合并符合新诊断标准的左束支阻滞的慢性心力衰竭患者应用心脏再同步化治疗的疗效分析

目的:分析慢性心力衰竭患者合并符合新诊断标准的左束支阻滞(LBBB)(真性LBBB)能否从心脏再同步化治疗(CRT)中更能获益。方法:研究入选2005-06至2013-05接受CRT的19例患者,依据术前体表心电图QRS波的形态,符合新诊断标准即为真性LBBB组(n=13),符合传统诊断标准即为假性LBBB组(n=6);比较所有入选患者CRT术前与术后左心室射血分数(LVEF)、左心室舒张末内径(LVEDD)、QRS波时限(QRSd)及心室间机械延迟时间(IVMD);同时比较两组患者术后LVEF、LVEDD、QRSd、IVMD、16节段达最小收缩末容积时间标准差(Tmsv16-SD)及16节段达最小收缩末容积时间的最大差值(Tmsv16-Dif)有无差异。结果:两组患者在CRT术后的LVEF、LVEDD、IVMD及QRSd均较术前有明显的改善;而且与假性LBBB组比,真性LBBB组的LVEDD[(5.95±0.72)mm vs(7.13±0.78)mm,P0.01]、IVMD[(22.45±8.00)ms vs(27.63±13.09)ms,P0.01]及QRSd[(140.38±5.80)ms vs(153.68±14.38)ms,P0.01]改善更明显;术后两组患者的Tmsv16-SD、Tmsv16-Dif及LVEF的差异均无统计学意义。结论:合并真性LBBB和假性LBBB的心力衰竭患者均能从CRT中获益,合并真性LBBB的心力衰竭患者获益更明显。     

左束支起搏与右室间隔部起搏的临床效果比较

目的 比较左束支起搏(LBBP)与右室间隔部起搏(RVSP)对电-机械同步性、起搏参数、心脏结构及功能的影响。方法 收集2020年6月至2021年12月在河南省胸科医院行永久双腔起搏器的患者，根据起搏部位分为LBBP组和RVSP组。比较两组起搏前后QRS波时限变化，起搏术前/术中、术后1及6个月、1年起搏参数(阈值、阻抗)及心脏结构及功能[左室舒张末期内径(LVEDD)、左房内径(LAD)、左室射血分数(LVEF)]变化和并发症情况。结果 共入选136例，其中LBBP组74例，RVSP组62例。LBBP组QRS波时限术前、术后无差异[(112.7±20.8)ms vs (114.9±10.9)ms,P>0.05],RVSP组术后QRS波明显延长[(142.0±14.9)ms vs (111.1±22.3)ms,P<0.01],术后RVSP组较LBBP组时限明显延长(P<0.01)。两组的阈值、阻抗在术后1个月较术中明显下降(P<0.01),后达到稳定，且两组相比无差异(P>0.05)。LBBP组术后6个月及1年LVEDD、LAD较术前降低，LVEF较术前升...     

单左室起搏实现心脏再同步化治疗对左房结构及功能的影响

目的探讨分析单左室起搏(LUVP)实现心脏再同步化治疗(CRT)对左房结构功能的影响。方法 30例接受CRT治疗的慢性心力衰竭(简称心衰)患者,根据起搏模式不同分成两组,其中15例为LUVP,15例为双心室起搏(BVP),收集30例患者CRT术前及术后1、3、6个月内心功能、十二导联心电图及超声心动图临床资料,比较两组NYHA心功能分级,QRS波时限,左房容积指数(LAVI),左房射血分数(LAEF),左室射血分数(LVEF),心室间机械延迟时间(IVMD),室间隔与左室后壁收缩期轴向应变达峰时间差(SPWMD),二尖瓣返流面积(MRA),左室舒张末期内径(LVEED)指标的术前及术后变化。结果与术前相比,LUVP组及BVP组术后6个月NYHA心功能分级降低,QRS波时限、IVMD、SPWMD、MRA、LAVI、LVEED较术前减小,LAEF及LVEF增加(P均<0.05)。与BVP组相比,LUVP组术后6个月QRS波时限缩短[(133.8±9.1) ms vs(141.3±8.4) ms,P<0.05],MRA减小[(1.9±1.0) cm~2 vs (3.0±1.0) cm~2,P<0.05]。结论慢性心衰患者左室及左房结构、功能在CRT术后得到明显改善;同时,在缩短QRS波时限、减小二尖瓣返流面积方面LUVP较BVP更有优势。     

