主动脉球内囊反搏在心脏手术后心功能不全患者中的应用价值

目的:探讨主动脉球内囊反搏置入在心脏手术后心功能不全患者中的临床应用价值。方法:收集我院收治的心脏术后患者60例,随机分为对照组和实验组,每组各30例,患者均给予相应常规对症治疗,包括吸氧、强心、利尿、扩血管治疗,实验组患者在对照组基础上给予主动脉球囊反搏置入。治疗结束后,对两组患者治疗前后的连续心输出量(CCO)、心脏指数(CI)、人氨基末端B型脑钠肽前体(NT-pro BNP)、中心静脉压(CVP)水平以及临床疗效进行检测并比较。结果:治疗后,两组患者的CCO以及CI水平与治疗前相比均升高(P0.05),NT-pro BNP以及CVP水平均下降(P0.05);与对照组相比,实验组患者治疗后CCO以及CI水平较高,NT-pro BNP以及CVP水平较低(P0.05);实验组患者的治疗总有效率与对照组患者相比较高(P0.05)。结论:主动脉球内囊反搏植入能够显著升高心脏手术后心功能不全患者患者的心输出量,降低心脏后负荷,提高心脏功能,具有较好的临床疗效。     

Surfactant Therapy for Patients with ARDS After Cardiac Surgery

This multicenter study investigated the possibility of reducing mortality rate by administering natural lung surfactant additional to standard therapy to treat patients after cardiac surgery who developed an acute respiratory failure (ARDS/ALI).

A total of 78 patients (1998–2002) diagnosed with ALI or ARDS were enrolled in the study; patients were considered for study entry only if they developed ALI/ARDS within 72h after cardiac surgery. A total of 36 patients (2000–2002) received Surfactant-BL via bronchoscope at a dose of 3 mg/kg twice a day, and 42 patients (1998–2000) served as the historical control.

Within 24h after the first Surfactant-BL administration the PaO₂/FiO₂ ratio increased from (mean ± SEM) 129.7 ± 9.9 mm Hg to 187.6 ± 17.6 mm Hg (p < 0.01), FiO₂ decreased from (mean ± SEM) 0.71 ± 0.03 to 0.56 ± 0.03 (p < 0.01), and 69.4% of the patients treated with surfactant were weaned from the ventilator compared with 50% of the control group during a 28-day period. The mortality rate among patients treated with Surfactant-BL was 30.6% compared with 50% in the control group.

In conclusion, early administration of Surfactant-BL leads to the reduction of mortality in cardiac patients who develop postoperatively an ALI or ARDS.     

The Significance of Post-operative Creatinine in Predicting Prognosis in Cardiac Surgery Patients

The purpose of the study is to investigate the effectiveness of serum creatinine, the most common indicator of acute kidney injury (AKI), in predicting the prognosis of critically ill patients after cardiac surgery. Also, we sought to validate the use of this biomarker in assessing the direct outcome of a clinical setting. We selected 592 patients from our hospital; the relevant information including name, disease, gender, age, EuroSCORE, length of stay (LOS), days of mechanical ventilation, days of noninvasive positive pressure ventilation, days of continuous renal replacement treatment, and mortality was recorded. Creatinine of pre-operative, 24, and 48 h post-operation specimens were analyzed. The difference in serum creatinine levels at various time points was compared using t test. Spearman correlation was used to analyze the correlation of serum creatinine to AKI and hard outcomes. Receiver-operating characteristic curves were generated, and the areas under the curves (AUCs) were compared to validate the adequacy of creatinine in predicting the post-operative AKI. The 48 h post-operative and pre-operative serum creatinine were found to be informative in predicting the outcome of patients as indicated by the t test and Spearman correlation analysis. The 48 h creatinine with AUC of 0.811 was indicated to be significantly associated with the hard outcome. However, the 24 h and pre-operative creatinine with AUCs of 0.701 and 0.658, respectively, were not adequately related to the outcomes. In conclusion, contrary to the existing belief that creatinine is not an informative parameter for the diagnosis and prognosis of AKI, we found that when measured at 48 h of cardiac surgery, serum creatinine is reflective of the outcome.     

