连续375例不停跳冠脉搭桥手术无早期死亡临床经验

目的 总结连续375例不停跳冠状动脉搭桥手术无住院死亡的临床经验.方法 回顾性分析连续375例择期不停跳冠脉搭桥手术患者临床资料.结果 本组中男244例,女131例,平均年龄(64.2±13.6)岁,术前预防性使用主动脉内球囊反搏辅助25例.术中平均搭桥(3.45±0.36)支,平均手术时间(329.2±53.9)min,乳内动脉使用率为95.2％,桡动脉使用率为46.7％,术中紧急转为体外循环下手术9例.6例发生围术期心肌梗死.术后呼吸机辅助呼吸时间为(11.5±3.8)h,监护室停留时间为(14.6±5.7)h,无住院手术死亡(手术后30d内).术后平均随访(53.5±18.9)个月,大多数患者心功能明显改善.结论 严格把握不停跳冠脉手术适应征,术中正确使用分流栓,no-touch以及精细的吻合技术是手术成功的关键,并可达到完全血管化的要求.     

微创冠脉搭桥手术临床应用和效果30例分析

目的：评价不停跳微创冠脉搭桥术的临床效果。方法：对30例冠心病患者采用胸骨正中切口,应用心脏表面固定器、心包深部牵引线、冠脉内分流器及吹雾器行不停跳搭桥术。结果：30例全部使用左侧乳内动脉,搭桥1－4根;平均手术时间161min;术中平均失血320ml。1例在术中改为常规体外循环冠脉搭桥手术;术后24h平均引流量380ml,平均输血或血制品320ml;4例术后在手术室内拔管,ICU机械辅助通气平均时间为4．2h;ICU监护时间平均12．6h（8－20h）;术后平均住院12．5d（8－19d）。1例术后2周死于严重的肺部感染,住院死亡率3．3％。术后随访1－7个月,所有患者术后心绞痛均消失。结论：不停跳心脏微创搭桥术创伤小、安全、经济、临床效果好,适用于单支、多支冠脉病变和具有高危因素的患者,值得在临床大力推广。     

非体外循环下冠脉搭桥手术26例临床分析

目的 :评价非体外循环下冠脉搭桥手术的临床效果。方法 :对 2 6例冠心病人实施了非体外循环下心脏不停跳冠脉搭桥手术。采用胸骨正中切口 ,应用心脏表面固定器、冠脉内分流器及吹雾器 ,心脏不停跳下行搭桥手术。 结果 :对 2 4例患者使用了左侧乳内动脉 ( L IMA)。搭桥 1～ 5根 ,平均 3.1根。手术时间 6 0～ 180 min,平均( 12 0± 5 9) min。术后 2 4 h引流量为 180～ 10 0 0 m l,平均 ( 2 2 0± 5 0 ) m l,输血或血制品 0～ 14 0 0 m l,平均 ( 2 5 0± 6 0 )ml。术后死亡 1例 ,死亡率 3.8%。术后住院天数 ( 8～ 16 ) d,平均 ( 11.5± 2 .5 ) d;术后随访 1～ 7个月 ,所有病人术后心绞痛消失。 结论:非体外循环心脏不停跳冠脉搭桥手术是一种创伤小、安全、经济和临床效果很好的手术技术 ,适用于单支、多支冠脉病变和具有高风险因素的患者 ,值得在临床大力推广     

经左胸小切口非停跳冠状动脉搭桥术的临床研究

目的:探讨经左胸小切口非停跳冠状动脉搭桥的临床价值,为冠心病需行搭桥手术治疗的患者寻求更好的手术方案。方法:选取冠心病需行冠状动脉搭桥手术治疗的患者210例,随机分为两组。对照组107例,采用体外循环冠状动脉搭桥手术;观察组103例,采用经左胸小切口非停跳冠状动脉搭桥手术。统计两组患者术后机械通气时间、ICU时间、住院时间、术后引流量及并发症发生率并进行比较。结果:对照组患者术后机械通气时间、ICU时间、住院时间以及术后引流量分别为(19.21±1.33)h、(5.08±0.57)d、(21.20±2.34)d和(997.68±96.35)mL,观察组分别为(7.73±0.74)h、(2.83±0.16)d、(15.67±1.18)d和(901.53±89.32)mL,两组比较差异有统计学意义(P<0.05)。对照组患者术后出现肾功能不全和心律失常发生率均为6.54%,观察组均为0.97%,观察组术后肾功能不全和心律失常发生率明显低于对照组,两组比较差异有统计学意义(P<0.05)。两组患者术后低心排、二次开胸止血、脑血管病变、肺部感染、围手术期心梗以及死亡发生率差别,无统计学意义(P>0.05)。结论:经左胸小切口非停跳冠状动脉搭桥手术是一种损伤小、恢复快的手术方式,对于需行冠状动脉搭桥手术治疗的冠心病患者而言可以作为首选的治疗方式。     

