丙泊酚对异氟醚心肌预处理效应的影响

目的 评价在心脏直视手术中异氟醚是否具有处理效应及丙泊酚对异氟醚预处理效应的影响。方法 将30例择期行心脏直视手术的室间隔缺损（VSD）患者分为三组：异氟醚吸入组（Ⅰ组）、异氟醚吸入加丙泊酚输注组（Ⅱ组）和对照组（Ⅲ组）。分别于麻醉诱导平稳后（T1）、主动脉阻断时（T2）、主动脉阻断开放后30min（T3）采血检测超氧化物歧化酶（SOD）、丙二醛（MDA）;分别于T2、T3、再灌注后3h（T4）及12h（T5）采血检测肌酸激酶同功酶（CK-MB）和乳酸脱氢酶（LDH）。结果 在T2时,与同期Ⅲ组比较,Ⅰ组SOD活性降低（P〈0．05）,MDA含量升高（P〈0．05）,Ⅱ组SOD活性升高（P〈0．05）。T3时Ⅰ组SOD活性和MDA含量均低于Ⅱ组和Ⅲ组（P〈0．05）。主动脉开放后的各个时点（T3、T4、T5）,三组的血清LDH活性和CK-MB活性均较T2时显著升高（P〈0．05）;Ⅰ组的LDH活性和CK-MB活性在T3、T4、T5时较Ⅱ组和Ⅲ组低（P〈0．05）。结论 心脏直视手术中缺血前吸入异氟醚对再灌注心肌具有一定保护作用。缺血前吸入异氟醚同时输注丙泊酚可能会减弱异氟醚对心肌的保护作用。     

异氟醚预处理对心脏瓣膜置换术病人血清心肌肌钙蛋白与心肌酶学的影响

目的 观察吸入异氟醚对心肌缺血再灌注损伤的保护效应。方法 准备行心脏瓣膜置换术的风湿性心脏瓣膜病病人25例,随机分为异氟醚组(n=13)和对照组(n=12),异氟醚组以芬太尼复合异氟醚维持麻醉,于主动脉阻断前吸入1.1％异氟醚30 min以上;对照组以芬太尼维持麻醉。分别于体外循环前、主动脉开放后30 min、术后8 h和24 h收集中心静脉血,检测血清心肌肌钙蛋白I(cTnI)浓度、CK-MB与CK的活性,记录相应时点的MAP、CVP、HR值,并在主动脉阻断前和开放后30min取右心房标本,对照观察心肌超微结构(线粒体记分)的变化。结果 两组病人术前cTnI、CK-MB、CK均在正常范围,在主动脉开放后各观察时点明显升高(P<0.01),对照组术后8 h、24 h血清中cTnI含量和CK-MB的活性显著高于异氟醚组(P<0.05);两组病人术后心肌细胞都出现不同程度的肿胀,线粒体记分升高(P<0.01),但异氟醚组明显低于对照组(P<0.05)。结论 在主动脉阻断前吸入异氟醚能产生心肌保护效应,在一定程度上减轻了心肌再灌注损伤。     

