急性心肌梗死患者心肌顿抑发病机制探讨

心肌顿抑也称缺血后心肌功能障碍,为持续数小时、数天、甚至数周的心肌细胞可逆性损伤。可见于急性冠脉综合症早期再灌注、心脏移植、心脏瓣膜置换等心脏外科大手术术后,应激性心肌病、心脏骤停、心肺复苏、主动脉狭窄、高血压性心脏病、房颤转复。心肌梗死后发生心肌顿抑是导致心梗死亡、心衰再住院的重要病因,但目前其发病机制尚不明确。有关心肌顿抑的研究已经由器官细胞水平,深入到分子基因水平。具体而言,心肌顿抑的发病机制包括：缺血再灌注导致的心肌细胞直接损伤、心肌细胞兴奋收缩脱偶联、线粒体及内质网损伤、血管内皮细胞功能障碍及微循环痉挛、能量代谢障碍、氧自由基损伤、钙超载理论、炎性介质释放理论、心肌顿抑的基因组学机制等。目前,广为接受的是氧自由基理论和钙超载理论。前者认为心肌梗死时,心肌组织氧自由基产生增多,清除障碍,导致心肌细胞结构受伤和功能障碍;后者认为心肌梗死时,心肌细胞酸中毒,细胞膜通透性增加,钙内流增多,同时,钙库重吸收钙障碍,导致钙超载,引起心肌细胞破坏、肌钙蛋白溶解,导致心功能障碍。阐明心肌顿抑发病机制,指导心梗治疗,有助于完善救治策略,改善预后。     

人类心房纤维性颤动变化的分子机制

近年来确认了心房纤维性颤动(AF)以促进心房的发生和维持的方式修饰了心房的电特征.并确立了节律紊乱发生的电生理变化.主要描述了功能的快变化和蛋白质表达的慢变化的分子机制,这种慢变化会引起心房纤维性颤动的电改变和收缩异常.心房纤维性颤动的一个重要分子特征是L型钙离子通道功能和蛋白质表达的减少.这种减少可能有助于保护细胞抵制由于心房纤维性颤动的激活率增加产生的潜在致死钙离子超载.对蛋白水解系统的可能作用也进行了讨论,其中重点讨论了钙蛋白酶作为一种与钙离子超载导致蛋白表达减少相联系的机制.     

一氧化氮对心肌缺血/再灌注损伤细胞凋亡和心功能的影响

目的:采取促进或抑制NO的方法,了解在重复可逆性心肌缺血/再灌注所致的心肌顿抑时,血液中一氧化氮(NO)的动态变化与细胞顿抑及心功能的影响.方法:新西兰兔15只,随机分为3组(n=5):对照组、在静脉内注射NO合成底物L-精氨酸为L-Arg组、静脉注射一氧化氮合酶抑制剂L-硝基-精氨酸为L-NNA组.用戊巴比妥钠静脉注射麻醉后,结扎前降支制成心肌缺血/再灌注模型,用电子自旋共振法测定血液中NO含量,同时记录左心室最大上升速率dp/dtmax.将兔心肌缺血10 min,共3次,第1、2次缺血后再灌注10 min,第3次缺血后再灌注120 min.结果:第1次缺血/再灌注5 min时NO升高的顺序依次为L-Arg组最大、对照组次之,而L-NNA组较缺血前降低.而dp/dtmax明显下降的是L-Arg组最大、对照组次之、L-NNA组最小.细胞凋亡指数:L-Arg组最大,对照组次之、L-NNA组最小.结论:再灌注早期NO的大量生成及细胞凋亡参与加重心肌顿抑的过程.     

淋巴抑瘤素对五株肿瘤细胞株的体外抑瘤效应的分析研究

淋巴细胞经刺激后分泌一种多肽类物质,这种细胞因子被称为淋巴抑瘤素。在体外培养中发现不同来源的肿瘤细胞对淋巴抑瘤素的敏感性是不同的,表现为三种类型:强反应株,此类细胞对其抑瘤效应反应强烈,抑制率达90％以上;弱反应株,此类细胞的抑制率在70％左右;另一类为负反应株,此类细胞对淋巴抑瘤素不但不表现出抑瘤效应,反而出现助长肿瘤细胞生长的效应。由于体外测定中有上述现象,所以建议在体内应用这类细胞因子时,应像抗菌素测抗菌谱一样测定其抗瘤谱,以利于对症用药。     

