Search

严重心功能不全致呼吸机依赖患者成功脱机一例

Clinical Observation of Insulin Resistance and Diabetic Cardiac Insufficiency in Type 2 Diabetes Mellitus

【摘要】　目的　探讨2型糖尿病（T2DM）胰岛素抵抗导致糖尿病性心功能不全的临床表现特点及相关激素的改变。　方法　2008年1-4月对T2DM患者35例（胰岛素抵抗指数HOMA-IRlt;2.69者19例为A1组，HOMA-IR≥2.69者16例为A2组）及健康体检者20人B组测体重指数（BMI）、空腹血糖（FPG）、胰岛素、心钠素（ANP）、脑钠素（BNP）水平；心脏彩色多普勒超声分别测E/A、e/a、S/D、LVEF、DT期。　结果　A2组BMI较A1、B组均明显增加（Plt;0.05），A1、B组间差异无统计学意义（Pgt;0.05）。ANP、BNP及DT值在A1、A2组均较B组增高（Plt;0.05），BNP在A2组高于A1组（Plt;0.05），ANP、DT值在A1、A2组间差异均无统计学意义（Pgt;0.05）。E/A、e/a和S/D在A1、A2组均较B组降低（Plt;0.05），A1、A2组间差异均无统计学意义（Pgt;0.05）。A2组患者LVEF较A1、B组均明显降低（Plt;0.05），A1、B组间差异无统计学意义（Pgt;0.05）。　结论　随着胰岛素抵抗加重，心肌舒张顺应性较差和收缩力下降，伴随相关激素（心脏利钠肽）分泌增加，最终产生心功能不全的临床表现、体征及多普勒超声心动图表现。【Abstract】　Objective　To investigate the clinical features and related hormone changes of diabetic cardiac insufficiency leaded by insulin resistance in type 2 diabetes mellitus (T2DM).　Methods　From January to April 2008, 35 patients with T2DM (group A1: HOMA-IRlt;2.69, n=19; group A2: HOMA-IR≥ 2.69, n=16) and 20 subjects without T2DM (group B) were enrolled. The body mass index (BMI), fasting plasma glucose (FPG), insulin (FINS), atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and E/A, e/a, S/D, LVEF and DT stage of all subjects were detected.　Results　The BMI in group A2 was higher than those in group A1 and group B (Plt;0.05), while the difference between the later two groups was not statistically significant (Pgt;0.05). The ANP, BNP and DT stage were all higher than those in group B (Plt;0.05), the BNP was higher in group A2 than in group A1 (Plt;0.05), while the difference of neither ANP nor DT stage between the later two groups was statistically significant (Pgt;0.05). The values of E/A, e/a and S/D in group A1 and A2 were all lower than those in group B (Plt;0.05), while there were no statistically significant diferences between group A1 and A2 (Pgt;0.05). The values of LVEF of group A1 and A2 were both significantly reduced than that in group B (Plt;0.05), and the values in group A2 were the lowest (Plt;0.05).　Conclusion　With the aggravating of insulin resistance, myocardial contractility and diastolic function will decline, meanwhile the ANP and BNP secretion will increase, and then the clinical and echocardiographic manifestation will appear.

Comparative Study on the Efficacy and Safety of Thrombolysis and Anticoagulation Therapy for Patients with Acute Sub-Massive Pulmonary Thromboembolism

Objective To compare the clinical efficacy and safety of thrombolysis with anticoagulation therapy for patients with acute sub-massive pulmonary thromboembolism. Methods The clinical data of 84 patients with acute sub-massive pulmonary thromboembolism were analyzed retrospectively, mainly focusing on the in-hospital efficacy and safety of thrombolysis and/ or anticoagulation. The efficacy was evaluated based on 6 grades: cured, markedly improved, improved, not changed, deteriorated and died. Results Among the 84 patients,49 patients received thrombolysis and sequential anticoagulation therapy( thrombolysis group) , 35 patients received anticoagulation therapy alone( anticoagulation group) . As compared with the anticoagulation group, the thrombolysis group had higher effective rate( defined as patients who were cured, markedly improved or improved, 81. 6% versus 54. 3%, P = 0. 007) , lower critical event occurrence ( defined as clinical condition deteriorated or died, 2. 0% versus 14. 3% , P = 0. 032) . There was no significant difference in bleeding rates between the two groups ( thrombolysis group 20. 4% versus anticoagulation group 14. 3% , P gt; 0. 05) . No major bleeding or intracranial hemorrhage occurred in any of the patients. Conclusions Thrombolysis therapy may be more effective than anticoagulation therapy alone in patients with acute sub-massive pulmonary thromboembolism, and thus warrants further prospective randomized control study in large population.

