【摘要】 目的 探討2型糖尿病（T2DM）胰島素抵抗導致糖尿病性心功能不全的臨床表現特點及相關激素的改變。 方法 2008年1-4月對T2DM患者35例（胰島素抵抗指數HOMA-IRlt;2.69者19例為A1組，HOMA-IR≥2.69者16例為A2組）及健康體檢者20人B組測體重指數（BMI）、空腹血糖（FPG）、胰島素、心鈉素（ANP）、腦鈉素（BNP）水平；心臟彩色多普勒超聲分別測E/A、e/a、S/D、LVEF、DT期。 結果 A2組BMI較A1、B組均明顯增加（Plt;0.05），A1、B組間差異無統計學意義（Pgt;0.05）。ANP、BNP及DT值在A1、A2組均較B組增高（Plt;0.05），BNP在A2組高于A1組（Plt;0.05），ANP、DT值在A1、A2組間差異均無統計學意義（Pgt;0.05）。E/A、e/a和S/D在A1、A2組均較B組降低（Plt;0.05），A1、A2組間差異均無統計學意義（Pgt;0.05）。A2組患者LVEF較A1、B組均明顯降低（Plt;0.05），A1、B組間差異無統計學意義（Pgt;0.05）。 結論 隨著胰島素抵抗加重，心肌舒張順應性較差和收縮力下降，伴隨相關激素（心臟利鈉肽）分泌增加，最終產生心功能不全的臨床表現、體征及多普勒超聲心動圖表現。【Abstract】 Objective To investigate the clinical features and related hormone changes of diabetic cardiac insufficiency leaded by insulin resistance in type 2 diabetes mellitus (T2DM). Methods From January to April 2008, 35 patients with T2DM (group A1: HOMA-IRlt;2.69, n=19; group A2: HOMA-IR≥ 2.69, n=16) and 20 subjects without T2DM (group B) were enrolled. The body mass index (BMI), fasting plasma glucose (FPG), insulin (FINS), atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and E/A, e/a, S/D, LVEF and DT stage of all subjects were detected. Results The BMI in group A2 was higher than those in group A1 and group B (Plt;0.05), while the difference between the later two groups was not statistically significant (Pgt;0.05). The ANP, BNP and DT stage were all higher than those in group B (Plt;0.05), the BNP was higher in group A2 than in group A1 (Plt;0.05), while the difference of neither ANP nor DT stage between the later two groups was statistically significant (Pgt;0.05). The values of E/A, e/a and S/D in group A1 and A2 were all lower than those in group B (Plt;0.05), while there were no statistically significant diferences between group A1 and A2 (Pgt;0.05). The values of LVEF of group A1 and A2 were both significantly reduced than that in group B (Plt;0.05), and the values in group A2 were the lowest (Plt;0.05). Conclusion With the aggravating of insulin resistance, myocardial contractility and diastolic function will decline, meanwhile the ANP and BNP secretion will increase, and then the clinical and echocardiographic manifestation will appear.
Objective To evaluate the cardiac protection function of high thoracic epidural anesthesia (HTEA) for patients with acute coronary syndrome or heart failure. Methods A literature search was conducted with computerized database on PubMed, EBSCO, Springer, Ovid, and CNKI from 1990 to May 2010. Further searches for articles were conducted by checking all references describing cardiac protection studies with HTEA. All included articles were assessed and data were extracted according to the standard of Cochrane review. The homogeneous studies were pooled using RevMan 4.2.10 software. Results A total of 28 articles involving 1 041 patients were included. The results of meta-analyses showed that, a) cardiac function: HTEA could significantly improve ejection fraction of left ventricle (WMD= –?10.28, 95%CI –?14.14 to –?6.43) and cardiac output (WMD= –?1.26, 95%CI –?1.63 to –?0.89), contract left ventricular diastolic dimension (WMD= 5.02, 95%CI 3.72 to 6.32), increase E peak (WMD= –?17.50, 95%CI –?29.40 to –?5.59) and decrease A peak (WMD= 27.36, 95%CI 24.46 to 30.26); b) ischemic degree for patients with heart failure: the change of NST-T (WMD= 1.45, 95%CI 1.12 to 1.78) and ∑ST-T (WMD= 1.02, 95%CI 0.78 to 1.26) got significantly decreased after HTEA; c) ischemic degree for patients with acute coronary syndrome: HTEA could obviously lessen the times (WMD= 4.24, 95%CI 0.48 to 8.00) and duration (WMD= 23.29, 95%CI 4.66 to 42.11) of myocardial ischemia, decrease the times of heart attack (WMD= 3.44, 95%CI 0.92 to 5.97), and decrease the change of NST-T (WMD= 1.10, 95%CI 0.84 to 1.36) and ∑ST-T (WMD= 1.33, 95%CI 1.01 to 1.65); d) hemodynamic change for patients with acute coronary syndrome: HTEA could obviously decrease heart beat (WMD= 8.44, 95%CI 3.81 to 13.07) and systolic arterial pressure (WMD= 2.07, 95%CI 0.81 to 3.34), but not decrease the diastolic blood pressure (WMD= 2.06, 95%CI –?0.52 to 4.64) so as to avoid influencing the infusion of coronary artery; and e) influence on Q-T interval dispersion: HTEA could significantly decrease Q-Td (WMD= 9.51, 95%CI 4.74 to 14.27), Q-Tcd (WMD= 11.82, 95%CI 5.55 to 18.09), and J-Td (WMD= 9.04, 95%CI 2.30 to 15.79). Conclusions High thoracic epidural anesthesia can obviously improve the systolic and diastolic function of left ventricle, decrease the heart beat and stabilize hemodynamic change, lessen the times and duration for myocardial ischemia, reserve the ST segment change, contract Q-T interval dispersion, which has to be further proved with more high quality studies.
