冠状动脉旁路移植术合并同期瓣膜手术患者256例经验总结

目的探讨同期施行冠状动脉旁路移植术和瓣膜手术的方法、疗效及影响因素。方法回顾分析256例行冠状动脉旁路移植术时同期行瓣膜手术患者的临床资料，着重分析手术方法、结果和随访情况。结果手术即刻成功率100％（256／256），早期死亡率5．8％（15／256），共移植血管452支，平均每例移植血管（1．8±1．2）支，术后呼吸机使用时间为（22．0±6．8）h，重症监护病房临护（2．8±1．2）d，住院时间（14．2±3．1）d。生存率为90％（217／241），随访3个月～13年，2例死亡，13例冠状动脉需再干预治疗。术后心功能Ⅰ级158例，Ⅱ级65例。结论冠状动脉旁路移植术同期行瓣膜手术的近、远期疗效良好，此术式是安全和有效的。     

冠状动脉旁路移植术同期行瓣膜手术临床分析

目的总结在冠状动脉旁路移植术同期行心脏瓣膜手术的临床经验。方法30例患者在冠状动脉旁路移植术同期进行瓣膜手术,年龄40-76（62．9±10．4）岁。其中缺血性瓣膜病变22例,风湿性瓣膜病变8例。术前冠状动脉造影诊断26例,术中发现冠脉严重病变4例。全组共移植血管133支（平均4．43支）。同期行主动脉瓣置换术3例、二尖瓣置换术12例、二尖瓣成形术8例、双瓣膜手术7例。结果术后住院死亡1例（3．3％）,死于严重低心排血量。术后心功能Ⅰ级22例、Ⅱ级7例,均较术前明显改善。结论同期行冠状动脉旁路移植术和瓣膜手术安全、有效。冠心病与心脏瓣膜病同时存在明显加重了心肌损害,完善纠治瓣膜病变、充分心肌再血管化和严格的术中心肌保护是手术成功的关键。     

序贯旁路移植同期行内膜剥脱在非体外循环冠脉搭桥术中的应用

目的:回顾性总结非体外循环下序贯旁路移植技术同期行内膜剥脱治疗严重弥漫性冠状动脉病变的临床疗效. 方法:52例冠心病患者接受非体外循环下冠状动脉旁路移植术,桥血管吻合采用序贯旁路移植技术,并同期行内膜剥脱完善再血管化治疗.分析所有病例的围手术期临床资料,中期随访不良事件的发生率,冠状动脉CTA评价桥血管及吻合口的通畅程度. 结果:52例病例共接受移植物82支,平均搭桥(1.6±1.2)支.同期共行内膜剥脱61次,平均内膜剥脱(1.1±0.2)次/例.围手术期死亡3例(5.8％),心肌梗死3例(5.8％).出院后平均随访时间为(23±5)个月,累计发生死亡6例(11.5％),心肌梗死5例(9.6％),再次血运重建4例(7.7％).术后1年冠状动脉CTA提示所有吻合口通畅率为93.5％,内膜剥脱后吻合口通畅率略低于未接受内膜剥脱的吻合口(80.6％ vs.98.9％,P＜0.05). 结论:非体外循环下序贯旁路移植同期行冠状动脉内膜剥脱可安全、有效地实现冠状动脉完全再血管化,近中期效果满意,是治疗弥漫性冠状动脉病变的有效方法.     

