永久埋藏式心脏起搏器置入术前后房颤的探讨

本文系一回顾性研究,118例安装永久性埋藏式心脏起搏器病人,随诊2—8年。探讨了房颤的发生率与易发原因,以及在阵发性房颤情况下,安装AAI起搏器的适应性与限制。     

急性前壁心肌梗死患者心电图aVR和aVL损伤图形的意义

目的 探讨急性前壁心肌梗死患者心电图aVR和aVL导联损伤图形与临床预后的关系。方法 入选急性前壁(包括前壁、广泛前壁、前壁 侧壁)心肌梗死患者102例，分析入院当时心电图，aVR导联损伤图形指Sr段抬高或压低≥0.05mV；aVL导联损伤图形包括以下情况之一：①ST段抬高≥0.05mV；②ST段抬高幅度≤0.05mV同时伴有T波对称住倒置；②ST段在等电线而伴有T波对称性倒置和病理性Q波形成(时间≥30ms)。所有患者于发病2周行超声心动图并测量左室射血分数(LVEF)。记录入院期间心脏事件情况。结果 ①伴aVR导联损伤图形者CK、CK—MB峰值明显增高。②伴aVL导联损伤图形者CK、CK—MB峰值明显增高而LVEF明显减低。②同时伴aVR和aVL导联损伤图形者CK、CK—MB峰值、左室收缩末期容积(ESV)和室壁瘤发生率明显增高，而LVEF明显减低。结论 急性前壁心肌梗死时aVR和aVL导联均表现损伤图形是判断预后不良的重要指标。     

伴卒中史患者非体外循环冠状动脉旁路移植术后再发急性脑梗死的影响因素分析

目的探讨伴有卒中史患者非体外循环冠状动脉旁路移植(OPCAB)术后再发急性脑梗死的相关因素。方法回顾性分析首都医科大学附属北京安贞医院2010年1月—2012年9月,468例有卒中史OPCAB手术患者的临床资料。根据术后有无再发急性脑梗死分为再发脑梗死组(A组)41例和无再发脑梗死组(B组)427例。分析与缺血事件发生的相关因素[术后再发脑梗死的时间为完成手术入住重症监护病房(ICU)期间]。结果 468例OPCAB手术患者术后再发急性脑梗死41例,占8.8%。①单因素分析显示,A、B组间术前双侧颈内动脉重度狭窄[(41.5%(17/41),8.9%(38/427)]、术前左心室射血分数≤35%[53.7%(22/41),25.8%(110/427)]、术中En-closeⅡ主动脉近端吻合器的应用[19.5%(8/41),76.3%(326/427)]、术后急性心肌梗死[34.1%(14/41),9.1%(39/427)]、术后心房颤动[48.8%(20/41),10.8%(46/427)]、术后低血压[68.3%(28/41),18.7%(80/427)]、术后机械通气时间>72 h[(75.6%(31/41),15.0%(64/427)]、入住ICU时间>72 h[(82.9%(34/41),25.3%(108/427)]及病死率[(29.3%(12/41),5.4%(23/427)],差异均有统计学意义(均P<0.01)。②多因素Logistic回归分析显示,术前双侧颈内动脉重度狭窄(OR=6.338,95%CI:2.283～21.019)、术前左心室射血分数≤35%(OR=2.737,95%CI:1.267～6.389)、术后急性心肌梗死(OR=3.656,95%CI:1.933～6.894)、术后心房颤动(OR=3.104,95%CI:1.135～8.016)与术后低血压(OR=4.173,95%CI:1.836～9.701)是OPCAB患者术后再发急性脑梗死的独立危险因素。术中应用EncloseⅡ主动脉近端吻合器(OR=0.556,95%CI:0.337～0.925)是OPCAB患者术后再发急性脑梗死的保护因素。结论伴有卒中史患者行OPCAB术后,再发急性脑梗死的发生率及病死率高,术前双侧颈内动脉重度狭窄、术前左心室射血分数≤35%、术后急性心肌梗死、术后心房颤动和术后低血压是伴有卒中史患者OPCAB术后再发急性脑梗死的独立危险因素。而术中应用EncloseⅡ主动脉近端吻合器是伴有卒中史患者OPCAB术后再发急性脑梗死的保护因素。     