单操作孔电视胸腔镜手术对老年孤立性肺结节患者肺功能和免疫球蛋白的影响

目的:探讨单操作孔电视胸腔镜手术(VATS)对老年孤立性肺结节(SPN)患者肺功能和免疫球蛋白的影响。方法:回顾性分析2016年2月～2019年1月期间南京医科大学附属无锡人民医院收治的78例老年SPN患者的临床资料。根据手术方式的不同将患者分为对照组(n=43)和研究组(n=35),对照组给予传统多孔VATS肺结节切除术治疗,研究组给予单操作孔VATS肺结节切除术治疗,比较两组患者临床指标、肺功能、免疫球蛋白、视觉疼痛模拟评分量表(VAS)、并发症以及复发情况。结果:两组手术时间比较无差异(P0.05),研究组住院时间短于对照组,术后引流量、住院费用、术中出血量均少于对照组(P0.05)。两组均未见严重的并发症,且两组均无复发病例。两组术后1个月第1 s用力呼气容积(FEV1)、每分钟最大通气量(MVV)、用力肺活量(FVC)均下降,但研究组高于对照组(P0.05)。两组术后3 d免疫球蛋白A(Ig A)、免疫球蛋白M(Ig M)、免疫球蛋白G(Ig G)均下降,但研究组高于对照组(P0.05)。术后1 d、3 d、5 d研究组VAS评分较对照组降低(P0.05)。结论:单操作孔VATS治疗老年SPN,可有效改善围术期指标,提高免疫力,减轻肺功能损伤,且安全性较好,临床应用价值较高。     

Renal Function Interferes with Copeptin in Prediction of Major Adverse Cardiac Events in Patients Undergoing Vascular Surgery

Objective

Precise perioperative risk stratification is important in vascular surgery patients who are at high risk for major adverse cardiovascular events (MACE) peri- and postoperatively. In clinical practice, the patient’s perioperative risk is predicted by various indicators, e.g. revised cardiac index (RCRI) or modifications thereof. Patients suffering from chronic kidney disease (CKD) are stratified into a higher risk category. We hypothesized that Copeptin as a novel biomarker for hemodynamic stress could help to improve the prediction of perioperative cardiovascular events in patients undergoing vascular surgery including patients with chronic kidney disease.

Methods

477 consecutive patients undergoing abdominal aortic, peripheral arterial or carotid surgery from June 2007 to October 2012 were prospectively enrolled. Primary endpoint was 30-day postoperative major adverse cardiovascular events (MACE).

Results

41 patients reached the primary endpoint, including 63.4% aortic, 26.8% carotid, and 9.8% peripheral surgeries. Linear regression analysis showed that RCRI (P< .001), pre- (P< .001), postoperative Copeptin (P< .001) and Copeptin level change (P= .001) were associated with perioperative MACE, but CKD remained independently associated with MACE and Copeptin levels. Multivariate regression showed that increased Copeptin levels added risk predictive information to the RCRI (P= .003). Especially in the intermediate RCRI categories was Copeptin significantly associated with the occurrence of MACE. (P< .05 Kruskal Wallis test). Subdivision of the study cohort into CKD stages revealed that preoperative Copeptin was significantly associated with CKD stages (P< .0001) and preoperative Copeptin measurements could not predict MACE in patients with more severe CKD stages.

Conclusion

Preoperative Copeptin loses its risk predictive potential for perioperative MACE in patients with chronic kidney disease undergoing vascular surgery.     

