风湿性心瓣膜病患者的心肌超微结构损害与临床相关因素探讨

本文对８４例风湿性心瓣膜病患者心肌超微结构进行了观察，心肌超微结构损害程度达Ⅰ级２７例、Ⅱ级２０例、Ⅲ级１７例。经直线相关分析，心肌超微结构改变与病程、心衰史、心房纤颤有显著正相关关系，与ＮＹＨＡ心功能分级无相关性。作者认为，ＮＹＨＡ心功能分级尚不能反映心肌超微结构损害程度。风湿性心瓣膜病病人出现心衰、心房纤颤，且靠强心利尿剂维持心脏代偿功能，提示心肌已有明显病理损害表现，应及早手术治疗。     

前负荷再充盈搏功在评价瓣膜病围术期左心功能中的应用

目的评价不受左心室负荷影响而较客观地反映其心肌收缩性能的指标，前负荷再充盈搏功（ＰＲＳＷ）在瓣膜病围术期中的应用价值。方法２０例患者中风湿性心脏瓣膜病（ＲＨＤ）组为研究组（ｎ＝１４）；先天性心脏病（ＣＨＤ）组作对照（ｎ＝６）。手术前后以心外膜超声测左心室容积并测左心室压，暂阻断下腔静脉改变左心室前负荷以绘出不同前负荷的左心室压－容积环推导出ＰＲＳＷ。结果ＰＲＳＷ：ＲＨＤ组术前７．９２７±０．５９Ｐａ，术后４．９７±０．６４Ｐａ（Ｐ＜０．０５）；术前ＲＨＤ组与ＣＨＤ对照组无差别，术后明显小于ＣＨＤ组。结论ＰＲＳＷ可用于评价术后瓣膜病左心功能，示心肌收缩性能明显减退     

风心瓣膜病患者血流动力学和左室功能改变与心肌超微结构损害关系探讨

本文对风心瓣膜病患者血流动力学，左室功能和心肌超微结构变化进行了研究：心肌超微结构改变Ⅱ-Ⅲ级组，PsAP,SVR,TSVR,TPVR明显较0－1级组增加；左室功能减退，提示：严重的血流动力学改变加重心肌超微结构损害，并导致左心室功能减退。     

大左心室心脏瓣膜病心瓣膜置换术后疗效及危险因素分析

目的探讨大左心室心脏瓣膜病心瓣膜置换术后疗效及危险因素,以提高手术疗效。方法回顾性分析2009年1月至2012年12月期间华中科技大学同济医学院附属协和医院144例大左心室心脏瓣膜病患者行心瓣膜置换术的临床资料,其中男116例、女28例,年龄15~69（44.9±11.9）岁;病程1个月~40年,平均病程（57.8±98.3）个月。风湿性心脏瓣膜病92例,退行性心脏瓣膜病28例,先天性心脏瓣膜病15例,感染性心内膜炎9例。对存活出院的137例患者进行随访,用t检验、卡方检验或Fisher′s精确概率法及logistic回归分析,探讨大左心室心脏瓣膜病患者行心瓣膜置换术后早期住院死亡、主要并发症发生及远期死亡的危险因素。采用寿命表生存率法计算术后远期生存率,并绘制生存曲线。结果术后早期主要并发症为低心排血量综合征19例（13.2%）,室性心律失常56例（38.9%）,人工瓣膜瓣周漏7例（4.9%）,胸腔积液33例（22.9%）,心包积液8例（5.6%）,肝功能不全23例（16.0%）,肾功能不全5例（3.5%）。术后早期住院死亡7例,死亡率4.9%。Logistic单因素分析显示：年龄〉50岁、风湿性心脏瓣膜病、术前心功能分级（NYHA）高（Ⅲ级或Ⅳ级）、病程长、术前左心功能低下[左心室射血分数（LVEF）〈40%]、双瓣膜置换术、合并其他心脏手术、体外循环及主动脉阻断时间长、术后低心排血量综合征和术后室性心律失常是大左心室心脏瓣膜病患者心瓣膜置换术后早期住院死亡的危险因素（P〈0.05）;Logistic多因素回归分析结果显示：年龄〉50岁、病程时间长、术前心功能分级（NYHA）高（Ⅳ级）、术前左心功能低下（LVEF〈40%）、双瓣膜置换术、体外循环时间长是术后早期住院死亡的危险因素（P〈0.05）。Logistic多因素回归分析结果显示：术前心功能分级（NYHA）高（Ⅲ级或Ⅳ级）、合并其他心脏手术、术前左心?     