迷宫手术的心电图观察

作者观察迷宫手术同期换瓣治疗风湿性心脏瓣膜病合并的房颤２０例,发现手术后心电图变化的大致情况是,心脏复跳扣不久１９例心电图表现为窦性心律,１例为结性心律,术后７２小时内心律变化较多,上述１９例以窦性心律为主,但几乎都有短暂的心律失常;术后两周内４７％病例偶有房性或室性民律失常;     

利用比较基因组学方法对猪BACDNA序列分析来研究抑肌素基因的调控

抑肌素(GDF8, MSTN)是调控骨骼肌发育的TGF-b超家族的一员. 作为负调节因子, 抑肌素通过控制肌纤维的大小和数量来调控骨骼肌的发育. 为了更深入研究它的表达和调控模 式, 我们利用比较基因组学方法对一个大约170 kb的猪BAC序列与人和小鼠的相应序列进行了分析, 这段基因组序列的特点是富含分散型重复而G+C含量较低. 抑肌素基因的同源性在猪、人和小鼠3种生物之间非常高, 正如所希望的, 在人与猪之间的同源性高于它们与小鼠的同源 性. 一个有意思的特征是在抑肌素启动子CCAAT盒下游有两个TA盒, 进一步分析表明TA盒1负责在人、猪中转录, 而TA盒2在小鼠中起作用; 另一个的特征是在猪抑肌素3′UTR有两个polyA信号序列(AATAAA). 进而, 我们在进化保守区域分析到许多潜在的转录因子结合位 点, 它们可能与抑肌素的调控有关. 许多潜在的转录调控因子在肌肉的发育中起重要作用, 暗示着抑肌素与这些因子的复杂相互作用可能是正常肌肉发育所必需的(文中所提到的序列已提交到GenBank, 序号为: AY208121).     

经犬心房外膜涂布实现外源基因在心房肌（细胞）的高效转染

肌基因治疗作为一种研究和治疗心脏疾病的有效方法而逐渐被学者重视.本研究探讨一种经心房外膜涂抹使携带有绿色荧光蛋白（EGFP）基因的腺病毒高效靶向转染心房肌细胞方法的可行性.经犬胸骨正中开胸术,将含有一定浓度携带EGFP基因的腺病毒、胰蛋白酶和poloxamer F407的混合溶液涂抹至右心房外膜.术后经荧光显微镜观察荧光强度和实时PCR检测EGFP mRNA表达水平.EGFP荧光强度和mRNA表达水平在第1~6周呈现先增高后减低的趋势,其高峰在第3周出现;第3周右心房前壁各层心肌细胞均有EGFP表达;右心耳EGFP mRNA表达水平高于右心房前壁,右心房前壁和后壁表达水平无明显差异;房间隔的表达水平低于右心房,但明显高于左心房;心室和其它脏器如肺脏、肝脏、脾脏、骨骼肌、胃壁及小肠壁等的表达水平远低于右心房;通过HE染色及Masson's染色,第3周心肌无明显炎症反应和纤维化改变. 因此,经心房外膜涂抹的方法使基因靶向转染心肌细胞具有较好的高效性、靶向性和安全性.     

电复律术及心房纤颤电复律术后对心功能的影响和临床意义

作者分析32例心房纤颤(AF)患者电复律术后对心功能的影响及临床意义,并介绍电复律术的原理、适应症、禁忌症及操作方法与术前准备。结果显示电复律术后患者心慌、胸闷、气短等症状消失,胸片示心胸比率缩少;收缩时间间期(STI)缩短、左室射血分数(FF)增加、左室短径缩短率(FS)增加、心脏每搏量(SV)及每分钟心排血量(CO)均增加,与房颤时比较,相差非常显著。上述结果说明电复律术后可以明显改善心功能,并可防止或减少血栓的形成及栓塞并发症。因此作者认为AF患者,如无电复律术的禁忌症,均应转复为窦性心律为好。     

糖尿病大鼠心房肌细胞心房特殊颗粒和心房肽免疫反应强度的观察

本研究运用透射电镜及立体计量学方法结合免疫组化技术对糖尿病大鼠右心耳肌细胞心房特殊颗粒(ASG)和心房肽(ANP)免疫反应强度进行了观察和定量研究.实验动物为体重150～250克之间的SD大鼠,糖尿病的诱导采用四氧嘧啶(150mg/kg)右腹股沟区皮下注射.电镜超微结构发现糖尿病未治疗组均出现线粒体肿胀、肌原纤维缩短等病理性改变.ASG膜溶解、排空等现象多见,ASG体密度明显减少.免疫组化分析表明糖尿病未治疗组心肌细胞ANP免疫反应强度减弱.胰岛素治疗组各指标与对照组相比均无显著差别.     

