选择性矫治左心室流出道来修复主动脉弓中断伴室间隔缺损:矫治左心室流出道梗阻

Objective: Left ventricular outflow tract obstruction remains an early and lat e complication after repair of interrupted aortic arch and ventricular septal de fect. We reviewed our experience with the selective management of the infundibul ar septum during primary repair to address left ventricular outflow tract obstru ction. Methods: From 1991 through 2001, all 27 patients presenting with interrup ted aortic arch/ventricular septal defect and posterior deviation of the infundi bular septum were analyzed. Fifteen patients with the smallest subaortic areas u nderwent myectomy or myotomy of the infundibular septum concomitant with interru pted aortic arch/ventricular septal defect repair. Results: Patients undergoing myectomy-myotomy(Group I) had significantly smaller subaortic diameter indexes( 0.83±0.16 cm/m2) when compared with those who had only interrupted aortic arch/ ventricular septal defect repair(group 2: 0.99±0.13 cm/m2, P=.012). Two hospita l deaths occurred in group 1, and 1 occurred in group 2. No late deaths occurred . No patient in group 2 required reoperation. Six group 1 patients required 9 re operations for left ventricular outflow tract obstruction. Five patients underwe nt resection of a new subaortic membrane. Only 1 patient had recurrent muscular left ventricular outflow tract obstruction. Three patients required a second reo peration, primarily related to aortic valve stenosis. Conclusions: Interrupted a ortic arch/ventricular septal defect with posterior malalignment of the infundib ular septum can be repaired with low mortality in the neonatal period. Tailored to the degree of subaortic narrowing, resection or incision of the infundibular septum at the time of primary repair was very effective in preventing or prolong ing the interval to recurrent left ventricular outflow tract obstruction compare d with the published data. However, reoperation for left ventricular outflow tra ct obstruction, often related to the development of a new and discrete subaortic membrane or valvar stenosis, is still required in a subset of patients.

以镁作为心脏外科手术中的神经保护因子:一项随机临床试验

Objective: We sought to evaluate magnesium as a neuroprotectant in patients un dergoing cardiac surgery with cardiopulmonary bypass. Methods: From February 200 2 to September 2003, 350 patients undergoing elective coronary artery bypass gra fting, valve surgery, or both were enrolled in a randomized, blinded, placebo-c ontrolled trial to receive either magnesium sulfate to increase plasma levels 1( 1/2) to 2 times normal during cardiopulmonary bypass(n=174) or no intervention(n =176). Neurologic function, neuropsychologic function, and depression were asses sed preoperatively,at 24 and 96 hours after extubation(neurologic) and at 3 mont hs(neuropsychologic, depression). Neurologic scores were analyzed using ordinal longitudinal methods, and neuropsychologic and depression inventory data were su mmarized by principal component analysis, followed by linear regression analysis using component scores as response variables. Results: Seven(2%) patients had a postoperative stroke, 2(1%) in the magnesium and 5(3%) in the placebo group( P=.4). Neurologic score was worse postoperatively in both groups(P< .0001); howe ver, magnesium group patients performed better than placebo group patients(P=.00 01), who had prolonged declines in short-term memory and reemergence of primiti ve reflexes. Three-month neuropsychologic performance and depression inventory score were generally better than preoperatively, with few differences between gr oups(P > .6); however, older age(P=.0006), previous stroke(P=.003), and lower ed ucation level(P=.0007) were associated with worse performance. Conclusions: Magn esium administration is safe and improves short-term postoperative neurologic f unction after cardiac surgery, particularly in preserving short-term memory and cortical control over brainstem functions. However, by 3 months, other factors and not administration of magnesium influence neuropsychologic and depression in ventory performance.

