经股静脉系统射频消融治疗左侧旁路并室上性心动过速48例

目的射频消融术是目前预防和治疗室上性心动过速的首选方法,创伤小,成功率高,并发症少。目前常规经锁骨下静脉置入冠状静脉窦电极作为参考电极,经主动脉逆行法进行标测和消融左侧旁路并室上性心动过速。本文报道48例经股静脉置入冠状静脉窦电极,并经股静脉穿刺房间隔置入大头导管,全股静脉系统进行标测和消融左侧旁路并室上性心动过速的经验。方法 48例患者,男31例,女17例,年龄年龄(45±18)岁。所有患者均有反复发作心慌、心悸数月至10多年的病史,有室上性心动过速心电图记录证据,其中15例显性预激。8例合并高血压病,1例二尖瓣狭窄,1例房间隔缺损。所有患者行胸片、超声心动图及血生化,甲状腺功能检测。并签署知情同意书。局麻下,穿刺左右股静脉,置入冠状静脉窦(CS)、希氏束(HBE)和右心室(RV)电极,行心内电生理检查。电生理检测明确左侧旁路并室上性心动过速,则行房间隔穿刺(图)。右股静脉穿刺成功后,送入SL1的Swartz鞘,成功穿刺房间隔后,鞘管内注射肝素5000U抗凝,之后每1小时静脉推注肝素1000 U。经Swarts鞘送入3.5 mm温控消融导管至二尖瓣环进行标测,标测到A、V或VA融合处放电消融。成功标准:心室起搏VA分离,无心动过速发作。术后卧床12 h。结果所有患者均一次消融成功,手术时间(66±25)min,暴光时间(32±15)min,其中左侧游离壁38例,左后间隔7例,心外膜旁路2例。术中及术后均未出现出血、血肿、心包填塞、恶性心律失常等并发症。复发1例,再次消融成功。结论经全股静脉系统进行标测和消融左侧旁路并室上性心动过速,安全有效,并发症低,患者卧床时间短。     

射频导管消融治疗伴发于Ebstein畸形的房室折返性心动过速

目的为治疗伴发于Ebstein畸形的阵发性室上性心动过速,我们对4例患者进行了射频导管消融。方法4例伴发于Ebstein畸形的阵发性室上性心动过速患者,年龄25～34岁,药物治疗效果不佳或不能耐受,遂进行电生理检查和射频导管消融。结果4例患者经心内电生理检查均证实为右侧旁路房室折返性心动过速。理想的消融靶点位于房室环、心内AV波大致相等处,其AV波间距较长。全部患者的射频导管消融均获成功。结论射频导管消融通过阻断右侧旁路而治愈伴发于Ebstein畸形的室上性心动过速。正确认识其解剖和电生理特点,是消融成功的关键。     

永存左上腔静脉畸形伴房室结折返性心动过速射频消融2例报告

阵发性室上性心动过速通常见于无器质性心脏病患者 ,但合并有先天性心脏病如房间隔缺损、室间隔缺损、埃布斯坦综合征者也屡有报告［１］。本文报告本院自１９９５年９月开展射频导管消融以来所发现的２例永存左上腔静脉畸形合并房室结折返性心动过速 ,至今国内少有文献报告。临床资料例１患者女性 ,２２岁。临床诊断 :阵发性室上性心动过速。行心内电生理检查及射频消融。局麻后经股静脉置入６Ｆ４极电生理标测导管至高位右心房 (ＨＲＡ)、希氏束 (Ｈｉｓ)、右心室心尖部 (ＲＶ)。经左锁骨下静脉穿刺送入导引钢丝 ,见导引钢丝经左锁骨下静…     

儿童心律失常的射频消融治疗

目的总结儿童心律失常患儿射频消融的疗效。方法回顾性研究2016年1月1日至2018年9月30日期间,因心律失常接受心内电生理检查+射频消融术治疗患儿的心律失常类型及疗效。结果 95例患儿进行了电生理检查,其中4例在术中未诱发心律失常,未行射频消融治疗。91例患儿中,阵发性室上性心动过速67例,其中房室折返性心动过速48例、房室结折返性心动过速19例,房性心动过速3例,室性心律失常21例。91例患儿射频消融术后随访(15±8)个月。84例消融成功,成功率92.31%;复发7例(7.69%),其中左侧隐匿性旁路复发3例(3/16),B型预激复发1例(1/23),左后分支室性心动过速3例(3/7)。只有1例患儿出现股浅动脉闭塞的并发症。结论射频消融治疗患儿心律失常安全有效。     

下腔静脉与奇静脉异位连接合并左侧旁道射频消融一例

患者女,69岁。诊断阵发性室上性心动过速,行电生理检查,穿刺右侧股静脉送入电生理标测导管的过程中,肝下段不能通过,行下腔静脉造影发现下腔静脉下段缺如。行左锁骨下静脉造影不能显现下腔静脉。电生理标测证实该例为左侧旁道参与的心动过速,经右股动脉穿刺逆行消融旁道成功。     

射频消融的延迟效应及其临床意义(附2例报道)

目的评价射频消融阵发性室上性心动过速的延迟作用及其临床意义.方法 2例顽固性阵发性室上性心动过速患者住院行射频消融术.例1女性,15岁,预激综合征,体表心电图及心内电生理检查示左侧旁路.例2男性,体表心电图正常,心内电生理检查证实为左侧房室旁路.结果在消融放电时,2例患者的房室旁路均可被阻断,但都因停止放电后旁路多次复发而致术中消融失败.例1术后一天预激消失,例2术后第七天重复心内电生理检查无旁路传导.平均随访7个月无心动过速复发.结论射频能量对心脏的作用,不仅发生在释放能量的当时,而且可延迟到术后一段时间.     