七氟醚在不停跳冠脉搭桥患者中心肌保护作用优于异丙酚

目的对比七氟醚与异丙酚用于不停跳冠脉搭桥患者心肌保护中的效果。方法选择40例择期行不停跳冠脉搭桥术的患者,依照入院顺序随机平均分为七氟醚组与异丙酚组,分别于术中予以七氟醚、异丙酚麻醉,对比两组患者采用不同药物麻醉的心肌保护效果。结果两组患者肌钙蛋白I麻醉前、手术开始时浓度相对稳定,再灌注之后逐渐上升,术后七氟醚组浓度明显低于异丙酚组（P〈0.05）;两组IL-6在麻醉前没有差异,手术过程及术后均有上升现象,且七氟醚组上升幅度大于异丙酚组（P〈0.05）;七氟醚组C反应蛋白上升幅度小于异丙酚组（P〈0.05）。结论从各项指标变化情况看来,七氟醚麻醉下可减小心肌损伤程度,可在不停跳冠脉搭桥手术中推广应用。     

婴幼儿浅低温心脏不停跳和中低温停跳心内直视手术临床对比

目的:比较浅低温心脏不停跳和中低温停跳技术在婴幼儿心内直视手术的应用. 方法:分析518例3岁以下行心脏手术患者,其中96例(组1)在中低温体外循环心脏停跳下手术,422例(组2)在浅低温体外循环心脏不停跳下进行手术. 比较两组患者的转流时间、术后低心排发生率、术后机械通气时间以及动脉血气等围手术期资料. 结果:不停跳组患者的平均转流时间较停跳组短(P<0.01),术后低心排的发生率也较停跳组低(P<0.05);不停跳组患者术后的失血量和输血量均较中低温停跳组少(P<0.01),并且术后机械通气时间也较停跳组短(P<0.01),而氧合指数高于停跳组;不停跳组术后肌酸磷酸激酶同工酶(CK-MB)浓度明显低于停跳组(P<0.01),另外不停跳组术后代谢性酸中毒的发生率也较低. 结论:浅低温体外循环心脏不停跳技术在婴幼儿心肌保护、改善术后呼吸功能及维持酸碱平衡等方面均优于中低温体外循环心脏停跳技术. 表明浅低温体外循环心脏不停跳可作为一项安全、有效的技术应用于婴幼儿心脏外科.     

心脏不停跳冠脉搭桥手术的配合要点

目的 探讨心脏不停跳冠脉搭桥手术的配合要点.方法 选取24例实施心脏不停跳冠脉搭桥手术治疗患者进行研究,分析其护理配合.结果 24例患者实施心脏不停跳冠脉搭桥手术治疗效果良好,没有严重并发症和死亡,术后早期1例患者出现心律失常现象.结论 手术护理配合可显著提高心脏不停跳冠脉搭桥手术的治疗效果,改善患者预后.     

56例高龄不停跳冠状动脉旁路移植术分析

目的探讨高龄(≥75岁)不停跳冠状动脉旁路移植术的疗效观察。方法回顾性分析梅州市人民医院心血管外科自2008年1月至2013年1月间接受冠状动脉旁路移植术的126例高龄患者的临床资料,按照治疗方法的不同分为不停跳组和常规组,不停跳组采用不停跳冠状动脉旁路移植术,常规组采用常规冠状动脉旁路移植术,对两组患者术中、术后相关指标进行比较。结果不停跳组和常规组术中、术后相关指标进行比较,手术时间[(210.5±22.6)min vs(250.6±30.2)min]、辅助呼吸时间[(6.3±2.4)d vs(8.9±2.6)d]、术后输血例数(21 vs 49)、住ICU天数[(5.2±2.2)d vs(7.3±2.5)d]、术后引流总量[(812.6±152.9)mL vs(1100.5±160.3)mL]、术后并发症(心、肝、肾、肺)的例数(5 vs 18)及住院总费用[(6.5±0.7)万元vs(7.5±0.5)万元],差异均有统计学意义(P<0.05)。结论高龄患者进行不停跳冠状动脉旁路移植术安全,效果显著,是高龄患者的冠状动脉外科治疗的首选。     

