特殊室间隔缺损的外科经胸封堵治疗

目的探讨特殊室间隔缺损（ventricular septal defect,VSD）经胸封堵治疗的安全性和手术效果。方法 2010年2~11月,应用外科经胸封堵治疗6例特殊VSD,包括2例不接受锯胸骨和X线辐射的先天性VSD（A组）,3例内科介入封堵失败的先天性VSD（B组）,1例急性心肌梗死室间隔穿孔形成的后天性VSD（C组）。经胸骨下段小切口不锯胸骨（A组）或锯部分胸骨（B组）或正中大切口（C组）行外科经胸封堵术。于右心室表面选择适当的穿刺点,在食道超声实时引导下,用输送鞘将封堵伞送入封堵VSD。术后密切随访病情变化,定期复查超声心动图、心电图和胸部X线片。结果 6例全部封堵成功,无死亡。5例采用对称封堵伞,1例因VSD上缘距主动脉瓣较近采用非对称的偏心封堵伞。4例术后即刻和3个月及9个月复查超声心动图均无分流和其他异常;1例术后即刻复查有3 mm分流,1例术后即刻复查有5 mm分流、3个月复查仍有3 mm分流,仍在随访中。无新发的主动脉瓣和三尖瓣反流、完全性房室传导阻滞、左或右室流出道狭窄,无溶血或血栓形成,无封堵伞移位。结论外科经胸封堵VSD是一种简单有效而又安全的治疗方法,尤其对于一些特殊的VSD病例不失为一种良好的选择。     

骨髓移植诱导临床心脏移植后供者特异性免疫耐受方案的探讨

目的 探讨骨髓移植诱导临床心脏移植后供者特异性免疫耐受的可行性.方法 采取供心的同时采用改良"灌流法"获取供者的骨髓350 ml,经过滤及离心处理后,加入细胞冷冻保护液共80ml,分装于低温冻存袋,经程序降温,置于-80℃冰箱中保存.在常规原位心脏移植术后40 d,取冻存骨髓快速复温,穿刺受者双侧髂后上嵴,立即行骨髓腔内骨髓细胞输注(IBM-BMT),共输注单核细胞1.2×107/kg,CD34+细胞2.38×105/kg.骨髓输注前3 d行预处理,包括应用氟达拉滨、抗胸腺细胞球蛋白及全身淋巴结照射.骨髓移植后静脉应用他克莫司(Tac),维持血Tac浓度谷值在10～20μg/L;3周后改为口服Tac+吗替麦考酚酯(MMF);6周后改为环孢素A及MMF.分别于心脏移植后2、4、8和12周采集受者外周血,分别于术后4、8和12周采集受者的骨髓,应用短串联重复序列-聚合酶链反应法检测供者嵌合体.心脏移植后每周行心肌内心电图检查,每月行心肌活检1次.术后3个月,取受者及第三者外周血单核细胞,行混合淋巴细胞反应(MLR).结果心脏移植后1、2及3个月时受者的外周血及髂骨内骨髓细胞中供者来源的细胞比例分别为26.3%、19.1%、4.8%和46.3%、24.4%、7.6%.IBM-BMT后心肌内心电图监测显示心肌阻抗及R波波幅无明显变化.术后3个月行心内膜心肌活检,未见排斥反应征象.术后3个月时行超声心动图检查,提示心脏舒张、收缩功能良好.MLR提示受者对供者特异性刺激呈现低反应性,而对第三者仍保持良好的免疫活性(P＜0.01).结论 采取分期骨髓移植免疫耐受诱导方案可安全、有效地建立嵌合体,成功诱导心脏移植后供者特异性免疫耐受,但远期效果有待进一步研究.

Abstract：

Objective To investigate a new strategy of bone marrow transplantation (BMT) for donor-specific tolerance induction after heart transplantation. Methods Donor bone marrow cells (BMCs)were harvested simultaneously with donor cardiac graft using modified perfusion method (PM) ,then stored in a -80 ℃ refrigerator after filtration and centrifugation. Whole BMCs (IBM-BMT) (monocytes 1.2 ×107/kg,CD34+ cells 2.38× 105/kg) in host iliac bones were injected into the bone marrow cavity 40 days after heart transplantation. Preconditoning regimens that consisted of fludarabine, antithymoctye globin and total lymphoid irradiation were performed 3 days before BMT. Tacrolimus (Tac) was administrated intravenously after BMT or orally in conjunction with mycophenolate mofetil (MMF) 3 weeks later.Cyclosporine and MMF were orally administrated 6 weeks later. Donor chimerism was detected using short tandem repeats-polymerase chain reaction in monocytes from peripheral blood at the 2nd,4th, 8th or 12th week after BMT or BMCs at the 4th, 8th or 12th week after BMT. Intramyocardium electrocardiography examination or endomyocardial biopsy was performed weekly or monthly respectively. Mixed lymphocyte reactions (MLR) were performed 3 months after BMT. Results Donor chimerism in monocytes in peripheral blood or BMCs in iliac bones measured at the 1 st,2nd and 3rd month after BMT was 26.3%, 19.1%,4.8% ,and 46.3%, 24.4%, 7.6%, respectively. After 3-month follow-up, there was no rejection confirmed by endomyocardial biopsy or intramyocardium electrocardiography. Echocardiography revealed that the diastolic and systolic function of the cardiac graft was maintained well 3 months after BMT. MLR revealed donor-specific hyporesponsiveness while immunocompetence was preserved to third-party antigens. Conclusion These findings indicate that the two-stage BMT strategy is a safe and feasible method for the induction of donor-specific tolerance via stable mixed chimerism and needs to be further confirmed after a long-term observation.     