射频导管消融360例儿童心律失常的疗效和安全性

目的 评价射频导管消融360例儿童心律失常的疗效和安全性。方法 回顾性分析2000年1月2013年12月360例因心律失常在我院接受射频导管消融的儿童患者360(男213例、女147)例,年龄15个月14(10±3)岁,平均体质量34 kg。结果 急性期消融成功率98.9%(356/360例),4例消融失败。360例患者中,阵发性室上性心动过速308例,占85.6%,307例(99.7%)患者消融成功,其中隐匿性房室旁路伴房室折返性心动过速121例、显性旁路(预激综合征)82例、房室结折返性心动过速105例;室性心律失常42例,其中室性早搏15例(均消融成功),27例室性心动过速(其中4例并发结构性心脏病,25例消融成功);房性心律失常10例(9例消融成功,其中典型心房扑动3例,不典型心房扑动1例,局灶性房性心动过速6例)。所有患儿围术期均未出现明重要并发症。术后随访至少12个月,随访期复发率为2.2%(8/356例),其中6例经再次消融成功。结论 射频导管消融术治疗有适应证的心律失常儿童安全有效。     

射频消融治疗儿童室上性心动过速的临床疗效评价

目的 探讨经导管射频消融术治疗儿童室上性心动过速的安全性和有效性.方法 回顾分析了本院39例室上性心动过速儿童射频消融治疗情况.结果 39例患儿均未发现器质性心脏病,其中男21例,女18例;年龄4.7～18.4(11.0±3.5)岁.心内电生理检查证实房室折返25例(64.1％),房室结折返11例(28.2％),持续性房速3例(7.7％).25例房室折返患儿中,显性旁道12例,隐匿性旁道13例;左侧游离壁旁道9例,右侧游离壁旁道8例,右侧间隔旁道8例.本组消融成功率37例(94.9％),2例复发(5.1％),术后随访所有患儿无消融相关并发症的发生.结论 经导管射频消融术治疗儿童室上性心动过速是安全、有效的.     

心外膜房室旁路的射频导管消融

目的 探讨不同部位心外膜房室旁路(AP)的电生理特点及射频导管消融的方法学及结果.方法 36例心外膜AP患者,男性17例,年龄9～74岁,均伴房室折返性心动过速,7例有1～3次导管消融失败病史,经心内膜途径标测无理想消融靶点和/或经导管消融失败后,分别经冠状静脉系统(尤心中静脉)、无冠窦、右心耳、右侧游离壁标测到理想AP电位或AV(VA)相对最近或融合处,应用普通射频导管或换用盐水灌注射频导管,分别于上述部位消融.结果 36例中,在心脏静脉系统内消融成功28例,其中25例在心中静脉内或其口部附近消融成功;无冠窦内消融成功1例;右心耳内消融成功2例,其中1例复发后再次消融失败,最终经心外科手术成功;5例右侧游离壁心外膜AP,经沿三尖瓣环心房侧线性消融成功电隔离AP 4例,失败1例.结论 心外膜AP的发生率为1.9%,多数(78%)位于心脏静脉系统(尤心中静脉)内,部分位于右侧游离壁,心耳内或无冠窦内罕见.术前通过分析体表心电图预激波极性可预测多数伴显性预激的心脏静脉系统心外膜旁路,在经心内膜标测和/或导管消融AP过程中如有疑问时应注意排除心外膜AP.盐水灌注射频导管可能有助于提高心外膜AP的消融成功率.     

心外膜房室旁路的经射频导管消融

目的探讨不同部位心外膜房室旁路(AP)的电生理特点及射频导管消融的方法学及结果。方法本中心经心电生理检查和射频导管消融证实的AP患者1865例(共1972条AP)中,36例心外膜AP患者,男17例,年龄9-74岁,均伴房室折返性心动过速,7例有1-3次导管消融失败病史,经心内膜途径标测无理想消融靶点和(或)经导管消融失败后,分别经冠状静脉系统(尤心中静脉)、无冠窦、右心耳、右侧游离壁标测到理想AP电位或A-V(V-A)相对最近或融合处,应用普通射频导管或换用盐水灌注射频导管,分别于上述部位消融。结果 36例中,在冠状静脉系统内消融成功28例,其中25例在心中静脉内或其口部附近消融成功,其余2例和1例分别在心后静脉内和心大静脉远端消融成功;无冠窦内消融成功1例,此例患者心动过速时消融导管标测提示逆向心房激动最早点位于前间隔希氏束附近,在此处及二尖瓣环前壁有较早心房激动时间处消融均无效,最后在主动脉无冠窦内应用盐水灌注射频导管消融成功;右心耳内消融成功2例,其中1例复发后再次消融失败,最终经心外科手术成功;5例右侧游离壁心外膜AP,4例有1～2次消融失败或复发病史,其AP均位于三尖瓣环7～9点处,局部标测前向或逆向旁路传导均无理想消融靶点,换用盐水灌注射频导管和/或CARTO电解剖标测系统,沿三尖瓣环心房侧较大范围线性消融以试图电隔离AP传导,最后4例消融成功,失败1例。结论心外膜AP的发生率为1.9%,多数(78%)位于心脏静脉系统(尤心中静脉)内,部分位于右侧游离壁,心耳内或无冠窦内罕见。术前通过分析体表心电图预激波极性可预测多数伴显性预激的心脏静脉系统心外膜旁路,在经心内膜标测或(和)导管消融AP过程中如有疑问时应注意排除心外膜AP。盐水灌注射频导管可能有助于提高心外膜AP的消融成功率。     

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.     

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.     

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.     

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.