感染日本血吸虫小鼠心房特殊颗粒的形态学观察和定量分析

小鼠感染日本血吸虫尾蚴后第２８天,右心耳心房特殊颗粒数目显著减少,且多见膜溶解、断裂,半月形排空和颗粒膜与横管膜及肌膜靠近、融合及颗粒向横管腔及肌膜下突出的现象。心肌细胞内线粒体有肿胀、基质变浅及部分嵴断裂现象。感染组小鼠右心耳心房特殊颗粒的体密度（０．０３２３±０．００２９μｍ３／μｍ３）、面数密度（０．８６４７±０．０６９２μｍ－２）、数密度（３．２３６３±０．１１１４μｍ－３）及颗粒平均直径（０．２６７１±０．０２０７μｍ）均显著小于对照组的０．０９７１±０．０１２７μｍ３／μｍ３、１．９２１±０．１１４５μｍ－２、０．２１８９±０．０８６６μｍ－３和０．３１０８±０．０１９５μｍ。本文阐述了日本血吸虫感染后,促进心房特殊颗粒释放增加。     

经食道超声心动图评估特发性房颤左心房左心耳的价值

目的:研究经食道超声心动图(TEE)评估特发性房颤左心房左心耳的临床价值。方法:选择自2015年1月到2016年8月在医院接受诊治的特发性房颤患者100例纳入本次研究,阵发性房颤92例,记为阵发性房颤组;持续性房颤8例,记为持续性房颤组。另选同期在医院进行健康体检的心功能正常志愿者90例作为对照组。利用TEE对受试者进行检查,对比房颤组与对照组的左心房及左心耳参数,是否含有自发性显影(LASEC)的房颤患者的左心房及左心耳参数,利用TEE分析对房颤患者的预后情况。结果:阵发性房颤组左心房的前后径和左右径,左心耳血流最大的排空速度(Lev)均明显小于对照组,左心耳的面积变化率及最大的充盈速度(Lfv)均明显大于对照组,差异有统计学意义(P0.05)。持续性房颤组左心房的前后径和左右径均明显大于对照组,左心耳的面积变化率、Lev及Lfv均明显小于对照组,差异有统计学意义(P0.05)。阵发性房颤组左心房的前后径和左右径均明显小于持续性房颤组,左心耳的面积变化率、Lev及Lfv均明显大于持续性房颤组,差异有统计学意义(P0.05)。有LASEC者左心房的前后径和左右径均明显大于无LASEC者,左心耳的面积变化率、Lev及Lfv均明显小于无LASEC者,差异有统计学意义(P0.05)。100例房颤患者中发现34例LASEC,占34.00%,其中有18例患者合并有左心耳血栓,占18.00%。总计有66例患者接受导管射频消融疗法,占66.00%,均未在术中及术后7d内出现血栓及栓塞并发症。结论:利用TEE对特发性房颤的患者左心房及左心耳进行评估,有利于更好的辅助患者的临床治疗,值得重视。     

Digitalis Does not Improve Left Atrial Mechanical Dysfunction After Successful Electrical Cardioversion of Chronic Atrial Fibrillation

This study was designed to investigate whether administration of digitalis could improve mechanical function of left atrial appendage (LAA) and left atrium prospectively in patients with atrial stunning. Fifty-four consecutive patients in whom atrial stunning was observed immediately after cardioversion of chronic atrial fibrillation (AF) were randomized into digitalis or control group for 1 week following cardioversion. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed prior to, immediately following, 1 day after and 1 week after cardioversion to measure transmitral flow velocity and LAA flow velocity. Electrical cardioversion of AF elicited significantly slower left atrial appendage peak emptying velocity (LAA-PEV) and peak filling velocity (LAA-PFV) immediately following cardioversion in both groups. 1 day post cardioversion, there were no significant differences in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or left atrial appendage ejection fraction (LAA-EF) between digitalis and control groups. 1 week post cardioversion, no significant differences were found in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or LAA-EF between the two groups. The occurrence rates of spontaneous echo contrast were not significantly different between digitalis and control groups one day and one week post cardioversion. In conclusion, digitalis did not improve left atrial and appendage mechanical dysfunction following cardioversion of chronic AF. Digitalis did not prevent the development of spontaneous echo contrast in left atrial chamber and appendage. This may be due to the fact that digitalis aggravates intracellular calcium overload induced by chronic AF and has a negative effect on ventricular rate.     

