利用欧洲心脏手术危险评估系统(EuroSCORE)预测国人冠状动脉旁路移植术后的机械通气时间

目的 探索标准EuroSCORE 能否预测国人冠状动脉旁路移植术(CABG)后患者的机械通气时间.方法 选择2008年3-7月接受择期CABG的患者243例.术前1天根据相关定义计算患者的标准EuroSCORE 评分.同时记录患者围术期的其他相关变量.结果 机械通气时间延长的发生率为7.4% (18/243).标准EuroSCORE受试者工作特征曲线下面积为0.693 (95%CI 0.582～0.803),显示标准EuroSCORE可以有效用于预测机械通气时间延长的发生.多因素logistic回归分析显示术前慢性阻塞性肺病 (OR=12.846, 95%CI 1.839～89.719, P=0.010)、术前肾功能损害 (OR=5.910, 95%CI 1.075～32.500, P=0.041)、手术时间长(OR=1.619, 95%CI 1.129～2.321, P=0.009) 和EuroSCORE≥3分(OR=3.663, 95%CI 1.110～12.088, P=0.033) 是机械通气时间延长的独立危险因素.在发生术后机械通气时间延长的患者中,患者术后监护室内滞留时间[(178.2±223.8)h vs. (43.1±30.2)h, P<0.001]和住院时间[(12.5±8.4)d vs. (7.9±2.4)d, P<0.001]显著延长,术后并发症 (38.1% vs. 16.7%, P=0.002) 和死亡发生率 (16.7% vs. 0.4%, P=0.029) 明显增加.结论 标准EuroSCORE≥3分是CABG术后机械通气时间延长的独立危险因素之一;标准EuroSCORE可以用于预测国人CABG术后发生机械通气时间延长的风险,但是需要进行校正;发生机械通气时间延长的患者预后明显恶化.     

GRACE风险评分联合脑钠肽对急性冠状动脉综合征近期死亡率预测研究

目的探讨全球急性冠状动脉事件注册(GRACE)风险评分联合脑钠肽(BNP)对急性冠脉综合征(ACS)患者近期死亡率(≤30 d)的预测价值。方法连续选取诊断为ACS的患者240例,测定各患者的BNP值,并计算GRACE风险评分,根据GRACE风险评分将研究人群分为低危组、中危组和高危组,分析ACS患者在院及出院后30 d内随访期间的死亡率与入院时BNP及GRACE风险评分的相关性。结果各组患者间性别、肥胖状况比较,差异有统计学意义(P<0.05);且高危组BNP的自然对数(Ln BNP)明显高于低危组,差异有统计学意义(P<0.01)。应用二元Logistic回归分析,Ln BNP与GRACE风险评分对于近期死亡率的预测均有统计学意义(P<0.01)。进一步绘制受试者工作特征(ROC)曲线提示,GRACE风险评分曲线下面积(AUC)为0.869(95%可信区间0.785~0.952,P<0.01),Ln BNP的AUC为0.861(95%可信区间0.755~0.967,P<0.01),两者联合AUC为0.900(95%可信区间0.806~0.989,P<0.01)。结论 GRACE风险评分联合BNP对ACS患者近期死亡率有更好的预测价值。     

乳酸及复合模型对非体外循环冠状动脉旁路移植术后机械辅助通气时间延长的预测价值

目的 基于剂量反应和决策曲线，探讨乳酸（Lac）及复合模型对非体外循环冠状动脉旁路移植（OPCABG）术后机械辅助通气时间延长（PMV）的预测价值。方法 回顾性分析北部战区总医院心外科2019年1-12月收治的683例OPCABG患者的临床资料。根据术后机械辅助通气时间是否>24 h，将其分为PMV组（_n=107）与非PMV组（_n=576）。收集两组患者的基线资料及其他临床指标，筛选有统计学差异的因素；采用多因素logistic回归分析OPCABG术后PMV的影响因素，并构建预测PMV发生风险的复合模型。应用受试者工作特征（ROC）曲线、限制性立方样条模型、决策曲线分析（DCA）等方法评估乳酸及复合模型对OPCABG术后PMV的预测价值。结果 两组性别、年龄、体重指数（BMI）、心功能NYHA分级、既往心肌梗死史、既往经皮冠状动脉介入治疗（PCI）史、吸烟史、高血压、糖尿病、高胆固醇血症、3支冠脉狭窄>50%、左主干狭窄>50%、桥血管数、术后即刻乳酸、术前肌酐、术后血红蛋白、术前总胆红素（TBil）、术前直接胆红素（DBi...     