左束支起搏在心脏再同步治疗的初步应用经验

目的:评价左束支起搏(LBBP)在需要行心脏再同步治疗心力衰竭(心衰)中的应用价值。方法:入选2017-12-2019-11有心脏再同步起搏器(CRT)植入适应证的患者12例,因CS电极植入失败或有备用插孔,所有患者均植入左束支电极。术后心室为单纯LBBP起搏。观察植入时LBBP和RV起搏参数,包括阈值、阻抗、感知,评价LBBP和RV的起搏参数;比较植入时LBBP、自身QRS、RV和BIV起搏的QRS时限。术前、术后检查心脏彩超,观察左室舒张末内径(LVEDD)和左室射血分数(LVEF)变化。结果:植入时LBBP与RV的起搏参数相当,LBBP起搏的QRS时限明显短于BIV(P0.05);LBBP纠正6例患者完全性左束传导阻滞。LVEDD较术前明显缩小[(6.1±0.26) cm∶(5.7±0.25) cm,P0.05]。LVEF较术前明显提高[(38±3.0)%∶(44±2.8)%,P0.05],随访未发现不良反应。结论:LBBP安全有效,可以改善心衰患者心功能,为传统CRT治疗无效患者提供新的选择。     

左室四极与双极导线在心脏再同步化治疗中对比研究

目的在心脏再同步化治疗(CRT)中应用左室四极与双极导线进行对比研究。方法选取符合CRT适应证的患者16例植入左室四极导线为观察组,25例植入双极导线为对照组,观察有关数据并进行比较。结果两组患者均成功植入CRT。观察组手术时间较对照组显著减少[(106.8±25.6)min vs(125.3±25.7)min,P0.05]。随访6个月观察组左室起搏阈值较对照组显著性降低[(1.20±0.48)V vs(1.91±1.14)V,P0.05]。对照组出现1例膈神经刺激。观察组术后3个月时QRS波时限更短[(152.7±15.8)ms vs(167.3±15.3)ms,P0.05]。结论左室四极较双极导线可显著简化手术流程、缩短手术时间,并改善左室电极起搏阈值。     

心脏再同步化治疗晚期扩张型心肌病13例的效果

目的: 观察心脏再同步化治疗（CRT）晚期充血性心力衰竭的临床疗效。方法: 晚期扩张型心肌病患者13例接受CRT,NYHA心功能分级为Ⅲ～Ⅳ级,左室射血分数（LVEF）为（27.4±9.7）%,左室舒张末期内径（LVEDD）为(72.8±9.6)mm,QRS时限为( 137.8＋30.4)ms。术后观察QRS时限的变化,随访左室电极起博阈值、心功能分级、LVEF及LVEDD。结果: 术后QRS时限减少为（123.8±17.1）ms。所有患者随访3～38月,左室电极慢性阈值为（1.1±0.6）V/0.4 ms。与术前相比,NYHA心功能分级从(3.4±0.5)降低为(1.5±0.9); LVEF从(27.4±9.7)%上升至(43.5±18.5)%(P<0.05);LVEDD从(72.8±9.6)mm缩小为(65.5±11.6)mm（P<0.05）。结论: CRT可改善心功能,提高LVEF,并可逆转左心室重构。     

单左室起搏通过频率适应性房室延迟实现双心室再同步

目的探讨单左室起搏通过频率适应性房室延迟(RAAV)算法跟踪生理性房室延迟(AVD)实现双心室再同步的可行性及治疗慢性充血性心力衰竭(CHF)的效果。方法入选符合心脏再同步化治疗(CRT)Ⅰ类适应证并植入带RAAV功能的三腔或双腔起搏器的CHF患者64例,其中RAAV单左室起搏(LUVP)组(单左室组)32例,以标准双室起搏(BVP)组(标准双室组)32例为对照组。两组给予标准心脏超声优化,比较主动脉前向血流速度时间积分(AVI),左室射血分数(LVEF)、十二节段达峰时间标准差(TS-SD12)、主肺动脉射血前时间差(IVMD)、二尖瓣返流面积(MRA)、EA峰间距(E/A pd)、QRS波时限、年平均治疗费用、NYHA分级、6min步行试验(6MWT)等指标。结果与标准双室组比较,单左室组电池寿命更长[(7.8±0.3)年vs(4.5±0.2)年,P0.001],QRS波时限短[(136±10)ms vs(142±11)ms,P0.05],优化耗时较短[(20±4)min vs(52±8)min,P0.001],MRA更少[(3.1±1.1)cm~2 vs(3.7±1.2)cm2,P0.05],IVMD缩短[(64.2±12.8)ms vs(72.3±13.6)ms,P0.05],年均治疗费用低[(1.3±0.1)万元vs(2.2±0.2)万元,P0.001];AVI增加[(21.8±2.3)cm vs(20.6±2.1)cm,P0.05],余指标两组比较均无统计学意义(P0.05)。结论 RAAV单左室起搏可实现双室再同步,疗效不劣于标准BVP,且更符合生理性并降低治疗费用。     

