心脏瓣膜置换后早期住院患者死亡因素分析

背景：积极加强对高危患者心脏瓣膜置换前、中和置换后的处理,可降低心脏瓣膜置换后早期死亡率。 目的：分析心脏瓣膜病患者置换治疗后早期住院死亡的危险因素,提高手术治愈率。 方法：回顾分析488例心脏瓣膜病患者行手术治疗作为临床资料;以置换后早期住院死亡为研究终点,采用单因素及多因素Logistic回归方法分析置换后早期死亡的危险因素。 结果与结论：488例心脏瓣膜置换患者中,置换后早期死亡27例,总死亡率5.5%。主要的死亡原因是低心排综合征、恶性心律失常、多器官功能衰竭。单因素分析显示：年龄≥60岁、心功能IV级、联合瓣膜手术以及同期冠状动脉旁路移植、左室射血分数≤50%、左室舒张末内径≥70 mm、体外循环时间≥120 min、主动脉阻断时间≥ 60 min与心脏瓣膜后死亡的发生具有相关性(P < 0.05)。多因素Logistic回归分析结果：年龄≥ 60岁、心功能IV级、瓣膜手术同期冠状动脉旁路移植、体外循环时间≥120 min、左室射血分数≤50% 、左室舒张末内径≥70 mm是影响心瓣膜置换后早期死亡的独立危险因素。重视围手术期处理,针对这些因素合理把握手术指征、选择合适的手术方式以及心肌保护,可以进一步降低这类患者手术并发症和病死率。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

组织工程化心肌片层移植心肌梗死大鼠的心功能及电生理变化

背景：组织工程化心肌组织在组成结构上类似于心脏组织的三维电偶联网络和肌肉横纹,而且具有心肌组织样收缩功能,为病损心肌提供了修复的可能性。 目的：观察心肌细胞/胶原复合体移植后心肌梗死大鼠心室肌的心功能及电生理变化。 方法：将成年SD大鼠分为假手术组、模型组、移植组,后2组制作心肌梗死动物模型,假手术组仅开胸,不结扎冠状动脉。移植组移植心肌细胞与胶原材料复合组织,其他2组不进行移植。 结果与结论：①左室心功能：与假手术组相比,模型组左室舒张末期内径、左室收缩末期内径均显著增大(P < 0.01),左室射血分数和左室短轴缩短率显著降低(P < 0.01);移植组左室舒张末期内径、左室收缩末期内径、左室射血分数和左室短轴缩短率均未见明显增大或降低(P > 0.01)。②左室有效不应期变化：与假手术组相比,模型组梗死周边区有效不应期显著缩短(P < 0.01);移植组梗死周边区有效不应期较模型组延长,差异有显著性意义(P < 0.01)。③Cx43免疫荧光结果：假手术组、模型组和移植组大鼠缝隙连接蛋白43阳性表达依次呈现阳性,弱阳性,弱阳性。但移植组缝隙连接蛋白43阳性表达高于模型组。结果可见移植的心肌细胞/胶原复合体在组织和结构上形成电偶联网络和收缩偶联,能改善心肌梗死大鼠心室肌的收缩功能及电生理特性。     

不同左心室构型甲亢性心肌病模型兔血浆B型脑钠肽与心功能的关系

背景：随着甲状腺功能亢进症(简称甲亢)发病率的增加,过量的甲状腺激素对心肌的毒害作用不容忽视,而B型脑钠肽作为心衰定量标志物,对甲亢性心肌病的心功能及心肌损害程度的早期估测有着良好的应用前景。目的：探索不同左心室构型兔甲亢性心肌病血浆B型脑钠肽水平变化及其与心功能的相关性。方法：随机取20只新西兰纯种白兔,连续4周腹腔注射左旋甲状腺激素(45 μg/kg),建立甲亢动物模型。出现易怒好斗、体质量减轻、饮食量增加等典型的甲亢症状兔为成功建模的实验兔共18只。对甲亢模型兔超声测量左心室数据,然后按照Ganau等的标准将此18只甲亢模型兔分为向心性肥厚组(n=7)与离心性肥厚组(n=11)。另10只兔每天腹腔注射5 mL生理盐水作为对照组。结果与结论：向心性肥厚组和离心性肥厚组血浆B型脑钠肽水平明显高于对照组(P < 0.01),而离心性肥厚组较向心性肥厚组血浆B型脑钠肽水平明显升高(P < 0.01)。与对照组相比,向心性肥厚组及离心性肥厚组二尖瓣环平均舒张期峰值血流速度减低(P < 0.01),同时离心性肥厚组二尖瓣环平均收缩期峰值血流速度亦减低 (P < 0.01)。B型脑钠肽与舒张期峰值速度及收缩期峰值速度呈负相关(均P < 0.01)。提示不同左心室构型甲亢性心肌病兔的血浆B型脑钠肽水平可较敏感的反映心功能的变化及其心肌损害程度。中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