脑钠素与非ST段抬高型心肌梗死冠状动脉病变程度的关系

 目的 探讨血浆脑钠素(BNP)与非ST段抬高急性心肌梗死(NSTEMI)患者冠状动脉病变程度的关系.方法 研究入选NSTEMI患者81例,均在治疗前采血检查血浆BNP水平,根据BNP中位数将患者分为2组,高BNP组(BNP≥150 pg/ml)和低BNP组(BNP＜150 pg/ml).用Judking法对每位患者行冠状动脉造影术(CAG),将其分为正常组、A、B1、B2、C型病变组.结果 高BNP组较低BNP组患者冠脉血管病变较重的B、C型病变组人数多,分别为39例(48.5%)和16例(19.8%),差异有统计学意义(P＜0.05).结论 NSTEMI 患者冠脉病变程度严重者血浆BNP升高,提示血浆BNP是NSTEMI患者冠脉病变程度的重要预测指标.     

血浆脑利钠肽水平对急性ST段抬高型心肌梗死急诊介入治疗后近期心室重构的预测价值

 目的 探讨急性心肌梗死(acute myocardial infarction,AMI)患者急诊冠状动脉介入(primary percutaneous coronary intervention,p-PCI)治疗后血浆脑利钠肽(brain natriuretic peptide,BNP)水平对术后6个月内左心室重构的预测价值。方法 连续收集AMI患者100例作为研究对象,所有患者均于发病12 h内完成p-PCI治疗,于发病24 h时采肘静脉血检测血浆BNP水平。分别于术后第7天和术后6个月进行超声心动图检查,测定左心室舒张末期容积值(left ventricular end diastolic volume,LVEDV)等参数,并计算左心室舒张末期容积增长率。根据是否发生左心室重构,将所有研究对象划分为非重构组(△LVEDV<20%,n=72)和重构组(△LVEDV>20%,n=28)。做24 h时BNP水平预测术后6个月内左心室重构的受试者工作特征(receiver operating characteristic,ROC)曲线,分析BNP水平对AMI患者术后6个月内发生左心室重构的预测价值。结果 AMI患者,发病24 h血浆BNP水平预测术后6个月内左心室重构的ROC曲线下面积为0.844,差异有统计学意义(P<0.05);截值为357.0 pg/ml时,预测发生左心室重构的特异性为81.9%,敏感性为75.0%。结论 AMI患者发病24 h时血浆BNP水平显著升高是近期发生左心室重构的重要危险因素,可为近期左心室重构的发生提供预测价值。     

ICU重症心力衰竭应用有创机械通气和常规方法治疗临床比较

目的 观察和探讨有创机械通气和常规方法治疗ICU重症心力衰竭临床治疗效果.方法 选取诊治的78例患者入院资料进行分析,将其随机分为两组.对照组39例采用常规方法治疗,研究组39例采用有创机械通气治疗,比较两组治疗效果.结果 研究组治疗30 min后30.77％ (12/39)好转;治疗24h后64.10％ (25/39)好转,高于对照组(P＜0.05);研究组治疗72 h后NT-pro BNP指标和LVEF指标优于对照组(P＜0.05).结论 ICU重症心力衰竭发病率较高,临床上采用有创机械通气治疗效果理想,能够有效的提高临床治愈率,改善患者肺功能,值得推广使用.     