Clinical Analysis of Patients with Acute Pulmonary Embolism, Normal Blood Pressure, and Right Ventricular Dysfunction

Objective To analyze the clinical features of patients with acute pulmonary embolism ( APE) with normal blood pressure and right ventricular dysfunction. Methods 130 hospitalized patients with normotensive APE between January 2009 and January 2012 were retrospectively analyzed. The patients underwent transthoracic echocardiography to determine if they were complicated with RVD. The clinical features, risk factors, diagnosis, and treatment were analyzed and compared between the normotensive APE patients with or without RVD. Results 41 normotensive APE patients with RVD were as RVD group, and other 89 patients without RVD were as non-RVD group. The incidences of syncope ( 34.1% vs. 7.8% ) , tachycardia( 41.4% vs. 21.3% ) , P2 hyperthyroidism( 46.3% vs. 25.8% ) , jugular vein filling ( 12.1% vs. 1.1% ) , and cyanosis ( 26.8% vs. 8.9% ) were all significantly higher in the RVD group than those in the non-RVD group ( P lt; 0.05) . Computed tomography pulmonary angiography ( CTPA) revealed that the incidences of thromboembolism involving proximal pulmonary artery ( 58. 3% vs. 8. 3% ) and thromboembolism involving lobar pulmonary ( 77.8% vs.51.2% ) were also higher in the RVD group ( P lt; 0.001, P = 0.025 ) . In the RVD group, the patients were assigned to received thrombolysis plus anticoagulation therapy, or anticoagulation therapy alone. The clinical indicators ( heart rate, PaCO2 , AaDO2 , SPAP, TRPG) were all statistically improved after thrombolysis or anticoagulation treatment ( P lt;0.001) . But compared with the patients who underwent anticoagulation therapy alone, the cost of treatment and the incidence of minor bleeding were significantly higher, and the levels of AaDO2 , SPAP and TRPG were statistically lower in the patients with thrombolysis plus anticoagulation therapy. Conclusions For APE patients with central pulmonary embolism demonstrated by CTPA, syncope, and tachycardia, transthoracic echocardiograph should be performed as early as possible to confirm RVD diagnosis. For normotensive APE patients with RVD, anticoagulant treatment can achieve higher efficacy of costeffectiveness ratio.

Application of One and A Half Ventricle Repair for Acute Right Ventricular Dysfunction after Biventricular Repair

Objective To investigate clinical outcomes of one and a half ventricle repair for acute right ventricular dysfunction after biventricular repair. Methods Clinical data of 5 pediatric patients with congenital heart diseases who underwent emergency bidirectional Glenn shunt without cardiopulmonary bypass for acute right ventricular dysfunction after biventricular repair，converting the operation into one and a half ventricle repair，from February 2007 to June 2012 in Qingdao Women and Children Hospital were retrospectively analyzed. There were 4 male patients and 1 female patient with their age of 7-18 months and body weight of 6-13 kg. Preoperative diagnosis included pulmonary atresia with intact　ventricular septum （PA/IVS） in 1 patient，tricuspid stenosis （TS） with ventricular septal defect （VSD） and atrial septal　defect （ASD） in 2 patients，and tricuspid stenosis with tetralogy of Fallot （TOF） in 2 patients. Postoperative care focused on cardiopulmonary support and control of pulmonary artery pressure. Results Mean pulmonary artery pressure （mPAP） was 12-18 mm Hg at 72 hours after emergency bidirectional Glenn shunt. Mechanical ventilation time was 3-182 hours and ICU stay was 2-13 days. Postoperatively 1 patient died of pulmonary hypertension crisis. The other 4 patients were discharged　with their transcutaneous oxygen saturation in the resting state of 93%-99%，which was improved in different degrees compared with preoperative value. These 4 patients were followed up from 6 months to 4 years. Three patients were in NYHA classⅠand 1 patient was in NYHA class Ⅱ during follow-up. Echocardiography showed smooth vena cava to pulmonary artery anastomosis without thrombosis formation. Conclusion One and a half ventricle repair can be used as an adjunct surgical strategy for acute right ventricular dysfunction after biventricular repair.