右冠状动脉旁路移植策略及早期桥血管通畅率影响因素

目的:归纳右冠状动脉病变特点与旁路移植方式,探索影响右冠状动脉桥血管术中流量和术后早期通畅率的相关因素,为制定右冠状动脉旁路移植的策略提供依据。方法:回顾并筛选2017年8月至2019年6月在我院完成患多支血管复杂病变且行冠状动脉旁路移植术的冠心病患者,纳入其中靶血管包括右冠状动脉的患者241例,其中男性178例,女性63例,包含262支右冠状动脉区域桥血管。分析所有患者的临床基线资料、右冠状动脉造影病变特点、手术相关资料,统计不同旁路移植方式下右冠状动脉的特点,以及术中桥血管流量和术后早期桥血管通畅率的预测因素。结果:全组患者均干预右冠状动脉系统,241例患者以老年[(62.5±8.8)岁]、男性[178例(73.9%)]为主,其中合并高血压151例(62.7%)、NYHA心功能分级为Ⅰ/Ⅱ级55例(22.8%)。接受非体外循环旁路移植术153例(63.5%),平均靶血管数3.2个。右冠状动脉旁路移植部位选择的方式包括:单纯右冠状动脉主干旁路移植76例(31.5%),单纯后降支(PDA)旁路移植81例(33.6%),单纯左心室后支(PL)旁路移植15例(6.2%),PDA+PL旁路移植54例(22.4%),右冠状动脉主干+PDA旁路移植12例(5.0%),右冠状动脉主干+PL旁路移植3例(1.2%)。术后总体桥血管通畅率为96.2%。多重线性回归分析显示,靶血管吻合于右冠状动脉远端分支的桥血管流量预测值差于吻合于右冠状动脉主干(B=-11.126,P0.001),序贯吻合与非序贯吻合相比其桥血管流量显著提高(B=19.954,P0.001),而桡动脉桥是预测术后早期桥血管闭塞的独立危险因素(OR=21.973,95%CI:4.657～103.687,P0.001)。结论:移植于右冠状动脉主干和序贯吻合桥可能是提高桥血管流量的独立因素;而桡动脉桥是术后早期桥血管显影不佳的独立危险因素。     

瓣膜替换或成形术同期行冠状动脉旁路移植术的临床分析

目的　分析 76例瓣膜替换或成形术同时行冠状动脉旁路移植术的危险因素 ,并介绍此类手术的成功经验。方法　行瓣膜替换或成形术同时行冠状动脉旁路移植术 76例。男 6 1例 ,女 15例 ,平均年龄 5 6岁 ,共移植旁路血管 117支 ,同时行主动脉瓣置换 (AVR) (1～ 3支桥 ) 2 5例 ,二尖瓣置换 (MVR) (1～ 4支桥 ) 31例 (MVR TVP 3例 ,MVR AVR 2例 ) ,双瓣置换 (BVR)(1～ 3支桥 ) 18例 (BVR TVP 2例 ) ,及MVP (1支桥 ) 1例 (MVP TVP 1例 )。 6 7例瓣膜病理改变为风湿性瓣膜病变 ,9例为瓣膜退行性病变或先天性畸形。应用SPSS统计软件进行手术相关危险因素的分析。结果　术后早期死亡 6例 (7.89% )。 6 3例患者有术后远期随访记录 ,随访率 90 % ,平均随访 2 6 .8个月 ,6 2例心功能明显改善 ,1例远期死亡 (术后 9个月死于亚急性细菌性心内膜炎 )。结论　瓣膜手术同时行冠状动脉旁路移植术的危险性高于单一手术 ,术前心肌梗塞中、心功能、EF、体外循环时间和动脉阻断时间与手术死亡率相关。彻底解除瓣膜病变、充分的心肌再血管化和良好的心肌保护是手术成功的主要因素。     

非体外循环下冠状动脉旁路移植术766例的分析

目的:探讨非体外循环下冠状动脉旁路移植术(OPCABG)的疗效。方法:回顾性分析766例OPCABG患者的临床资料。结果:766例中支病变40例,支病变109例,支病变617例,其中左主干病变83例,均选择胸部正中切口,每例移植血管1~6支,平均移植血管3.78支;随访1~56个月,631例(82.4%)症状完全消失,127例(16.6%)症状明显减轻,生活质量提高,6例死亡(0.78%),8例(1.04%)术中改常规体外循环冠状动脉旁路移植(CABG)。术后3~12个月2例因血管桥堵塞需要作PTCA。呼吸机使用时间平均(16.35±19.8)h。住院时间(18.2±8)d。结论:非体外循环下冠状动脉旁路移植术是绝大多数病例的首选术式,可以做到完全再血管化,满意的桥血流量,低并发症,操作安全,近期效果好,远期效果有待观察。     

