风湿性二尖瓣狭窄伴心房颤动患者血栓前状态的研究

目的 :观察风湿性二尖瓣狭窄伴心房颤动 (房颤 )的血栓前状态。方法 :使用酶联免疫法和凝固法测量 2 4例风湿性心脏病 (风心病 )伴窦性心律患者 (窦律组 )、2 5例风心病伴房颤患者 (房颤组 )和 2 0例对照者 (对照组 )的外周血浆因子Ⅷ相关抗原 (VWFAg)、血小板α颗粒膜蛋白 14 0 (GMP 14 0 )、D 二聚体 (D dimer)和纤维蛋白原 (Fg)的水平变化 ,进行统计学分析。 结果 :与对照组比 ,窦律组血浆VWFAg、D dimer和Fg水平均显著升高(P <0 .0 5 ) ,而血浆GMP 14 0水平无显著性改变 (P >0 .0 5 ) ;房颤组血浆GMP 14 0、D dimer和Fg水平也明显升高 (P <0 .0 5 )。房颤组与窦律组相比血浆GMP 14 0、VWFAg、D dimer水平更高 (P <0 .0 5 ) ,而Fg水平在二者之间无明显变化 (P >0 .0 5 )。结论 :风湿性二尖瓣狭窄伴房颤患者外周血存在血栓前状态。     

风湿性心脏病心房颤动患者心房组织胶原及转化生长因子β基因表达的研究

目的　观察风湿性心脏病 (风心病 )心房颤动 (房颤 )患者心房组织中Ⅰ型和Ⅲ型胶原和转化生长因子 β(TGF β1、TGF β2 )基因表达的改变。方法　将 4 9例风心病二尖瓣病变接受换瓣手术者于术中获取的右心耳 (约 10 0mg)分为三组 ,其中窦性心律组 2 0例 ,阵发性房颤组 8例 ,持续性房颤组2 1例 (≥ 6个月 ) ,以 β肌动蛋白为内参照基因 ,通过半定量逆转录 聚合酶链反应 (RT PCR)技术 ,测定各组心房组织中Ⅰ型和Ⅲ型胶原和TGF β1、TGF β2 的mRNA的含量。结果　与风心病窦性心律组相比 ,Ⅰ型胶原、Ⅲ型胶原、TGF β1mRNA表达在阵发性和持续性房颤组均显著增加 ;与阵发性房颤组相比 ,持续性房颤组中这三种基因的表达继续明显增加 ;三组间TGF β2 mRNA表达差异无显著性。结论　风心病患者心房组织中Ⅰ型胶原、Ⅲ型胶原和TGF β1mRNA表达上调可能是心房纤维化发生的分子机制之一 ,为风心病患者房颤的发生和维持提供了结构基础     

风湿性心脏病心房颤动患者HCN2mRNA的表达

目的通过风湿性心脏病(简称风心病)心房颤动(简称房颤)患者右心耳组织超极化激活环核苷酸门控阳离子通道-2(HCN2)基因mRNA表达检测,探讨其与房颤的可能关系。方法 28例风心病患者根据是否存在房颤,分为房颤组和窦性心律(简称窦律)组,术前均行心脏彩色多普勒超声检测,术中取右心耳组织,应用半定量聚合酶链式反应技术检测HCN2mRNA表达。结果房颤组右房径大于窦律组((59.2±10.9 mm vs 41.7±15.5mm,P<0.05);HCN2mRNA表达水平高于窦律组(0.911 9±0.7052 vs 0.4735±0.3909,P<0.05)。结论HCN2mRNA表达异常增高,可能与风心病房颤的发生相关。     

风湿性瓣膜病心房颤动患者心房肌HCN2基因mRNA及蛋白的表达

目的研究风湿性心脏瓣膜病(简称风心病)心房颤动(简称房颤)患者心房肌超极化激活环化核苷酸门控通道-2(HCN2)基因mRNA及蛋白表达的变化。方法选取风心病二尖瓣狭窄患者38例,根据是否合并房颤将其分为两组,房颤组(n=21),窦性心律组(n=17),术中取右心耳组织,应用逆转录聚合酶链反应及蛋白质免疫印迹法分别检测心房肌HCN2基因mRNA及蛋白的表达水平,并分析其与左右房内径的关系。结果与窦性心律组比较,房颤组心房肌HCN2 mRNA表达增加[(0.613±0.179)vs(0.439±0.158),P0.01],其蛋白表达亦增加[(0.431±0.195)vs(0.225±0.121),P0.01],但其表达与左右房内径无相关关系。结论风心病房颤患者心房肌HCN2基因表达上调。     

