小剂量洋地黄对急性心肌梗死PCI术后合并心力衰竭患者心率变异性的影响

目的:探讨早期应用小剂量洋地黄类药物对急性心肌梗死(Acute myocardial infarction,AMI)行经皮冠状动脉介入治疗(Percutaneous coronary intervention,PCI)术后合并心力衰竭患者心率变异性(Heart rate variability,HRV)的影响。方法:入选32例在发病24小时内接受PCI治疗且合并心力衰竭的AMI患者,再灌注后随机分为洋地黄组(西地兰0.2 mg,n=17)和对照组(生理盐水20 m L,n=15)。在用药前、用药后30分钟、用药后3小时、用药后6小时、用药后12小时、用药后24小时进行5分钟HRV分析。结果:1洋地黄组的心率在用药6小时后显著小于对照组(P0.05);2洋地黄组SDNN在用药后3小时-6小时显著大于对照组(P0.05),两组RMSSD比较无显著统计学差别(P0.05);3洋地黄组LFnorm在用药后3小时-6小时显著大于对照组(P0.05);用药3小时后,洋地黄组HFnorm显著大于对照组(P0.05),LF/HF显著小于对照组(P0.05)。结论:小剂量洋地黄可以显著降低AMI PCI术后合并心力衰竭患者的心率、逆转迷走神经与交感神经活性的失衡状态,改善HRV。     

New Concepts of Digitalis

The data presented in this review have substantiated the following ideas:• There is a direct relationship between digitalis dosage and myocardial contractile force. A small dose of digitalis produces a small increase of the contractile force of the heart and a large dose increases the force of the heart''s contraction by a much greater amount, whether the heart is normal, has a poor reserve, or is in frank failure.• Digitalis is of benefit to the patient with cardiovascular disease whether his heart is in failure or not.     

不同剂量舒芬太尼对心脏瓣膜置换术患者应激反应、炎性因子及心肌损伤的影响

目的:探讨不同剂量舒芬太尼对心脏瓣膜置换术患者应激反应、炎性因子及心肌损伤的影响。方法:根据随机数字表法将100例行心脏瓣膜置换术的患者分为低剂量组(n=33,舒芬太尼剂量为1.0μg/kg)、中剂量组(n=33,舒芬太尼剂量为1.5μg/kg)以及高剂量组(n=34,舒芬太尼剂量为2.0μg/kg),比较三组患者应激反应、炎性因子、心肌损伤等指标的变化以及围术期指标情况。结果:中剂量组、高剂量组麻醉诱导后(T1)、插管后1 min(T2)、插管后5 min(T3)、插管后10 min(T4)时间点心率(HR)、平均动脉压(MAP)均低于低剂量组同时间点,且高剂量组低于中剂量组(P<0.05)。与低剂量组比较,中剂量组、高剂量组阻断后30 min(T6)、开主动脉后2h(T7)以及术后1d(T8)时间点白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)均降低(P<0.05)。与低剂量组比较,中剂量组、高剂量组体外循环停机2h(T9)、体外循环停机8h(T10)、体外循环停机24h(T11)、体外循环停机48h(T12)时间点心肌肌钙蛋白I(cTnI)、肌酸磷酸激酶同工酶(CK-MB)均降低(P<0.05)。低剂量组、中剂量组重症监护室(ICU)滞留时间、拔管时间显著短于高剂量组(P<0.05),而三组心血管不良事件发生率比较差异无统计学意义(P>0.05)。结论:给予1.0μg/kg舒芬太尼麻醉的患者应激反应小,1.5μg/kg、2.0μg/kg舒芬太尼可更好地控制心脏瓣膜置换术患者炎性反应,同时对患者心肌损伤有一定的保护作用,但2.0μg/kg舒芬太尼会延长患者ICU滞留时间、拔管时间。     

Timing of Atropine and Neostigmine in the Reversal of Muscle Relaxants

The antimuscarinic effects of atropine were studied in 46 patients to whom neostigmine had been given after operation to reverse the action of a muscle relaxant. Neostigmine was given to alternate patients three minutes after, or together with, atropine, and the effects of the two procedures were compared by measuring the secretions which collected in the buccal and oropharyngeal cavities and observing the heart rate.It was found that the glands of the oral cavity were stimulated to a greater extent when neostigmine was given with atropine than after atropine. Any dose of atropine sufficient to inhibit peristaltic movements of the bowel is more than enough to block completely secretion by the salivary glands, and the appearance of some secretion in all cases after the administration of neostigmine suggests that the bowel was at liberty to react to the neostigmine in every case, but perhaps particularly so when atropine and neostigmine were given mixed. The integrity of an anastomosis of the bowel could be endangered by vigorous peristalsis in the early postoperative period.Electrocardiograms in about half the patients from each group confirmed earlier work that the muscarinic effects of neostigmine on the heart can be prevented by giving the atropine either before or together with the neostigmine.     