Objective To compare the clinical efficacy and safety of thrombolysis with anticoagulation therapy for patients with acute sub-massive pulmonary thromboembolism. Methods The clinical data of 84 patients with acute sub-massive pulmonary thromboembolism were analyzed retrospectively, mainly focusing on the in-hospital efficacy and safety of thrombolysis and/ or anticoagulation. The efficacy was evaluated based on 6 grades: cured, markedly improved, improved, not changed, deteriorated and died. Results Among the 84 patients,49 patients received thrombolysis and sequential anticoagulation therapy( thrombolysis group) , 35 patients received anticoagulation therapy alone( anticoagulation group) . As compared with the anticoagulation group, the thrombolysis group had higher effective rate( defined as patients who were cured, markedly improved or improved, 81. 6% versus 54. 3%, P = 0. 007) , lower critical event occurrence ( defined as clinical condition deteriorated or died, 2. 0% versus 14. 3% , P = 0. 032) . There was no significant difference in bleeding rates between the two groups ( thrombolysis group 20. 4% versus anticoagulation group 14. 3% , P gt; 0. 05) . No major bleeding or intracranial hemorrhage occurred in any of the patients. Conclusions Thrombolysis therapy may be more effective than anticoagulation therapy alone in patients with acute sub-massive pulmonary thromboembolism, and thus warrants further prospective randomized control study in large population.
ObjectiveTo analyze the early outcomes of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) patients with severe left ventricular dysfunction after surgical repair, and to explore the predictors for extracorporeal membrane oxygenation (ECMO) support for these patients.MethodsThe clinical data of ALCAPA patients with severe left ventricular dysfunction (left ventricular ejection fraction<40%) who underwent coronary artery reimplantation in the pediatric center of our hospital from 2013 to 2020 were retrospectively analyzed. The patients were divided into an ECMO group and a non-ECMO group. Clinical data of the two groups were compared and analyzed.ResultsA total of 64 ALCAPA patients were included. There were 7 patients in the ECMO group, including 4 males and 3 females aged 6.58±1.84 months. There were 57 pateints in the non-ECMO group, including 30 males and 27 females aged 4.34±2.56 months. The mortality of the patients was 6.25% (4/64), including 2 patients in the ECMO group, and 2 in the non-ECMO group. The postoperative complications rate was significantly higher in the ECMO group than that in the non-ECMO group (P=0.041). There were statistical differences in the cardiopulmonary bypass time [254 (153, 417) min vs. 106 (51, 192) min, P=0.013], aortic cross-clamping (ACC) time (89.57±13.66 min vs. 61.58±19.57 min, P=0.039), and preoperative left ventricular end-diastolic diameter/body surface area (132.32±14.71 mm/m2 vs. 108.00±29.64 mm/m2, P=0.040) between the two groups. Multivariate logistic regression analysis showed that ACC time was an independent risk factor for postoperative ECMO support (P=0.005). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve was 0.757, the sensitivity was 85.70%, specificity was 66.70%, with the cut-off value of 66 min.ConclusionACC time is an independent risk factor for postoperative ECMO support. Patients with an ACC time>66 min have a significantly higher risk for ECMO support after the surgery.
