症危险因素的病例对照研究

目的:探讨口眼华发林抗凝治疗过程中出血并发症的主要危险因素.方法:采用病例对照研究方法,连续选取住院及门诊病人口服华发林抗凝治疗中发生出血者共55例,并以口服华发林至少1个月以上且未发生出血的住院及门诊连续病例110例作为对照,对可能与华发林抗凝出血有关的因素进行调查后予以比较.结果:55例出血病例中,轻度出血21例,严重出血34例,其中致死性出血7例.多因素Logistic回归分析显示:INR值增高(OR 1.8,95%CI 1.4～2.4)、无房颤史(OR 15.1,95%CI 2.9～77.7)及心脏瓣膜换瓣术后(OR 4.1,95%CI 1.5～11.0)是华发林抗凝治疗中发生出血的独立危险因素.INR≥2.5时,判断出血(包括轻度和严重出血)及严重出血的敏感度分别为80%(95%CI,69.4%～90.6%)和73.5%(95% CI,58.7%～88.3%);INR≥3.0时,判断出血及严重出血的敏感度分别为69%(95%CI,56.8%～81.2%)和58.8%(95%CI,42.3%～75.3%).致死性出血病例的INR均大于3.0.结论:INR值增大、心脏瓣膜换瓣术后以及无房颤史是华发林抗凝治疗中出血的独立危险因素;国人应用华发林抗凝治疗时,INR的上限为2.5可能为最佳值,INR 3.0可视为INR的最高警戒点.     

Valve replacement in pediatric patients: a single center experience

Background  Reconstructive surgery is the primary goal in pediatric patients with valve disease. However, in cases with irreparable valve lesions, valve replacement is the only option. This study aimed to retrospectively analyze the clinical experience of heart valve prosthesis replacement in children.

Methods  Between January 1990 and July 2009, 35 pediatric patients (16 boys, 19 girls) underwent mechanical valve replacement in Shandong University Qilu Hospital. The ages ranged from 2.5 to 14 years (mean, (8.8±3.8) years) and body weight varied from 11 to 37 kg (mean, (22.1±5.2) kg). Mechanical valve replacement was performed because of congenital heart disease in 23 patients, rheumatic disease in ten patients and infective endocarditis in two patients. St. Jude bileaflet mechanical valves were implanted in all the 35 patients including mitral valve replacement (MVR) in 18, aortic valve replacement (AVR) in 12, tricuspid valve replacement (TVR) in two, AVR and MVR in two and MVR and TVR in one. The size of the prostheses ranged between 19 and 27 mm. All patients received long-term anticoagulation treatment with sodium warfarin, aiming to maintain an international normalized ratio between 1.5 to 2.0. Follow-up was performed in all the patients with a total follow-up of 119.4 patient-years.

Results  The operative mortality was 8.57% (3/35). One patient, who underwent cardiac debridement and AVR, died 2 hours after being admitted to the intensive care unit because of severe low cardiac output syndrome and ventricular fibrillation. Two patients died of cardiogenic shock and renal failure during initial hospitalization after the operation. One patient who received replacement of a tricuspid valve developed complete heart block requiring temporary pacing and recovered sinus rhythm 4 days later. Thirty-two patients survived and their cardiac function was in New York Heart Association (NYHA) class I to class II when discharged. Late events included hemorrhage and endocarditis. Two patients required reoperation. No late deaths occurred during the follow-up.

Conclusions  Mechanical valve replacement remains an acceptable treatment option in children when the valve reparation is impossible or unsuccessful. The operative mortality and incidence of any valve-related events such as endocarditis, reoperation, thromboembolism or anticoagulation-related bleeding are acceptable.

     

风湿性心脏病瓣膜置换术后严重高胆红素血症合并急性肾损伤患者的不良预后及其危险因素

目的 分析风湿性心脏病瓣膜置换术严重高胆红素血症合并急性肾损伤患者的不良预后及其危险因素.方法 回顾性筛选本院2015年1月至2018年12月行瓣膜置换手术治疗的患者,因风湿性心脏病行瓣膜手术治疗且术后同时发生严重高胆红素血症和急性肾损伤(AKI)的患者被纳入研究.采用单因素和多因素COX回归分析远期死亡相关的危险因素...     

Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials

CONTEXT: Lowering low-density lipoprotein cholesterol (LDL-C) is known to reduce risk of recurrent coronary heart disease in middle-aged men. However, this effect has been uncertain in elderly people and women. OBJECTIVE: To estimate the risk reduction of coronary heart disease and total mortality associated with statin drug treatment, particularly in elderly individuals and women. DATA SOURCES: Trials published in English-language journals were retrieved by searching MEDLINE (1966-December 1998), bibliographies, and authors' reference files. STUDY SELECTION: Studies in which participants were randomized to statin or control treatment for at least 4 years and clinical disease or death was the primary outcome were included in the meta-analysis (5 of 182 initially identified). DATA EXTRACTION: Information on sample size, study drug duration, type and dosage of statin drug, participant characteristics at baseline, reduction in lipids during intervention, and outcomes was abstracted independently by 2 authors (J.H. and S.V.) using a standardized protocol. Disagreements were resolved by consensus. DATA SYNTHESIS: Data from the 5 trials, with 30 817 participants, were included in this meta-analysis. The mean duration of treatment was 5.4 years. Stati n drug treatment was associated with a20% reduction in total cholesterol, 28% reduction in LDL-C, 13% reduction in triglycerides, and 5% increase in high-density lipoprotein cholesterol. Overall, statin drug treatment reduced risk 31 % in major coronary events (95% confidence interval [CI], 26%-36%) and 21 % in all-cause mortality (95% CI, 14%-28%). The risk reduction in major coronary events was similar between women (29%; 95% Cl, 13 %-42 %) and men (31 %; 95% CI, 26%-35%), and between persons aged at least 65 years (32%; 95% CI, 23%-39%) and persons younger than 65 years (31 %; 95% CI, 24%-36%). CONCLUSIONS: Our meta-analysis indicates that reduction in LDL-C associated with statin drug treatment decreases the risk of coronary heart disease and all-cause mortality. The risk reduction was similar for men and women and for elderly and middle-aged persons.     

老年及老年前期风湿性心脏病的临床特点

目的：研究老年及老年前期风湿性心脏病的临床特点。方法：对５２例４５岁以上的风心病病人与同期５３例１４～４４岁的风心病病人的资料进行对比分析。结果：显示老年及老年前期风心病起病隐袭，有风湿史者少，风湿活动少，病程长，合并症多，瓣膜病变重，发生二尖瓣钙化的病例多，左房增大明显，发生持续性心房纤颤例数多，与对照组比较，差别显著或非常显著。结论：了解老年风湿性心脏病的临床特点，采取积极的治疗措施，将有助于改善患者的预后。     

Failures in reconstructive mitral valve surgery

From 1969 to 1985, mitral valve repairs using Carpentier's technique were performed for acquired mitral valve incompetence. 72 patients required a reoperation 3 days to 13 years later (mean 5 +/- 3.5 years). The reoperation rate risk was dependent upon the etiology: Barlow 0.6 +/- 0.2% patient year, fibro-elastic deficiency 0.7 +/- 0.3, endocarditis 1.7% Rheumatic disease 4.6 +/- 1.4%. The risk of reoperation in Rheumatic disease is significantly higher (p less than 0.05) than in degenerative disease. The causes of failures could be categorized into two groups according to whether they are surgeon related or valve related: Group I, Prosthetic ring dehiscence or malposition 15%, anulus dilatation (when no ring was implanted) 4%, triangular resection of the anterior leaflet 4% residual prolapse 8.3%. Group II, Recurrent prolapse 16.6% valve stenosis 17%, leaflet retraction 35%. Failures in Group I can be reduced with "increased" experience as opposed to group II. At reoperation valve repair was possible in 15.3% of the cases whereas valve replacement was necessary in 84.7% with an overall operative mortality of 1.4%. We conclude that mitral valve repair in acquired mitral incompetence carries out a small risk of reoperation. Most of the repair failures are surgeon related in degenerative disease and valve related in rheumatic disease.     