七氟醚对冠状动脉旁路移植术患者心肺功能的影响

目的:探讨七氟醚对冠状动脉旁路移植术(CABG)患者心肺功能的影响。方法:选择行CABG治疗的冠心病患者60例,随机分为观察组与对照组,每组各30例,两组患者均采用静脉全麻,全麻后对照组仅给予面罩吸氧,生理盐水维持静脉通道通畅;观察组于体外循环心肺转流(CPB)开始即洗入1%七氟醚辅助麻醉,维持至CPB结束,观察麻醉前30min(T0)、术后2h(T1)、6h(T2)、24h(T3)、48h(T4)心肺功能变化。结果:1T1、T2、T3时间段观察组平均动脉压(MAP)、心率(HR)、左室射血分数(LVEF)低于对照组,T1-T4时间段观察组肌酸激酶同工酶(CK-MB)低于对照组,比较差异有统计学意义(P0.05);2T1、T2时间段两组患者潮气量(Vt)、肺活量(Vc)、氧合指数(PaO_2/FiO_2)降低,呼吸频率(RR)、肺泡-动脉血氧分压差(PA-aO_2)呈增高趋势,T3、T4时间段下降;T1、T2时间段观察组Vt、Vc高于对照组,RR低于对照组,T1-T4时间段观察组PaO_2/FiO_2高于对照组,PA-aO_2低于对照组,两组比较差异均有统计学意义(P0.05)。结论:七氟醚有助于维持CABG患者围术期心功能稳定,减轻心肌损伤,改善呼吸抑制。     

CARDIAC OPERATIONS UNDER DIRECT VISION—Experience with Extracorporeal Oxygenation of the Blood

A heart-lung machine capable of oxygenating the blood and maintaining normal pressures during cardiopulmonary by-pass was used in 11 cases in which cardiac operations with the heart under direct vision were carried out. The first patient died. Improvements then were made in the machine and it was used in ten additional operations. One of the ten patients died, 18 hours postoperatively, of cardiac tamponade. Since then six more patients have been operated upon with no complications.     

Cardiac operations under direct vision; experience with extracoporeal oxygenation of the blood

A heart-lung machine capable of oxygenating the blood and maintaining normal pressures during cardiopulmonary by-pass was used in 11 cases in which cardiac operations with the heart under direct vision were carried out. The first patient died. Improvements then were made in the machine and it was used in ten additional operations. One of the ten patients died, 18 hours postoperatively, of cardiac tamponade. Since then six more patients have been operated upon with no complications.     

Emotional problems in children; the uses of drugs in therapeutic management

The repair of intracardiac defects under direct vision by opening the heart to expose the operative field, with the aid of hypothermia or a pump-oxygenator, is now a practical clinical method. Twelve patients were operated upon by this method. In eight patients an atrial septal defect was repaired during total circulatory occlusion under hypothermia. The seven patients in this group who had uncomplicated atrial defects survived the operation and are doing well after a short follow-up period. One patient with an unrecognized, associated ventricular defect died at the time of operation. Four patients were operated upon during total cardiac by-pass with the DeWall bubble-oxygenator. The first three patients survived operation and are continuing to do well after a brief follow-up period. In the fourth patient an atrioventricularis communis was repaired by the reconstruction of an atrial and ventricular septum with a plastic prosthesis. This patient died at the end of operation.     

Cognitive function and behavioural status in paediatric heart and heart-lung transplant recipients: the Harefield experience.