左心室及双心室辅助装置对缺血心肌的影响

目的 比较左心室辅助装置（LVAD）和双心室辅助装置（BVAD）对缺血心肌再灌注后心脏血流动力学、心肌能量代谢物质和心肌超微结构中线粒体形态的影响。方法 将16只绵羊随机分为LVAD组和BVAD组,每组8只,常温阻断升主动脉25分钟,造成双心室缺血损伤的动物模型。结扎右颈内动脉远端,在心脏复跳后应用转子泵分别行LVAD（左心室－右颈内动脉径路）和BVAD（左心室－右颈内动脉和右心室－肺动脉径路）辅助循环120分钟,测定血流动力学,心肌三磷酸腺苷、磷酸肌酸、观察心肌超微结构变化。结果 施行BVAD或LVAD辅助循环的同时增加容量负荷能够显著改善心脏血流动力学,但LVAD组右心房压显著高于BVAD组（P＜0．05）;BVAD组右心室心肌三磷酸腺苷、磷酸肌酸含量和心肌线粒体比表面值均高于LVAD组（P＜0．05）。结论 BVAD与LVAD更有助于促进双心室缺血损伤心肌的功能恢复。     

肠道病毒感染与慢性风湿性瓣膜病发病的关系

为了探讨肠道病毒感染在风湿性心脏病发病中的作用,通过应用套式聚合酶链反应对63例慢性风湿性瓣膜病二尖瓣或主动脉瓣手术标本进行肠道病毒基因检测,发现24例患者二尖瓣膜组织中存在肠道病毒基因,而9例脑外伤患者瓣膜组织对照均为阴性,由于取材前无呼吸道、肠道感染史,表明患者瓣膜组织中存在肠道病毒感染或持续感染。心肌中肠道病毒持续感染为其慢性持续性损害的原因,部分慢性风湿性瓣膜病患者可能亦存在相似的致病机制。本研究揭示肠道病毒感染或持续可能是部分风湿性瓣膜病发病的原因之一。     

40例风湿性心脏瓣膜病人工瓣膜置换术临床应用观察

目的分析比较人工瓣膜置换术与二尖瓣分离术治疗风湿性心脏瓣膜病的临床效果。方法选取2012-01—2014-12间在郑州市第七人民医院确诊收治的80例风湿性心脏瓣膜病患者作为研究对象。将患者随机分为2组,各40例。对照组给予常规二尖瓣分离术,观察组患者给予人工瓣膜置换术。观察比较2组临床效果。结果患者均未出现明显并发症。观察组患者的体外循环时间和主动脉阻断时间显著短于对照组,差异有统计学意义(P0.05)。结论采用人工心脏瓣膜置换术治疗风湿性心脏瓣膜病,能够有效减少体外循环时间和缩短主动脉阻断时间,疗效确切,具有较高的临床应用价值,可作为治疗风湿性心脏瓣膜病的首选术式。     

心脏不停跳下改良迷宫手术治疗慢性心房颤动

目的：探讨心脏不停跳下施行改良迷宫手术治疗慢性心房颤动的可行性减少严重并发症,提高手术疗效。方法：回顾性总结16例风湿性心瓣膜病合并心房颤动患者,在心脏不停跳下行改良迷宫术的经验。结果：16例患者全部存活。随访3－14个月,14例为窦性心律,2例心房颤动复发;无Ⅲ度房室传导阻滞。结论：心脏不停跳改良迷宫手术有以下优点;（1）心脏不停跳手术有良好的心肌保护作用,可增加手术的安全性。（2）用电热凝代替左心房切口,缩短手术时间,减少出血;（3）无水酒精注射代谢冷冻简单可靠;（4）术中电生理监测对手术有一定的指导意义。     