乌司他丁对心肺转流下心脏手术患者炎症因子及认知功能的影响

目的:探索乌司他丁(UTI)对心肺转流(CPB)下心脏手术患者炎症因子及认知功能的影响。方法:选择自2010年5月至2014年9月我院收治的CPB瓣膜置换手术患者60例,按照随机数表法将患者分成对照组和观察组,每组30例。观察组患者在麻醉诱导后静脉泵入1.2×10~4U/kg UTI,在CPB结束前5 min从体外管道内给予0.6×10~4U/kg UTI,对照组患者给予等量的生理盐水。对比两组CPB前(T0)、CPB开始后1 h(T1)、CPB结束后1 h(T2)、术后4 h(T3)及术后24 h(T4)的血浆肿瘤坏死因子-α(TNF-α)、白细胞介素-6/10(IL-6/10)、中性粒细胞弹性蛋白酶(NE)、星形胶质细胞S100蛋白的β亚型(S100β)、超氧化物歧化酶(SOD)和丙二醛(MDA),在术前1 d和术后7 d时,采用简易精神状态检查表(MMSE)对患者进行神经精神功能测试,并评价患者的术后认知功能障碍(POCD)的发生率。结果:与T0相比,两组患者T1-T4的TNF-α、IL-6、NE、S100β、MDA水平明显升高,且观察组显著低于对照组,而两组IL-10、SOD水平显著下降,观察组显著高于对照组(P0.05)。术后7d,两组患者MMSE评分均明显高于术前1 d,且观察组显著高于对照组(P0.05);观察组POCD的发生率明显低于对照组(P0.05)。结论:UTI可以有效降低CPB下行瓣膜置换术患者的炎症因子水平,并改善患者的POCD,对于临床用药具有指导意义。     

Combining Smaller Patch,RV Remodeling and Tissue Regeneration in Pulmonary Valve Replacement Surgery Design May Lead to Better Post-Surgery RV Cardiac Function for Patients with Tetralogy of Fallot

Patients with repaired Tetralogy of Fallot (ToF), a congenital heart defect which includes a ventricular septal defect and severe right ventricular outflow obstruction, account for the majority of cases with late onset right ventricle (RV) failure. The current surgical approach, which includes pulmonary valve replacement/insertion (PVR), has yielded mixed results. A computational parametric study using 7 patient-specific RV/LV models based on cardiac magnetic resonance (CMR) data as "virtual surgery" was performed to investigate the impact of patch size, RV remodeling and tissue regeneration in PVR surgery design on RV cardiac functions. Two patch sizes, three degrees of scar trimming (RV volume shrinkages: 9%, 17%, 25%) and hypothetical use of regenerated myocardium as replacement of patch and scar were considered in these models. Our preliminary results indicate that each of the three techniques (smaller patch, RV remodeling, and myocardium regeneration) had modest improvement on post-PVR RV ejection fraction (from 1.76%-4% over the conventional PVR procedure) and combination of all three techniques had the best performance (a 4.74% improvement in ejection fraction over the conventional PVR, for the patient studied). Changes in RV stress, strain and curvatures were also observed. However, their linkages to RV ejection fraction were less clear. Further investigations are required to confirm our findings.     

Cardiorespiratory Studies in Patients with Pulmonary Tuberculosis

Cardiorespiratory studies in 13 young females and 11 middle-aged men with localized acute pulmonary tuberculosis revealed evidence of significant resting hyperventilation and reduction in the dynamics of ventilation indicative of restrictive lung disease. Indices of intrapulmonary mixing and pulmonary diffusing capacities were normal, as were alveolar-arterial pCO₂ gradients.The ventilation/perfusion ratios were slightly elevated in both groups, while pulmonary artery pressure and total pulmonary vascular resistance (TPVR) showed a rise in the males only.Both groups showed an increase in actual QBF flows and a resultant significant decrease in arterial pO₂, which suggests that the areas of tuberculous infection are metabolically active.     

