起源于肺静脉的阵发性心房颤动导管射频消融治疗

目的　探讨环状电极 (Lasso电极 )标测指导起源于肺静脉的阵发性心房颤动 (房颤 )导管射频消融治疗的安全性和有效性。方法与结果　 2 0 0 1年 5～ 12月 ,12例药物治疗无效的阵发性房颤患者 ,男 8例 ,女 4例 ,平均年龄 (47 8± 14 9)岁 ,行心内电生理检查和射频消融术。在Lasso电极指导下标测肺静脉 ,以确定诱发房颤的房性早搏起源处。确定房性早搏的消融靶点后 ,在有房性早搏或冠状窦远端起搏或右心耳起搏下寻找优势肺静脉电位 (PVP)放电消融 ,或肺静脉口环状消融。消融终点设定为 :①肺静脉电位振幅明显减低或消失 ;②肺静脉自律性电位与心房电活动无关 ;③诱发房颤的房早消失。结果成功隔离 2 6条肺静脉 ;其中左上肺静脉 12条 ,右上肺静脉 8条 ,左下肺静脉 5条 ,右下肺静脉1条。有 2例仅消融 1条肺静脉 ,均为左上肺静脉 ;8例消融2条肺静脉 ,消融 3条与 4条肺静脉者各 1例。术程 (196 4±6 5 8)min ,X线曝光时间 (5 2 0± 14 4 )min。术后随访 2～ 8个月 ,有 1例频发房早发生 ,经口服胺碘酮后房早消失 ;4例有房颤短阵发作 ,其中 3例接受口服药物 (2例服用胺碘酮 ,1例服用索他洛尔 ) ,1例植入有抗房颤程序的DDDR起搏器 ,能够有效抑制房颤发作。术中选择性肺静脉造影发现 6例有轻度肺静脉狭窄 ,其     

起源于肺静脉的阵发性房颤的电生理特点及射频消融治疗

目的探讨环状电极(Lasso电极)标测诱发阵发性房颤的肺静脉电位的电生理特点并对射频消融靶点进行评介。方法16例阵发性房颤者在Lasso电极标测寻找优势肺静脉电位(PVP),温控消融放电。结果起源于肺静脉的局灶性房颤其电生理特征包括:①异位激动灶主要分布于两上肺静脉。②肺静脉内可观察到从肺静脉内至心房传导阻滞。消融成功的靶点与体表心电图P′波提前(74±33)ms。成功隔离38条肺静脉:其中左上肺静脉16条,右上肺静脉12条。术程(186.7±63.8)min,X线曝光时间(51.5±15.0)min。术后随访1～12个月,11例(68.7%)无需药物而维持窦性心律。结论阵发性房颤异位起源点大多数位于左房肺静脉,起源于肺静脉的局灶性房颤有其特殊的电生理表现。     

环肺静脉左心房线性消融术后复发的房性心律失常

目的研究心房颤动(房颤)患者环肺静脉左心房线性消融术后复发房性心律失常的机制。方法28例房颤患者接受环肺静脉左心房线性消融术,平均年龄(54±11)岁,其中阵发性房颤10例,持续性房颤18例。采用Carto电解剖标测系统及双Lasso标测导管技术,分别进行环左、右侧肺静脉线性消融;消融终点为肺静脉电位消失,左心房-肺静脉双向阻滞。复发患者再次消融术采用双Lasso导管指导在原环形消融线上标测“漏点”并消融封闭之,对不能终止心动过速者再行拖带标测、激动标测或结合Carto系统标测;对典型心房扑动(房扑)行右心房峡部线性消融。结果初次消融术后平均随访(245±65)d,18例无复发;8例复发房性心律失常包括5例典型房扑、2例其他房性心动过速、1例阵发性房颤;2例左上肺静脉电位未完全隔离者仍持续房颤。除外1例持续性房颤,另外9例接受了再次消融术,证实所有复发患者均有左心房-肺静脉传导恢复;8例射频消融成功并随访(192±92)d无复发。结论左心房-肺静脉传导恢复是环肺静脉左心房线性消融术后复发房性心律失常的重要因素;初次手术附加右心房峡部线性消融可能减少复发率。     