92例非体外循环冠状动脉旁路移植术的临床分析

目的 总结非体外循环冠状动脉旁路移植术治疗冠心病或合并左心功能不全或心肌梗死患者的临床经验。 方法 回顾性分析2008年1月至2013年1月宜昌市第一人民医院92例冠心病或合并左心功能不全或心肌梗死患者行非体外循环冠状动脉旁路移植术治疗的临床资料，其中男71例，女21例；年龄（64.25±7.93） 岁。术前心功能（NYHA分级） Ⅲ～Ⅳ级44例，不稳定型心绞痛21例，左主干病变＞50% 8例，3支血管病变46例。92例冠心病患者中发生心肌梗死19例，心肌梗死发生率为20.65％。 结果 手术时间（5.43±1.46） h，术后中位机械通气时间1.0 d，中位住ICU时间3.0 d，远端吻合口数（2.70±0.82） 个。围术期死亡1例，术后左心室射血分数（LVEF）＜50% 19例，发生心律失常16例，呼吸衰竭24例，肾功能衰竭31例，低心排血量13例，住ICU时间延迟53例，主动脉内球囊反搏4例，院内感染11例。发生上述并发症的患者均经相应的治疗治愈或好转。术后血肌酐与术前相比有所增高，差异有统计学意义［（110.22±53.03） μmol/L vs. （84.70±26.87） μmol/L，t =5.163，P=0.000）。术后随访91例，随访时间为术后0.5个月至2年。术后0.5个月常规心脏超声心动图检查未发现异常；术后1个月移植血管发生狭窄或血管闭塞3例，出现胸闷5例，2年后下肢取血管部位疼痛20例， CTA检查移植血管狭窄或血管闭塞10例。上述病变均经对症处理好转。 结论 非体外循环冠状动脉旁路移植术治疗冠心病或合并左心功能不全的冠心病患者，疗效满意。

心功能不全冠心病患者非体外循环冠状动脉旁路移植术的疗效分析

分析心功能不全冠心病患者施行非体外循环冠状动脉旁路移植术（OPCAB）的临床资料，探讨其手术风险，提出治疗方案。 方法 将2004年1月至2008年6月首都医科大学附属北京安贞医院66例冠心病患者，按心功能不同分为3组，每组22例，组1：男18例，女4例；年龄55.3±9.1岁；术前左心室射血分数（LVEF）lt;30%；组2：男19例，女3例；年龄55.5±10.2岁；30%≤LVEFlt;40%；组3：男17例，女5例；年龄55.8±8.7岁；LVEF≥40％；组2和组3作为对照。观察围术期临床资料包括术前调整时间、移植血管支数、同期室壁瘤手术、呼吸机辅助呼吸时间、主动脉内球囊反搏(IABP)使用时间、住ICU时间、强心药种类、术后住院时间和住院费用等的改变。 结果 术后无死亡和严重并发症发生，均痊愈出院。组1术前调整时间（18.9±14.6 d vs. 10.8±7.4 d,P=0.023）、使用IABP例数（7 vs.1, P=0.012）、住ICU时间（3.0±0.7 d vs. 1.2±0.6 d,P=0.008）、强心药种类（1.6±0.7种 vs. 1.0±0.2种,P=0.000）、术后住院时间（17.4±12.1 d vs. 11.8±34 d,P=0.038）和住院费用（11.4±5.2万元 vs. 7.6±1.7万元,P=0.007）均多于组3，两组比较差异均有统计学意义。3组患者均获得随访，随访时间3～6个月，均生存，随访期间无明显心绞痛发作。 结论 心功能不全患者行OPCAB手术安全，但所需医疗资源多，须慎重选择。

Longterm Results of Coronary Artery Bypass Grafting in the Treatment of Ischemic Cardiac Diseases with Heart Insufficiency

Objective To evaluate the longterm results of coronary artery bypass grafting (CABG) in treating cardiac diseases with heart insufficiency by analyzing the longterm survival rate and heart failure exemption rate of the patients. Methods A total of 239 patients who had coronary heart disease with left heart dysfunction (LVEFlt;40%) were enrolled in our study. Among the patients, there were 215 males and 24 females aged from 32 to 78 years old with an average age of 59.1. Before operation, 193 patients had a past history of myocardial infarction and 31 had angina. According to the New York heart function assessment (NYHA), 26 patients were categorized as class Ⅰ, 106 as class Ⅱ, 73 as class Ⅲ and 34 as class Ⅳ. Coronary angiography showed 10 cases (4.2%) of single vessel disease, 35 cases (14.6%) of double vessel disease and 194 cases (81.2%) of triple vessel disease. The result of preoperative ultrasound cardiogram showed that LVEF was 35.7%±4.6%. All patients received CABG, including 153 (64.0%) onpump surgeries and 86 (35.9%) offpump surgeries. Selective operation was done on 237 patients and there were 2 emergency cases. Valve repair or replacement, ventricular aneurysmectomy or aneurysm plication were not carried out during the operation. Results There were 1 to 6 (3.4±1.1) bypass grafting vessels in each case. Five (2.09%) patients died during the hospital stay, among which 2 died of low cardiac output and circulation failure, 1 died of malignant arrhythmia, 1 died of renal failure, and 1 died of coma with multiorgan failure. The followup period was 512±1.79 years. During the followup, 18 patients (7.7%) were lost and 29 patients died. Among them, there were 24 cardiac deaths and the cardiac death rate at the first year and the fifth year was 2.8% and 9.4% respectively. There were 40 cases of heart failure during the followup period. The exemption rate of heart failure was 93.7% and 81.8% at the first year and the fifth year respectively. The survival rate was 97.2% at the first year and 89.3% at the fifth year. Conclusion The longterm result of CABG in treating patients with ischemic heart insufficiency is satisfying.