肾功能损伤分级系统在成人心脏术后的应用

Objective The aim of this study was to evaluate of adilty of two acute renal failure-specific scoring systenms (the classification by Bellome et al and the AKIN criteria) for predicting hospital mortality after cardiac surgery in adult patients. Methods Between October 1 st 2006 to Decemjber 31 st 2006, 509 adult patients who ungerwent coronary artery bypass grafting (CABG) and/ or valve operation were enrolled in this study. The medical data collection included gender, age, types of operation, perioperative he- modynamic parameters, urine output, biochemical parameters and outcome. Renal function was assessed daily according to the classi- ficatinn by Bellomo and the AKIN criteria, respectively. As references, Acure Physiology and Chronic Health Evaluation(APACHE) Ⅱ and Sepsis-related Organ Failure Assessment (SOFA) score were also calculated. Resuits Three hundred and forty-one patients were male (67.0%), and 168 were female (33.0%), mean age was (56.2±12.0) years old. Tnree hundred and nine patieats un- derwent CABG, 182 underwent valve operation and 18 underwent CABG plus valve operation, Mean duration of ventilation support was (20.4±17.7) houra, and the ICU stay was (1.4±1.0) days. Postoperative hospital stay was (13.8±9.1) days. According to the classification by Bellomo., the highest in-hospital mortality was 52.9% in ARFS group. Mahiplicatinn of in-hospital morality rate was abserved (X2 for trend, P<0.01) in 0.4% (non-ARF), 1.2% (stage 1), 12.0% (stal～ 2) and 32.4% (stage 3) of pa- tients based on the AKIN criteria. By applying the area under the receiver operating characteristic ourve, the classification by Bellomo and the AKIN criteria had good discriminative power. Furthering, multivariate logistic regression analysis verified that the Odds Ratio of the AKIN criteria was 5.478 (P =0.028, 95% Confidence Interval 1.027- 24.856), after adjusting for gender and age. Con- clusion Analytical data confinned good discriminative power of both the AKIN criteria and the classification by Bellomo for predicting hospital mortality of adult postoperative patient with ARF.     

国产硝酸异山梨酯注射液治疗心绞痛的临床观察

目的：比较国产和进口硝酸异山梨酯注射液治疗心绞痛的疗效和安全性。方法：选择心绞痛患45例随机分为国产（试验组）和进口（对照组）硝酸异山梨酯组。静滴210mg/h,8-10h/d，持续7天。观察心绞痛发作次数、诱发心绞痛的劳力程度、硝酸甘油日水泵量、用药前后心电图的变化、心率、血压和心率血压乘积及不良反应等。将疗效按显效、有效、无效和加重分为四组。结果：试验组和对照组临床疗效的显效率（70%，67%）、有效率（23%，27%），无效率（7%，7%）和加重率（0%，0%）均无显差异试验组和对照组心电图疗老头儿 的显效率（23%，13%）、有效率（17%，20%），无效率（60%，67%）和加重率（0%，0%）亦无显差异。试验组和对照组均无明显不良反应发生。结论：国产和进口硝酸异山梨酯注射液治疗心绞痛均有确切疗效且较安全，国产硝酸异山梨酯可作为同类进口药物的替代品。     

肾功能分级在成人心脏术后肾功能衰竭的应用

Objective To evaluate the ability of the RIFLE classification to predict hospital mortality in adult patients who underwent cardiac surgery. Methods From October Ist 2006 to December 31st 2006, five hundred and nine adult patients who underwent coronary artery bypass grafting and/or valve operation were enrolled in this study. Renal function was assessed daily according to the RIFLE classification, meanwhile, APACHE Ⅱ score and SOFA score were also evaluated, as well as the maximum scores were recorded. Results Mean duration of ventilation support was 18(14 - 19) hours, the time of ICU stay was 1.4 ± 1.0 days, and the time of postoperative hospital stay was 12. 0(10.0- 15.0) days. 167 patients (32. 8%) incurred postoperative ARF according to the RIFLE classification. The overall mortality was 4. 3% (22/502). A significant increase (P < 0. 01) was observed for mortality based on RIFLE classification. By applying the area under the receiver operating characteristic curve, the RIFLE classification had more powerful discrimination power [0. 933, (95% CI 0. 872 -0. 995) ,P <0. 001]. Conclusions ARF is one of the major complications in postcardiotomy patients. Analytical data suggested the good discriminative power of the RIFLE classification for predicting inpatient mortality of adult postoperative patient with ARF, and the RIFLE classification is simple and practically performed. According to the RIFLE classification, patients with RIFLE class I or class F incur a significantly increased risk of in-hospital mortality compared with those who never develop ARF.     