风湿性心脏病心外膜标测心房电位的对比研究

采用术中心外膜标测方法 ,对风湿性心脏病 (简称风心病 )慢性心房颤动 (简称房颤 )及其电复律后窦性心律、风心病窦性心律及非风心病窦性心律的心房电位进行比较研究。选择风心病慢性房颤患者 18例 (Ⅰ组 )、风心病窦性心律患者 9例 (Ⅱ组 )、非风心病窦性心律患者 8例 (Ⅲ组 ) ,采用 18导同步心外膜标测 ,通过心外膜电图对房波电位顺序进行分析 ,并对三组患者的心房有效不应期 (ERP)进行比较。结果 :窦性心律患者 (Ⅱ组与Ⅲ组 )以右房侧壁上部房波电位最为领先 ,慢性房颤患者 (Ⅰ组 )左房房波多以后下部最为领先 ;Ⅰ组心房ERP最短 ,Ⅱ组次之 ,Ⅲ组最长 ,以左房后壁中部、中下部、下部相差最为明显 (P <0 .0 1) ,而心房其它部位亦有显著差异 ,P <0 .0 5 ;Ⅰ组左房与右房ERP比较 ,左房中、中下及下部ERP均明显短于右房相应部位的ERP(P <0 .0 5 ) ;Ⅰ组中左房传导时间均明显长于Ⅱ组与Ⅲ组 (P <0 .0 1)。结论 :风心病慢性房颤患者的房波电位多起源于左房 ,其左房传导时间明显长于窦性心律患者 ,而心房ERP明显短于窦性心律患者。     

二尖瓣狭窄左心房血栓前状态局部凝血功能异常的研究

目的　研究风湿性心脏 (风心 )病二尖瓣狭窄左心房局部血小板、凝血和纤溶功能的改变。方法　测定左心房、右心房、股静脉和股动脉的血浆血小板颗粒膜蛋白 (GMP 140 )、抗凝血酶Ⅲ(ATⅢ )、蛋白C(PC)、纤溶酶原激活物抑制物 1(PAI 1)、纤维蛋白降解产物 (FDP)、组织纤溶酶原激活物 (t PA)、D 二聚体 (DD)和vonWillbrand因子 (vWF)。结果　对照组和风心病组均表现左心房局部的高血小板活化、高凝血和高纤溶状态 ,而右心房则相反。风心病组左心房GMP 140含量显著高于对照组 (P <0 0 5 ) ,ATⅢ含量显著低于对照组 (P <0 0 0 1) ,纤溶功能和对照组比较差异无显著性。风心病无或轻度左心房云雾影患者和重度云雾影患者比较 ,血浆GMP 140含量显著低于重度组(P <0 0 5 ) ,血浆ATⅢ含量显著高于重度组 (P <0 0 5 ) ,PC含量显著低于重度组 (P <0 0 5 )。风心病左心房ATⅢ含量和云雾影呈直线相关 (r=- 0 72 ,P <0 0 1)。结论　风心病二尖瓣狭窄患者左心房血小板和凝血功能显著亢进 ,左心房云雾影能够反映左房高凝状态。     