重度支气管哮喘并发肺部感染的危险因素及其预测模型构建

目的 探讨重度支气管哮喘并发肺部感染的危险因素及其预测模型构建。方法 选取2019-01至2021-10解放军联勤保障部队第908医院呼吸内科接受治疗的176例重度支气管哮喘患者为研究对象，根据患者是否并发肺部感染分为感染组(n=54)和未感染组(n=122)。收集两组患者的临床资料，分析肺部感染相关因素；ROC曲线推测指标预测价值；logistic回归分析独立危险因素；R语言软件4.0“rms”包构建列线图预测模型，校正及决策曲线进行内部验证与预测效能评估。结果 两组患者年龄、糖尿病史、病程、抗生素使用时间、糖皮质激素使用时间、机械通气、机械通气时间、低蛋白血症方面差异具有统计学意义(P<0.05)。年龄、病程、抗生素使用时间、糖皮质激素使用时间、机械通气时间的AUC分别为0.795、0.714、0.799、0.828、0.830,最佳截断值分别为60岁、4年、11 d、8 d、6 d。年龄、糖尿病史、抗生素使用时间、糖皮质激素使用时间、机械通气、低蛋白血症是重度支气管哮喘并发肺部感染的独立危险因素。列线图模型预测重度支气管哮喘患者并发肺部感染的C-index为0.876(95...     

BMI联合术前氧合指数对Stanford A型主动脉夹层术后低氧血症的预测价值

目的 探讨Stanford A型主动脉夹层(TAAD)患者术后发生低氧血症的危险因素及其预测价值。方法 收集2018年1月-2021年6月南方医科大学南方医院收治的146例诊断为TAAD并接受孙氏手术的患者进行回顾性分析。根据术后24 h内的氧合指数将患者分为低氧血症组(PaO₂/FiO₂≤200 mmHg)与非低氧血症组(PaO₂/FiO₂>200 mmHg)。比较两组患者术前氧合指数、气管插管时间和院内病死率等临床结局的差异，采用多因素logistic回归分析患者术后发生低氧血症的危险因素，并利用受试者工作特征(ROC)曲线分析各危险因素的预测价值。结果 TAAD患者术后低氧血症发生率为45.9%。与非低氧血症组比较，低氧血症组机械通气时间(P<0.001)和ICU停留时间(P=0.039)明显延长，且病死率明显增高(P=0.011)。多因素logistic回归分析显示，体重指数(BMI)高是TAAD患者术后发生低氧血症的独立危险因素(OR=1.701,P<0.001)，而术前...     

血清BNP、CRP、PCT水平对慢阻肺急性加重期患者并发心力衰竭的预测价值

目的 探讨血清B型钠尿肽(BNP)、C反应蛋白(CRP)、降钙素原(PCT)水平对慢阻肺急性加重期(AECOPD)患者并发心力衰竭的预测价值。方法 回顾性收集2021年06月-2023年06月收治的48例住院治疗期间并发心力衰竭的AECOPD患者病历资料为发生组,另收集医院同期收治的住院治疗期间未并发心力衰竭的48例AECOPD患者病历资料为未发生组。对比两组患者基线资料及血清BNP、CRP、PCT等实验室指标,通过受试者工作曲线(ROC)检验血清BNP、CRP、PCT预测AECOPD患者并发心力衰竭的价值。结果 发生组年龄、血清BNP、CRP、PCT水平均显著高于未发生组,差异有统计学意义(P<0.05)。经点二列相关性分析显示,血清BNP、CRP、PCT与AECOPD患者并发心力衰竭间呈正相关(r>0,P<0.05)。绘制ROC曲线,结果显示,血清BNP、CRP、PCT水平单独及联合预测AECOPD患者并发心力衰竭的曲线下面积(AUC)值分别为为0.802、0.740、0.764、0.898,联合预测价值最高。结论 血清BNP、CRP、PCT能较好预测AECOPD...     

俯卧位对不同类型手术病人全身麻醉机械通气下肺顺应性的影响

目的观察俯卧位对全身麻醉机械通气下不同手术类型病人肺顺应性的影响。方法选择择期行脊柱手术患者53例(其中脊柱侧弯手术病人20例,脊柱普通手术病人33例)。麻醉诱导气管插管后,间歇正压通气模式机械呼吸,潮气量6～10 ml/kg,呼吸频率12次/min。术前仰卧位通气10 min后改为手术俯卧位通气10min,分别经麻醉机采集不同潮气量时压力-容积曲线,计算肺顺应性。结果全身麻醉机械通气下,脊柱侧弯手术病人术前仰卧位肺顺应性为(33.6±10.0)ml/cmH2O,术前俯卧位的肺顺应性降低为(28.2±8.6)ml/cmH2O,术前仰卧位与俯卧位的肺顺应性之间差异有统计学意义(P<0.05);普通手术组病人术前仰卧位肺顺应性为(40.2±9.1)ml/cmH2O,其术前俯卧位肺顺应性降低为(36.1±4.2)ml/cmH2O,差异有统计学意义(P<0.05)。结论俯卧位时全身麻醉机械通气下手术病人的肺顺应性下降。     