心肌肌钙蛋白Ⅰ在评价心脏直视手术心肌缺血再灌注损伤的应用

目的探索心脏直视手术中心肌缺血再灌注损伤的快速准确的诊断方法。方法３５例患者按病种分为３组,组１：１０例风湿性心脏瓣膜病患者;组２：１５例先天性心脏病患者;对照组：１０例食管癌或肺癌患者。使用Ｂｅｃｋｍａｍ－ＣｏａｌｔｅｒＡｃｃｅｓｓ微粒子化学发光分析仪及配套试剂于转流前（组３为术前）、术毕、术后８～１２小时、２４小时、７２小时和７天对心肌肌钙蛋白Ⅰ（ｃａｒｄｉａｃｔｒｏｐｏｎｉｎⅠ,ｃＴｎＩ）、磷酸肌酸激酶同工酶（ｃｒｅａｔｉｎｅｋｉｎａｓｅＭＢｍａｓｓ,ＣＫ－ＭＢｍａｓｓ）以及肌红蛋白（ｍｙｏｇｌｏｂｉｎ）３种指标进行检测,其结果结合临床资料和心电图分析比较。结果组１和组２患者都存在不同程度的心肌缺血再灌注损伤,３种检验的敏感性相同;ｃＴｎＩ较ＣＫ－ＭＢｍａｓｓ和肌红蛋白更特异反映心肌损伤;组１主动脉阻断时间长、ｃＴｎＩ浓度升高明显、持续时间也越长,反映了心肌缺血损害较重,与组２比较差异有显著性（Ｐ＜０．０５）。结论ｃＴｎＩ在心脏直视手术心肌缺血再灌注损伤的诊断中具有高度的敏感性和特异性,ｃＴｎＩ浓度反映了心肌损害的程度,并对预后有直接影响。ＣＫ－ＭＢｍａｓｓ和肌红蛋白敏感性与ｃＴｎＩ相同,但特异性较差     

自制SDMC—1液对热缺血冷保存狗心保护的实验研究

为提高心脏离体保存效果，作者研制了ＳＤＭＣ１号（山东医科大学心脏１号）心脏保存液。实验采用狗心异体异位移植。供心先经６分钟常温缺血后，实验组（ｎ＝６）用ＳＤＭＣ１液，对照组（ｎ＝６）用Ｃｏｌｉｎｓ液分别进行心脏灌洗并离体低温保存（４℃）６小时。观察指标：（１）供心再供血至恢复稳定节律时间；（２）电除颤次数；（３）血清肌酸激酶同功酶（ＣＫＭＢ）和丙二醛（ＭＤＡ）；（４）供心左心室功能和心肌超微结构。结果显示：ＳＤＭＣ１液灌洗并单纯低温离体保存的狗心移植后，心电活动和左心室功能恢复快，较Ｃｏｌｉｎｓ液有更好的心肌保护效果。     

七氟醚后处理对换瓣术患者炎性因子及心肌超微结构的影响

目的研究七氟醚后处理对心脏瓣膜置换术患者全身炎性因子和心肌超微结构的影响。方法经心肺转流(CPB)瓣膜置换术患者随机分为七氟醚后处理组(S组)与对照组(C组),每组15例。S组于主动脉开放即刻经CPB输氧装置以2%七氟醚后处理15min,C组不做此处理采取全凭静脉麻醉。测定手术开始时(T1)、主动脉开放后0.5h(T2)、3h(T3)、24h(T4)时血浆IL-6、IL-10浓度,电镜下观察心肌超微结构的变化。结果与C组比较,S组T2～T4时血浆IL-6和IL-10的浓度降低(P<0.05);与T1时比较,T2、T3时两组血浆IL-6与IL-10浓度升高(P<0.05)。结论七氟醚后处理可以降低瓣膜置换术患者CPB后炎性因子的释放,减轻心肌超微结构的损伤,有利于心功能的恢复。     

辅酶Q10在换瓣术中对心肌缺血再灌注损伤的作用

目的：探讨换瓣术ＣＰＢ中ＣｏＱ１０对心肌缺血再灌注损伤的作用。方法：将２４例行体外循环心脏瓣膜置换术患者分为两组。对照组应用冷停跳液灌注，试验组于心肌冷停跳液中加入辅酶Ｑ１０（２ｍｇ／ｋｇ）。观察血浆丙二醛（ＭＤＡ），心肌三磷酸腺苷（ＡＴＰ），能量储备（ＥＣ），心肌超微结构（线粒体计分）。结果：（１）再次证实存在心肌缺血再灌注损伤；（２）试验组较对照组减轻了心肌缺血再灌注过程中血浆ＭＤＡ升高；心肌能量保存较多；超微结构改变较轻。结论：冷停跳液内加入辅酶Ｑ１０能减少氧自由基产生，抗脂质过氧化，稳定细胞膜，改善心肌能量代谢，从而对瓣膜置换术中心肌缺血再灌注损伤产生一定保护作用。为较有效的心肌保护方法，应用于临床是可行的。     