异氟醚预处理对心脏瓣膜置换术中患者中性粒细胞NF-κB活性的影响

目的 探讨异氟醚预处理对心脏瓣膜置换术中患者中性粒细胞NF-κB活性的影响.方法 择期体外循环(CPB)下二尖瓣和/或主动脉瓣置换术患者20例,ASAⅡ或Ⅲ级,年龄20～60岁,随机分成2组对照组(C组)和异氟醚预处理组(Ⅰ组),每组10例.两组麻醉诱导均采用静脉注射咪唑安定0.08～0.12 mg·kg-1、芬太尼5～10μg·kg-1、维库溴铵0.1 mg·kg-1;气管插管后机械通气.麻醉维持C组间断静脉注射芬太尼、咪唑安定及维库溴铵,Ⅰ组吸入异氟醚2 MAC及间断静脉注射芬太尼、咪唑安定、维库溴铵.CPB前维持收缩压90～120 mm Hg、舒张压50～80 mm Hg及心率60～90次·min-1;CPB开始时Ⅰ组停吸异氟醚.于气管插管后即刻(T0)、主动脉开放后30 min(T1)、1 h(T2)、2 h(T3)采桡动脉血15ml,并分离提取中性粒细胞,用凝胶电泳迁移率改变分析法测定中性粒细胞NF-κB活性,记录心脏自动复跳情况、多巴胺及硝普纳用量.结果 与C组比较,Ⅰ组T0时NF-κB活性差异无统计学意义,而其他时点NF-κB活性降低,心脏自动复跳率升高,多巴胺用量降低(P＜0.05),硝普钠用量差异无统计学意义(P＞0.05);每组多巴胺用量与中性粒细胞NF-κB活性的最高值呈正相关[C组r=0.962,Ⅰ组r=0.908(P＜0.01)].结论 异氟醚预处理通过降低中性粒细胞NF-κB活性,对CPB下心脏瓣膜置换术患者心肌产生一定的保护作用.     

地氟醚,七氟醚和异氟醚预处理对缺氧／复氧心肌细胞损害的保护作用

目的 研究地氟醚，七氟醚和异氟醚预处理对恼肌细胞缺氧／复氧损害的保护作用。方法 原代培养乳鼠心肌细胞，随机分为对照，单纯缺氧／复氧及１．５ＭＡＣ地氟醚，七氟醚和异氟醚预处理５组，实验结束测定乳酸脱氢酶（ＬＤＨ）和肌酸激酶（ＣＫ）活性。细胞存活和凋亡率。结果 与对照组比，单纯缺氧／复氧使ＬＤＨ，ＣＫ和细胞凋亡率升高及细胞存活率显著下降（Ｐ〈０．０１），１．５ＭＡＣ地氟醚，七氟醚和异氟醚预处理显著减轻     

地氟醚、七氟醚和异氟醚预处理对缺氧/复氧心肌细胞损害的保护作用

目的　研究地氟醚、七氟醚和异氟醚预处理对心肌细胞缺氧／复氧损害的保护作用。方法　原代培养乳鼠心肌细胞，随机分为对照、单纯缺氧／复氧及 １．５ＭＡＣ地氟醚、七氟醚和异氟醚预处理５组。实验结束测定乳酸脱氢酶（ＬＤＨ）和肌酸激酶（ＣＫ）活性、细胞存活和凋亡率。结果　与对照组比，单纯缺氧／复氧使ＬＤＨ、ＣＫ和细胞凋亡率升高及细胞存活率显著下降（Ｐ＜０．０１）；１．５ＭＡＣ地氟醚、七氟醚和异氟醚预处理显著减轻ＬＤＨ、ＣＫ和细胞凋亡率升高及细胞存活率下降，其中七氟醚减轻作用最强。结论　地氟醚、七氟醚和异氟醚预处理对心肌细胞缺氧／复氧损害有一定的保护作用，七氟醚的保护作用可能更强。     

异氟醚麻醉对体外循环心脏瓣膜置换术患者心肌的保护作用

体外循环(CPB)心脏直视手术中可发生全身炎性反应, 其中多种炎性细胞因子释放、粘附分子表达增加,可促进活化的白细胞与内皮细胞间的牯附,引起血管内皮细胞损伤, 进而导致心肌损伤。离体实验证实,异氟醚不仅可抑制炎性细胞因子的产生,还抑制粘附分子的表达。异氟醚是否可以抑制粘附炎性细胞因子的产生及粘附分子表达,进而对心肌产生保护作用尚未定论。本研究拟观察CPB下心脏瓣膜置换术患者术前吸入异氟醚围术期肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)以及P-选择素、L-选择素、细胞间粘附分子-1(ICAM-1)的变化,评价其心肌保护作用。     