慢性心房颤动患者心房组织转化生长因子-β分子重构的研究

目的　探讨风湿性心脏瓣膜病 (风心病 )心房颤动 (房颤 )患者心房组织中转化生长因子 β(transforminggrowthfactor β ,TGF β)基因转录和蛋白质表达的改变。　 方法　 4 2例风心病接受换瓣手术者分为二组 ,其中窦性心律组 2 0例 ,慢性房颤组 2 2例 (≥ 6个月 ) ,于术中获取的右心耳组织 (约 10 0mg) ,通过半定量逆转录 聚合酶链反应 (RT PCR)技术 ,测定心房组织中TGF βmRNA的相对含量 ;运用免疫组织化学方法 ,检测心房组织中TGF β的定位和蛋白相对表达量。　 结果　与窦性心律组相比 ,慢性房颤组TGF β1 mRNA相对含量增加差异有显著性 (P <0 0 0 1) ,两组间TGF β2 mRNA水平差异无显著性 (P >0 0 5 )。TGF β1 、TGF β2 在两组患者心房组织中主要表达在心房肌细胞。与窦性心律患者相比 ,慢性房颤患者的心房组织的TGF β1 蛋白表达增加差异有显著性 (P <0 0 1) ,而TGF β2 的蛋白表达差异无显著性 (P >0 0 5 )。　结论　房颤患者心房组织中TGF β1 分子重构可能是房颤时心房纤维化发生的分子机制之一 ,与房颤的发生和维持有关。     

心房颤动的外科手术治疗

心房颤动 (房颤 )是最常见的心律失常 ,发生率为 0 .1 5%～ 1 .0 0 %。在二尖瓣疾病中房颤的发生率高达 79.0 0 %。近期文献报道二尖瓣疾病合并房颤的患者在二尖瓣手术后持续房颤者占 93.89%,1年后仍有 74.0 0 %存在房颤[1-3 ] 。　　为达到根治房颤的目的 ,1 980年 Williams等提出了左房隔离术 ( isolation procedure) ,1 985年Guiraudon提出了治疗房颤的走廊术 ( corridorprocedure) ,但直至 1 989年 Cox等报道了心房电迷宫手术 ( maze procedure) ,才使房颤达到了较理想的根治效果 ,即 :1永久消除房颤 ;2保留房室同步激动 ;3保留心房的…     

犬快速心房起搏心房颤动模型肺静脉及左右心房组织细胞内钙含量变化的实验研究

目的探讨持续性心房颤动(房颤)时肺静脉及心房细胞内钙含量的变化,以期阐明房颤的发病机制。方法建立快速心房起搏式房颤模型犬8只。正常对照犬8只。实验分为6组1.房颤犬左上肺静脉组;2.房颤犬左心房峡部组;3.房颤犬右心耳组;4.正常对照犬左上肺静脉组;5.正常对照犬左心房峡部组;6.正常对照犬右心耳组。每组取相应部位心肌8块。测定细胞内钙含量。结果房颤犬肺静脉、左心房峡部和右心耳组织细胞内钙含量显著高于正常对照组(P<0.05)。房颤犬肺静脉细胞内钙含量显著高于左心房峡部(P<0.05),左心房峡部细胞内钙含量显著高于右心耳(P<0.05)。结论细胞内钙超载,可能是肺静脉和心房发生电重构的原因;肺静脉和左心房峡部,可能是房颤电重构的关键部位。     

经皮球囊二尖瓣成形术后房颤患者ANP和BNP水平变化研究

目的探讨房颤患者行经皮球囊二尖瓣成形术（PBMV）后心房利钠肽（ANP）和脑钠肽（BNP）变化及与血流动力学参数的关系。方法选择因风湿性二尖瓣狭窄伴持续性房颤成功行PBMV患者38例,术前、术后1d及半年分别用放射免疫法和酶链免疫法测定血浆中ANP、BNP值,由超声心动图测左房内径（LAD）、二尖瓣口面积（MVA）、二尖瓣跨瓣压差（MPG）及肺动脉压（PAP）。结果PBMV术后患者血流动力学参数明显改善;术后1d及半年ANP水平较术前明显下降,BNP变化不明显。术后半年与术前比较,LAD与ANP下降相关（r=0．774,P〈0．05）,△BNP与△MPG相关（r=0．574,P〈0．05）。结论房颤患者PBMV术后半年血中ANP逐步下降,BNP降低不明显。房颤律时△ANP和△BNP仍是反映LAD和MPG变化的有效指标。     

Effect of Direct Current Shocks on Left Atrial Mechanical Function in Patients With Structural Heart Disease