Objective To systematically review whether the prevalence of left ventricular diastolic dysfunction was higher in systemic sclerosis (SSc) patients. Methods The Cochrane Library, PubMed, EMbase, CBM, CNKI and WanFang Data databases were electronically searched to collect the studies about comparing echocardiographic parameters in SSc patients and controls from January 1990 to June 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software. Results A total of 22 studies involving 1 146 patients were included. The results of meta-analysis showed that: compared to controls, patients with SSc had prolonged left isovolumetric relaxation time (MD=10.40, 95%CI 4.04 to 16.77, P=0.001), higher trans-mitral A-wave velocity (MD=0.11, 95%CI 0.07 to 0.15, P<0.000 01), prolonged mitral deceleration time (MD=8.04, 95%CI 2.66 to 13.42,P=0.003), larger mean left atrial dimension (MD=1.43, 95%CI 0.11 to 2.76, P=0.03), higher estimated pulmonary artery pressure (MD=11.35, 95%CI 6.08 to 16.6, P<0.001), higher E/E’ ratio (MD=2.08, 95%CI 0.19 to 3.96,P=0.03) and lower trans-mitral E-wave velocity (MD=–0.03, 95%CI –0.05 to –0.01, P=0.000 3), mitral E/A ratio (MD=–0.24, 95%CI –0.32 to –0.15, P<0.000 01) and trans-mitral E’-wave velocity (MD=–1.52, 95%CI –2.44 to –0.60,P=0.001). There were no differences in left ventricular ejection fraction, isovolumetric end-systolic dimension, septal end-diastolic thickness and posterior wall end-diastolic thickness, trans-mitral A’-wave velocity, E’/A’ ratio. Conclusion SSc patients are more likely to have echocardiographic parameters of LVDD. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify above conclusion.
Objective To analyze the clinical features of patients with acute pulmonary embolism ( APE) with normal blood pressure and right ventricular dysfunction. Methods 130 hospitalized patients with normotensive APE between January 2009 and January 2012 were retrospectively analyzed. The patients underwent transthoracic echocardiography to determine if they were complicated with RVD. The clinical features, risk factors, diagnosis, and treatment were analyzed and compared between the normotensive APE patients with or without RVD. Results 41 normotensive APE patients with RVD were as RVD group, and other 89 patients without RVD were as non-RVD group. The incidences of syncope ( 34.1% vs. 7.8% ) , tachycardia( 41.4% vs. 21.3% ) , P2 hyperthyroidism( 46.3% vs. 25.8% ) , jugular vein filling ( 12.1% vs. 1.1% ) , and cyanosis ( 26.8% vs. 8.9% ) were all significantly higher in the RVD group than those in the non-RVD group ( P lt; 0.05) . Computed tomography pulmonary angiography ( CTPA) revealed that the incidences of thromboembolism involving proximal pulmonary artery ( 58. 3% vs. 8. 3% ) and thromboembolism involving lobar pulmonary ( 77.8% vs.51.2% ) were also higher in the RVD group ( P lt; 0.001, P = 0.025 ) . In the RVD group, the patients were assigned to received thrombolysis plus anticoagulation therapy, or anticoagulation therapy alone. The clinical indicators ( heart rate, PaCO2 , AaDO2 , SPAP, TRPG) were all statistically improved after thrombolysis or anticoagulation treatment ( P lt;0.001) . But compared with the patients who underwent anticoagulation therapy alone, the cost of treatment and the incidence of minor bleeding were significantly higher, and the levels of AaDO2 , SPAP and TRPG were statistically lower in the patients with thrombolysis plus anticoagulation therapy. Conclusions For APE patients with central pulmonary embolism demonstrated by CTPA, syncope, and tachycardia, transthoracic echocardiograph should be performed as early as possible to confirm RVD diagnosis. For normotensive APE patients with RVD, anticoagulant treatment can achieve higher efficacy of costeffectiveness ratio.
Objective To explore and compare the diagnostic value of blood pressure, brain natriuretic peptide (BNP), pulmonary artery systolic pressure (PASP) in evaluating right ventricular dysfunction (RVD) in patients with acute pulmonary embolism (APE). Methods A retrospective study was conducted on 84 APE patients who were diagnosed by computed tomographic pulmonary angiography. The patients were divided into a RVD group and a non-RVD group by echocardiography. Eighteen clinical and auxiliary examination variables were used as the research factors and RVD as the related factor. The relationship between these research factors and RVD were evaluated by logistic regression model, the diagnostic value of BNP and PASP to predict RVD was analyzed by receiver-operating characteristic (ROC) curve analysis. Results The patients with RVD had more rapid heart rate, higher diastolic blood pressure, higher mean arterial pressure, higher incidence of BNP>100 pg/ml and higher incidence of PASP>40 mm Hg (allP<0 05="" upon="" logistic="" regression="" model="" bnp="">100 pg/ml (OR=4.904, 95%CI 1.431–16.806, P=0.011) and PASP>40 mm Hg (OR=6.415, 95%CI 1.509–27.261, P=0.012) were independent predictors of RVD. The areas under the ROC curve to predict RVD were 0.823 (95%CI 0.729–0.917) for BNP, and 0.798 (95%CI 0.700–0.896) for PASP. Conclusions Blood pressure related parameters can not serve as a predictor of RVD. Combined monitoring of BNP level and PASP is helpful for accurate prediction of RVD in patients with APE.