比较七氟醚、异氟醚和安氟醚对颅内压的影响

目的：为了观察七氟醚对颅内压的影响。方法：选择２４例颅内肿胶病人,测定七氟醚麻醉的时颅内压变化并与异氟醚和安氟醚进行比较。术前用药、麻醉诱导及维持的静脉用药相同。于Ｌ３－４穿刺蛛网膜睛腔测脑脊液压（代表颅内压,ＩＣＰ）。依吸入药不同随机分为七的氟醚（Ｓ）组,异氟醚（１）组和安氟醚（Ｅ）组,监测ＢＰ、ＭＡＰ、ＥＣＧ、ＳｐＯ２、ＰＥＴ、ＣＯ２和ＭＡＣ,调整ＶＴ和ＲＲａＣＯ２维持在４～４．６６ＫＰＡ。三     

异氟醚和七氟醚麻醉对患者心率变异性的影响

目的研究异氟醚和七氟醚麻醉对患者心率变异性(HRV)的影响。方法60例择期颅脑手术患者,用动态心电图仪记录麻醉诱导前、插管后10 min、停药时、停药后1、2 h和4 h的HRV。结果ISO1组(异氟醚,年龄<60岁)和ISO2组(异氟醚,年龄≥60岁)插管后10 min、停药时、停药后1、2 h的低频功率(LF)、高频功率(HF)值均显著低于麻醉诱导前(P<0.05)。SEV1组(七氟醚,年龄<60岁)和SEV2组(七氟醚,年龄≥60岁)的LF、HF值在插管后10 min、停药时、停药后1 h均显著低于麻醉诱导前(P<0.05)。ISO组插管后各时点的LF、HF值均显著低于SEV组(P<0.05)。结论异氟醚对患者的交感神经和迷走神经都有明显的抑制作用,而对于交感神经和副交感神经活性的均衡性没有显著的影响。异氟醚对于交感神经和迷走神经的抑制作用比七氟醚更为明显。     

异氟醚和七氟醚对老年患者术后认知功能的影响

目的观察异氟醚和七氟醚麻醉对老年患者术后12个月认知功能和血清β淀粉样蛋白(β-amyloid,Aβ)浓度的影响。方法选择全麻下行腹部手术患者77例,男43例,女34例,年龄65~75岁,ASAⅠ~Ⅲ级,采用随机数字表法分为两组:异氟醚组(I组,n=32)和七氟醚组(S组,n=45)。采用简易精神状态量表(mini-mental state examination,MMSE)于术前1 d、术后3 d和术后12个月进行认知功能评分。同时留取患者血清,于以上时点测定Aβ40和Aβ42浓度。结果术后3 d I组和S组的MMSE评分明显低于术前(P0.05),且I组明显低于S组(P0.05);术后12个月I组和S组POCD发生率差异无统计学意义[13例(40.6%)vs 15例(33.3%)]。两组不同时点血清Aβ42和Aβ40浓度差异无统计学意义。结论七氟醚对近期认知功能的影响小于异氟醚,但长期的影响可能是一致的;两者对患者术后12个月血清β淀粉样蛋白浓度无影响。     

异氟醚预处理对大鼠局灶性脑缺血损伤的保护作用

目的探讨异氟醚预处理能否诱导脑缺血耐受产生。方法30只雄性SD大鼠(350～400g)，随机分为三组对照组(n＝10)，动物不接受任何处理；Iso/5d／1h组(n＝10)，动物每天接受1h的异氟醚预处理(2％异氟醚，98％氧)，连续5d；O2／5d／1h组(n＝10)，动物每天接受1h的吸氧处理(98％氧，无异氟醚)，连续5d。所有动物均采用右侧颈动脉丝线栓塞大脑中动脉致局灶性脑缺血120min，观察再灌注后1，3，6，12，16，24h动物神经行为学改变及24h时脑梗死容积。结果术后各时间点神经行为学评分Iso／5d／1h组明显低于对照组和O     