冠脉内注射重组人脑利钠肽对AMI合并心衰患者PCI术后心功能的影响

目的 研究冠脉内注射重组人脑利钠肽对AMI合并心衰患者PCI术后心功能的影响.方法 将急性前壁心肌梗死合并心力衰竭的患者皆接受PCI治疗,并随机分为脑利钠肽组和对照组,脑利钠肽组予冠脉内注射脑利钠肽后予脑利钠肽连续静滴72h,其余同常规治疗,对照组给予常规治疗,随诊8周观察两组患者临床疗效、左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)情况.结果 两组临床疗效比较,治疗组较对照组疗效更佳(P<0.05);两组左室舒张末直径(LVEDD)同治疗前比较均无显著性差异(P>0.05),两组左室射血分数均较治疗前明显改善(P<0.05),但治疗组更优.结论 冠脉内注射重组人脑利钠肽可明显改善AMI患者PCI术后近期心功能.     

真武汤加味对冠心病心力衰竭患者左心功能的影响

目的：评价真武汤加味对冠心病心力衰竭患者左心功能的影响。方法：100例冠心病心力衰竭患者随机分为治疗组和对照组,各50例。对照组用西医常规药物治疗,治疗组用西医常规药物加真武汤加味治疗,于入院当天和入院第90天行二维超声心动图测量,计算左心室舒张末内径、左心室收缩末内径和左室射血分数,并抽血检查血浆N端脑钠肽前体水平的变化。结果：与治疗前比较,两组的左心室舒张和收缩末内径均显著缩小（均P〈0．01）,左心室射血分数均明显增加（均P〈0．01）,血浆N端脑钠肽前体水平均显著降低（均P〈0．01）,用药后治疗组各指标改善明显优于对照组（均P〈0．011。结论：西医常规药物加真武汤加味治疗可以显著改善冠心病心力衰竭患者的左心功能和心室重构。     

粒细胞集落刺激因子动员2型糖尿病患者外周血CD34+细胞的变化

背景：与正常人比较,2型糖尿病患者外周血CD34+细胞含量已有明显下降。 目的：分析2型糖尿病患者外周血动员后CD34+细胞比例的变化。 方法：将234例2型糖尿病患者按病程分为5组(<1年,1~5年,>5~<10年,10~15年和≥15年),予以粒细胞集落刺激因子动员。动员5 d后,使用流式细胞仪检测外周血CD34⁺细胞的含量,并利用Person简单相关及多元回归方法分析其与病程、血脂、尿酸的关系。 结果与结论：糖尿病者外周血动员后CD34⁺细胞水平与三酰甘油相关(r=-0.202,P=0.002),与载脂蛋白B相关(r=-0.276,P=0.000),与尿酸相关(r=-0.297,P=0.000)。经统计分析发现,糖尿病者外周血动员后CD34⁺细胞数随糖尿病病程进展而逐渐下降。     