ObjectiveTo investigate the perioperative change of parathyroid hormone (PTH) and its effect on cardiac function in patients with rheumatic heart disease.MethodsFrom January 2018 to June 2019, 76 patients were randomly divided into calcium supplement group (n=39) and control group (n=37). Mitral valve replacement was performed in both groups with cardiopulmonary bypass (CPB). Blood gas was measured immediately and every 6 h within 24 h after CPB. The patients in the calcium supplement group were given 1 g of calcium gluconate when hypocalcemia occurred, while the control group received no calcium supplementation. Values of radial arterial blood PTH and calcium ion (Ca2+) were measured in the two groups before operation (T1), at 30 min after starting CPB (T2), immediately after stopping CPB (T3), at 24 h after operation (T4), and at 48 h after operation (T5), respectively.ResultsThere were 71 patients enrolled in this study finally, including 38 in the calcium supplement group and 33 in the control group. The PTH values of patients in the two groups gradually increased, reached the peak at T3 time-point, then began to recover gradually. There was no significant difference between the two groups at T1, T2 or T3 time-point (P>0.05), while there were significant differences at T4 and T5 time-points (P<0.05). The Ca2+ values of the two groups gradually decreased after CPB, and gradually increased after blood ultrafiltration. There was no significant difference between the two groups at T1 or T3 time-point (P>0.05), while there were significant differences at T2, T4 and T5 time-points (P<0.05). The postoperative 24-hour values of ejection fraction (EF) and cardiac troponin T (cTnT) and the 72-hour total amount of epinephrine used in the calcium supplement group were (42.66±4.18)%, (1 881.17±745.71) ng/L, and (3.04±0.86) mg, respectively, and those in the control group were (40.76±3.39)%, (2 725.30±1 062.50) ng/L, and (4.69±1.37) mg, respectively. There were statistically significant differences in EF, cTnT and the 72-hour total amount of epinephrine used between the two groups (P<0.05). Values of PTH at T4 and T5 time-points were respectively negatively correlated with postoperative 24-hour value of EF (r=-0.324, P=0.006; r=-0.359, P=0.002), positively correlated with postoperative 24-hour value of cTnT (r=0.238, P=0.046; r=0.248, P=0.037) and the 72-hour total amount of epinephrine used (r=0.324, P=0.006; r=0.383, P=0.001).ConclusionsHyperparathyroidism occures after CPB, and calcium supplementation could relieve the hyperparathyroidism. Hyperparathyroidism may be related to postoperative cardiac insufficiency.
Objective To investigate clinical outcomes of one and a half ventricle repair for acute right ventricular dysfunction after biventricular repair. Methods Clinical data of 5 pediatric patients with congenital heart diseases who underwent emergency bidirectional Glenn shunt without cardiopulmonary bypass for acute right ventricular dysfunction after biventricular repair，converting the operation into one and a half ventricle repair，from February 2007 to June 2012 in Qingdao Women and Children Hospital were retrospectively analyzed. There were 4 male patients and 1 female patient with their age of 7-18 months and body weight of 6-13 kg. Preoperative diagnosis included pulmonary atresia with intact ventricular septum （PA/IVS） in 1 patient，tricuspid stenosis （TS） with ventricular septal defect （VSD） and atrial septal defect （ASD） in 2 patients，and tricuspid stenosis with tetralogy of Fallot （TOF） in 2 patients. Postoperative care focused on cardiopulmonary support and control of pulmonary artery pressure. Results Mean pulmonary artery pressure （mPAP） was 12-18 mm Hg at 72 hours after emergency bidirectional Glenn shunt. Mechanical ventilation time was 3-182 hours and ICU stay was 2-13 days. Postoperatively 1 patient died of pulmonary hypertension crisis. The other 4 patients were discharged with their transcutaneous oxygen saturation in the resting state of 93%-99%，which was improved in different degrees compared with preoperative value. These 4 patients were followed up from 6 months to 4 years. Three patients were in NYHA classⅠand 1 patient was in NYHA class Ⅱ during follow-up. Echocardiography showed smooth vena cava to pulmonary artery anastomosis without thrombosis formation. Conclusion One and a half ventricle repair can be used as an adjunct surgical strategy for acute right ventricular dysfunction after biventricular repair.