一种预测先兆子痫的联合方法:同步进行子宫灌注测量和心率、血压变异性分析

Objective: Pre-eclampsia is a serious complication of pregnancy with high mor bidity and mortality and an incidence of 3-5%in all pregnancies. Early predict ion is still insufficient in clinical practice. Although most pre-eclamptic pat ients have pathological uterine perfusion in the second trimester, perfusion dis turbance has a positive predictive accuracy(PPA) only of approximately 30%. Met hods: Non-invasive continuous blood pressure recordings were taken simultaneous ly via a finger cuff for 30 min. Time series of systolic as well as diastolic be at-to-beat pressure values were extracted to analyse heart rate and blood pres sure variability and baroreflex sensitivity in 102 second-trimester pregnancies , to assess predictability for pre-eclampsia(n=16). All women underwent Doppler investigations of the uterine arteries. Results: We identified a combination of three variability and baroreflex parameters to best predict pre-eclampsia seve ral weeks before clinical manifestation. The discriminant function of these thre e parameters classified patients with later pre-eclampsia with a sensitivity of 87.5%, a specificity of 83.7%, and a PPA of 50.0%. Combined with Doppler inv estigations of uterine arteries, PPA increased to 71.4%. Conclusions: This tech nique of incorporating onestop clinical assessment of uterine perfusion and vari ability parameters in the second trimester produces the most effective predictio n of pre-eclampsia to date.

对吸烟的交感神经反应具有年龄依赖性

Objective: Smoking is an important risk factor for cardiovascular disease. Sym pathetic responses to cigarette smoking may be implicated in the link between sm oking and cardiovascular disease. We tested the hypothesis that the sympathetic neural responses to smoking are age dependent. Methods: We examined the effects of cigarette smoking and sham smoking on muscle sympathetic nerve activity, bloo d pressure and heart rate in 14 normotensive middle-aged(49±4 years) and 12 yo ung(29±4 years) habitual smokers matched for body mass index(25±2 kg/m2 in bot h groups). Results: Sham smoking had no significant effect on sympathetic drive, blood pressure or heart rate in either group. Cigarette smoking increased heart rate in both middle-aged subjects and young subjects. In comparison to younger subjects, middle-aged smokers showed similar smoking-related increases in sys tolic blood pressure(SBP)[10±3 versus 12±2 mmHg, respectively, not significant (NS)]. Smoking decreased sympathetic nerve activity by 28±12%of baseline value s(P< 0.01) in young subjects. However, muscle sympathetic nerve activity did not change significantly after smoking in middle-aged subjects(5±8%, NS), despit e the increased blood pressures, which would be expected to inhibit sympathetic activity. By contrast, in young subjects, the heart rate increase(22±2 bpm) was greater than that seen in middle-aged subjects(13±2 bpm, P< 0.01). Conclusion s: The autonomic responses to smoking are age dependent. While blood pressure in creases are similar in both groups, young subjects respond to smoking by marked increases in heart rate and suppression of central sympathetic outflow. In middl e-aged subjects, the heart rate increase is less marked, but sympathetic vasoco nstrictor activity is not suppressed.

Cheatham覆膜铂金支架用于治疗主动脉缩窄:早期和中期结果

OBJECTIVES: This study sought to evaluate the use of covered Cheatham-platinu m(CP) stents in the treatment of aortic coarctation(CoA). BACKGROUND: Aortic ane urysms and stent fractures have been encountered after surgical and transcathete r treatment for CoA. Covered stents have previously been used in the treatment o f abdominal and thoracic aneurysms in adults. We implanted covered CP stents as a rescue treatment in patients with CoA aneurysms or previous stent-related com plications and in patients at risk of developing complications because of comple x CoA anatomy or advanced age. METHODS: Thirtythree covered CP stents were impla nted in 30 patients; 16 patients had had previous procedures. The remaining pati ents had complex or near-atretic CoA. RESULTS: The mean patient age and weight were 28(±17.5) years(range 8 to 65 years), and 62(±13) kg(range 28 to 86 kg), respectively. The systolic gradient across the CoA decreased from a mean(±SD) o f 36±20 mm Hg before to a mean of 4±4 mmHg after the procedure(p< 0.0001), and the diameter of the CoA increased from 6.4±3.8 mm to 17.1±3.1 mm(p< 0.0001). The follow-up period was up to 40 months(mean, 11 months). All stents were pate nt and in good position on computed tomography or magnetic resonance imaging per formed three to six months later. In 43%of the patients antihypertensive medica tion was either decreased or stopped. CONCLUSIONS: Covered CP stents may be used as the therapy of choice in patients with complications after CoA repairs, wher eas they provide a safe alternative to conventional stenting in patients with se vere and complex CoA lesions or advanced age.