患儿体外循环直视心脏术后高尿酸血症分析

目的：探讨体外循环心脏术后24h患儿高尿酸血症发生的原因、影响因素和预后。方法：以2006年9～12月我院心脏外科收治的106例体外循环心脏手术患儿为研究对象,收集其年龄、体外循环时间、尿量、预后资料和心脏术后24h血尿酸、尿素氮、肌酐、胱抑素、血糖、总胆红素、直接胆红素等生化指标数据;以空腹血尿酸为标准,将患儿分为无高尿酸血症组和高尿酸血症组,用SPSS11．0软件分析两组之间临床资料的差异、高尿酸血症组血尿酸与其他指标的相关性及影响患者预后的因素。结果：患儿术后高尿酸血症组患者53例（50％）,与无高尿酸血症组相比P〈0．01,除年龄因素外,其他临床指标均有统计学意义;高尿酸血症组的血尿酸与血糖、总胆红素无相关性,与年龄、尿量呈显著负相关,与转流时间、尿素氮、肌酐、胱抑素、直接胆红素含量呈极显著正相关;在预后良好组与死亡组的比较中,转流时间、血尿酸、尿素氮、肌酐含量有统计学意义。结论：患儿体外循环心脏术后高尿酸血症的发生较常见,血尿酸水平对患者术后肾功能状态及预后具有重要临床意义,连续监测术后血尿酸、尿素氮、肌酐水平是及时判断患者临床状况以采取相应措施改善预后的重要方法;低心排血量综合征是引起患者死亡的危险因素之一,通过提高体外循环心脏手术水平,尽量缩短转流时间,加强围手术期监护,可有效减少术后并发症,降低死亡率。     

CD62L (L-Selectin) Shedding for Assessment of Perioperative Immune Sensitivity in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

Objective

To investigate the suitability of blood granulocyte and monocyte sensitivity, as measured by the quantity of different agonists required to induce CD62L shedding, for assessment of perioperative immune changes in patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods

Patients scheduled for aortocoronary bypass grafting or for valve surgery were included in this prospective observational study. Blood samples were drawn before anesthesia induction, directly after surgery and 48 hours after anesthesia induction. We determined the concentration of two different inflammatory stimuli – lipoteichoic acid (LTA) and tumor necrosis factor alpha (TNF) - required to induce shedding of 50% of surface CD62L from blood granulocytes and monocytes. In parallel monocyte surface human leukocyte antigen (HLA)-DR, and plasma interleukin (IL)-8, soluble (s)CD62L, soluble (s)Toll-like receptor (TLR)-2 and ADAM17 quantification were used to illustrate perioperative immunomodulation.

Results

25 patients were enrolled. Blood granulocytes and monocytes showed decreased sensitivity to the TLR 2/6 agonist Staphylococcus aureus LTA immediately after surgery (p = 0.001 and p = 0.004 respectively). In contrast, granulocytes (p = 0.01), but not monocytes (p = 0.057) displayed a decreased postoperative sensitivity to TNF. We confirmed the presence of a systemic inflammatory response and a decreased immune sensitivity in the post-surgical period by measuring significant increases in the perioperative plasma concentration of IL-8 (p≤0.001) and sTLR (p = 0.004), and decreases in monocyte HLA-DR (p<0.001), plasma sCD62L (p≤0.001). In contrast, ADAM17 plasma levels did not show significant differences over the observation period (p = 0.401).

Conclusions

Monitoring granulocyte and monocyte sensitivity using the “CD62L shedding assay” in the perioperative period in cardiac surgical patients treated with the use of cardiopulmonary bypass reveals common changes in sensitivity to TLR2/6 ligands and to TNF stimulus. Further long-term follow-up studies will address the predictive value of these observations for clinical purposes.     

