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一期手術治療主動脈縮窄合并升主動脈瘤一例

機器人輔助的微創冠狀動脈旁路移植術

目的介紹機器人輔助的微創冠狀動脈旁路移植手術. 方法應用da Vinci機器人系統取左乳內動脈,然后經左胸第2肋間小切口在體外循環下行冠狀動脈旁路移植術. 結果本組34例患者無圍術期死亡和心肌梗死;術后有4例發生低心排血量綜合征,2例發生急性腎功能不全. 結論機器人輔助的微創冠狀動脈旁路移植術是一種安全可靠的手術方法,可以減輕術后疼痛和促進術后恢復.

烏司他丁在深低溫停循環主動脈手術中的肺保護作用

摘要： 目的 探討烏司他丁對深低溫停循環(DHCA)主動脈手術患者的肺保護作用。 方法 將2006年6月至2008年6月，25例在DHCA下行主動脈手術患者隨機分為兩組，烏司他丁組(n=14)：男11例，女3例；平均年齡52.21歲；停循環前給予烏司他丁20 000 U/kg；對照組(n=11)：男7例，女4例；平均年齡5682歲；常規DHCA手術。比較兩組在DHCA前、DHCA結束、結束后6 h和12 h的肺功能指標和靜脈血腫瘤壞死因子α(TNF-α)含量；同時觀察兩組呼吸機輔助呼吸時間、急性呼吸窘迫綜合征（ARDS）、二次氣管內插管、氣管切開等情況。 結果 對照組圍術期因大出血死亡1例（4.0%）。烏司他丁組術后呼吸機輔助呼吸時間明顯短于對照組（23.21±9.96 h vs.57.81±55.00 h，Plt;0.05）。烏司他丁組術后發生ARDS 1例，無二次氣管內插管和氣管切開；對照組發生ARDS 2例，二次插管1例，氣管切開2例。DHCA結束后12 h烏司他丁組動態胸肺順應性（68.69±8.74 ml/cm H2O vs.46.18±11.54 ml/cm H2O）和氧合指數(331.78±35.45 mm Hg vs.281.73±45.32 mm Hg)高于對照組（Plt;0.05）；DHCA結束后12 h烏司他丁組氣道阻力［7.16±0.49 cm H2O/(L·s) vs.11.68±1.01 cm H2O/(L·s)］和肺泡動脈氧分壓差(147.98±32.84 mm Hg vs.216.45±23.41 mm Hg)低于對照組（Plt;0.05）；烏司他丁組靜脈血TNFα含量低于對照組(67.57±9.78 pg/ml vs.92.45±9.52 pg/ml，Plt;0.05）。 結論 烏司他丁對DHCA主動脈手術患者有一定的肺保護作用，能縮短術后呼吸機輔助呼吸時間。

Application of Sequential Noninvasive Ventilation in Weaning Patients off Mechanical Ventilation after Coronary Artery Bypass Grafting

Objective To investigate the application of sequential noninvasive ventilation (NIV) in weaning patients off mechanical ventilation after coronary artery bypass grafting (CABG). Methods From July 2007 to July 2009, 52 patients who underwent CABG with mechanical ventilation for no less than 24 hours and P/F Ratio lower than 150 mm Hg were divided into two groups with random number table. In the sequential NIV group (SNIV group), there were 19 patients including 16 males and 3 females whose ages were 69.26±8.10 years. In the prolonged mechanical ventilation group (PMV group), there were 33 patients including 28 males and 5 females whose ages were 70.06±7.09 years. Clinical data of these two groups were compared and the influence of NIV on the circulation and respiration of the patients were observed. Results The SNIV group weaned off mechanical ventilation earlier than the PMV group (26.46±3.66 h vs. 38.65±9.12 h, P=0.013). The SNIV group held shorter total ventilation time (29.26±21.56 h vs.54.45±86.57 h,P=0.016), ICU stay time (2.44±2.99 d vs. 4.89±7.42 d, P=0.028) and postoperative hospital time (10.82±4.31 d vs. 14.01±19.30 d, P=0.039) than the PMV group. Furthermore, the SNIV group had lower pneumonia rate (5.26% vs. 30.30%, P=0.033) and total postoperative complication rate (10.53% vs.45.45%, P=0.030) than the PMV group. However, there was no significant difference (Pgt;0.05) between the two groups in the successful weaning rate, repeated tracheal intubation rate, tracheotomy rate and mortality 30 days after operation. After NIV, SNIV group had no significant change in heart rate, central vein 〖CM(1585mm〗pressure, pulmonary arterial pressure and pulmonary arterial wedge pressure than the baseline value, while systolic pressure (129.66±19.11 mm Hg vs. 119.01±20.31 mm Hg, P=0.031), cardiacindex ［3.01±0.30 L/(min.m2) vs. 2.78±0.36 L/(min.m2), P=0.043］ and P/F Ratio (205.95±27.40 mm Hg vs. 141.33±9.98 mm Hg, P=0.001) were obviously elevated. Conclusion Sequential NIV is a effective and safe method to wean CABG patients off mechanical ventilation.