Objectives. This study examined the effect of endocardial and transthoracic direct current (DC) shocks on left atrial and left atrial appendage function in humans with structural heart disease.Background. DC cardioversion of atrial fibrillation (AF) to sinus rhythm is associated with transient left atrial and left atrial appendage dysfunction and the development of spontaneous echo contrast (SEC). This phenomenon has been termed atrial “stunning” and may be associated with thrombus formation and embolic stroke. To what extent the shock itself contributes to atrial stunning is unclear.Methods. Thirteen patients in sinus rhythm undergoing implantation of a ventricular implantable cardioverter defibrillator (ICD) were prospectively evaluated. All patients had significant structural heart disease. To evaluate the effects of DC shocks on left atrial and left atrial appendage function, biphasic R wave synchronized endocardial shocks of 1, 10 and 20 J were delivered between the right ventricular electrode and the left pectoral generator of the ICD in sinus rhythm. R wave synchronized transthoracic shocks of 360 J were also delivered between anteriorly and posteriorly positioned chest electrodes. Transesophageal echocardiography was performed to evaluate left atrial appendage velocities, mitral inflow velocities and the presence of SEC before and immediately after each DC shock.Results. There were no significant changes in left atrial or left atrial appendage function after endocardial or transthoracic DC shocks. Left atrial SEC did not develop after endocardial or transthoracic DC shocks.Conclusions. Endocardial and transthoracic DC shocks are not directly responsible for left atrial and left atrial appendage stunning and do not contribute to the stunning that is observed after the cardioversion of AF to sinus rhythm.     

Atrial natriuretic peptide and vasopressin during percutaneous transvenous mitral valvuloplasty and relation to renin-angiotensin-aldosterone system and renal function

To study the relation between plasma atrial natriuretic peptide (ANP) and cardiac pressure, and to assess the pathophysiologic significance of ANP in water and electrolyte metabolism, the changes in plasma levels of ANP and arginine vasopressin (AVP) were examined in 11 patients with mitral stenosis who underwent percutaneous transvenous mitral valvuloplasty, and compared with the changes in the renin-angiotensin-aldosterone system and renal function. Immediately after valvuloplasty, plasma ANP levels decreased significantly with a concomitant decrease in mean pressures in the left atrium, the pulmonary artery and the right atrium. Plasma ANP levels decreased to the normal range in 4 of the 6 patients with normal sinus rhythm, while all 5 patients with atrial fibrillation had higher levels despite a similar degree of decrease in atrial pressure. There were significant positive correlations between plasma ANP levels and the mean left atrial pressure (r = 0.61, p less than 0.01), the mean pulmonary arterial pressure (r = 0.49, p less than 0.01) and the mean right atrial pressure (r = 0.54, p less than 0.01). The mean plasma AVP levels, on the other hand, showed a transient increase after valvuloplasty from 0.5 +/- 0.1 to 1.2 +/- 0.4 pg/ml (p less than 0.05). The mean plasma renin activity (1.3 +/- 0.3 vs 2.7 +/- 0.8 ng/ml/hr, p less than 0.05) and plasma aldosterone concentration (8.6 +/- 2.3 vs 17.2 +/- 5.2 ng/dl, p less than 0.05) also increased significantly 30 minutes after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical determinants of sinus conversion by radiofrequency maze procedure for persistent atrial fibrillation in patients undergoing concomitant mitral valvular surgery

The radiofrequency Maze procedure can effectively restore sinus rhythm in most patients with atrial fibrillation (AF) and mitral valve disease. AF after cardiac surgery is associated with increased morbidity and mortality. However, clinical determinants of long-term postoperative AF after the radiofrequency Maze procedure and concomitant mitral valve surgery are poorly defined. This study comprised 99 consecutive patients with persistent AF and mitral valve disease who underwent radiofrequency Maze procedures and concomitant mitral valvular operations. The predictive values of clinical variables for postoperative AF were examined. After a mean follow-up period of 46.1+/-24.6 months, 83 patients (83.8%) had sinus conversion after the Maze procedure, and 16 patients remained in persistent or paroxysmal AF. Multiple logistic regression analysis determined that predictors of sinus conversion were preoperative left atrial diameter (odds ratio [OR] 1.127 per 1-mm increment in left atrial diameter, 95% confidence interval [CI] 1.045 to 1.215, p<0.002) and the duration of AF (OR 1.022 per 1-month increment in duration of AF, 95% CI 1.009 to 1.035, p<0.001). Discriminant analysis showed that the sinus conversion rate was significantly lower in patients with preoperative left atrial diameters>56.8 mm (p<0.001) or AF duration>66 months (p<0.001) than in patients with preoperative left atrial diameters<56.8 mm or AF duration<66 months. In conclusion, the preoperative left atrial size and duration of AF are primary predictors of sinus conversion by the radiofrequency Maze procedure for patients with persistent AF and mitral valve disease.     