在心房颤动持续过程中行肺静脉电学隔离术的可行性

探讨在心房颤动 (简称房颤 )持续过程中行肺静脉电学隔离术的可行性。 9例在导管消融术中房颤持续发作的房颤患者 ,根据肺静脉环状标测电极导管记录的肺静脉激动特征采用 2种方法进行肺静脉开口部的消融 :①肺静脉激动有序且有一种或多种固定的激动顺序 ,采用射频导管消融环状电极记录的最早的激动部位 ;②肺静脉激动无序或无明确的激动顺序 ,首先使用超声球囊导管消融 ,如未达终点再加用射频导管消融。 2种方法的消融终点均为肺静脉电学隔离。总计对 31根肺静脉进行了消融 ,其中 2 8根在房颤心律下消融。房颤心律下电隔离肺静脉的成功率为 92 .9% (2 6根 )。总操作时间和X线透视时间分别为 1 38± 2 1min和 38± 9min。本组无肺静脉狭窄及其他并发症。随访 6 .3± 2 .9(3～ 1 1 )个月后 ,4例 (44.4% )患者无房颤发作 (无需药物 )。结论 :在房颤持续过程中行肺静脉电学隔离术方法可行 ,且较为安全 ;联用超声球囊消融和射频消融对于房颤发作过程中无序或无明确激动顺序的肺静脉具有较好的电学隔离效果。     

心房颤动环肺静脉口外线性消融术后二次消融的电生理发现及随访结果

目的介绍三维导航下环肺静脉口外线性消融治疗心房颤动（房颤）术后快速房性心律失常及房颤复发患者二次消融时的电生理发现、消融策略及随访结果。方法2004年4月至2006年5月,采用左心房线性消融治疗房颤共91例。术后4例患者因心动过速反复发作或无休止发作于2周内行二次消融术。随访3个月后,25例患者有快速性心律失常发作,其中15例接受二次消融术。在所有接受二次消融的19例患者中,第一次消融前房颇为阵发性者11例,持续性2例,永久性6例,其中男性17例,女性2例,年龄25～65（53±12）岁。所有患者术中均使用环状电极行肺静脉电位探查。结果5例患者发现窦律下左侧肺静脉延迟电位,1例出现右侧肺静脉延迟电位,2例患者双侧同时出现延迟肺静脉电位;此类患者于环状电极指导下标测原消融线径的传导“缺口”并再次隔离成功。3例患者左侧肺静脉内颤动样节律,递减传导至左心房出现不规则房性心动过速;此类患者再次于三维标测指导下行左侧环状消融隔离成功;1例患者左侧肺静脉心动过速并1：1传导至左心房,经终止心动过速后隔离成功。4例患者肺静脉探查未发现肺静脉电位,但诱发出其他心动过速,包括右房瘢痕性房性心动过速、隐匿性旁路介导的室上性心动过速、右后间隔局灶性房性心动过速及三尖瓣峡部依赖的心房扑动。此4例患者在常规标测和三维标测指导下,心动过速均被成功消融。术中呈房颤节律者3例,再次于三维标测指导下行环肺静脉线性消融获成功。平均随访4～26（11．5±8．5）个月,16例患者无快速性心律失常发作,1例有频繁房性早搏,1例永久性房颤患者仍呈房颤节律,另1例永久性房颤患者转为阵发性房颤。结论肺静脉与左心房之间电传导恢复是消融术后出现快速房性心律失常的主要因素。肺静脉以外的心动过速在左心房线性消融术后可以表现为独立的心动过速,也可以触发房颤;环肺静脉口外线性消融不足以完全改良永久性房颤的维持基质。     

心房颤动消融术后二尖瓣峡部房性心动过速的发生机制及消融治疗

目的探讨心房颤动(简称房颤)患者环肺静脉左房线性消融术后二尖瓣峡部房性心动过速(简称房速)的发生机制及其消融策略。方法122例房颤患者采用EnSite-NavX和环状电极行环肺静脉左房线性消融,术后32例复发房颤或房速,8例经EnSite-NavX激动标测及拖带标测证实存在二尖瓣峡部房速,在三维导航下于左下肺静脉口部下缘至二尖瓣环之间行线性消融,对不能成功阻断二尖瓣峡部传导者予以冠状静脉窦内消融。术中同时探查双侧肺静脉电位,如传导恢复予以再次隔离。结果8例中2例呈无休止性发作,6例为阵发性,可被程序刺激诱发。房速的周长217.5±20.6ms,其中顺钟向折返5例,逆钟向折返3例。二尖瓣峡部线性消融至完全性双向传导阻滞5例,3例心内膜途径失败者经冠状静脉窦内消融,其中1例获得成功。术后随访5.5±4.3个月,6例无房颤及房速发作,1例仍有阵发性房速发作。另1例术后房速呈无休止发作,予以胺碘酮及美托洛尔控制心室率治疗。结论环肺静脉线性消融术后发生的二尖瓣峡部房速与左房线性消融治疗房颤的致心律失常作用有关,其主要的机制是消融线相关的大折返性心动过速,阻断峡部传导可以治疗此类房速。     