再次冠狀動脈旁路移植術一例

Coronary Artery Bypass Grafting in Senile Patients with Coronary Atherosclerotic Heart Disease

Objective\ To discuss the characteristics and experience of coronary artery bypass grafting in senile patients. Methods\ The operative techniques and postoperative management of coronary artery bypass grafting in 31 cases of patients with coronary atherosclerotic heart disease over 70 years old at our hospital were analyzed retrospectively. Results\ No operative death and no severe postoperative complications happened among this group. Conclusion\ Coronary artery bypass grafting for patients over 70 y...

MicroRNA-129 Promotes Cardiomyogenesis in Bone Marrow Mesenchymal Stem Cells

Objective To explore the induction of cardiomyogenesis of microRNA-129 （mir-129） in rat bone marrowmesenchymal stem cells （BM-MSCs） and its mechanism. Methods BM-MSCs were isolated from Sprague-Dawley rats and cultured in vitro. Overexpression of mir-129 or both mir-129 and glycogen synthase kinase-3β （GSK-3β） in BM-MSCs was produced with a lentiviral vector system. All the BM-MSCs were divided into four groups: control group （MSCs），Lentiviral vectors＋MSCs group （Lv-MSCs），mir-129 transfection group （mir-129-MSCs），and mir-129＋GSK-3βdouble transfection group （mir-129＋GSK-3β-MSCs）. Five-Azacytidine （5-Aza） （10 μmol/L） was used to induce BM-MSCsdifferentiation into cardiomyocytes. On the 1st，5 th，10 th，15 th and 20 th day after induction，realtime-PCR was performedto detect mRNA levels of GATA-4，Nkx2.5 and MEF-2C. On the 10 th，15 th and 20 th day after induction，Western blottingwas performed to examine expression levels of cTnI，Desmin，GSK-3β，phosphorylated β-catenin and dephosphorylated β-catenin. Results Compared with the control group，at respective time points，mRNA levels of cardiomyogenic genes and expression levels of cardiomyocyte-related proteins of mir-129 transfection group were significantly elevated，theexpression level of GSK-3β was significantly decreased，and the ratio of dephosphorylated/phosphorylated β-catenin was significantly elevated. When both mir-129 and GSK-3β were overexpressed in BM-MSCs，mRNA levels of cardiomyogenicgenes and expression levels of cardiomyocyte-related proteins were significantly lower than those of mir-129 transfection group，and the ratio of dephosphorylated/phosphorylated β-catenin was significantly decreased. Conclusion Overexpression of mir-129 can promote cardiomyogenesis of rat BM-MSCs possibly via inhibiting GSK-3β production and thus decreasing the inhibition of phosphorylation of β-catenin which then enters the nucleus and activates downstream signaling pathways that regulate cardiomyogenic differentiation of BM-MSCs.

左心瓣膜手術后重度三尖瓣反流的外科治療

目的 總結左心瓣膜手術后重度三尖瓣反流（TR）的外科治療經驗。 方法 回顧性分析自1999年2月至2009年12月上海交通大學醫學院附屬仁濟醫院31例左心瓣膜手術后重度TR患者的臨床資料，男3例，女28例；年齡35～60歲（38.4 ± 8.3歲）。 31例左心瓣膜手術后重度TR患者均合并心房顫動，有不同程度的右心功能不全表現，其中心功能分級（NYHA）Ⅱ級3例，Ⅲ級24例，Ⅳ級4例。所有患者接受了三尖瓣手術，其中18例采用CarpentierEdwards半硬環行三尖瓣成形術（TVP），13例采用生物瓣行三尖瓣置換術（TVR）。對上述患者術前、術后的臨床資料進行比較。 結果 圍術期死亡2例，均死于心力衰竭，以右心功能衰竭為主。29例生存患者術后無嚴重并發癥發生，均好轉出院。隨訪29例，隨訪時間3個月~9年（5.3±2.5年），隨訪期間均給予強心、利尿等治療。術后3個月患者心功能均有明顯改善（NYHA分級Ⅰ級3例，Ⅱ級19例，Ⅲ級5例，Ⅳ級2例）；超聲心動圖提示：TR明顯改善，右心房內徑（50.2±8.8 mm vs. 63.1±12.4 mm，P=0.005）、右心室內徑（28.3±7.1 mm vs. 35.7±8.2 mm，P=0.008）較術前明顯縮小。 結論 對左心瓣膜手術后重度TR患者，早期應積極地行外科手術治療；手術方式應根據患者三尖瓣的具體情況和手術者的經驗，以選擇置入半硬成形環的TVP為主，必要時采用生物瓣行TVR。但對有嚴重右心功能衰竭（NYHA分級Ⅳ級）患者需慎重選擇手術治療，應以內科保守治療為主。