非体外循环冠状动脉旁路移植术后房颤相关因素的探讨

目的　调查非体外循环下冠状动脉旁路移植术术后房颤发生率 ,并探讨引起房颤的高危因素。方法　回顾分析 383例非体外循环下冠状动脉旁路移植术的患者 ,并将患者分为房颤者和非房颤者两组 ,调查术前、术中和术后的相关因素 (30个变量 )并进行统计学分析 ,从而筛选出易致房颤的有关因素。结果　房颤发生率 12 .5 %(48例) ,高龄 (>70岁 )、术前脑卒中病史和胸膜破损是引起房颤的高危因素。结论　高龄是导致非体外循环冠状动脉旁路移植术后房颤发生的病理基础 ,而脑卒中病史和胸膜破损是引起房颤的高危因素。     

Postoperative chest radiographic changes after on- and off-pump coronary surgery

AIM: A variety of chest radiograph abnormalities are recognized after coronary artery bypass grafting (CABG). This study analyzes the appearance of preoperative and postoperative chest radiographs in two groups of patients undergoing myocardial revascularization with or without the use of cardiopulmonary bypass (CPB). METHODS: Chest radiographs (preoperative and at 1 day, 6 days and 6 to 8 weeks post operatively) were analyzed according to a detailed protocol in cases of conventional CABG on CPB (n=60) or off-pump coronary artery bypass (OPCAB) (n=60) surgery. On each film 17 different major potential postoperative abnormalities were analyzed. RESULTS: Clinical findings were similar in the two groups. Patients undergoing OPCAB surgery had decreased blood loss, decreased red cell and platelet transfusion, significantly lower intubation time and required less postoperative inotropic support compared with patients undergoing CPB. The CPB group had a significantly higher incidence of left band atelectasis than the OPCAB group (37.6% vs 17.5%, p=0.01) at 6 days postoperatively. There was no other statistically significant difference in any of the 16 remaining major chest radiograph findings between the two groups. CONCLUSION: Although OPCAB surgery is associated with improved clinical outcome compared with conventional CABG surgery, the analysis of postoperative chest radiographs demonstrated only a minor benefit as shown by a reduced degree of left band atelectasis in the OPCAB group.     

Interpretability of coronary CT angiography performed with a novel whole-heart coverage high-definition CT scanner in 300 consecutive patients with coronary artery bypass grafts

AimsCoronary CT angiography (CCTA) is an accurate non-invasive tool for the evaluation of coronary artery bypass graft (CABG). However, inability to sustain a long breath-hold, high heart rate (HR) and atrial fibrillation may affect image quality. Moreover, radiation exposure is still a matter of some concern. A scanner combining 0.23-mm spatial resolution, new iterative reconstruction and fast gantry rotation time has been recently introduced in the clinical field. The aims of our study were to evaluate interpretability, radiation exposure and diagnostic accuracy of CCTA performed with the latest generation of cardiac-CT scanners compared to invasive coronary angiography (ICA) in the assessment of bypass grafts, and non-grafted and post-anastomotic native coronary arteries.Methods and resultsWe prospectively enrolled 300 patients undergoing clinically indicated CCTA with a 16-cm z-axis coverage, 256-detector rows, and 0.28-sec gantry rotation time scanner. Coronary artery and graft interpretability, image quality and effective dose (ED) were assessed in all patients and diagnostic accuracy was evaluated in a subgroup of 100 patients who underwent ICA.Mean HR during the scan was 69.6 ± 10.8. Sinus rhythm was present in 118 patients with HR < 75 bpm and in 112 patients with HR ≥ 75 bpm, while 70 patients had atrial fibrillation. CABG interpretability was 100%. Compared to ICA, CCTA was able to correctly detecting occlusions or significant stenoses of all CABG segments. Overall interpretability of native coronary segments was 95.6%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of coronary arteries were 98.3%, 97.4%, 93.1%, 99.3% and 96.5%, respectively. The diagnostic accuracy in a patient based analysis was 95.2%. Mean ED was 3.14 ± 1.7 mSv.ConclusionsThe novel whole-heart coverage CT scanner allows to evaluating CABG and native coronary arteries with excellent interpretability and low radiation exposure even in the presence of unfavorable heart rhythm.     