肾动脉狭窄支架置入术后冠状动脉旁路移植术的安全性及疗效

目的:探讨冠心病患者肾动脉狭窄支架置入术后行冠状动脉(冠脉)旁路移植术的安全性及疗效.方法:22例行肾动脉狭窄支架置入术后接受冠脉旁路移植术冠心病患者,记录各例临床、冠脉、肾动脉造影情况,随访分析各例肾动脉狭窄支架置入术前后肾功能及冠脉旁路移植术情况,并测定手术前、后及随访期间血清肌酐水平.结果:22例患者均成功置入肾动脉支架(25枚),旁路移植术后72小时血清肌酐较基础测值明显下降[(153±22)μmol/L比(163±31)μmol/L,P<0.05].各例平均移植旁路血管(3.12±0.77)支,术后1例发生脑梗塞.平均随访(15±8)个月,各例血清肌酐水平进一步下降,2例复发胸痛,其中1例接受冠脉支架术,无严重心脏事件生存率95.5%.结论:肾动脉狭窄支架置入术有助于改善患者肾功能,增加冠脉旁路移植术的安全性及改善预后.     

40例老年冠状动脉旁路移植术临床分析

目的总结40例老年冠状动脉旁路移植术(CABG)无死亡的临床体会,比较非体外循环不停跳冠状动脉搭桥术(OPCAB)和体外循环下冠状动脉旁路移植术(CCABG)后的早中期结果。方法回顾性地分析2003年9月至2006年6月连续完成的40例老年冠状动脉搭桥术。患者年龄65～85岁,其中12例CCABG,28例OPCAB。结果患者无手术死亡。OPCAB组3支病变26/28,CCABG组3支病变10/12,其中1例同期室壁瘤切除,1例同期主动脉瓣置换。平均旁路移植支数为(3.4±0.8)支。患者随访率100%,随访时间1～34个月。随访期间仅有1例术后1个月剧烈活动后出现心绞痛,其他无任何症状。结论对于选择性病例,只要掌握手术适应证,OPCAB和CCABG均可以获得较满意的早中期效果。     

胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术

目的介绍并探讨经胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术的外科技术和临床经验.方法经胸骨下段正中较小切口游离左侧乳内动脉,用于冠状动脉前降支旁路移植术.对冠状动脉多支病变患者同时游离大隐静脉,用于冠状动脉其它分支旁路移植术.在非体外循环,心脏跳动下,完成冠状动脉单支或多支病变血管的旁路移植术.观察术后恢复情况.结果全组22例患者采用该手术方法,其中5例为前降支单支病变,17例为多支病变.22例患者前降支旁路移植术均采用左乳内动脉.平均冠状动脉旁路移植支数2.40±1.04(1～4)支/人.冠状动脉旁路移植的靶血管包括前降支、对角支、右冠状动脉或后降支和高位边缘支.全组患者术后恢复顺利,无严重术后并发症和死亡.患者术后平均8.1±1.6天痊愈出院.结论该手术方法创伤较小,安全易行,对有手术适应证的多支病变患者是一种较好的微创冠状动脉旁路移植手术方法.     

非体外循环和体外循环冠状动脉旁路移植术桥流量变化的对比分析

目的通过超声瞬间血流仪在术中测定体外和非体外循环冠状动脉旁路移植术患者血管桥流量和血流搏动指数变化,了解非体外循环冠状动脉旁路移植术血管桥吻合口的质量.方法91例患者采用非体外循环方法(非体外组)行冠状动脉旁路移植术,同期有107例应用体外循环方法(体外组)行冠状动脉旁路移植术,测定两组间不同旁路移植术部位的血管桥流量和血流搏动指数变化.结果冠状动脉旁路移植术两组间每个吻合口的平均血流量分别为(25.94±12.84)ml/min和(30.29±11.42)ml/min(P＜0.05);血流搏动指数分别为2.06±0.76和2.12±0.78(P＞0.05).除前降支和用大隐静脉为移植材料的对角支部位,体外组较非体外组冠状动脉桥的平均血流量明显增多(P均＜0.05)外;其余部位的平均血流量两组间无显著差异.两组间各部位总的血流搏动指数也无显著差异.结论尽管非体外循环冠状动脉桥血流量偏低,但其血流搏动指数尚满意,说明术后早期吻合口质量可靠.     

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.