心脏外科术后心包积液的危险因素与治疗

目的 探讨心脏外科手术后心包积液的危险因素和治疗方法.方法 回顾分析22 462例患者临床资料,定义心包积液诊断标准.观察心包积液患者与无积液患者的临床表现,对症治疗,分析危险因素.结果 509例(2.3％)患者有心包积液262例有临床特殊症状,其中51例有心包压塞的临床表现.有、无心包积液的患者年龄、性别、冠心病史等因素差异无统计学意义(P＞0.05);而大体重、瓣膜病、主动脉阻断和体外循环时间差异有统计学意义(P＜0.05).结论 心包积液的危险因素有大体重,术前心功能Ⅲ、Ⅳ级,瓣膜病,先天性心脏病,大血管疾病,体外循环和主动脉阻断时间延长.超声引导下的心包积液穿刺引流是安全有效的.     

继发孔房间隔缺损3种治疗技术的对比研究

目的:对外科微创封堵、导管介入封堵与体外循环直视修补术3种治疗继发孔房间隔缺损(ASD)的技术进行回顾性对比研究。方法:2006年1月至12月,116例继发孔ASD患者分别接受了外科微创封堵术(A组)、导管介入封堵术(B组)与体外循环直视修补术(C组)的治疗。结果:3组患者均无围术期死亡病例。C组在手术时间,总出血量和术后住院天数等方面均要明显大于A组和B组,后2组间则无明显差异。术后带气管插管时间,C组明显大于A组。住院费用方面,B组要明显高于A组和C组,而后2组间则无明显差异。结论:3种技术均是治疗继发孔ASD的有效方法。外科微创封堵术适应症广、无X线辐射、术后恢复快、住院时间短、费用低及疗效可靠;而且操作简单并利于推广。在很大程度上要优于体外循环直视修补术和导管介入封堵术。     

微创胸腔镜心外膜电极技术和冠状静脉窦电极技术进行心脏再同步治疗的比较研究

Objective To compare the minimally invasive surgical implantation of left ventricular epicardial electrode technique and coronary vein sinus endocardial electrode technique for cardiac resynchronization therapy(CRT) in cardiomyopathy heart failure. Methods During April 2007 to May 2009 total 28 patients were diagnosed as advanced heart failure with cardiac dysynchronization through ECG and Tissue Doppler Echos. Ten received surgical epicardial electrode implantation ( group 1 ) and 18 received coronary sinus electrode implantation ( group 2). For the group 1 patients, the electrodes were placed in right atrial and ventricle guided by X ray under the general anesthesia. The right atrial and ventricle electrodes were connected with the three chamber pacemaker. The Tissue Doppler Echo TEE technique was used to search suitable left ventricle place for the ideal CRT therapy. Then the epicardial electrode was fixed at the ideal place. The resynchronization features were examined after surgery during the follow of 5 ～ 24 months. Results The endocardial and epicardial electrodes were implanted successfully without any serious complication in group 1 patients. All patients were discharged without any adverse cardiac episodes. For the group 1 patients during the 5 ～ 24 months follow-up the left ventricle maximize delay time decreased from ( 390. 7 ± 42.1) ms to ( 135.7 ± 37.2 ) ms, the left dysynchronization index (Ts-SD) decreased from ( 143.7 ±30. 1 ) ms to (50. 3 ±22. 3) ms,the inter-ventricle mechanical delay time (IVMD) decreased from (57.7 ±24. 9) ms to (27.0 ± 10. 8) ms,left ventricle end-dilation diameters (LVEDD) increased from (71.3 ± 12. 8) mm to (62. 3 ±6. 5) mm and the left ventricle ejection fraction (LVEF) increased from 0. 320 ±0. 007 to 0. 400 ±0. 006. For the group 2 patients during the follow up period the left ventricle maximize delay time decreased from (396. 7 ± 36. 1 ) ms to (293.7 ± 119. 2)ms,Ts-SD decreased from ( 147.7 ± 22. 1 ) ms to (96. 3 ± 34.3) ms,IVMD decreased from ( 59.7 ± 35.9 ) ms to (27.0±25.8) ms,LVEDD increased from (71.3 ±9.8) mm to (67.3 ±9.5) mm and LVEF increased from 0. 281 ±0. 077 to 0. 330 ±0. 076. The left ventricle resynchronization results were better in the group 1 cases. Conclusion Cardiac resynchronization results were good in both groups and the surgical epicardial therapy could improve the left ventricle resynchronization.     