自体骨髓间充质干细胞移植修复无功能心肌的对比

背景：目前有关干细胞技术的临床试验多集中在心肌梗死方面,对原发性心肌病研究尚少,且尚未见到两者对比的相关报道。 目的：比较自体骨髓间充质干细胞经冠状动脉内移植修复缺血及非缺血所致无功能心肌的有效性及安全性。 方法：38例拟行择期经皮冠状动脉介入治疗的急性心肌梗死患者随机分为对照A组与试验A组,36例扩张型心肌病患者随机分为对照B组与试验B组。对照组与试验组在介入治疗后分别通过大腔导管于相应冠状动脉内注入等量生理盐水与骨髓间充质干细胞。 结果与结论：移植后1个月试验组左室射血分数较移植前和对照组显著升高(P < 0.05);移植后3个月试验组左室射血分数较移植前和对照组明显升高、心肌灌注缺损面积百分比较移植前和对照组明显降低(P < 0.05),而试验组间仅左室射血分数差异有显著性意义(P < 0.05);试验A组左室舒张末期内径较移植前、对照A组和试验B组均明显减小(P < 0.05),而试验B组仅较移植前明显降低(P < 0.05)。随访期间恶性心血管事件发生率在试验组和对照组间无显著性差异(P > 0.05)。提示经冠状动脉途径行骨髓间充质干细胞移植对无功能心肌的修复是安全有效的,且对急性心肌梗死的疗效优于扩张型心肌病。     

血浆脑利钠肽浓度与心室重构的关系

目的研究血浆脑利钠肽(BNP)浓度与心脏射血分数(EF)、左室收缩(LVSD)及舒张内径(LVED)、左室后壁及室间隔厚度、左房内径、心功能的关系。方法对547例患者测定血浆脑利钠肽浓度,行超声心动图检查,测量心脏射血分数、左室后壁及室间隔厚度、左室收缩及舒张内径、左房内径。结果547例患者BNP值均数为(558.5±838.08)pg/ml。有305例做了心超检查,其中测EF值304例,作E、A峰比较214例,窦性心律388例,房颤者154例。病情恶化29例,好转512例。LGBNP(BNP值以10为底的对数值)与EF值呈显著负相关,与左室后壁及室间隔厚度、左室收缩及舒张内径、左房内径、心功能显著相关;在房颤和窦性心律的病人中LGBNP相关不显著。在病情好转及恶化的病人中LGBNP相关显著。结论血浆BNP水平能较好地反映心衰病人的心功能及心脏结构的状况。     

人工腱索移植和马鞍环环缩修复退行性二尖瓣关闭不全

背景：人工腱索移植是二尖瓣成形的难点,瓣环环缩也是二尖瓣成形术式中的关键步骤之一,而目前国内相关此类治疗方法的安全性、有效性和中期疗效的较大样本报道较少。目的：总结二尖瓣人工腱索移植和马鞍环环缩技术治疗退行性二尖瓣关闭不全的有效性和安全性。方法：2009年1月至2013年5月间解放军沈阳军区总医院心血管外科应用人工腱索移植和马鞍环环缩技术治疗退行性二尖瓣关闭不全患者85例。用Gore-Tex缝线作为人工腱索,马鞍环用SJM^TM刚性鞍形成形环。共行人工腱索移植41例、人工腱索移植+后叶楔形切除21例、人工腱索移植+后叶楔形切除+Sliding技术23例。均行人工瓣环环缩术。结果与结论：治疗后随访78例,随访率为 91.7%(78/85)。随访时间为6个月-4年。78例中,1例于治疗后13个月死于脑梗死,1例死于交通事故,余76例均存活。NYHA心功能分级Ⅰ级59例,Ⅱ级17例。复查心脏彩超示微量及以下反流67例,轻度反流9例。超声心动图显示左心房直径明显减少(P < 0.05或P < 0.01),左心室舒张末期内径明显减少(P < 0.05或P < 0.01),左心室收缩末期内径明显减少(P < 0.05或P < 0.01),反流速面积/左房面积明显减少(P < 0.05或P < 0.01),肺动脉平均压明显降低(P < 0.05或P < 0.01),射血分数明显增加(P < 0.05或P < 0.01)。未出现二尖瓣收缩期前向运动现象(SAM征)。并发症情况：治疗后出现窦性心动过缓12例,阵发性室上性心动过速25例。1例治疗前伴快-慢综合征患者,治疗后安装永久起搏器。1例治疗后1周出现延迟性心包填塞,经心包穿刺置管引流后治愈。无成形环断裂或撕脱、无溶血、左室流出道梗塞、人工腱索断裂或劈裂发生。无再次手术行瓣膜置换患者。结果可见二尖瓣人工腱索移植和马鞍环环缩治疗退行性二尖瓣关闭不全安全、有效,近中期疗效满意。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