逆行性灌注浅低温氧合血心脏不停跳与冷血心脏停搏液对cTn I的影响

目的　对比研究逆行性灌注浅低温氧合血心脏不停跳与低温冷血心脏停搏液对外周血清心肌肌钙蛋白 I(c Tn I)的影响。　方法　将 18例双瓣膜置换术患者分为心脏不停跳组和心脏停搏组 ,观察围手术期外周血清c Tn I、肌酸激酶 (CK)、肌酸激酶同工酶 (CK- MB)及主动脉阻断前后用透射电子显微镜观察心肌超微结构变化。结果　心脏不停跳组主动脉开放后各个时相点 CK虽略低于心脏停搏组 ,但差别无显著性意义 (P>0 .0 5 ) ;主动脉开放后 6小时 CK- MB明显低于心脏停搏组 (P<0 .0 5 ) ,主动脉开放后各个时相点心脏不停跳组 c Tn I明显低于心脏停搏组 (P<0 .0 5 )。两组患者主动脉阻断前心肌超微结构均有轻度改变 ,主动脉阻断 90分钟心脏停搏组心肌超微结构损伤较心脏不停跳组明显。　结论　逆行性灌注浅低温氧合血心脏不停跳围手术期外周血清 c Tn I较低 ,可能与该方法使体外循环期间发生不可逆损伤的心肌细胞较少 ,心肌超微结构损伤较轻有关。     

Valve replacement in patients with huge heart]

In general, valve replacement for patients with big heart (cardiac-thoracic rate greater than 0.80) has been considered a contraindication. Mitral valve replacement was done in 11 patients with a C/T rate of 0.81 to 0.97. In addition, aortic valve replacement was performed in 2 patients and tricuspid valvuloplasty in 5. One patient died from low cardiac output after operation. The heart function of the survivor was improved from III or IV to II degree after operation. We consider that active pre- and postoperative management for preserving myocardial function and preoperative technique are important for the successful treatment of patients with huge heart.     

Aortic valve replacement. Aortic root versus coronary sinus perfusion with blood cardioplegic solution.

The role of retrograde coronary sinus cardioplegia in patients undergoing aortic valve replacement for aortic stenosis alone or in combination with myocardial revascularization has not been fully defined. Sixty-three patients undergoing elective aortic valve replacement received cold potassium blood cardioplegic solution via either the aortic root (36 patients) or the coronary sinus (27 patients). The patients were similar with respect to age, degree of aortic stenosis, ventricular function, severity of coronary artery disease, crossclamp time, completeness of revascularization, and mean volume and temperature of the infusion solution. The mean septal temperature and the release of myocardium-specific isoenzyme in the first 2 hours after crossclamp removal was higher in the retrograde group (p less than 0.008). Right and left ventricular function was preserved equally in the two groups, and volume-loading studies suggested improved diastolic performance in patients having retrograde cardioplegia. There were no differences between the two groups with respect to clinical outcome. We conclude that coronary sinus cardioplegia is as safe as aortic root perfusion for myocardial preservation in patients undergoing elective aortic valve replacement.     

Ultrastructural study comparing the efficacy of five different methods of intraoperative myocardial protection in the human heart

The quality of myocardial protection during cardiac arrest in cardiac operations was investigated in 310 patients. Eighty patients underwent aortic valve replacement and 230 had coronary artery bypass grafting. Four different cardioplegic solutions (Kirsch, Bretschneider, St. Thomas' Hospital, and Hamburg) and the method of induced fibrillation were tested by ultrastructural analysis of the degree of ischemic injury at the end of the cardiac arrest period. Hypothermia was identical in all five groups. In this study, subendocardial and subepicardial needle biopsies were evaluated by a standardized scoring system. Chemical cardioplegia produced mainly moderate ultrastructural injury independent of the time of ischemia. Kirsch cardioplegia and the intermittent fibrillation procedure produced ischemic injury of greater and unpredictable severity. Only with Kirsch cardioplegia was a correlation observed between the duration of intraoperative arrest and the degree of injury, which is indicative of a lack of myocardial protection. The tolerance to ischemia was significantly better in patients undergoing bypass grafting than in those with aortic valve disease and therefore longstanding hypertrophy. In conclusion, the Bretschneider, St. Thomas' Hospital, and Hamburg solutions provide satisfactory myocardial protection but are not able to completely prevent myocardial ischemic injury. Kirsch cardioplegia and the intermittent fibrillation procedure provide insufficient myocardial protection. Patients with left ventricular hypertrophy are at a greater risk during cardiac operations than patients undergoing coronary bypass operations.     

Surgical treatment of ischemic mitral valve regurgitation.