丙泊酚对风心瓣膜置换术后转流后左室功能的影响

目的　观察丙泊酚静脉复合麻醉对风心瓣膜置换手术患者心肺转流 (CPB)后左室功能的影响。方法　 2 0例风心瓣膜置换手术患者 ,随机分为咪唑安定组 (C组n =10 )和丙泊酚组 (P组n=10 ) ,分别以咪唑安定 0 1～ 0 2mg·kg-1·h-1或丙泊酚 2～ 6mg·kg-1·h-1维持麻醉 ,CPB期间和CPB后持续注药。两组芬太尼应用相同。观察缺血 /再灌注后 3 0分钟、60分钟和 2 4小时血清心肌酶谱变化 ,并采用Swan Ganz导管技术监测停CPB后MAP、HR、SI、CI、PCWP、SVRI和LVSWI变化。结果　缺血 /再灌注后三个时点LDH和CK MP均较麻醉前升高 ,C组升高更为明显。CK MB再灌注后 60分钟和 2 4小时 ;LDH再灌注 2 4小时与P组相比差异显著 (P <0 0 5 )。P组停CPB后各时点HR较基值显著减慢 (P <0 0 1) ,PCWP、SVRI显著降低 (P <0 0 1) ,SI、LVSWI显著增高 ,CI较C组相对为高。结论　丙泊酚维持麻醉 ,减轻了心肌缺血 /再灌注损伤 ,并降低心脏前、后负荷 ,维持满意的心脏指数 ,促进缺血后左心功能的恢复。     

异氟醚预处理对心脏瓣膜置换术病人血清一氧化氮与肌钙蛋白Ⅰ的影响

目的探讨异氟醚预处理对心肌缺血-再灌注损伤的保护效应及机制。方法择期行心脏瓣膜置换术的风湿性心脏瓣膜病病人32例,随机分为异氟醚组和对照组,每组16例。异氟醚组以1.5%~2%异氟醚吸入复合芬太尼维持麻醉,心肺转流(CPB)开始前洗脱10min,CPB后以芬太尼维持麻醉;对照组以芬太尼维持麻醉。分别于麻醉前(T0)、CPB前(T1)、CPB30min(T2)、术后8h(T3)、24h(T4)抽取中心静脉血测定一氧化氮(NO)、NO合酶(NOS)与心肌肌钙蛋白I(cTnI)浓度。结果两组病人T0时NO、NOS与cTnI浓度差异无显著意义;异氟醚组T1、T2时NO、NOS浓度明显高于对照组(P<0·05),T3、T4时cTnI浓度明显低于对照组(P<0·05)。结论异氟醚具有心肌预适应作用,其机制可能与增加NO释放有关。     

Reverse left ventricular remodelling after aortic valve replacement for severe aortic insufficiency

 Open in a separate windowOBJECTIVESThe goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome.METHODSA total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF <35% (n = 43), moderate EF 35–50% (n = 150) or normal EF >50% (n = 285).RESULTSActuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P < 0.0001). Echocardiography at 1 year post-AVR demonstrated that EF substantially improved in all groups. We noted a significant difference in survival (P = 0.0086) and in freedom from major adverse cerebral and cardiovascular events (P = 0.024) between patients with an EF ≥35% and those with an EF <35% in the LO EF group. The multivariable logistic regression model showed that predictive factors for lack of improvement in EF 1 year post-AVR in the LO EF group included plasma brain natriuretic peptide >365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m² (P = 0.0018).CONCLUSIONSLong-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF <25%, pre-brain natriuretic peptide >365 pg/mL or LV mass index >193 g/m².     

Delayed left ventricular rupture after mitral valve replacement

Posterior left ventricular rupture (LVR) is a serious complication following mitral valve replacement (MVR), especially if occurring postoperatively with the chest already closed or the patient in the intensive care unit. Only one of the patients with this delayed type of LVR reported earlier has been treated successfully. Our experience consists of 4 such complications among 161 MVR patients, the incidence being 2.5%. Two of these patients survived. Mechanical factors seem to constitute the most important etiologic causes for this complication. Immediate reoperation must be performed, and extracorporeal circulation is generally mandatory for successful repair. The reconstruction of the ruptured posterior left ventricular wall in both surviving patients was performed from the epicardial surface of the heart using pledget sutures. The auricle of the left atrium was used to cover the site of the tear when bleeding was not stopped with pledget sutures. It usually seems possible to avoid this complication if all mechanical etiologic factors are taken into consideration. After successful correction, a pseudoaneurysm may arise and, for that reason, a cardiac echo sonography follow-up is recommended.     