大鼠心脏移植淋巴细胞多基因差异表达及淋巴细胞表面蛋白分子的表达时相比较

目的建立大鼠异体异位心脏移植动物模型,观察心脏移植前后淋巴细胞多基因表达和CD4、CD8分子表达及环孢素A对其影响。方法 SD大鼠为供体,Wistar大鼠为受体,分为心脏移植对照组和环孢素A干预两组。移植前、移植后24 h、3 d、7 d、10 d和12 d测定外周血淋巴细胞CD4、CD8分子表达、荧光差异显示分析淋巴细胞编码基因表达水平。结果 (1)移植组:7个基因差异表达,比同组的CD4和CD8分子开始正调表达的时间提前24 h;(2)环孢素A组外周血淋巴细胞的基因表达水平发生变化的有5个基因差异表达;(3)环孢素A组2.3-bisphosphoglycerate比对照组的第一个正调表达时相至少晚24 h,环孢素A还可抑制心脏移植后7 d内外周血淋巴细胞对gig18基因的转录;移植后24 h内,环孢素A组外周血淋巴细胞Na-通道蛋白基因正调表达。结论淋巴细胞多基因差异表达及与表面蛋白分子表达时相比较对于深入研究移植排斥反应机制和环孢素A的作用机制具有一定的意义。     

共无定形给药系统研究进展

共无定形药物是将活性药物成分和其他药物或辅料等小分子固体组分混合形成的一种二元单相无定形固体分散体给药系统。作为一种新颖的药物传递系统，共无定形药物可能改善水难溶性药物的溶解度和口服生物利用度问题，为仿制药物和复方药物的开发提供了新的策略和思路。近年来，共无定形药物在学术和制药工业领域受到广泛关注。本文综述了共无定形药物的载体材料的筛选、制备方法、物理稳定机制，以及体外溶出性能和体内吸收情况，并对共无定形药物的未来发展前景进行了展望。     

经导管主动脉瓣置入手术的历史与现状

经导管主动脉瓣置入手术自从2002年临床成功开展以来发展非常迅猛，各类技术更新层出不穷，输送器尺寸越来越小已经发展到14F，卒中比例小于4%，瓣周漏和起搏器的比例也随着临床技术经验和瓣膜产品设计更新而不断降低。而且在二叶畸形、重度钙化等领域置入技术也获得良好效果。中国经导管主动脉瓣置入手术起步较晚，但是自2017年自主知识产权瓣膜上市之后发展很快，2019年全国完成超过2000例手术，也组织发布了一些专家共识。另外一方面，国内大多数单位还处于起步阶段，经导管主动脉瓣置入手术的技术研究和推广尚待规范化的进行。     

针刺干预早期膝关节骨性关节炎:随机对照试验

目的:观察对于早期膝关节骨性关节炎(KOA)针刺联合基础治疗与单纯基础治疗的临床疗效差异。方法:将60例单侧KOA患者按随机数字表法分为基础治疗组和针刺联合基础治疗组,每组30例。基础治疗组采用患者教育和患膝局部涂抹双氯芬酸二乙胺乳胶剂,每天涂抹3次,连续2周。针刺联合基础治疗组在基础治疗组的基础上,针刺患侧阿是穴、足三里、阳陵泉、阴陵泉、内膝眼和犊鼻,每次留针30min,每周一、三、五治疗1次,连续治疗2周。于治疗前后测评患者的视觉模拟量尺(VAS)评分及西安大略和麦克马斯特大学(WOMAC)骨关节炎量表评分,并在治疗后观察患者的临床疗效。结果:两组患者治疗后患膝VAS评分均低于治疗前(P0.05),且针刺联合基础治疗组治疗后评分低于基础治疗组(P0.05),治疗前后差值大于基础治疗组(P0.05)。两组患者治疗后患膝WOMAC评分均低于治疗前(P0.05),且针刺联合基础治疗组治疗后评分低于基础治疗组(P0.05),治疗前后差值大于基础治疗组(P0.05)。治疗后基础治疗组的愈显率为73.33%(22/30),针刺联合基础治疗组的愈显率为83.33%(25/30),两组比较差异无统计学意义(P0.05)。结论:针刺联合基础治疗对于早期KOA比单纯基础治疗更能减轻患者疼痛,改善膝关节活动度,有潜在的临床疗效优势。     

江西省部分地区结核病患者知信行现况调查

结核病是一种慢性呼吸道传染病,我国结核病患者数量位居全球第三位[1],疫情严重.为了解结核病患者结核病知识、信念及预防行为,更有效开展结核病健康促进工作提供科学资料.2014年4月,江西省对部分地区结核病患者开展了知识、信念、行为调查研究.