外周血间充质干细胞移植心肌梗死兔新生血管及心功能的变化

背景：药物治疗和支架置入治疗尚不能修复心肌梗死后已坏死的心肌。 目的：观察外周血间充质干细胞移植治疗对心肌梗死兔新生血管及心功能的影响。 方法：随机抽签法将36只大白兔分为假手术组,间充质干细胞移植组和对照组,结扎兔冠状动脉左室支建立心肌梗死模型。 结果与结论：移植后4周,流式细胞仪分析显示绝大部分间充质干细胞表达CD44,极少量细胞表达CD34和CD45。间充质干细胞移植组梗死心肌组织有移植的间充质干细胞存活,超声心动仪示间充质干细胞移植组左心室射血分数及短轴缩短率明显高于对照组(P < 0.01);左心室收缩末内径和舒张末内径明显小于对照组(P < 0.01)。间充质干细胞移植组心肌纤维化程度、心肌梗死面积均明显小于对照组(P < 0.01)。免疫组织化学染色显示间充质干细胞移植组新生毛细血管密度明显高于对照组(P < 0.01)。提示外周血间充质干细胞移植增加了梗死心肌新生血管密度,改善心脏的功能。     

Effect of intracoronary shunt on right ventricular function during off-pump grafting of dominant right coronary artery with poor collateral

Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.     

Surgical Myocardial Revascularization of Patients with Ischemic Cardiomyopathy and Severe Left Ventricular Disfunction

OBJECTIVE:

To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction.

METHODS:

Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis.

RESULTS:

Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27±8%/23±7% to 37±5%/31±6%, p <0.001.

CONCLUSIONS:

In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.     

Off-pump coronary artery bypass surgery in selected patients is superior to the conventional approach for patients with severely depressed left ventricular function

OBJECTIVES:

Patients with coronary artery disease and left ventricular dysfunction have high mortality when kept in clinical treatment. Coronary artery bypass grafting can improve survival and the quality of life. Recently, revascularization without cardiopulmonary bypass has been presented as a viable alternative. The aim of this study is to compare patients with left ventricular ejection fractions of less than 20% who underwent coronary artery bypass graft with or without cardiopulmonary bypass.

METHODS:

From January 2001 to December 2005, 217 nonrandomized, consecutive, and nonselected patients with an ejection fraction less than or equal to 20% underwent coronary artery bypass graft surgery with (112) or without (off-pump) (105) the use of cardiopulmonary bypass. We studied demographic, operative, and postoperative data.

RESULTS:

There were no demographic differences between groups. The outcome variables showed similar graft numbers in both groups. Mortality was 12.5% in the cardiopulmonary bypass group and 3.8% in the off-pump group. Postoperative complications were statistically different (cardiopulmonary bypass versus off-pump): total length of hospital stay (days)—11.3 vs. 7.2, length of ICU stay (days)—3.7 vs. 2.1, pulmonary complications—10.7% vs. 2.8%, intubation time (hours)—22 vs. 10, postoperative bleeding (mL)—654 vs. 440, acute renal failure—8.9% vs. 1.9% and left-ventricle ejection fraction before discharge—22% vs. 29%.

CONCLUSION:

Coronary artery bypass grafting without cardiopulmonary bypass in selected patients with severe left ventricular dysfunction is valid and safe and promotes less mortality and morbidity compared with conventional operations.     