功能性二尖瓣反流在主动脉瓣置换术后的转归及预测因素分析

目的 总结重度主动脉瓣关闭不全(aortic insurficiency,AI)合并左心室扩大及功能低下患者伴随的功能性二尖瓣反流(functional mitral regurgitation,FMR)在主动脉瓣置换术(aortic valve replacement,AVR)后的转归,判断在此类患者中,轻中度或中度FMR(2+＜FMR≤3+)预后的相关因素.方法 2000年1月至2011年4月,74例重度主动脉瓣关闭不全合并左心室舒张期未径(LVEDD)≥70 mm及左心室射血分数(LVEF)≤0.35,并伴2+＜FMR≤3+的患者.男61例,女13例.收集患者术前、术中及围手术期详细临床资料.术后进行随访.计算FMR术前/FMR术后比值,对年龄、性别、体质量、高血压、室性心律失常、房颤、LVEDD、LVEF、左心房内径(LAD)、肺动脉压(PAH)、二尖瓣对合点与瓣环水平间距离(CPMA)进行logistic多因素回归分析.结果 围手术期死亡6例,病死率8.1％.术后平均随访(14.9±7.7)个月,随访率83.8％.随访期间死亡5例.多因素回归分析显示FMR术前/FMR术后与年龄、性别、体重、LVEDD≥75 mm、LVEF≤0.30、高血压、室性心律失常不相关.而PAH≥50mm Hg(1 mm Hg =0.133 kPa)、LAD≥50 mm、CPMA≥15 mm、术前房颤与FMR术后改善呈负相关.结论 重度主动脉瓣关闭不全合并左心室扩大及功能低下患者,如PAH≥50 mm Hg、LAD≥50 mm、CPMA≥15 mm、术前房颤,其伴随的轻中度或中度功能性二尖瓣反流在主动脉瓣置换术后通常不会改善甚至加重,应在行主动脉瓣置换术时同期治疗.     

Early evidence of beneficial effects of chordal preservation in mitral valve replacement on left ventricular dimensions

Earlier authors have shown the improved left ventricular (LV) function after chordae-preserving mitral valve replacement (MVR) in follow-up studies. Seventy-nine consecutive patients undergoing MVR were studied preoperatively and pre-discharge with M-mode and two-dimensional Color Doppler echocardiography for early LV morphometric changes. Conventional MVR was performed in 42 patients (Group 1) and the posterior leaflet-chordae-papillary muscle complex was preserved in 37 patients (Group 2). Both cohorts were similar in age, sex, preoperative NYHA class and valve pathology. Four St. Jude bioprostheses, 9 Medtronic and 66 Sorin prostheses were implanted. The intraoperative and perioperative management protocol was uniform for both groups. The median left atrial dimension in both groups decreased to better physiological levels (53 to 46 mm in group 1, 52.5 to 46 mm in group 2). The median LV enddiastolic dimension increased from 47 to 48 mm in group 1 while it decreased from 56.5 to 49 mm in group 2. The median LV endsystolic dimension remained unchanged in group 1 but decreased in group 2 (37.6 to 36 mm). Echocardiographic documentation of such early changes in the LV dimensions after modified MVR indicates that the beneficial effects of chordal preservation become evident early in the postoperative period and may explain the improved perioperative LV function after modified MVR compared to conventional MVR.     