心脏外科术后重症患者死亡影响因素的Logistic回归分析及对预后的预测价值

摘要 目的：探讨心脏外科术后重症患者死亡的影响因素并分析其对预后的预测价值。方法：回顾性分析2016年3月至2021年6月本院重症监护室（ICU）收治的108例心脏外科术后重症患者的临床资料,根据出院前临床结局分为死亡组及存活组,比较两组临床指标的差异,采用Logistic回归分析患者死亡的危险因素,绘制受试者特征工作曲线（ROC）分析危险因素对预后的预测价值。结果：108例患者存活组80例,死亡组28例;死亡组房颤史比例、Killip心功能分级≧III级比例、左室射血分数（LVEF）<40%比例、血管活性药物输注比例、急性生理学与慢性健康状况评分II（APACHEII）、心肌肌钙蛋白I（cTnI）、血肌酐（Scr）、B型钠尿肽（BNP）高于存活组,肾小球滤过率（eGFR）低于存活组,差异有统计学意义（P<0.05）;多因素Logistic回归分析显示,APACHEII评分、eGFR、cTnI是心脏外科术后重症患者死亡的独立危险因素（P<0.05）;ROC曲线显示,APACHEII评分、eGFR、cTnI预测心脏外科术后重症患者预后的曲线下面积分别为0.836、0.799、0.710,三者联合预测曲线下面积为0.862。结论：APACHEII评分、eGFR、cTnI是心脏外科术后重症患者预后的独立危险因素,三者联合用于预后的预测价值更高,可为临床治疗提供一定参考。     

Genetic Polymorphisms in Endothelin-1 as Predictors for Long-Term Survival and the Cardiac Index in Patients Undergoing On-Pump Cardiac Surgery

Genetic variants within the endothelin-1 gene (EDN1) have been associated with several cardiovascular diseases and may act as genetic prognostic markers. Here, we explored the overall relevance of EDN1 polymorphisms for long-term survival in patients undergoing on-pump cardiac surgery. A prospectively collected cohort of 455 Caucasian patients who underwent cardiac surgery with cardiopulmonary bypass was followed up for 5 years. The obtained genotypes and inferred haplotypes were analyzed for their associations with the five-year mortality rate (primary endpoint). The EDN1 T-1370G and K198N genotype distributions did not deviate from Hardy–Weinberg equilibrium and the major allele frequencies were 83% and 77%, respectively. The cardiovascular risk factors were equally distributed in terms of the different genotypes and haplotypes associated with the two polymorphisms. The five-year mortality rate did not differ among the different EDN1 T-1370G and K198N genotypes and haplotypes. Haplotype analysis revealed that carriers of the G-T (compound EDN1 T-1370G G/K198N T) haplotype had a higher cardiac index than did non-carriers (p = 0.0008); however, this difference did not reach significance after adjusting for multiple testing. The results indicate that common variations in EDN1 do not act as prognostic markers for long-term survival in patients undergoing on-pump cardiac surgery.     

The Correlation between Lung Sound Distribution and Pulmonary Function in COPD Patients

Background

Regional lung sound intensity in chronic obstructive pulmonary disease (COPD) patients is influenced by the severity and distribution of emphysema, obstructed peripheral airways, and altered ribcage and diaphragm configurations and movements due to hyperinflation. Changes in the lung sound distribution accompanied by pulmonary function improvements in COPD patients were observed after bronchodilator inhalation. We investigated the association of lung sound distribution with pulmonary functions, and the effects of emphysematous lesions on this association. These studies were designed to acquire the basic knowledge necessary for the application of lung sound analysis in the physiological evaluation of COPD patients.

Methods

Pulmonary function tests and the percentage of upper- and lower-lung sound intensity (quantitative lung data [QLD]) were evaluated in 47 stable male COPD patients (54 - 82 years of age). In 39 patients, computed tomography taken within 6 months of the study was available and analyzed.

Results

The ratio of lower QLD to upper QLD showed significant positive correlations with FEV₁ %predicted (%FEV₁; ρ = 0.45, p<0.005) and MEF₅₀ %predicted (%MEF₅₀; ρ = 0.46, p<0.005). These correlations were not observed in COPD patients with dominant emphysema (% low attenuation area >40%, n = 20) and were stronger in less emphysematous patients (n = 19, %FEV₁; ρ = 0.64, p<0.005, %MEF₅₀; ρ = 0.71, p<0.001).

Conclusions

In COPD patients, the ratio of lower- to upper-lung sound intensities decreased according to the severity of obstructive changes, although emphysematous lesions considerably affected lung sound distribution.     