The Relation Between Preoperative Pulmonary Artery Pressure and Postoperative Complications in Heart Transplantation Patients and the Prevention and Treatment to Postoperative Complications

Objective To analyze the relation between preoperative pulmonary artery pressure(PAP) and postoperative complications in heart transplant patients, and summarize the experience of perioperative management of pulmonary hypertension (PH), to facilitate the early period heart function recovery of postoperative heart transplant patients. Methods A total of 125 orthotopic heart transplant patients were divided into two groups according to preoperative pulmonary arterial systolic pressure(PASP) and pulmonary vascular resistance(PVR), pulmonary [CM(1583mm]hypertension group (n=56): preoperativePASPgt;50 mm Hg or PVRgt;5 Wood·U; control group (n=69): preoperative PASP≤50 mmHg and PVR≤5 Wood·U. Hemodynamics index including preoperative cardiac index (CI)，preoperative and postoperative PVR and PAP were collected by SwanGanz catheter and compared. The extent of postoperative tricuspid regurgitation was evaluated by echocardiography. Postoperative pulmonary hypertension was treated by diuresis，nitrogen oxide inhaling，nitroglycerin and prostacyclin infusion, continuous renal replacement therapy(CRRT)and extracorporeal membrane oxygenation(ECMO). Results All patients survived except one patient in pulmonary hypertension group died of multiorgan failure and severe infection postoperatively in hospital. Acute right ventricular failure occurred postoperatively in 23 patients, 10 patients used ECMO support, 10 patients with acute renal insufficiency were treated with CRRT. 124 patients were followed up for 2.59 months，7 patients died of multiple organ failure, infection and acute rejection in follow-up period, the survivals in both groups have normal PAP, no significant tricuspid regurgitation. No significant difference in cold ischemia time of donor heart, cardiopulmonary bypass(CPB) and circulation support time between both groups; but the patients of pulmonary hypertension group had longer tracheal intubation time in comparison with the patients of control group (65±119 h vs. 32±38 h, t=2.17，P=0.028). Preoperative PASP，mean pulmonary artery pressure(MPAP) and PVR in pulmonary hypertension group were significantly higher than those in control group, CI was lower in pulmonary hypertension group ［PASP 64.30±11.50 mm Hg vs. 35.60±10.20 mm Hg; MPAP 43.20±8.50 mm Hg vs. 24.20±7.20 mm Hg; PVR 4.72±2.26 Wood·U vs. 2.27±1.24 Wood·U; CI 1.93±0.62 L/（min·m2） vs. 2.33±0.56 L/（min·m2）; Plt;0.05］. Postoperative early PASP, MPAP and PVR in pulmonary hypertension group were significantly higher than those in control group (PASP 35.40±5.60 mm Hg vs. 31.10±5.70 mm Hg, MPAP 23.10±3.60 mm Hg vs. 21.00±4.00 mm Hg, PVR 2.46±0.78 Wood·U vs. 1.79±0.62 Wood·U; Plt;0.05). Conclusion Postoperative right heart insuficiency is related to preoperative pulmonary hypertension in heart transplant patients. Donor heart can quickly rehabilitate postoperatively by effectively controlling perioperative pulmonary hypertension with good follow-up results.

腺苷对犬体外循环后肺缺血-再灌注损伤的作用

目的　研究腺苷是否能减轻体外循环后肺组织损伤。　方法　12条犬随机分为实验组和对照组。建立体外循环模型，实验组使用腺苷(50μg/kgmin)中心静脉持续滴注；对照组滴注生理盐水。分别于各时间点测定血流动力学、右心功能和动脉血气分析；测定肺组织含水量、丙二醛含量，并进行病理分析。　结果　两组心率、体循环平均动脉压、左心房压、中心静脉压比较无差异，与对照组比较实验组体外循环后肺血管阻力降低，右心功能改善，动脉血氧分压明显升高；肺组织含水量较少，肺组织丙二醛含量较低(P＜0.05或P＜0.01)。病理检查：实验组犬肺泡结构正常，无明显中性粒细胞浸润。　结论　腺苷能够减轻体外循环后肺缺血-再灌注损伤，改善右心功能，在一定剂量范围内并不对体循环血流动力学构成明显影响。