Evaluating the novel parameters for assessing the LAA function and thrombus formation with nonvalvular atrial fibrillation

The dysfunction of left atrial appendage (LAA) is prone to form thrombus when atrial fibrillation (AF) sustained more than 48 h. Traditional 2D-TEE (transesophageal echocardiography) can not accurate evaluate the function of LAA. The purpose of this study is to analyze the relationship of LAA function parameters and thrombus formation in patients with non-valvular atrial fibrillation (NVAF) by real-time three-dimensional transesophageal echocardiography (RT-3D-TEE). High risk patients can be identified according to the characteristics of ultrasonic index in patients with left atrial appendage thrombosis, which has important clinical value and significance in the risk assessment, guiding treatment and judging prognosis. We examined the relationship between the echocardiographic parameters of LAA function and the incidence of thrombus in 102 NVAF patients. They underwent RT-3D-TEE and left atrial appendage thrombus (LAAT)/severe spontaneous echocardiographic contrast (SSEC) was found in 67 patients (thrombus group) but absent in the remaining 35 patients (non-thrombus group). After measured by QLAB software, the LAA functional parameters were significantly associated with LAAT/SEC formation. Univariate analysis indicated that AF time, LAD, LVEF, LAA-OAmax, LAAVmax, LAAVI and LAAEF demonstrated a positive association (P < 0.05). However, logistic regression analysis identified that AF time (OR:1.73, P < 0.05)、LAAEF (OR:4.09, P < 0.01)and LAAVI (OR:3.28, P < 0.01) were independent predictors of LAAT/SSEC. In patients with nonvalvular atrial fibrillation, echocardiographic parameters of LAA function are significantly associated with LAAT/SSEC.     

Characterizing left atrial appendage functions in sinus rhythm and atrial fibrillation using computational models

Clinical studies show that the left atrial appendage, a blind-ended structure that is attached to the left atrium, may be the cause of 90% of atrial thrombi in atrial fibrillation (abnormal heart rhythm), and it is much reduced in sinus (normal) rhythm. In this paper, the effects of blood flows in left atrium and left atrial appendage are studied to help characterize the atrial appendage functions in sinus rhythm and atrial fibrillation using mathematical models. Our results show that the left atrial appendage is not functional in sinus rhythm because the atrial transmitral velocities remained almost identical for atria with and without appendage, which agrees with the current clinical observations. However, in atrial fibrillation, a proper atrial contraction is absent, which causes the second emptying velocity (A-wave) to be missing in both transmitral velocity and appendage filling/emptying velocity. Without the proper emptying of the blood, vortices generated in the chamber remain high strengths and with longer durations. They induce ineffective emptying of the blood in the atrium and appendage, which then lead to blood stagnation and subsequent thrombus formation.     

术前使用左心耳3D模型及左心耳封堵体外模拟治疗心房颤动患者的疗效

摘要 目的：探讨术前使用左心耳3D模型及左心耳封堵体外模拟治疗心房颤动患者的疗效。方法：回顾性选择2021年1月至2022年10月来我院诊治的心房颤动患者,对照组行经食管超声心动图检查、心脏CT造影检查及左心耳封堵术。观察组行经食管超声心动图检查、心脏CT造影检查、基于心脏CT造影数据打印左心耳3D模型、应用3D打印模型进行左心耳封堵体外模拟演练及左心耳封堵术,对比两组相关指标。结果：两组经食管超声心动图检查左心耳各径线对比无差异（P>0.05）。两组经CT检查左心耳各径线对比无差异（P>0.05）。两组封堵器固定大小对比有差异（P<0.05）。术后经食管超声心动图检查发现,观察组术后3个月及12个月血流通过封堵器几率高于对照组,但组间对比无差异（P>0.05）。术后3个月及12个月时,两组的左心房内径降低,且同时间点观察组较对照组（P<0.05）;两组术后3个月及12个月时左心室内径对比无差异（P>0.05）。观察组的封堵器型号匹配率较对照组高,手术操作时间、X线曝光量、造影剂使用量、封堵器术中释放次数较对照组低（P<0.05）,观察组的残余分流及手术并发症较对照组低,但组间对比无差异（P>0.05）。观察组术后3个月封堵器位置、有无残腔及不良心血管事件与对照组相比无差异（P>0.05）,术后12个月,封堵器位置良好率较对照组低（P<0.05）,其余两组间对比无差异（P>0.05）。结论：术前使用左心耳3D模型及左心耳封堵体外模拟可提高心房颤动患者的疗效。     