Relationship between aortic valve sclerosis and left ventricular hypertrophy in chronic haemodialysis patients

Background Cardiac valve calcification is a frequent finding in chronic haemodialysis patients. Left ventricular hypertrophy (LVH) is a significant predictor of cardiovascular mortality in patients with end-stage renal disease. We evaluated the influence of aortic valve sclerosis (AVS) on the development of LVH in chronic haemodialysis patients. Methods A total of 82 consecutive patients (52 male, mean age 48 ± 12 years) undergoing chronic haemodialysis treatment for >1 year were subjected to echocardiography for the screening of AVS and the assessment of transaortic flow velocity and the left ventricular mass index (LVMI). The absence (group 1, n = 42) and presence of AVS (group 2, n = 40) was established. The average values of systolic, diastolic and pulse pressure were obtained. Plasma calcium, phosphorus, intact parathyroid hormone, C-reactive protein, haemoglobin and lipid levels were also measured. Results LVH was detected in 59 (72%) of the study patients. The LVMI was higher in the AVS group (171 ± 39 vs. 132 ± 41 g/m², p < 0.001). Patients with AVS also had higher transaortic flow velocities (1.64 ± 0.36 vs. 1.21 ± 0.21 m/s, p < 0.01) and maximal pressure gradients (10.8 ± 7.1 vs. 5.9 ± 3.4 mmHg, p < 0.01). The LVMI showed a direct correlation with transaortic flow velocity in the AVS group (r = 0.60, p < 0.01). Stepwise linear regression analysis revealed transaortic flow velocity (p = 0.02), pulse pressure (p = 0.01) and haemoglobin levels (inverse relationship) (p = 0.02) to be independent predictors of the LVMI. Conclusion These data suggest that AVS is strongly and independently interrelated with LVH in chronic haemodialysis patients. The underlying mechanism might be the valve resistance to left ventricular outflow, as shown by increased transaortic flow velocities and maximal pressure gradients in AVS patients.     

Effect of aortic valve replacement on left ventricular function in adult patients with aortic stenosis]

Echocardiographic and hemodynamic studies were obtained in 16 consecutive adult patients who underwent aortic valve replacement (AVR) with St. Jude Medical valve for aortic stenosis (AS). Three cases of congenital AS was included and two of them had undergone aortic valvotomy in childhood. One of 16 patients died due to late cardiac tamponade six weeks after AVR. Postoperative studies showed improved left ventricular (LV) functions. LV end diastolic and end systolic diameter (LVDs and LVDs) fell from 50.3 and 38.2 to 44.6 and 31.6 mm respectively (p less than 0.05). Fractional shortening (%FS) rose from 26.5 to 32.2% (p less than 0.05). End systolic wall stress (ESWS) fell from 126.2 to 69.6 k dynes/cm2 (p less than 0.01). Cardiac index and pulmonary arterial wedge pressure improved from 3.4 and 14.4 to 3.6 l/min/m2 and 10.5 mmHg respectively (ns). Preoperatively, six were functional class II, eight were class III and one was class IV (New York Heart Association classification). Postoperative improvement was as follows, eight: class I, seven: class II. In four cases, preoperative echocardiography revealed most depressed LV function in %FS (smaller than 21%) and ESWS (greater than 140). Postoperatively they improved from 18.3 and 164 to 26.0% and 72.8 k dynes/cm2 respectively. These results suggested that depressed LV function in the patients with longstanding AS was largely related to limited preload reserve due to LV enlargement and mechanical unloading of LV (correction of afterload mismatch) resulted in improvement of LV function. In conclusion, LV dysfunction owing to AS alone is reversible and AVR results in great clinical improvement.     

Left ventricular pseudoaneurysm following mitral valve repair

We present a rare case of a left ventricular pseudoaneurysm following mitral valve repair probably due to testing the valve’s competence. The pseudoaneurysm was treated successfully with a sutureless technique in which layers of a biodegradable collagen system with fibrinogen-based coating were used. We reviewed the literature regarding left ventricular rupture following mitral valve surgery published from 1990 until 2006. Overall, the incidence of this complication was 0.56% for 10978 operations, and the mortality rate was 57.4%. We also describe a possible mechanism common to all forms of left ventricular rupture.