Outcomes of Off-Pump Coronary Bypass Grafting with the Bilateral Internal Thoracic Artery for Left Ventricular Dysfunction

This study evaluated the outcomes of off-pump coronary artery bypass surgery (OPCAB) with severe left ventricular dysfunction using composite bilateral internal thoracic artery grafting. From January 2001 to December 2008, 1,842 patients underwent primary isolated OPCAB with composite bilateral internal thoracic artery grafting. A total of 131 of these patients were diagnosed with a severely depressed preoperative left ventricle ejection fraction (LVEF) (≤0.35). These patient outcomes were compared with the outcomes of 830 patients that had mildly or moderately depressed LVEF (0.36 to 0.59) and 881 patients with normal LVEF (>0.6). The early mortality for patients with severe LVEF was 2.3%. The 3-yr and 7-yr survival rate for patients with severe LV dysfunction was 86.0% and 82.8%, respectively. Multivariate analysis showed that severe LV dysfunction EF increased the risk of all-cause death (P=0.012; hazard ratio [HR],2.14; 95% confidence interval [CI],1.19-3.88) and the risk of cardiac-related death (P=0.008; HR,3.38; 95% CI, 1.37-8.341). The study identified positive surgical outcomes of OPCAB, although severe LVEF was associated with two-fold increase in mortality risk compared with patients who had normal LVEF.     

重组人脑利钠肽用于重症急性心肌炎伴 心力衰竭患者治疗的临床研究

目的 研究重组人脑利钠肽应用于重症急性心肌炎伴心力衰竭患者在临床治疗的效果。方法 选取我院2014年1月~2017年6月收治的98例急性心肌炎合并心力衰竭患者,并随机均分为实验组和对照组,每组49例。对照组行常规的抗心力衰竭治疗,实验组在对照组的基础上行静脉泵入重组人脑利钠肽。72 h后测定两组患者用药前后血清N末端脑钠肽前体水平、左室射血分数和Supper-Score的评分。结果 72 h后两组患者N末端脑钠肽前提水平均:用药前>对照组>实验组,左室射血分数:实验组>对照组>用药前,差异存在统计学意义（P<0.05）,两组患者用药前N末端脑钠肽前体水平、左室射血分数的差异,无统计学意义（P>0.05）。结论 重组人脑利钠肽应用于重症急性心肌炎伴心力衰竭患者的疗效显著,可推广应用。     

AMI患者血浆NT-proBNP含量的变化及其与心功能的相关性研究

目的:探讨急性心肌梗死(AMI)患者血浆N末端脑钠肽原(NT-proBNP)水平的变化及其与心功能指标的相关性.方法:采用荧光免疫分析对189例AMI患者及55例健康对照者进行血浆NT-proBNP测定,同时以彩色多普勒超声心电动仪测定AMI患者左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)、左心室...     

Ventricular expression of atrial and brain natriuretic peptides in dilated cardiomyopathy. An immunohistocytochemical study of the endomyocardial biopsy specimens using specific monoclonal antibodies.

Although brain natriuretic peptide is expressed in ventricles of failing hearts including dilated cardiomyopathy, its morphological localization is still unclear. In this study, we analyzed the immunohistocytochemical localization of atrial and brain natriuretic peptides in ventricles of dilated cardiomyopathy at both light and electron microscopic levels. Ventricular specimens were obtained by endomyocardial biopsy in 31 patients (26 with dilated cardiomyopathy and 5 controls without any specific cardiac disease). By light microscopic immunohistochemistry using specific monoclonal antibodies, all (26 of 26) of the left ventricular endomyocardial biopsy specimens and 31% (8 of 26) of the right ventricular specimens showed immunoreactivity for both of these natriuretic peptides in dilated cardiomyopathy. In contrast, none of the normal controls showed immunoreactivity for either of these peptides. The percentage of atrial natriuretic peptide-containing or brain natriuretic peptide-containing myocytes in the left ventricular specimens showed an inverse correlation with the left ventricular ejection fraction (r = -0.72 and r = -0.69, respectively). By electron microscopy, we identified specific secretory granules in ventricular myocytes from patients with dilated cardiomyopathy, but not in those from normal controls. Double immunocytochemistry using a two-face immunogold staining method revealed brain natriuretic peptide colocalized with atrial natriuretic peptide in the same ventricular granules. These findings suggest that brain natriuretic peptide is expressed in ventricular myocytes in response to hemodynamic stress in dilated cardiomyopathy. Brain natriuretic peptide may be, at least in part, synthesized simultaneously and secreted together with atrial natriuretic peptide by granules from failing ventricles, although the secretory turnover is different between these two peptides.