Left atrial appendage closure: outcomes and challenges

Whereas the left atrial appendage plays a rather minor role under physiological circumstances, it gains an importance in patients with atrial fibrillation. Compelling evidence has revealed that the left atrial appendage is implicated as the source of thrombus in the vast majority of strokes in atrial fibrillation. Oral anticoagulation remains the standard of care for stroke prevention in atrial fibrillation; nevertheless, this treatment has several limitations and is often contraindicated, particularly in the elderly population in whom the risk of stroke is high. Therefore, occluding the left atrial appendage is a logical approach to prevent thrombus formation and subsequent cardioembolic events in these patients. We present a review of clinical outcomes of patients with atrial fibrillation undergoing left atrial appendage closure and the challenges faced in this field.     

Left Atrial Appendage Dysfunction in a Patient with Premature Ventricular Contractions - A Risk Factor for Stroke?

A 16-year-old female with ventricular dysfunction and frequent ventricular arrhythmia presented with a cardioembolic stroke. Prior electrophysiology study and ablation was performed for ventricular tachycardia (VT). For remaining ventricular ectopy, the patient was maintained on carvedilol and mexiletine. After one year on this regimen, she presented with an acute stroke. Transesophageal echocardiography revealed no evidence of an intracardiac or ventricular thrombus but demonstrated markedly decreased left atrial appendage (LAA) flow velocity worsened during frequent premature ventricular contractions (PVC). In the absence of atrial fibrillation (AF), the LAA dysfunction was considered secondary to the frequent PVCs and was thought to be the underlying cause for the stroke. We present this case to highlight a potential under recognized association between LAA dysfunction and ventricular arrhythmia, similar to that observed with atrioventricular dyssynchronous pacing.     

Protective mechanism of SIRT1 on Hcy‐induced atrial fibrosis mediated by TRPC3

High plasma levels of homocysteine (Hcy) are regarded as a risk factor for atrial fibrillation (AF), which is closely associated with the pathological consequence of atrial fibrosis and can lead to heart failure with a high mortality rate; here, we show that atrial fibrosis is mediated by the relationship between canonical transient receptor potential 3 (TRPC3) channels and sirtuin type 1 (SIRT1) under the stimulation of Hcy. The left atrial appendage was obtained from patients with either sinus rhythm (SR) or AF and used to evaluate the relationship between the concentration of Hcy and a potential mechanism of cardiac fibrosis mediated by TRPC3 and SIRT1. We next performed transverse aortic constriction (TAC) in mouse to investigate the relationship. The mechanisms underlying atrial fibrosis involving TRPC3 and SIRT1 proteins were explored by co‐IP, BLI and lentivirus transfection experiments. qPCR and WB were performed to analyse gene and protein expression, respectively. The higher level of atrial fibrosis was observed in the HH mouse group with a high Hcy diet. Such results suggest that AF patients may be more susceptible to atrial fibrosis and possess a high probability of progressing to hyperhomocysteinemia. Moreover, our findings are consistent with the hypothesis that TRPC3 channel up‐regulation leads to abnormal accumulation of collagen, with the down‐regulation of SIRT1 as an aetiological factor of high Hcy, which in turn predisposes to atrial fibrosis and strongly enhances the possibility of AF.     

左房增大对起搏器术后的老年阵发性房颤患者再发房颤的影响

目的：探讨植入心脏起搏器的老年阵发性房颤患者再发房颤（包括无症状性房颤）发生率及左房容积指数对再发房颤的影响。方法：收集2012年1月-2013年12月在我院起搏器门诊长期随访且未服用抗心律失常药物的起搏器术后老年阵发性房颤患者148例,记录基线特征、超声心动图参数及随访期间内房颤发生情况。分别根据左房容积指数及房颤负荷进行分组,应用Cox回归分析探讨起搏器检测的再发房颤及房颤高负荷的危险因素。结果：患者平均随访时间为22.79个月,期间57.43%的患者再发房颤,22.97%的患者为房颤高负荷,15.54%的患者为无症状房颤。多因素Cox回归分析发现左房增大分别是再发房颤及房颤高负荷的独立危险因素。结论：左房容积指数是预测起搏器术后老年阵发性房颤患者房颤复发及房颤高负荷的独立危险因素。