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先天性心脏病矫治术后膈肌麻痹的诊断与治疗

目的 总结先天性心脏病矫治手术后膈肌麻痹的原因、临床表现和外科治疗经验，以提高对该类患者的诊治水平。 方法 2000年1月至2007年6月，36例患者在先天性心脏病矫治手术后出现膈肌麻痹，其中13例因手术后撤呼吸机困难，无法脱离呼吸机；6例术后出现呼吸矛盾运动，二氧化碳潴留（动脉血二氧化碳分压＞50 mm Hg）和低氧血症（动脉血氧饱和度＜90% ）；4例反复发生肺部感染无法治愈，均施行了膈肌折叠术，平均年龄为13个月；另外13例膈肌麻痹患者能顺利撤离呼吸机，未行手术治疗。 结果 术后因败血症和弥漫性血管内凝血死亡1例。膈肌折叠手术后胸部X线片示：所有患者膈肌位置正常或抬高小于1个肋间，肺部体征明显改善，呼吸矛盾运动消失，能正常撤离呼吸机。随访13例，失访22例，随访时间1~6年，其中行膈肌折叠的10例患者膈肌位置保持正常；未行膈肌折叠的3例患者膈肌仍然抬高1~2个肋间，但呼吸运动正常，未发生反复呼吸道感染。 结论 先天性心脏病手术后并发膈肌麻痹的原因大多与术中损伤膈神经有关；对低龄儿童和婴儿，早期施行膈肌折叠术可获得较好的临床治疗效果。

EXPERIMENTAL STUDY ON PROMOTION OF SOMATO-VISCERAL HETEROGENIC REINNERVATION WITH NERVE GROWTH FACTOR IN RAT PHRENIC-TO-VAGUS ANASTOMOSIS MODEL

Objective To investigate the influence of nerve growth factor (NGF) on neuroal regeneration of somatovisceral heterogenic reinnervation using a rat phrenic-to-vagus anastomosis model. Methods Forty male SD rats, aging 3 months and weighing 200 g, were selected and randomly divided into 3 groups. In group A (n=10, control group), phrenic and vagusnerves were exposed and no neurorraphy was performed. In group B (n=15) and group C (n=15), both nerves were transected and proximal stump of phrenic nevers were microsurgically anastomosed to the distal stump of vagus nerves. Postoperatively, group C was intraperitoneally injected with NGF (20 μg/kg·d), while groups A and B were given matching sal ine solution. Twelve weeks later, cardiac function was examined under electrical stimulation of the regenerated nerve. Light and electron microscopies were used to examine the heterogenic regenerated nerve, and the passing rate of axon and thickness of myel in sheath were calculated. Results Under electrical never stimulation in groups A, B, and C, the decreases of blood pressure were (20.12 ± 2.57), (10.63 ± 2.44), and (14.18 ± 2.93) mmHg (1 mmHg=0.133 kPa), respectively; and the decreases of heart rate were (66.77 ± 9.96), (33.44 ± 11.82), and (43.27 ± 11.02)/minutes, respectively. In group B, the decrease ampl itudes of blood pressure and heart rate were 52.83% and50.08% of group A, respectively. Blood pressure and heart rate in group C also decreased dramatically; the decrease ampl itudes of blood pressure and heart rate in group C were 70.48% and 64.80% of group A. There were significant differences in the decrease ampl itudes of blood pressure and heart rate (P lt; 0.05) between group B and group C. Morphological observation showed that heterogenic nerve fibers had the structure of matured myel in sheath and their axons could regenerate into the vagus nerve. In group B and group C, the passing rates of axon were 66.83% ± 4.46% and 81.63% ± 3.56%, respectively; and the thicknesses of myel in sheath were (0.25 ± 0.10) μm and (0.46 ± 0.08) μm, respectively; showing significant differences (P lt; 0.05) between group B and group C. Conclusion Heterogenic nerve is primarily a somatic motor nerve; NGF can promote the axons of heterogenic nerve to regenerate into the parasympathetic nerve.

INFLUENCE OF EXPRESSION LEVELS OF EPIDERMAL GROWTH FACTOR AND KERATINOCYTE GROWTH FACTOR AFTER UNILATERAL PHRENECTOMY IN PIGLETS

Objective To investigate the different influence of the expression levels of the epidermal growth factor (EGF) and the keratinocyte growth factor (KGF) after the unilateral phrenectomy in piglets. Methods Thirty-six piglets were divided into 3 groups according to their ages during the operation (10 d,30 d,50 d). In each group, 6 piglets underwent the left cervical phrenectomy and 6 piglets were used as the shamoperation controls. The expression levels of EGF and KGF were determined by the real time quantitative RT-PCR at 2 weeks after operation.Results The melting curves of RTPCR showed that there was a single peark at the temperature of 80.0, 84.5 and 89.0℃ of EGF,KGF and GAPDH, respectively. In the experimental group, the expression levels of EGF were 3.53±0.36 and 1.73±0.29, and the expression levels of KGF were 4.71±0.42 and 2.77±0.29 in thepiglets undergiong the operation at their ages of 10 d and 30 d.Compared with the control group,the expression levels of EGF (4.60±0.41，2.18±0.24) and KGF(6.05±0.42，3.58±0.31) showed that there was a significant decrease postoperatively in the piglets undergoing the operation at their ages of 10 d and 30 d（P＜0.05）. However, there was no significant change in the piglets undergoing the operation at their ages of 50 d（P＞0.05）. The expression levels of EGF and KGF were significantly decreased with the lung development of the piglets（P＜0.05）. Conclusion The unilateral phrenectomy performed in the piglets younger than 30 d may cause abnormity of the EGF and KGF expression levels. The piglets older than 50 d may not cause a significant influence.