One year echocardiographic study of rheumatic heart disease at Enugu, Nigeria

BACKGROUND: Rheumatic heart disease is one of the commonest causes of heart disease in Nigeria. Previous studies on rheumatic heart disease in Nigeria were either clinical or retrospective echocardiographic studies. This study was aimed at determining the burden of chronic rheumatic mitral valve disease, pattern of valvular involvement, severity and associated valvular lesions, using echocardiography. PATIENTS AND METHODS: Between May, 2004 and April 2005, patients with symptomatic rheumatic heart disease, seen in the cardiac clinics of University of Nigeria Teaching Hospital, Enugu, were recruited for the study. The patients were investigated non-invasively with M-mode, Two-dimensional, Pulsed wave, Continuous wave and colour flow Doppler echocardiographic techniques in order to assess the mitral and other intracardiac valves for evidence of rheumatic heart disease. RESULTS: There were a total of 55 patients, 39 (70.9%) females and 16 (29.1%) males with a mean age of 29.34 +/- 11.57 years. Mitral valve disease was found in 54 (98.2%) and isolated aortic valve disease in 1 (1.8%) of cases. Mitral regurgitation occurred in 64.8%, mixed mitral valve disease in 25.9% and pure mitral stenosis in 9.3%. Mitral valve disease was associated with aortic valve disease in 33.3%, with tricuspid valve disease in 24.1% and with functional pulmonary incompetence in 9.3% of cases. CONCLUSION: Rheumatic heart disease in Nigeria is essentially a disease of the mitral valve as seen elsewhere in the world. Echocardiography should be done routinely for patients with rheumatic heart disease to facilitate accurate diagnosis and definitive treatment.     

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。     

基质金属蛋白酶在风湿性心脏病二尖瓣病变组织中的表达研究

目的探讨基质金属蛋白酶（MMPs）在风湿性心脏病（RHD）二尖瓣膜病理改变中的作用及其机制。方法实验组为成人RHD患者二尖瓣16例，对照组为同期意外死亡的无心脏病变的成人二尖瓣7例。经HE染色及电镜观察两组形态学和超微结构变化，采用逆转录-聚合酶链反应（RT-PCR）和免疫组织化学染色（SABC法）测定MMP-2、MMP-13在二尖瓣组织的mRNA含量和蛋白表达。结果实验组为风湿性病理改变，对照组结构基本正常。实验组MMP-2、MMP-13的mRNA表达分别为0．96±0．27，0．93±0．38，较对照组均明显增加（P〈0．01）；其MMP-2、MMP-13蛋白表达亦明显高于对照组。结论RHD患者二尖瓣膜中MMPs表达增强，可能参与二尖瓣细胞外基质（ECM）的重构，是其风湿性改变的重要分子机制之一。     

体外循环心脏瓣膜置换术对风湿性心脏病患者T淋巴细胞主要免疫表型的影响

目的观察风湿性心脏病(RHD)患者在体外循环(ECC)心脏瓣膜置换术前、后细胞免疫功能的变化。方法用流式细胞仪检测28例ECC瓣膜置换术RHD患者(RHD组,其中单瓣组15例,双瓣组13例)和20例非体外循环冠状动脉搭桥术患者(对照组)术前、术毕及术后第1、3、5、8天外周血CD3+、CD3+/CD4+、CD3+/CD8+T细胞、NK细胞(CD3-/CD16+56+)、CD3+CD4-CD8-双阴性T细胞的水平。结果 RHD组患者与术前比较,术后CD3+、CD4+、CD4+/CD8+、NK细胞计数明显降低(P<0.05),CD8+、CD3+CD4-CD8-计数明显升高(P<0.05)。双瓣组的上述指标波动明显大于单瓣组。与对照组比较,术后RHD组患者的CD3+、CD4+和CD4+/CD8+T细胞计数明显下降(P<0.05),而CD8+和CD3+CD4-CD8-计数明显升高(P<0.05)。对照组NK细胞在术前、术后无明显变化(P>0.05)。结论 ECC瓣膜置换术可使RHD患者的细胞免疫功能受到明显的抑制。