Surgical Ablation of Atrial Fibrillation

The Cox-maze procedure for the restoration of normal sinus rhythm, initially developed by Dr. James Cox, underwent several iterations over the years. The main concept consists of creating a series of transmural lesions in the right and left atria that disrupt re-entrant circuits responsible for propagating the abnormal atrial fibrillation rhythm. The left atrial appendage is excluded as a component of the Maze procedure. For the first three iterations of the Cox- maze procedure, these lesions were performed using a surgical cut-and-sew approach that ensured transmurality. The Cox-Maze IV is the most currently accepted iteration. It achieves the same lesion set of the Cox- maze III but uses alternative energy sources to create the transmural lesions, potentially in a minimally invasive approach on the beating heart. High-frequency ultrasound, microwave, and laser energy have all been used with varying success in the past.Today, bipolar radiofrequency heat or cryotherapy cooling are the most accepted sources for creating linear lesions with consistent safety and transmurality. The robust and reliable nature of these energy delivery methods has yielded a success rate reaching 90% freedom from atrial fibrillation at 12 months. Such approaches offer a significant long-term advantage over catheter-based ablation, especially in patients having longstanding, persistent atrial fibrillation with characteristics such as dilated left atrial dimensions, poor ejection fraction, and failed catheter ablation. Based on these improved results, there currently is significant interest in developing a hybrid ablation strategy that incorporates the superior transmural robust lesions of surgical ablation, the reliable stroke prevention potential of epicardial left atrial appendage exclusion, and sophisticated mapping and confirmatory catheter-based ablation technology. Such a minimally invasive hybrid strategy for ablation may lead to the development of multidisciplinary “Afib teams” to obtain optimal long-term sinus rhythm control. This article provides an overview of current surgical strategies for patients with atrial fibrillation and addresses the two main goals in its management.     

迷宫手术对二尖瓣病合并的慢性心房颤动电生理的影响

对21例二尖瓣疾患伴心房颤动（简称房颤）施行了迷宫手术和二尖辩手术的患者，采用12导联心电图、心内电生理、动态心电图、踏车运动试验方法进行检查，探讨迷宫手术对慢性房颤患者心脏围手术期和远期电生理的影响。平均随访17．9±7．9个月。结果如下：①术后3个月90％（18／20）恢复窦性心律，随访1年以上者（14例）房颤均未见复发。②术后除1例窦房结恢复时间延长外余均正常，无窦性起搏或房室给传导功能障碍。③术后都有正常的心房激动和房室同步激动顺序。④术后在各标测部位猝发刺激和程控刺激均不能诱发心房扑动和颤动，心房各部位有效不应期均显著长于高位右房有效不应期。⑤动态心电图和运动试验证明有良好的心率变时性反应和运动耐力。⑥1例术后4个半月死于急性坏死性肝炎。以上表明通过电生理检查手段证实了迷宫手术治疗房颤能达到：①消除房颤恢复窦性心律，②重建和（或）维持房室同步活动，③恢复心房传输功能。提出对二尖瓣疾患合并的慢性房颤病人在施行二尖瓣手术时应作迷宫手术。     

Atrial lead placement in the right atrial appendage during recent or chronic arrhythmia