序贯式不停跳冠脉搭桥与非序贯式不停跳冠脉搭桥的对比研究

目的：通过多项指标对比序贯式不停跳冠脉搭桥与非序贯式不停跳冠脉搭桥临床疗效。方法随机选取于2009年1月至2015年1月在我院接受冠状动脉旁路移植手术的非序贯式不停跳冠脉搭桥手术患者与序贯式不停跳冠脉搭桥手术患者各28例为研究对象,总计56例。将行非序贯式不停跳冠脉搭桥患者记为对照组,行序贯式不停跳冠脉搭桥患者记为观察组。对比两组术后1天(A1)以及术后2天(A2)的心肌肌钙蛋白I(cTnI)浓度、肌酸激酶-同工酶(CK-MB)活性、氨基酸末端前体脑钠肽(NT-proBNP)浓度以及桥血管使用数目、手术时间、出血量、住院费用。结果行序贯式不停跳冠脉搭桥患者组(观察组)在A1、A2时刻的cTnI、CK-MB、NT-proBNP低于行非序贯式不停跳冠脉搭桥患者组(对照组)。此外,观察组在桥血管使用数目、手术时间、出血量、住院费用显著低于对照组。结论序贯式OPCABG术对心肌损伤的程度小于非序贯式OPCABG,并且序贯式OPCABG术桥血管使用少,手术时间短,住院费用更低,尤其对于主动粥样斑块较多,桥血管缺乏,基础状态较差的病人优于非序贯式OPCABG,极大地增加了OPCABG手术适应症。     

停跳与不停跳冠状动脉搭桥术后并发症的比较

目的通过比较停跳冠脉搭桥(CCAB)和不停跳冠脉搭桥(OPCAB)术后并发症,探讨两种术式的优缺点。方法总结6年来我院所实施的心脏停跳下单纯冠脉搭桥术59例和心脏不停跳冠脉搭桥术113例的临床资料,比较分析了术后常见并发症和病死率。结果OPCAB组在术后机械通气时间I、CU和术后住院时间比CCAB组显著缩短,且术后低心排发生率I、ABP使用和术后心律失常也比CCAB组明显减少,而肾功能不全、围术期心梗、引流量、肺部感染、中风等术后主要并发症和病死率则两组相差不显著。结论OPCAB在术后恢复上明显优于CCAB,虽远期血管桥通畅率有待临床进一步观察,但其近期优越性是显而易见的。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Electro-Acupuncture Combined with the Trigger Point Needle-Embedding for Treatment of Primary Trigeminal Neuralgia in 31 Cases

In recent years, the author of this essay has applied electro-acupuncture combined with the trigger point needle-embedding for treatment of primary trigeminal neuralgia in 31 cases, yielding satis- factory results as reported in the following.     

Investigation of Matrix Metalloproteinase -1, 2 and tissue inhibitor of matrix metalloproteinases-1 in Endometriosis

Objective： To explore the role of matrix metalloproteinase-1,2 （MMP-1, MMP-2） and tissue inhibitor of matrix metalloproteinases-1 （TIMP-1） in endometriosis. Methods： The eutopic and ectopic endometria from 40 subjects suffering from endometriosis and regular.endometria from 40 subjects （excluding endometriosis） were collected and examined by in situ hybridization technology and western blot assay. Results： Both expressions of MMP-1 and -2 were stronger in ectopic endometrium and eutopic endometrium than in normal endometrium. On the contrary, the expression of TIMP-1 in ectopic endometrium and eutopic endometrium was lower. The differences were significant （P 〈 0.01 ）. Moreover, there was no relationship among the expressions of MMP-1, 2 and TIMP-1 in ectopic endometrium. Conclusion： The expressions of MMP-1, 2 and TIMP-1 lose balance and lack of periodic changes in ectopic endometrium , which explains the biological invasive behavior of endometriosis. It was suggested-that regulating the balance between the MMPs and TIMP-1 should be an ideal therapeutic target to endometriosis.     

Shi Da-zhuo (史大卓) —An outstanding cardiologist of integrative medicine

Prof. SHI Da-zhuo, Ph.D., male, was born on March 20, 1960. Prof. SHI entered the Ph.D. program in 1990 at the China Academy of Chinese Medical Sciences under the supervision of Prof. CHEN Ke-ji, majoring in the treatment of cardiovascular diseases. After receiving his Ph.D. degree in 1993, Prof. SHI started working at the Cardiovascular Center in Xiyuan Hospital affiliated to China Academy of Chinese Medical sciences.     

Persist in and Carry Forward the Integrative Medical Research——Speech at the 6th National General Congress of Chinese Association of Integrative Medicine by Academician CHEN Zhu,Minister of Ministry of Health

The 6th National General Congress of Chinese Association of Integrative Medicine （CALM） was convened at 19-20, April 2008 in Beijing. Academician CHEN Zhu, the minister of Ministry of Health indicated at the congress that the integration of Chinese and Western medicine is very well in keeping with the situation of our country and the general rule of development in medical science; and as a good integration of Chinese medicine and Western medicine, it is mutually beneficial and advantageous to both of them. Seeing the creativity shown in integrative medical investigation in theoretic and methodological sides, we should and must persist in and develop it.