Overhydration,Cardiac Function and Survival in Hemodialysis Patients

Background and objectives

Chronic subclinical volume overload occurs very frequently and may be ubiquitous in hemodialysis (HD) patients receiving the standard thrice-weekly treatment. It is directly associated with hypertension, increased arterial stiffness, left ventricular hipertrophy, heart failure, and eventually, higher mortality and morbidity. We aimed to assess for the first time if the relationship between bioimpedance assessed overhydration and survival is maintained when adjustments for echocardiographic parameters are considered.

Design, setting, participants and measurements

A prospective cohort trial was conducted to investigate the impact of overhydration on all cause mortality and cardiovascular events (CVE), by using a previously reported cut-off value for overhydration and also investigating a new cut-off value derived from our analysis of this specific cohort. The body composition of 221 HD patients from a single center was assessed at baseline using bioimpedance. In 157 patients supplemental echocardiography was performed (echocardiography subgroup). Comparative survival analysis was performed using two cut-off points for relative fluid overload (RFO): 15% and 17.4% (a value determined by statistical analysis to have the best predictive value for mortality in our cohort).

Results

In the entire study population, patients considered overhydrated (using both cut-offs) had a significant increased risk for all-cause mortality in both univariate (HR = 2.12, 95%CI = 1.30–3.47 for RFO>15% and HR = 2.86, 95%CI = 1.72–4.78 for RFO>17.4%, respectively) and multivariate (HR = 1.87, 95%CI = 1.12–3.13 for RFO>15% and HR = 2.72, 95%CI = 1.60–4.63 for RFO>17.4%, respectively) Cox survival analysis. In the echocardiography subgroup, only the 17.4% cut-off remained associated with the outcome after adjustment for different echocardiographic parameters in the multivariate survival analysis. The number of CVE was significantly higher in overhydrated patients in both univariate (HR = 2.46, 95%CI = 1.56–3.87 for RFO >15% and HR = 3.67, 95%CI = 2.29–5.89 for RFO >17.4%) and multivariate (HR = 2.31, 95%CI = 1.42–3.77 for RFO >15% and HR = 4.17, 95%CI = 2.48–7.02 for RFO >17.4%) Cox regression analysis.

Conclusions

The study shows that the hydration status is associated with the mortality risk in a HD population, independently of cardiac morphology and function. We also describe and propose a new cut-off for RFO, in order to better define the relationship between overhydration and mortality risk. Further studies are needed to properly validate this new cut-off in other HD populations.     

Cardiac Function and Outcome in Patients with Cardio-Embolic Stroke

Background

The relationship between whole spectrum of Ejection fraction (EF) and cardioembolic stroke (CES) outcome has not been fully described yet. Notably, it remains unclear whether borderline EF (41∼49%) is related with poor outcome after CES. We sought to evaluate whether lower ejection fraction and borderline EF could predict the outcome in patients with CES.

Method and Results

We evaluated the relationship between EF and functional outcome in 437 consecutive patients with CES. EF was introduced as continuous and categorical (EF≤40%, EF 41∼49%, EF≥50%) variable. Patients with CES and the subgroup with AF were evaluated separately. Poor short-term outcome (modified Rankin Score≥3at discharge or death within 90 days after stroke onset) and long-term mortality were evaluated. A total of 165 patients (37.8%) had poor short-term outcomes. EF tends to be lower in patients with poor short-term outcome (56.8±11.0 vs. 54.8±12.0, p-value 0.086). Overall cumulative death was136 (31.1%) in all CES patients and 106 (31.7%) in the AF subgroup. In a multivariable model adjusted for possible covariates, the hazard ratio for mortality significantly decreased by 3% for every 1% increase in ejection fraction in CES patients and 2% for every 1% increase in the AF subgroup. Reduced EF (EF≤40%) showed higher mortality (HR 2.61), and those with borderline EF (41∼49%) had a tendency of higher mortality (HR 1.65, p-value 0.067)compared with those with normal EF.

Conclusion

We found a strong association between lower EF and CES outcome. Echocardiographic evaluation helps to better determine the prognosis in CES patients, even in subgroup of patients with AF.