OBJECTIVE--To assess the psychological impact of cardiac and cardiopulmonary transplantation on children. DESIGN--Retrospective cross sectional study. SETTING--One British centre performing paediatric heart and heart-lung transplant operations, four cardiac units in London, three London schools, two London health centres, and the dental department of a London children''s hospital. SUBJECTS--65 children who had been given heart or heart-lung transplants and two reference groups of 52 children who had had other types of cardiac surgery and 45 healthy children. MAIN OUTCOME MEASURES--Development, cognition, and behaviour at home and at school as assessed by measures with proved validity and reliability. RESULTS--Developmental and cognitive measures indicated that children given transplants had significantly lower scores on several parameters, particularly in terms of development in children under 4 1/2 years of age. Performance on all tests, however, was within the normal range. There were no significant differences in behavioural ratings between the transplant and reference groups, though problem behaviour at home was more prevalent in the transplant group. CONCLUSIONS--Though cognitive development may be within the normal range, there are adverse psychological effects associated with cardiac and cardiopulmonary transplantation. These data indicate the need for a controlled prospective study in which children and their families are seen before and at regular intervals after transplantation. Interventions should be developed that are tailored to the particular needs of this very specialised group of paediatric patients and their families.     

乌司他丁对体外循环法洛四联症患儿围心脏手术期循环和呼吸功能的影响

目的:探讨乌司他丁对体外循环法洛四联症患儿围心脏手术期循环和呼吸功能的影响。方法:选取我院于收治的60例法洛四联症婴幼儿参与研究,并将其随机分为对照组和试验组两组,每组患儿30例。其中试验组患儿在体外循环前以及患儿进行手术后的三天内每天均给予10000U/kg乌司他丁,而对照组患儿则在相应的时间点给予等量的生理盐水。分析比较两组患儿的体外循环时间、心脏停搏时间、手术时间、在监护室治疗的时间以及患儿术后住院时间和患儿肺部感染发生例数等临床病理情况。结果:所有入选患儿均痊愈出院,在两组患儿的手术操作情况和治疗效果对比中,对照组患儿的手术时间、体外循环时间和心脏停搏时间均显著低于试验组患儿,但重症监护时间及术后住院时间则高于试验组患儿;在两组患儿治疗后的循环功能指标比较中,试验组患儿超滤后CVP和血管活性药物均低于对照组患儿而超滤后MAP则显著高于对照组患儿;在两组患儿治疗后的呼吸功能指标的比较中,试验组患儿的动脉血氧分压明显高于对照组患儿以及试验组患儿的术后机械通气时间和肺部感染例数均低于对照组患儿,两组患儿的数据比较差异除手术时间、体外循环时间和心脏停搏时间外均具有统计学意义(均P0.05)。结论:乌司他丁对体外循环法洛四联症患儿围心脏手术期的循环和呼吸功能具有较好的保护作用,值得在临床上加以广泛推广和运用。     

血红蛋白200g/L以上紫绀型先天性心脏病患者手术效果分析

目的:明确血红蛋白200 g/L以上紫绀型先天性心脏病患者的手术效果。方法:选取2009年3月至2012年3月于我中心就诊手术治疗的紫绀型先天性心脏病患者,按血红蛋白计数≥200 g/L和200 g/L分为A组和B组,完善术前检查后进行手术治疗。记录患者手术效果和随访情况;观察比较两组患者手术中情况包括:手术方式、手术时间、体外循环时间、心脏停搏时间、心脏自动复跳情况;记录并比较两组患者手术后恢复情况,包括机械通气时间、监护室滞留时间、手术后24小时内出血量、二次开胸止血例数和血管活性药物评分,以及监护室内肝肾功能异常和肺部并发症发生例数。结果:A组死亡3例(5.2%),23例术后3个月随访效果良好;B组死亡2例(5.8%),12例术后3个月随访效果良好。两组患者手术方式、手术时间、体外循环时间和心脏停搏时间、自动复跳例数均无明显差异(P0.05)。与B组比较,A组患者术后机械通气和监护室滞留时间长,术后24小时出血量多,血管活性药物使用评分高,肝肾功能异常例数和肺部并发症发生例数较多有统计学意义(P0.05),两组间二次开胸止血例数无统计学差异(P0.05)。结论:血红蛋白200 g/L以上紫绀型先天性心脏病患者与其他紫绀型先天性心脏病患者手术效果相似,但手术后恢复慢,并发症较多。     

Factitious Aortic Valve Insufficiency

One hundred consecutive aortograms, performed with careful attention to recommended technical details, were reviewed to identify cases of “factitious” aortic valve insufficiency, viz. aortic regurgitation seen during aortography for which there is no clinical evidence. Five patients with this condition were identified. Two of these subsequently underwent mitral valve replacement under cardiopulmonary by-pass. Aortic insufficiency was not detected during this procedure and the aortic valve appeared to be anatomically normal at postmortem examination. That factitious aortic insufficiency may exist should be remembered when aortography is used to differentiate aortic from pulmonary valve insufficiency.     