肾功能损伤分级系统在成人心脏术后的应用

目的 探讨肾功能损伤分级系统在成人心脏术后的临床应用价值.方法 连续收集2006年10月1日至2006年12月31 日(以手术日期为准)首次行冠状动脉移植术和(或)瓣膜置换术的509例病人资料.记录性别、年龄、手术类型、围术期血流动力学指标、尿量、血生化指标和临床转归等内容.按照Bellomo评分和AKIN分级系统在心脏手术后分别对病人进行分级、评分.结果 509例中男341例(67.0%),女168例(33.0%),平均年龄(56.2±12.0)岁.行冠状动脉移植术309例,瓣膜手术182例,冠状动脉移植术合并瓣膜手术18例.Bellomo评分和AKIN分级ROC曲线下面积分别为0.875和0.923.多因素Logistic回归分析显示,AKIN分级OR值为5.478(P=0.028,95%CI 1.027～24.856).结论 ARF是心脏手术后的常见并发症之一,BellOMO评分和AKIN分级系统对心脏手术后ARF病人的住院死亡有良好的预测能力.     

体外膜肺氧合治疗瓣膜手术后急性心脏功能衰竭

目的探讨体外膜肺氧合（ECMO）治疗瓣膜手术后急性心脏功能衰竭的经验。方法回顾心脏外科监护病房（ICU）收治的60例瓣膜手术后因急性心脏功能衰竭接受ECMO辅助的患者的临床资料。男38例,女22例;年龄15-74岁,平均年龄（51±14）岁;采用静脉-动脉（V-A）转流模式。结果43例（71.7%）成功脱离ECMO,35例（58.3%）痊愈出院。平均ECMO辅助时间59h,平均监护室停留时间4d。主要并发症为出血19例、感染7例、肾功能衰竭需要透析15例、氧合器血浆渗漏18例、肢体缺血3例。结论ECMO是治疗瓣膜手术后急性心脏功能衰竭的一种有效的机械辅助方法,及时安装并积极防治并发症可降低病死率。     

心脏手术后医院感染病原菌分布与耐药性研究

目的调查医院心脏手术后医院感染病原菌分布与耐药性情况,以指导临床合理使用抗菌药物。方法分析2005年1月-2009年12月医院心脏手术后患者医院感染患者各种标本所分离的病原菌,采用VITEK-Jr全自动细菌鉴定及药敏分析系统鉴定细菌类别,纸片扩散(K-B)法进行药敏试验,应用WHONET5.4进行数据分析。结果共分离各种病原菌606株,其中革兰阴性杆菌357株占58.9%,革兰阳性球菌195株占32.2%,真菌54株占8.9%;呼吸道感染384例占63.4%,血液感染136例占22.4%,其他部位感染86例占14.2%;革兰阴性杆菌主要为不动杆菌属102株占16.8%、铜绿假单胞菌76株占12.5%、肺炎克雷伯菌47株占7.8%,革兰阳性球菌主要为表皮葡萄球菌63株占10.4%和金黄色葡萄球菌28株占4.6%,真菌主要为白色假丝酵母菌37株占6.1%;泛耐药鲍氏不动杆菌(PDR-AB)比例约60.0%;碳青霉烯类抗菌药物、头孢哌酮/舒巴坦及哌拉西林/他唑巴坦对非发酵革兰阴性杆菌保持相对较高的抗菌活性;耐甲氧西林金黄色葡萄球菌(MRSA)和耐甲氧西林凝固酶阴性葡萄球菌(MRCNS)分别占95.2%和97.2%,未发现耐万古霉素葡萄球菌。结论非发酵革兰阴性杆菌及葡萄球菌属是医院心脏手术后患者医院感染的重要病原菌,耐药性突出,应合理使用抗菌药物,并注意避免医源性交叉感染。     

A型主动脉夹层手术后医院感染分析

目的探讨Stanford A型主动脉夹层手术后的医院感染特点和相关危险因素分析。方法回顾性收集、分析医院2009年2月-2010年10月A型主动脉夹层手术后患者的医院感染资料。结果 A型主动脉夹层手术252例,年龄(47.31±10.63)岁,男193例,女59例;医院感染32例,感染率12.7%;分离病原菌76株,革兰阴性菌49株,占64.5%,革兰阳性菌18株,占23.7%,真菌9株,占11.8%;感染组患者院内死亡9例,死亡率28.1%,非感染组院内死亡7例,死亡率3.2%,差异有统计学意义(P<0.01);多元回归分析显示,术后气管切开、急性肾衰竭床旁血滤和术后脑卒中是导致医院感染的独立危险因素。结论医院感染是A型主动脉夹层术后患者院内死亡的危险因素之一,术后气管切开,急性肾衰竭床旁血滤和术后脑卒中是增加医院感染的独立危险因素。