CLINICAL COMPARISON OF VASCULARIZED AND NON-VASCULARIZED FULL-LENGTH PHRENIC NERVE TRANSFER

Objective To investigate the clinical effect of vascularized and non-vascularized full-length phrenic nerve transfer on treating brachial plexus injury. Methods From August 1999 to March 2000, full-length phrenic nerve transfer to musculocutaneous nerve was conducted with the technique of Video-AssistedThoracic-Surgery in 15 patients（M 13, F 2）that all suffered from avulsion. Threekinds of procedures were carried out. The first was retaining initial point of phrenic nerve and dissecting full-length distal nerve (group A). The second waskeeping cervical segment and isolating thoracic segment of phrenic nerve (group B). The last was vascularized phrenic nerve transfer (group C). All these phrenic nerves were sutured to musculocutaneous nerves. The results of electrophysiology and function of biceps brachii muscle were compared. Results The lengthof the dissecting full-length distal nerves in group A, group B and group C compared with that of conventional operation increased by 17.8±1.1 cm, 10.2±1.0 cm and 8.8±0.5 cm respectively. There was significant difference when group A was compared with group B and group C, when group B was compared with group C. All three procedures had no significant difference and led to the same function recovery of biceps brachii muscle to grade Ⅲ about 6 months later. Conclusion There is no difference in treating effect between vascularized and non-vascularized full-length phrenic nerve transfer, when the recipientbed has normal vascularity.

STUDY ON CONTRACTILE PROPERTIES OF THE POSTEROIR CRICOARYTENOID MUSCLE REINNERVATED FROM PHRENIC NERVE

The contractile function of the posteroir cricoarytenoid muscle was investisated after reinnervated from the phrenic nerve. The data showed that the posteroir cricoarytenoid muscles reinnervated from the phrenic nerve repined contraction very well. As to the contractile properties, it had no difference in the contractile tension and the time of contraction of the posteroir cricoarytenoid muscles on the reinnervated side and on the normal side. The results demonstrate that the method to reinnervate the posteroir cricoarytenoid muscle by the phrenic nerve in order to restore muscle function was possible.

冷冻球囊行肺静脉电隔离治疗阵发性心房颤动二例

Assessment of Diaphragm Function with A Newly Designed Multi-function Esophageal Electrode Catheter and Bilateral Anterolateral Magnetic Stimulation of Phrenic Nerves in Patients Underwent Mechanical Ventilation

ObjectiveTo monitor the diaphragm function of mechanical ventilated patients in the intensive care unit. MethodsA prospective study was conducted on mechanical ventilation patients who had been evaluated by ventilation weaning screening test and planning to underwent spontaneous breathing trial between May 2013 and November 2013. A newly designed multi-function esophageal electrode was used to record the phrenic nerve conduction time (PNCT),diaphragm compound muscle action potential (CMAP) and twitch transdiaphragmatic pressure (TwPdi) elicited by bilateral anterolateral magnetic phrenic nerve stimulation. Results14 patients were recruited in this study. 1 case exited because of intolerance of repetitive magnetic stimulation,2 cases had no diaphragmatic electromyographic signals nor twitch signals,1 case had diaphragmatic electromyographic signal but could not be elicited by magnetic stimulation,1 case had no available TwPdi value with PNCT of 7.2 ms and CMAP of 1.26 mV. In the rest 9 cases,the PNCT,CMAP and TwPdi were (8.5±1.5)ms,(1.01±0.35)mV,(11.2±4.7)cm H2O,respectively. ConclusionNewly designed multi-function esophageal electrode catheter combined with bilateral anterolateral magnetic phrenic nerve stimulation can be used for non-volitional comprehensive assessment of diaphragm in critically ill patients,but not suitable for all subjects.

Diaphragm function in mechanical ventilated chronic obstructive pulmonary disease patients before weaning

ObjectiveTwitch transdiaphragmatic pressure is used to evaluate the diaphragm function of mechanical ventilated chronic obstructive pulmonary disease patients before weaning in the intensive care unit, and compared with healthy normal values.MethodsPatients were recruited if they were with acute exacerbation of chronic obstructive pulmonary disease, admitted between May to November in 2013 and December 2014 to February 2016 to the intensive care unit in the First Affiliated Hospital of Guangzhou Medical University, intubated and mechanical ventilated more than 72 hours, and recovered to the clinical stability states after passing the readiness to wean, getting ready for spontaneous breathing test. The newly designed esophageal electrode catheter and bilateral anterolateral magnetic phrenic nerves stimulation were utilized to detect the twitch transdiaphragmatic pressure. At the same time, the function of diaphragm was detected in 10 healthy adults for comparison.ResultsTwenty-two patients were recruited in this study. Two cases had no twitch signals. In the rest 20 cases, the twitch transdiaphragmatic pressure was (7.6±2.5) cm H2O. In 10 healthy adults, twitch transdiaphragmatic pressure was (26.7±4.9) cm H2O. There was significant difference between the patients and the health control subjects (P<0.05).ConclusionTwitch transdiaphragmatic pressure is significantly decreased in weaning chronic obstructive pulmonary disease patients compared with healthy adults.