上胸段硬膜外阻滞治疗缺血性心肌病心力衰竭的临床观察

目的 探讨上胸段硬膜外阻滞（HTEA）治疗缺血性心肌病心力衰竭（CHF）的疗效和安全性。方法缺血性心肌病心力衰竭患者117例,其中男90例,女27例;年龄45～81岁。入选患者：冠状动脉造影证实至少1支冠状动脉及其分支狭窄≥50％;心功能NYHA分级Ⅱ-Ⅳ级;左室射血分数（LVEF）≤45％。将患者随机分为HTEA组和对照组：HTEA组63例,男51例,女12例;对照组54例,男39例,女15例。所有患者均给予心衰常规药物治疗,HTEA组在常规药物治疗的基础上联合应用HTEA治疗,即给予患者硬膜外置管,每间隔2h经硬膜外导管注入0．5％利多卡因3～5ml,夜间睡眠时暂停给药。两组患者于治疗前后行超声心动图检查,同时比较治疗前后的血浆脑钠素（BNP）水平。结果HTEA组治疗总有效率为95．2％,高于对照组（85．2％,P〈0．05）。治疗后HTEA组二、三尖瓣返流明显减少,患者二尖瓣返流面积分别由（6．64±3．7）cm。降至（4．3±2．7）cm^2,三尖瓣返流面积从（5．4±3．2）cm^2降至（3．3±2．3）cm^2（P〈0．01）。LVEF由（38±12）％增至（494-10）％,显著高于对照组（P〈0．01）。HTEA组左室舒张末期容积（LVEDV）和收缩末期容积（LVESV）显著缩小,LVEDV由（337±132）ml降至（2744±109）ml;LVESV由（215±99）ml降至（147±73）ml（P〈0．01）。对照组上述指标改善则不明显。HTEA对心脏舒张功能指标改善不明显（P〉0．05）。治疗后HTEA组患者血浆BNP水平显著低于对照组（6784±521）ng／Lvs237±225）ng／L]（P〈0．05）。结论联合HTEA治疗缺血性心肌病心力衰竭效果明显且安全,可显著改善心脏功能。

Clinical observation of high thoracic epidural anesthesia therapy for patients with congestive heart failure secondary to ischemic cardiomyopathy

OBJECTIVE: To investigate the effects of high thoracic epidural anesthesia (HTEA) on chronic heart failure (CHF) and its safety. METHODS: 117 patients with ischemic cardiomyopathy (ICM) of NYHA class II - IV and with the LVEF < or = 45%, 90 males and 27 females, aged 45 - 81, were Randomly divided into 2 groups: control group (n = 54, treated with the routine medication) and HTEA group (n = 63, administrated epidurally with 0.5% lidocaine 3 - 5 ml every two hours from 9 a.m. to 11 p.m. everyday via an epidural catheter for one month in addition to the routine treatment). Echocardiography was performed before and after the treatment to examine the cardiac structure and left ventricular systolic function. The plasma brain natriuretic peptide (BNP) was examined before and after the treatment. RESULTS: The clinical symptoms and signs of the HTEA group were improved markedly. The total effective rate was 95.2% in the HTEA group, significantly higher than in the control group (85.2%, P < 0.05). Echocardiographic parameters showed that the diameters of ventricles and atriums decreased by 3 - 5 mm in the HTEA group. The left ventricular end diastolic volume (LVEDV) of the HTEA group reduced from (337 +/- 132) ml before treatment to 274 ml +/- 109 ml after treatment, and the left ventricular end systolic volume (LVESV) of the HTEA group reduced from (215 +/- 99) ml before treatment to (147 +/- 73) ml after treatment (both P < or = 0.001). The regurgitation area of mitral valve of the HTEA group reduced from (6.6 +/- 3.7) cm(2) before treatment to (4.3 +/- 2.7) cm(2) after treatment, and the regurgitation area of tricuspid valve of the HTEA group reduced from (5.4 +/- 3.2) cm(2) before treatment to (3.3 +/- 2.3) cm(2) after treatment (both P < 0.01). No changes were observed in the E/A ratio in both groups. The BNP level fell from (678 +/- 521) ng/L to (237 +/- 225) ng/L in the HTEA group (P < or = 0.05). In the HTEA group, one patient died because of deterioration of cardiac function. HTEA was well tolerated and caused lower incidence of adverse events. CONCLUSIONS: HTEA obviously improves the heart function of the patients with CHS secondary to ICM. Consequently, HTEA is effective and safe in CHF patients with favorable tolerance.