束支阻滞类型对心脏再同步治疗效果的影响

目的 探讨不同类型束支阻滞对心脏再同步治疗(CRT)效果的影响.方法 159例难治性心力衰竭患者接受CRT治疗,其中6例已植入永久起搏器,其余153例患者根据体表心电图QRS波形态分为左束支阻滞(LBBB)、右束支阻滞(RBBB)、非特异性室内阻滞(IVCD)、右束支伴左侧分支阻滞(RBBB伴LHB)及室内伴左侧分支阻滞(IVCD伴LHB)5组,比较植入术前及术后6个月心功能(NYHA分级)、QRS时限、左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)等指标的差异.结果 153例患者年龄21～ 84(61.43±12.54)岁,其中男118例,女35例.LBBB组治疗后心功能(3.13±0.55对2.84±0.65)、QRS时限[173.37±28.54)ms对(156.29±22.25)ms]及LVEF[(0.31±0.07)对(0.39±0.09)]、LVEDD[(73.09± 10.81) mm对(68.18± 11.36) mm]、LVESD[(61.38±11.60)mm对(55.20±13.25)mm]等均明显改善(P＜0.01).RBBB组治疗后各项指标未得到显著改善(P＞0.05),IVCD组与RBBB伴LHB组治疗后LVEF显著提高,LVEDD缩小(P＜0.05),而IVCD伴LHB组除QRS时限外,心功能、LVEF、LVEDD、LVESD等指标均得以改善(P＜0.05).此外,RBBB组与IVCD组超声心动图指标的改变不及LBBB组(P＜0.05),而RBBB伴LHB组及IVCD组超声心动图指标改善程度与LBBB组相近(P＞0.05).应用Cox回归分析显示LBBB者较其他束支阻滞类型生存期长(风险比0.30,95％可信区间0.12～0.77,P＜0.01).结论 LBBB者对CRT的反应性优于RBBB者,IVCD者疗效可能介于两者之间,而RBBB伴LHB或IVCD者疗效优于单纯RBBB或IVCD者.     

希氏束起搏和传统右室心尖起搏对患者心脏结构及功能的影响

目的比较希氏束起搏(HBP)与右室心尖起搏(RVAP)在保持左室结构和收缩功能方面的效果。方法选取2012年3月~2015年1月于郑州大学第一附属医院心内科和郑州大学人民医院心内科因房室传导阻滞住院行永久性起搏器植入术共39例患者,其中HBP组成功植入患者15例,RVAP组成功起搏器植入18例,随访观察24个月,比较两组患者的纽约心脏协会(NYHA)心功能分级、左室射血分数(LVEF)、左室舒张末期内径(LVEDD)变化。结果 HBP组NYHA心功能分级术前、术后无明显变化(P0.05),RVAP组NYHA心功能分级由术前平均1.4下降至2.5(1.4±0.7 vs.2.5±0.9,P0.001);HBP组永久性起搏器植入前后LVEF、LVEDD变化无明显变化(P0.05),RVAP组永久性起搏器植入术后LVEF显著降低[(58.3±6.3)%vs.(50.8±7.5)%,P=0.002],LVEDD显著增加[(43.1±4.6)mm vs.(53.3±7.9)mm,P0.001]。结论与传统右室心尖起搏相比,希氏束起搏对于收缩功能和左室舒张末内径有优势。     

CRT治疗慢性心衰的临床观察

目的观察心脏再同步化治疗(CRT)慢性心力衰竭(CHF)患者的临床疗效。方法选择2006年5月～2009年4月植入CRT起搏器的患者8例,其中7例为窦性心律;1例为房颤。优化AV间期及/或VV间期等参数,随访10.1±8.9个月,观察患者心功能改善情况、QRS波时限改变和左室射血分数(LVEF)、左室舒张末内径(LVEDD)、二尖瓣返流及左/右心室不同步等心脏超声参数的变化。结果所有8例患者植入CRT起搏器后,心功能分级与LVEF提高,临床症状明显减轻,6分钟步行距离增加,QRS波时限、LVEDD及MR减少,左/右心室不同步明显改善,心衰平均住院时间减少约33%(p0.05);1例患者CRT植入后13个月发生VT/VF猝死。结论CRT可明显改善CHF患者的心功能,缓解临床症状并提高生活质量;对可能发生VT/VF的高危CHF患者,置入CRT(D)可预防心源性猝死。     

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.