平衡超滤技术对小儿先心病术后炎症因子、凝血功能及肺功能的影响

目的:探讨平衡超滤技术对小儿先心病术后炎症因子、凝血功能及肺功能的影响。方法:选择2014年9月至2017年9月我院接诊的100例先天性心脏病患儿进行研究,通过随机数表法分为观察组55例和对照组45例,两组均于体外循环下实施心内直视手术,观察组在体外循环启动后患儿复温时开始平衡超滤,并于体外循环结束后即刻进行改良超滤,对照组仅在体外循环结束后即刻进行改良超滤。比较两组不同时间点炎症因子、凝血功能及肺功能的变化、术后恢复情况及并发症。结果:于体外循环结束后(术后)20 min(T1)、术后2 h(T2)、术后6 h(T3)各时点,观察组血清肿瘤坏死因子(TNF)-α、白介素(IL)-6、IL-10均明显比对照组低(P<0.05);观察组各时点活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(FIB)均明显低于对照组(P<0.05);观察组各时点肺静脉顺应性(Cstat)、氧合指数(OI)在各时点均明显高于对照组,肺泡-动脉氧分压梯度(AaDO2)明显低于对照组(P<0.05);观察组血管活性药使用时间、呼吸机使用时间和ICU住院时间均明显比对照组短(P<0.05),观察组感染、弥散性血管性凝血、肺功能损伤等发生率明显低于对照组(P<0.05)。结论:在改良超滤技术上,联合平衡超滤更有助于减轻小儿先心病术后炎症因子的释放,具有较好的凝血功能、肺功能保护作用,可有效促进术后恢复,减少围术期并发症。     

Veratrum viride; hypotensive and cardiac effects of intravenous use

The hypotensive action of veratrum viride given intravenously was studied in 24 patients, 22 of them hypertensive and 2 normotensive. Vasodepression of considerable but variable degree was obtained in all patients. Maximum hypotension occurred 8 to 15 minutes after injection and relative hypotension usually lasted at least two hours. In four patients subnormal hypotension occurred but there were no clinical manifestations of shock. The blood pressure rose promptly when pressor drugs were administered.A dose of 0.3 to 0.5 mg. brought about a satisfactory decrease in blood pressure. The degree of decrease was affected by the speed of administration and in a few patients by idiosyncratic sensitivity to the drug. Veratrum has an extravagal action on the pulse rate, and in that and other respects resembles digitalis. Veratrum should be given with caution to digitalized patients. Atropine reduced but did not abolish the hypotensive effect of veratrum, and was more effective when given before veratrum. This indicates that the parasympathomimetic action of veratrum is important in the mechanism of blood pressure reduction.     

Purification of endogenous digitalis-like factor(s) from cord blood of neonate by immunoaffinity chromatography.

We have previously shown that antidigoxin antibodies may neutralize partially purified endogenous digitalis like factor(s) present in newborn (umbilical cord) plasma. We here report on the preparation of an immunoaffinity chromatographic system (high affinity digoxin-binding antibodies (Fab fragments) bound covalently to Sepharose) for the purification of endogenous digitalis like factor(s). Neonate plasma extract loses all its biological digitalis-like activity (erythrocyte 86Rb uptake inhibition) after absorption on Sepharose coupled to Fab fragments but not after absorption on uncoupled Sepharose. Endogenous digitalis like factor(s) absorbed to Sepharose coupled to Fab fragments can be eluted by methanol. Subsequent HPLC separation indicate that at least two molecular species with digitalis-like properties are retained by antibodies bound to Sepharose and can be recovered with methanol.     

Digitalis sensitivity of Na+,K(+)-ATPase, myocytes and the heart.

Cardiac Na+,K(+)-ATPase, the receptor molecule for digitalis glycosides, have isoforms with different intrinsic affinities for the glycosides. Expression of these isoforms are under developmental and hormonal regulation. Switching in isoforms to those with lower intrinsic affinity may decrease digitalis sensitivity of the heart. In addition to the intrinsic affinity of the cardiac Na+,K(+)-ATPase for the glycoside, increases in the rate of Na+ influx and decreases in extracellular K+ concentrations increase glycoside sensitivity of the heart and also reduces the margin of safety by reducing reserve capacity of the sodium pump. Reserve capacity of the sodium pump is also reduced by pathological conditions or aging, resulting in reduced margin of safety for the glycoside. Events that follow sodium pump inhibition also affect sensitivity of the heart to digitalis toxicity. These are hypercalcemia and magnesium depletion. It is now feasible to predict digitalis sensitivity of the heart, not empirically but based on the understanding of the mechanisms responsible for the positive inotropic and toxic actions of the glycoside.     

