80岁以上老年人冠状动脉旁路移植术合并瓣膜置换手术的临床分析

目的：总结老年患者行冠状动脉旁路移植术（CABG）合并瓣膜置换（VR）手术的特点及经验。方法：上海交通大学附属第一人民医院心血管外科2001年11月至2010年3月对60例年龄大于80的患者施行冠状动脉搭桥＋瓣膜置换手术,男33例,女27例。年龄80-87岁,平均年龄（83.77±2.45）岁。均为冠心病合并瓣膜病变患者。其中36例患者行冠状动脉旁路移植＋二尖瓣置换手术,15例患者行冠状动脉旁路移植＋主动脉瓣置换手术,9例患者行冠状动脉旁路移植＋双瓣置换手术,同时8例患者行三尖瓣成形手术,3例患者行射频消融手术,1例升主动开成形术。置换生物瓣膜者51例,置换机械瓣膜者9例。CABG平均搭桥（2.13±0.75）根,搭桥材料为左乳内动脉与大隐静脉。结果：全组早期死亡9例（15%）,1例死于术后出血,1例死于多器官功能衰竭,7例死于术后心衰。早期生存51例（85%）,出现术后并发症10例,其中2例发生胸腔积液,1例心包填塞,3例肺部感染,1例心房扑动后发生室颤,3例二次开胸止血。给予相应对症治疗后痊愈出院。门诊随访49例,随访时间1～60个月,心功能I级2例、Ⅱ级29例、Ⅲ级18例、Ⅳ级0例（NYHA分级）。结论：对老年患者行冠脉搭桥＋瓣膜置换手术,只要掌握手术适应证,充分作好术前准备、术中及术后处理,手术治疗可以取得良好效果。     

冠心病患者介入治疗前后血清IL-18、sCD40L和hs-CRP水平的变化及其意义

目的：探讨冠心病患者血清白介素18（Interleukin-18,IL-18）、白细胞分化抗原40配体（CD40L）、及高敏C反应蛋白（hs-CRP）水平在经皮冠状动脉介入术治疗前后的变化和意义。方法：选择经冠状动脉造影确诊的冠心病患者85例,根据病变程度分为单支病变组（n=32）、双支病变组（n=28）和多支病变组（n=25）,采用双抗体夹心ELISA法测定PCI术前术后血清IL-18、CD40L和hs-CRP水平。结果：血清IL-18水平测定结果：多支病变组高于双支病变组,双支病变组高于单支病变组;支架置入术后显著高于术前,差异均有统计学意义（P〈0.01）。血清CD40L水平测定结果：多支病变组高于双支病变组和单支病变组,差异均有统计学意义（P〈0.01）,双支病变组与单支病变组间差异无统计学意义（P〉0.05）;支架置入术后较术前显著升高,差异有统计学意义（P〈0.01）。血清hs-CRP水平测定结果：多支病变组高于双支病变组,双支病变组高于单支病变组;支架置入术后显著高于术前,差异均有统计学意义（P〈0.01）。结论：冠心病患者血清IL-18、CD40L和hs-CRP与冠脉病变程度密切相关,介入治疗可使冠心病患者血清IL-18、CD40L和hs-CRP水平升高,监测血清中IL-18、CD40L和hs-CRP水平变化可了解治疗效果和炎症程度。     

冠状动脉旁路移植术后血糖变化临床分析

目的：分析冠状动脉旁路移植术（CABG）后患者高血糖的发生率及血糖的变化规律。方法：回顾性分析我院2005年1月～2009年12月行CABG的冠心病患者138例的糖尿病史、术前术后血糖水平、后高血糖和血糖峰值的出现时间等资料。按术前有无糖尿病分为糖尿病组和非糖尿病组,比较析两组的差异。结果：138例患者中有101例发生术后高血糖,发生率为73.2%,非糖尿病组发生率为69.7%;糖尿病组发生率为77.4%,2组术后高血糖发生率未见统计学差异（x2=1.027,P=0.3109）。术前血糖水平与术后高血糖发生率呈正相关,99.0%的患者出现在入住重症强医疗病房（ICU）24h以内,术后血糖峰值的出现时间入住ICU16h,且非糖尿病组出现时间较糖尿病组早。结论：CABG后高血糖的发生率较高,且绝大多数出现在术后24 h以内,术后高血糖发生率与术前血糖水平呈正相关。     