阵发性心房颤动的射频导管消融大静脉电隔离治疗

目的报道阵发性心房颤动(房颤)的射频导管消融电隔离肺静脉和腔静脉的疗效。方法阵发性房颤患者36例,年龄(42.5±13.2)岁。经1次房间隔穿刺放置环状标测电极导管(Lasso导管)和冷盐水灌注消融导管,在Lasso导管的指导下,采用全肺静脉或上腔静脉与靶静脉节段性电隔离相结合的方法对肺静脉和腔静脉行标测和电隔离治疗。窦性心律时最早激动的肺静脉和腔静脉电位处和/或心房起搏时最短的心房和静脉电位间期处为靶点行消融。结果36例阵发性房颤患者均接受一次电隔离治疗,共电隔离大静脉115根,其中左上肺静脉34根,左下肺静脉22根,右上肺静脉30根,右下肺静脉17根,上腔静脉12根,即刻电隔离成功率为95.6%,术中并发症发生率2.78%。随访3~22个月,成功率(无房颤发作或房颤发作明显减少)为75.0%。结论射频导管消融电隔离肺静脉或腔静脉与心房间的电活动连接,可有效预防房颤的复发。治疗的关键是消融靶点的标测和确定。     

起源于肺静脉的阵发性心房颤动:电生理特征与射频消融治疗

目的　探讨起源于肺静脉的阵发性心房颤动 (简称房颤 )的电生理特征 ,并对其射频消融治疗的结果进行评价。方法　 39例发作频繁 (>2次 周 )、症状明显、药物治疗难以控制的阵发性房颤 ,其中男 2 7例 ,女 12例 ,平均年龄5 0 3± 19 7(2 9～ 75 )岁。Ｈｏｌｔｅｒ记录显示 35例 (89 7% )合并有频发房性早搏 (简称房早 ,>70 0次 日 )。 15例 (38 5 % )合并有器质性心脏病。常规放置高位右房、冠状静脉窦及左、右上肺静脉标测电极后进行房早 房颤的诱发。以房早或房颤开始发作时局部双极电位较体表心电图Ｐ′波起点最为提前处为消融靶点 ,采…     

起源上腔静脉快速房性心律失常的电生理特征和射频导管消融治疗

目的:分析上腔静脉起源的异位冲动诱发阵发性心房颤动(房颤)和房性心动过速(房速)的特点,总结射频导管消融电隔离上腔静脉治疗快速房性心律失常的经验。方法:连续收治快速房性心律失常患者108例,对经电生理检查证实房性心律失常起源于上腔静脉的11例患者行上腔静脉造影,明确上腔静脉开口位置后应用标测导管于上腔静脉进行激动标测,标测上腔静脉最早激动点及肌袖电位分布位置进行消融,直至房性心律失常终止及上腔静脉电位消失。结果:11例患者中,房速5例,房颤6例。5例房速患者上腔静脉房速发作周长为260～390ms;P波形态除1例判定不清外,其余4例均为Ⅰ、Ⅱ、Ⅲ、aVF、aVL导联直立,aVR导联倒置。6例房颤患者中,4例在环肺静脉隔离后仍可诱发或自发短阵房速或频发房性期前收缩,经标测起源于上腔静脉;2例术中自发房颤标测过程中发现上腔静脉电位频率较肺静脉电位频率更快。上腔静脉电隔离后,术中均成功终止心动过速。随访6～20个月,1例患者阵发性房颤复发,1例患者因窦性停搏行永久起搏器治疗。结论:上腔静脉是房速和房颤的起源部位之一,射频导管消融治疗有很高的成功率。     

环状电极在Ensite/NavX指导下的心房颤动环肺静脉消融术中的应用

目的评价环肺静脉消融术联合应用环状电极标测对心房颤动(房颤)消融成功率的影响。方法连续入选61例房颤患者,其中男40例,女21例,阵发性房颤50例,慢性房颤11例。在EnsiteNavX三维电解剖标测系统指导下行环肺静脉消融术。应用环状电极标测肺静脉电位,以肺静脉电隔离为消融终点。结果61例均顺利完成手术。环左肺静脉消融使左肺静脉电隔离34例(55.7%),环右肺静脉消融使右肺静脉电隔离35例(57.4%),环左、右肺静脉消融使所有肺静脉电隔离23例(37.7%)。16例阵发性房颤和5例慢性房颤放电时终止房颤,终止房颤部位为左、右上肺静脉外近房顶前、后壁19例,右上肺静脉外后壁中部1例,完成左肺静脉消融时房颤终止1例。平均随访6±2个月,50例阵发性房颤中42例(84.0%)以及11例慢性房颤中5例(45.4%)无房颤发作,总成功率为77%。并发症:少量心包积液1例,经心包穿刺引流后积液消失;左侧血胸1例,经胸腔穿刺引流痊愈。结论EnsiteNavX系统指导下的环肺静脉消融术中联合应用环状电极标测可使房颤消融成功率进一步提高。     

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.