RT-PCR detection of the Na,K-ATPase beta3-isoform in human heart.

The Na,K-ATPase is a heterodimer composed of an alpha-catalytic and a beta-glycoprotein subunit. At present, three different alpha-polypeptides (alpha1, alpha2, alpha3) and two distinct beta-isoforms (beta1 and beta2) have been detected in human heart. The aim of the present study was to determine whether or not the beta3-isoform of the Na,K-ATPase can be detected in human heart. Using the highly sensitive method of RT-PCR, we here show that human heart expresses the beta3-isoform of the Na,K-ATPase. Given the differences in pharmacological properties of the nine different Na,K-ATPase isoenzymes (containing all combinations of the subunit isoforms), the study of beta3-isoform regulation in human heart may be of interest in understanding the altered response of human myocardium to digitalis therapy during heart failure.     

DICUMAROL AND QUINIDINE IN THE AMBULATORY TREATMENT OF CHRONIC AURICULAR FIBRILLATION

Thirty-three patients with chronic auricular fibrillation were treated with digitalis and quinidine and in addition were given Dicumarol® to reduce the risk of embolism. In 21 of the patients the fibrillation was caused by rheumatic heart disease, and in 12 by arteriosclerosis or hypertension. Normal sinus rhythm was restored in 55 per cent of the 33 patients, in 67 per cent of those with arteriosclerosis or hypertension, and in 45 per cent of those with rheumatic heart disease. Embolism did not occur.     

磷酸肌酸钠注射液治疗高龄多病因心力衰竭患者疗效分析

目的：观察磷酸肌酸钠注射液治疗≧80 岁高龄多病因心力衰竭患者的疗效。方法：≧80 岁高龄多病因心力衰竭患者115 例,随机分为治疗组58 例,对照组57 例。对照组给予常规抗心衰治疗,治疗组在此基础上加用磷酸肌酸钠注射液,观察两组治疗 前后NYHA心功能分级、血浆NT-proBNP 水平,磷酸肌酸钠注射液相关不良反应发生率并监测治疗前后的肝肾功能等指标。结 果：治疗5 天后治疗组总有效率显著高于对照组（P<0.05）,血浆NT-proBNP 含量显著低于对照组（P<0.05）,需加用洋地黄类强心 药物的患者人数显著低于对照组（P<0.05）;治疗14天后两组各指标均有显著改善,总有效率、血浆NT-proBNP 下降幅度无明显 区别。结论：常规抗心衰治疗基础上加用磷酸肌酸钠注射液能够更快改善≧80 岁高龄多病因心力衰竭患者症状,安全有效。     

运动康复锻炼对冠心病经皮冠状动脉介入术后患者心肺功能及生活质量的影响

目的:探讨运动康复锻炼对冠心病经皮冠状动脉介入术(PCI)后患者心肺功能及生活质量的影响。方法:选取2016年10月-2018年4月期间我院收治的冠心病稳定性心绞痛患者80例,根据随机数字表法将患者分为对照组(n=40)和运动康复组(n=40),其中对照组给予常规康复运动,运动康复组在此基础上联合运动康复训练。比较两组患者术后12周的心肺功能指标,比较两组患者术前、术后2周、术后12周的6 min步行距离,比较两组患者术前、术后12周生活质量评分。结果:运动康复组患者术后12周峰值摄氧量、峰值通气量、峰值功率、每搏输出量、代谢当量以及摄氧效率斜率均高于对照组患者(P0.05)。两组患者术后2周、术后12周6 min步行距离均较术前增加,且运动康复组高于对照组(P0.05)。两组患者术后12周生理机能、生理职能、躯体疼痛、精神健康评分均较术前升高,且运动康复组高于对照组(P0.05);而两组患者术后12周社会功能、总体健康、精力、情感职能评分比较差异无统计学意义(P0.05)。结论:PCI术后患者给予运动康复锻炼,可显著提升患者生活质量,对患者心肺功能恢复具有较好的促进作用。