应用超声心动图预测冠状动脉搭桥术后房颤的多因素分析

目的探讨超声心动图对非体外循环下不停跳冠状动脉旁路移植术后房颤发生的预测价值。方法采用病例-对照研究方法对113例单纯行非体外循环下不停跳冠状动脉旁路移植术患者进行分析,根据术后是否发生房颤分为房颤组和对照组,采集术前一般临床资料、超声心动图数据,进行多因素回归分析。结果 31例(27.4%)患者发生术后房颤。单因素分析显示房颤组和对照组患者年龄、室壁运动积分(WMI)、二尖瓣E峰/A峰(E/A)、二尖瓣侧壁处收缩期峰速(S’)、E峰/二尖瓣侧壁处舒张早期峰速(E/E’)、肺动脉收缩压(PASP)、二尖瓣反流(MI)差异有统计学意义(P<0.05)。多因素回归分析显示术后房颤的独立危险因素以相对危险度由高到低排序依次为MI程度、E/E’增高、年龄增加、PASP升高。44例术前有MI,其中房颤组18例,对照组26例,术后1周超声心动图发现房颤组有13例(72.2%)MI无变化,而对照组仅6例(23.1%)MI无变化,两组间比较差异有统计学意义(P=0.001),其余25例患者MI均减轻或消失。房颤组和对照组中MI患者术前E/E’值分别为13.5±4.9和9.9±3.2,两者比较差异显著(P=0.005)。结论 CABG术后房颤的独立危险因素为MI、E/E’增高、年龄增加、PASP升高。二尖瓣功能性反流同时伴有左室舒张功能异常(E/E’≥8~10)的患者,应该考虑CABG同时行二尖瓣成形术。     

房颤超声消融术同期行冠脉搭桥、瓣膜手术

目的对于行冠状动脉旁路移植或瓣膜置换术伴有心房颤动的病人同期实施经心外膜途径的超声消融术治疗房颤的治疗效果进行随访总结。方法房颤病史大于6个月的89例病人入选,其中永久性房颤的67例,阵发性房颤22例,所有病人需同期实施冠状动脉旁路移植术或瓣膜手术。首先在心脏跳动下,应用Epico装置经心外膜途径围绕肺静脉实施房颤超声消融术,随后采用Epico装置在肺静脉环形消融线与二尖瓣环之间附加一条消融线,然后行冠状动脉旁路移植术、瓣膜置换术或瓣膜成形术。结果术后6～12个月随访时,房颤治愈率为83%,其中永久性房颤的治愈率为78%,阵发性房颤的治愈率为100%。房颤的治愈率与房颤病史长短及房颤的类型有关。结论在心脏跳动下经心外膜途径的超声消融术对于冠心病和瓣膜病等器质性心脏病所合并的心房颤动是一种安全可行、简便有效的治疗方法。     

Presurgical identification of hibernating myocardium by combined use of technetium-99m hexakis 2-methoxyisobutylisonitrile single photon emission tomography and fluorine-18 fluoro-2-deoxy-d-glucose positron emission tomography in patients with coronary artery disease