罗格列酮对2型糖尿病合并急性冠脉综合征患者血清TGF—β1及IL-1β的影响

目的：观察罗格列酮对2型糖尿病合并急性冠脉综合征患者血清转化生长因子-β1（TGF—β1）及白细胞介素-1β（IL-1β）的影响。方法：116例2型糖尿病合并急性冠脉综合征患者,随机分为罗格列酮治疗组（n=58）和常规治疗组（n=58）。检测两组患者治疗前后空腹血糖、血脂及血清TGF-β1、IL-1β的变化。结果：治疗前两组患者空腹血糖、血脂及血清TGF-β1、IL-1β的水平无显著差异（P〉0．05）;治疗4月后,两组患者空腹血糖、血脂无显著差异,血清IL-1β较治疗前下降（P〈0．01）,罗格列酮组较常规治疗组下降明显,两组间差异显著（P〈0．05）;治疗后血清TGF—β1较治疗前上升（P〈0．05）,罗格列酮组与常规治疗组比较,差异显著（P〈0．05）。结论：罗格列酮能调控糖尿病合并急性冠脉综合征患者炎症介质和抗炎因子的分泌,可能具有改善动脉粥样硬化的作用。     

冠状动脉介入治疗对冠心病患者Caspase-3,9 水平的影响

目的:通过对冠心病患者经皮冠状动脉介入治疗(PCI)前后血清Caspase-3,9水平变化的观察,探讨冠状动脉介入治疗对冠心病患者血清Caspase-3,9水平的影响。方法:冠状动脉介入组(PCI组)30例和单纯造影组(CAG组)29例,在术前0.5h,术后3h,术后6h,术后12h,术后24h,术后48h分别测定血清Caspase-3,9水平。结果:CAG组术前与术后的血清Caspase-3,9水平差异均无统计学意义,PCI组术后3h、6h的Caspase-3水平较术前0.5h均有降低趋势,差异均有统计学意义(P<0.05),PCI组术后48h的Caspase-9水平与术后3h、6h相比均有升高趋势,差异均有统计学意义(P<0.05)。结论:PCI术后狭窄或闭塞的冠状动脉血管重新恢复血供,血清中Caspase-3,9水平在PCI术后先降低后又逐渐升高,提示再灌注后可出现细胞的凋亡程度加重,血清中Caspase-3,9的水平可作为心肌再灌注损伤后细胞凋亡程度的评估指标并可作为诊断临床症状不典型的再灌注损伤的一个指标。PCI术可有效改善心肌血供,减少因术前缺血缺氧造成的细胞凋亡,但PCI术后再灌注损伤可进一步加重细胞凋亡。     

冠状动脉TF/TFPI 与急性冠脉综合征关系的研究

目的:研究急性冠脉综合症患者冠状循环局部血液TF/TFPI改变。方法:入选40名冠状动脉造影患者,其中不稳定心绞痛(Unstable pectoris,UP)20例,稳定性心绞痛(Stable pectoris,SP)和正常对照组各10例。所有受试者在冠状动脉造影时,同时经导管抽取主动脉根部、冠状静脉窦和股静脉血样,采用ELISA法测定血浆TF、TFPI水平,计算TF/TFPI比值。结果:三组受检者基本情况均相似,UA组和SA组冠心病危险因素无统计学差异。股静脉血中TF、TFPI浓度及TF/TFPI比值比较:UA组和SA组血TF水平显著高于对照组,UA组血TF水平显著高于SA组。UA组血TFPI水平低于SA组及对照组;SA组血TFPI水平略低于对照组,但未达到统计学意义;UA组血TF/TFPI比值显著高于对照组和SA组,SA组与对照组比较差异无统计学意义。不同部位血TF、TFPI水平及TF/TFPI比值比较:UA组冠状静脉窦血中TF水平较主动脉根部显著升高,CS-AO差值显著高于FV-AO差值;UA组冠状静脉窦血TFPI水平较主动脉根部有升高趋势,但差异无统计学意义,而TF/TFPI比值较主动脉根部升高,差异有统计学意义,CS-AO差值显著高于FV-AO差值。血TF、TFPI水平及TF/TFPI比值在股静脉与主动脉根部之间差异无统计学意义(P>0.05)。SA组和对照组血TF、TFPI水平及TF/TFPI比值三部位间差异无统计学意义。结论:冠脉循环TF/TFPI比值能较敏感地反映ACS的情况。     

Antiarrhythmic Mechanisms of n-3 PUFA and the Results of the GISSI-Prevenzione Trial

The purpose of this paper is twofold: on the one hand, to confirm the positive results on n-3 PUFA from the overall results Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GlSSI)-Prevenzione trial; on the other, to summarize and describe how the results of an important trial can help generate hypotheses either on mechanisms of action or on differential results in particular subgroups of patients, as well as test the pathophysiological hypotheses that have accompanied in the years the story of the hypothesized mechanisms of action of a drug. GISSI-Prevenzione was conceived as a pragmatic population trial on patients with recent myocardial infarction and it was conducted in the framework of the Italian public health system. In GISSI-Prevenzione, 11,323 patients were enrolled in a clinical trial aimed at testing the effectiveness of n-3 polyunsaturated fatty acids (PUFA) and vitamin E. Patients were invited to follow Mediterranean dietary habits, and were treated with up-to-date preventive pharmacological interventions. Long-term n-3 PUFA at 1 g daily, but not vitamin E at 300 mg daily, was beneficial for death and for combined death, non-fatal myocardial infarction, and stroke. All the benefit, however, was attributable to the decrease in risk for overall (−20%), cardiovascular (−30%), and sudden death (−45%). At variance from the orientation of a scientific scenario largely dominated by the “cholesterol-heart hypothesis”, GISSI-Prevenzione results indicate n-3 PUFA (virtually devoid of any cholesterol-lowering effect) as a relevant pharmacological treatment for secondary prevention after myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSI) Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Italy. Istituto di Ricerche Farmacologiche Mario Negri - Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy *The names of GISSI-Prevenzione Investigators are reported in Lancet 1999; 354:447–55. (40)     