An atrial arrhythmia could be encountered during the atrial lead implantation. The lead placement must subsequently be delayed after restitution of the sinus rhythm or completely abandoned. The authors investigate the atrial lead placement during atrial arrhythmia and the lead performance at 6-month follow-up. The study population was 65 patients aged 78.5 years, 42 males and 28 structural heart diseases. They were implanted for sick sinus syndrome (n=14), atrioventricular block (n=44), infra-hisian conduction abnormality (n=7) in association with an atrial fibrillation (63.1%), an atrial flutter (24.6%) or an atrial tachycardia (12.3%). The onset of the arrhythmia was < or = 7 days (47.7%) or > 7 days (52.3%). An atrial lead was placed in the right atrial appendage under fluoroscopic control. If the sinus rhythm was not restored at 1 month, an electrical cardioversion was performed. The per-implantation atrial signal amplitude was 2.2+/-1.5 mV (range 0.5 mV to 7 mV). Sinus rhythm was restored in 54 patients. At 1 month, one patient was in an incessant atrial fibrillation. The 53 patients in sinus rhythm had a good atrial lead performance. Out of 46 patients who completed the 6-month follow-up, 4 had an arrhythmia recurrence. The 42 patients in sinus rhythm had a good atrial lead performance. At 1 and 6-month follow-up, the atrial pacing threshold (1.1+/-0.7 V vs 1.2+/-1.0 V, ns) and the atrial signal amplitude (2.1+/-1.0 mV and 2.1+/-0.9 mV, ns) were stable. Comparing the patients with a recent or a chronic arrhythmia, the pacing thresholds (1.2+/-1.1 V vs 1.14+/-0.8 V, ns), the atrial signal amplitudes (2.17+/-0.9 mV vs 2.05+/-0.9 mV, ns) and the proportion of satisfactory pacemaker performance in DDD(R) mode for the patients in sinus rhythm (100% vs 100%, ns) did not statistically differ between the two groups at 6 months. In conclusion, the placement of an atrial lead in the right atrial appendage during an atrial arrhythmia is feasible with a good lead performance at 6 months in sinus rhythm regardless the onset time of the arrhythmia and provides a satisfactory atrial-based pacing with the preservation of the atrioventricular synchrony.     

Plasma atrial natriuretic peptide levels for predicting the outcome of atrial fibrillation.

The predictive value of plasma atrial natriuretic peptide (ANP) on the cardioversion outcome was evaluated in 46 hospitalized patients with recent-onset atrial fibrillation (AF). Cardioversion was successful in 42 (91%) patients, 7 (15%) of them regained sinus rhythm spontaneously. After 12 months, 14 (33%) cardioverted patients were in chronic AF. There were no differences in plasma ANP levels between groups where cardioversion failed, those who cardioverted but later developed chronic AF or those who remained in sinus rhythm. However, among patients who were on antiarrhythmic therapy, ANP levels obtained after cardioversion were lower in those who later remained in sinus rhythm. We conclude that lower ANP after cardioversion may be associated with increased chances of long-term preservation of sinus rhythm.     

射频迷宫术治疗心房颤动

为探讨射频迷宫术治疗心房颤动（简称房颤）的效果，比较１８例二尖瓣置换术中加做迷宫术（治疗组）和１８例单纯二尖瓣置换术（对照组）的慢性房颤治疗结果。治疗组前２例采用切割冷冻法完成迷宫术，后１６例采用改良的射频法。其中１６例（８８．９％）于术后当日至２２日转为窦性心律。切割冷冻法有１例因术后出血给予大量输血引起急性肾功能衰竭而死亡，余未见明显并发症。随访２～１２个月未见房颤复发。对照组中５例曾于术后恢复短暂窦性心律，但出院时又转为房颤。结果表明迷宫术能有效地治愈慢性房颤，改良的射频法比切割冷冻法操作简单，无出血并发症，心房肌损伤小。提示心房的大小、ｆ波的粗细、心功能的好坏等是影响迷宫术成功的因素     

Right Atrial Appendage Thrombus Found in a Patient in Normal Sinus Rhythm with Normal Right Ventricular Systolic Function

A 79‐year‐old woman underwent transesophageal echocardiography to evaluate the severity of her mitral regurgitation prior to urgent bypass. Evaluation of the right‐sided chambers was notable for a mass in the right atrial appendage (RAA). Surgical excision and pathologic examination proved this to be a thrombus. This is the first reported case of a RAA thrombus in a patient with normal sinus rhythm and normal right ventricular (RV) function. It illustrates that complete transesophageal studies may sometimes demonstrate incidental findings, and that right atrial thrombus can (rarely) be found in patients in sinus rhythm with normal RV function.