In cases of old myocardial infarction, the presence of mitral valve regurgitation is one of the predicting factors of long-term prognosis. The mechanism of ischemic mitral regurgitation consists of mitral annular dilatation, left ventricular (LV) dilatation followed by tethering of the mitral valve, etc. Since long-term prognosis of the patients in whom the degree of mitral valve regurgitation is 2+ or more is typically poor, the mitral valve procedure should be considered at the time of coronary artery bypass grafting (CABG) or more. In this type of surgery, the treatment essentially involves the use of an artificial ring implantation as the basic technique. In the chronic stage, a significant degree of mitral regurgitation persists in approximately 20% of the cases if they have been treated by ring annuloplasty alone. Additional surgical procedures that reduce or eradicate the tethering are essential for the control of the regurgitation completely in cases with strong tethering. We recently employed two new surgical techniques, namely, cutting the secondary chordae to the anterior mitral valve leaflet and the anterior and posterior papillary muscle reapproximation. The surgical results of the acute phase appear to be promising; however, the long-term results of such new methods are yet to be determined. If the mitral valve regurgitation cannot be controlled even by various operative techniques of mitral valve repair, mitral valve replacement should be considered. This is because the long-term survival rate of the suboptimal repair surgical patients is lower when compared with that of mitral valve replacement patients.     

Aortic valve replacement and aorta-coronary bypass surgery. Results with perfusion of proximal and distal coronary arteries.

The results in 80 patients undergoing simultaneous aortic valve replacement and aorta-coronary saphenous vein bypass grafting were analyzed to assess the effect of operative technique. The over-all operative mortality rate of 6.3% (five of 80) did not differ significantly from our results with aortic valve replacement alone. All patients who had isolated aortic valve replacement were operated upon with moderate hypothermia. The combined operation was performed in two ways. Thirty-one patients had aortic valve replacement prior to bypass grafting with intermittent coronary ostila perfusion. There were two deaths (6.5%), and five myocardial infarctions (16.1%) were diagnosed by standard electrocardiographic and enzyme criteria. More recently, 49 patients have undergone bypass grafting prior to aortic valve replacement. The proximal ends of the grafts were either anastomosed high on the aortic root or else individually cannulated to provide continuous distal perfusion during subsequent aortic valve replacement, with continuous coronary ostial perfusion. There were three operative deaths (6.1%) and one myocardial infarction (2.0%). The risk of combined aortic valve replacement and coronary bypass need be no greater than the risk of aortic valve replacement alone. Our experience suggests that myocardial perfusion distal to significant coronary artery stenoses reduces the risk of myocardial infarction in patients with coronary artery disease requiring aortic valve replacement.     

The structural examination of myocardial samples from patients with end-stage heart failure supported by ventricular assist devices using electron microscopy and amino acid analysis reveals low degree of reverse remodeling.

BACKGROUND: Chronic heart failure is a multifactorial, progressive disease of many causes and is associated with complex ventricular remodeling. Deposition of extracellular matrix proteins and sarcomeric disarray of the myocytes occur in end-stage heart failure. Ventricular assist devices (VAD), implanted as bridge to transplantation, may reverse ventricular remodeling. Although successfully weaning patients from VAD support has been reported, it is not clear to what degree reversal of remodeling occurs in unloaded failing hearts. Because collagen deposition and ultrastructural disarray are hallmarks of myocardial remodeling, we analyzed the myocardial ultrastructure and collagen content of VAD-supported hearts before and after mechanical unloading. METHODS: We used amino acid analysis to measure collagen content (4-hydroxyproline content) in 24 transplant candidates receiving VAD support. We used transmission electron microscopy to examine the ultrastructure in 6 patients receiving VAD support. RESULTS: The 4-hydroxyproline content increased significantly at VAD implantation and was not altered by mechanical unloading. The ultrastructure showed signs of persisting cardiomyopathy. CONCLUSION: Mechanical unloading does not alter the total collagen content of the supported, failing heart. Thus, structural reversal of the remodeling process associated with heart failure is not a general phenomenon in mechanically unloaded hearts.     

川芎嗪预处理对心肺转流手术患者心肌线粒体变化的影响

目的探讨川芎嗪预处理在心肺转流(CPB)心脏手术中的心肌保护作用。方法28例非发绀型先天性心脏病患者,随机均分为川芎嗪预处理组(川芎嗪组)和对照组。川芎嗪组麻醉诱导后经颈内静脉滴入川芎嗪3mg/kg,30min内滴完,CPB期追加1mg/kg于氧合器中;对照组给予等量生理盐水。分别于CPB前和CPB后(主动脉开放后30min)取右心耳心肌组织,应用电镜技术观察心肌超微结构和心肌线粒体变化。结果川芎嗪组心肌超微结构受损较对照组为轻。川芎嗪组CPB后心肌线粒体记分明显低于对照组(P<0.05)。结论川芎嗪预处理有较好的内源性心肌保护作用。