Adiponectin expression in human epicardial adipose tissue in vivo is lower in patients with coronary artery disease

BACKGROUND: Intra-peritoneal adipose tissue is recognized as a predictor of metabolic syndrome and may contribute to the risk for cardiovascular disease by the production of adipocytokines, including adiponectin. Nevertheless, there is no knowledge on whether other visceral depots of adipose tissue, including the epicardial fat, have any metabolically active role, including production of adiponectin. AIM OF THE STUDY: We sought to evaluate adiponectin protein expression in epicardial adipose tissue in vivo both in patients with severe coronary artery disease (CAD) and in subjects without CAD. METHODS: Twenty-two patients were enrolled for the study. We selected 16 patients who underwent elective coronary artery bypass graft surgery for critical CAD, 5 who underwent surgery for valve replacement and 1 for correction of an interatrial defect. Epicardial adipose tissue biopsy samples were obtained before the initiation of cardiopulmonary bypass. Adiponectin protein level in epicardial adipose tissue was evaluated by Western blotting. RESULTS: Adiponectin protein value, expressed as adiponectin/actin ratio, in epicardial adipose tissue was significantly lower in patients with severe CAD than in those without CAD (1.42 +/- 0.77 vs 2.36 +/- 0.84 p = 0.02, 95% CI 0.64-1.74). CONCLUSIONS: This study showed for the first time that human epicardial adipose tissue expresses adiponectin. Adiponectin expression is significantly lower in epicardial fat isolated from patients with CAD.     

Autoantibodies against oxidized LDL are associated with severe chest pain attacks in patients with coronary heart disease

Autoantibodies against oxidized low-density lipoprotein (oxLDL) predict the progression of atherosclerosis. Several studies have shown that oxLDL is present in atherosclerotic lesions and that several factors present in active atherosclerotic plaques can oxidatively modify LDL. Oxidation of LDL induces production of autoantibodies against oxLDL (oxLDLab) that can be measured using an EIA test. Our aim was to see whether oxLDLab are associated with severe chest pain attacks in coronary heart disease (CHD) patients. Patients having two- or three-vessel CHD, as assessed by coronary angiography, and their siblings were recruited into the study (n = 568, mean age 55.8 years, range 29.3–83.2 years). Nondiabetic patients having a history of severe chest pain attacks had significantly higher oxLDLab levels (0.611 ± 0.56) than those who did not have a history of severe chest pain attacks (0.487 ± 0.40) (p = 0.027), even though age, cholesterol level, body mass index, and blood pressure were similar in both groups. However, no difference was found in oxLDLab levels in diabetic patients with or without a history of severe chest pain attacks. Increased levels of oxLDL autoantibodies are associated with severe chest pain attacks in nondiabetic patients with CHD.     

Coronary artery bypass surgery in high-risk patients

Background

In high-risk coronary artery bypass patients; off-pump versus on-pump surgical strategies still remain a matter of debate, regarding which method results in a lower incidence of perioperative mortality and morbidity. We describe our experience in the treatment of high-risk coronary artery patients and compare patients assigned to on-pump and off-pump surgery.

Methods

From March 2002 to July 2004, 86 patients with EuroSCOREs > 5 underwent myocardial revascularization with or without cardiopulmonary bypass. Patients were assigned to off-pump surgery (40) or on-pump surgery (46) based on coronary anatomy coupled with the likelihood of achieving complete revascularization.

Results

Those patients undergoing off-pump surgery had significantly poorer left ventricular function than those undergoing on-pump surgery (28.6 ± 5.8% vs. 40.5 ± 7.4%, respectively, p < 0.05) and also had higher Euroscore values (7.26 ± 1.4 vs. 12.1 ± 1.8, respectively, p < 0.05). Differences between the two groups were nonsignificant with regard to number of grafts per patient, mean duration of surgery, anesthesia and operating room time, length of stay intensive care unit (ICU) and rate of postoperative atrial fibrillation

Conclusion

Utilization of off-pump coronary artery bypass graft (CABG) does not confer significant clinical advantages in all high-risk patients. This review suggest that off-pump coronary revascularization may represent an alternative approach for treatment of patients with Euroscore ≥ 10 and left ventricular function ≤ 30%.