We tested the possibility of identifying areas of hibernating myocardium by the combined assessment of perfusion and metabolism using single photon emission tomography (SPET) with technetium-99m hexakis 2-methoxyisobutylisonitrile (^99mTc-MIBI) and positron emission tomography (PET) with fluorine-18 fluoro-2-deoxy-d-glucose (¹⁸F-FDG). Segmental wall motion, perfusion and ¹⁸F-FDG uptake were scored in 5 segments in 14 patients with coronary artery disease (CAD), for a total number of 70 segments. Each subject underwent the following studies prior to and following coronary arterybypass grafting (CABG): first-pass radionuclide angiography, electrocardiography gated planar perfusion scintigraphy and SPET perfusion scintigraphy with ^99mTc-MIBI and, after 16 h fasting, ¹⁸F-FDG/PET metabolic scintigraphy. Wall motion impairment was either decreased or completely reversed by CABG in 95% of the asynergic segments which exhibited ¹⁸F-FDG uptake, whereas it was unmodified in 80% of the asynergic segments with no ¹⁸-FDG uptake. A stepwise multiple logistic analysis was carried out on the asynergic segments to estimate the postoperative probability of wall motion improvement on the basis of the preoperative regional perfusion and metabolic scores. The segments with the highest probability (96%) of functional recovery from preoperative asynergy after revascularization were those with a marked ¹⁸F-FDG uptake prior to CABG. High probabilities of functional recovery were also estimated for the segments presenting with moderate and low ¹⁸F-FDG uptake (92% and 79%, respectively). A low probability of functional recovery (13 %) was estimated in the segments with no ¹⁸F-FDG uptake. Despite the potential limitations due to the semiquantitative analysis of the images, the method appears to provide reliable information for the diagnostic and prognostic evaluation of patients with CAD undergoing CABG and confirms that the identification of hibernating myocardium with ¹⁸F-FDG is of paramount importance in the diagnosis of patients undergoing CABG.Correspondence to: G. Lucignani     

肺癌术后呼吸衰竭的临床分析

目的探讨肺癌术后呼吸衰竭的原因、预防及治疗。方法对我院2002年1月—2006年10月肺癌术后发生呼吸衰竭的20例患者均进行了机械通气治疗,17例行气管切开术。结果术后呼吸衰竭发生率4.9%(20/412),死亡率20.0%(4/20)。结论呼吸道感染、手术创伤、伤口疼痛刺激、术前心肺功能异常等是引起术后呼吸衰竭的主要原因。尽早诊断、及时行气管切开术并给予机械通气是抢救成功的最有效手段,加强围术期呼吸道管理、避免手术并发症是预防术后呼吸衰竭的关键。     

Preoperative extracranial carotid artery examination with ultrasonography in patients undergoing coronary artery bypass grafting in Japan

Purpose We investigated the incidence, degree, and plaque characteristics of extracranial carotid stenosis with carotid ultrasonography (CUS) in patients undergoing coronary artery bypass grafting (CABG). Materials and methods Preoperative CUS was performed on 221 patients (442 carotid arteries) undergoing CABG. The degree of extracranial carotid stenosis was calculated based on the area stenosis, and it was classified into six grades as follows: grade (G) 0, G1 (1%–29%), G2 (30%–49%), G3 (50%–69%), G4 (70%–99%), and G5 (occlusion). Results The incidence of G4 was 4.1% and G5 1.6%. There were 48 arteries rated G3 or G4. Hypoechoic plaque was detected in 28 of the 48 arteries (58%), and heterogeneous plaque was detected in 37 arteries (73%). Ulcerative plaque was detected in 27 arteries (56%); when comparing the G3 and G4 groups, ulcerative plaque was found more frequently in G4 than in G3 (14/18 vs 13/30 arteries, P < 0.02). Conclusion Our study demonstrated that patients undergoing CABG with extracranial severe carotid stenosis tend to have heterogeneous, hypoechoic, and ulcerative plaque. We believe that preoperative CUS should be used to evaluate the plaque characteristics of extracranial carotid stenosis.     

电子束CT血管造影对冠状动脉疾病的诊断与随访

目的评价电子束CT血管造影(EBA)及其三维血管成像技术对冠状动脉疾病的诊断与随访价值. 资料与方法 87例经EBA检查的患者,其中支架置入术后随访16例,搭桥术后随访9例.除9例搭桥患者外,其余78例均有冠状动脉造影(CAG)结果证实. 结果 EBA可评价的冠状动脉中,对左主干和前降支的诊断敏感性、特异性最高,尤其是近段,其次为右冠,对回旋支的诊断敏感性和特异性则较低;16例支架置入术后患者共放置支架47枚,EBA准确定位45枚(95.7%),对支架内开通诊断的符合率为74.5%;9例冠状动脉搭桥术后的患者,共搭建冠状动脉桥血管27支,EBA对桥血管开通与否诊断的符合率为81.5%. 结论 EBA对冠状动脉狭窄的诊断具有较高的术前筛选价值,对术后的随访也有较大的潜力,是一项很有优势的无创性冠心病检查方法.