Diagnosis and Treatment for Prosthetic Valve Endocarditis

Abstract: Objective To summarize the experiences of treatment for prosthetic valve endocarditis (PVE), paying special emphasis on some interrelated conceptions of PVE, its microbiology, diagnosis, prevention and treatment. Methods From September 1979 to September 2009, 33 patients diagnosed to have PVE were treated in our department. There were 17 males and 16 females. Their age ranged from 19 to 57 years old with an average age of 34 years. The incidence of PVE was 1.48% （33/2 236）including 1.03%（16/1 551）, 3.00%（7/233）, 2.28%（10/438）, and 0% of PVE in mitral valve replacement (MVR), aortic valve replacement (AVR), double valve replacement (DVR), tricuspid valve replacement (TVR), respectively. Pure medical treatment (Penicillin or Vancomycin with other broadspectrum antibiotics, Fluconazole and Amphotericin) was performed on 22 patients. Combined medical and surgical treatment was performed in 11 patients. The patients underwent operation after adequate antibiotics treatment and general condition improvement. The infective tissue and vegetation were completely debrided after the infective prosthetic valve was removed. Before the new valve was transplanted, paravalvular tissue was cleaned with antibiotics, iodine solution and normal saline. Results Hospital death occurred in 19 patients (86.36%) and only 3 patients (13.64%) recovered in the group with pure medical treatment. The main reasons for death were infective shock and cardiac failure in 9 patients, and cerebral complications including embolism, bleeding and multipleorgan failure in 10 patients. For the group with combined medical and surgical treatment, 10 patients (90.91%) survived and only one patient (9.09%) died of multipleorgan failure. Follow-up was done in 13 patients for 6 months to 15 years averaging 41 months. During the follow-up, only one patient was reoperated because of the paravalvular leak eight year later. There was no PVE recurrence in all the rest patients. Conclusion Compared with pure medical treatment, combined medical and surgical treatment is a better solution for PVE.

miR-190a-5p targeting the C/EBPα-PU.1 pathway promotes the polarization of bone-marrow-derived macrophages from M1-type to M2-type

ObjectiveTo investigate the effect of miR-190a-5p on the polarization of bone-marrow-derived macrophage (BMDM) induced by lipopolysaccharides to M1- and M2-types.MethodsBMDM (M1-type) induced by bacterial lipopolysaccharide was a M1 group. The macrophage M1-type interfered with negative control miRNA mimics was a NC group. miR-190a-5p mimics interfered with the M1-type of macrophages in the miR-190a-5p group. Morphological changes of macrophages were observed under a microscope, and the proportion of M2-type macrophages (CD206+, F4/80) was detected by flow cytometry. The mRNA expression levels of argininase-1 (Arg1), inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α), target gene C/EBPα and PU.1 were detected by fluorescence quantitative PCR to verify whether C/EBPα and PU.1 were potential target genes of miR-190a-5p. The expression of pathway proteins C/EBPα and PU.1 were detected by Western blotting.ResultsAfter miR-190a-5p mimics interfered with macrophage M1-type, the antenna of macrophages elongated and showed long cord M2-type cell morphological characteristics. miR-190a-5p mimics interfered with M1-type macrophages for 24 h, and the percentage of M2-type macrophages increased significantly (P<0.05). Effects of miR-190a-5p simulator on mRNA expression levels of M1-type macrophages included: the expression of iNOS and TNF-α was significantly decreased (P<0.05), the expression of Arg1 marked by M2 macrophages was significantly increased (P<0.05), and the mRNA expression levels of target genes C/EBPα and PU.1 were significantly decreased (P<0.05). Western blotting results showed that the overexpression of miR-190a-5p significantly inhibited the protein expressions of C/EBPα and PU.1, while the miR-190a-5p inhibitor increased the expressions of both proteins.ConclusionmiR-190a-5p can promote the polarization of BMDM from M1-type to M2-type.