腰椎滑脱症是由于先天或后天的各种因素导致的腰椎上位椎体相对于下位椎体部分或全部滑移, 是一种腰椎不稳的表现,其临床症状主要表现为下腰痛,可伴有神经根痛或间歇性跛行[1] 。腰椎滑脱症在骨科疾病的发生率为5%,其中约1/5 的患者需行手术治疗[2] 。目前,对于腰椎滑脱症患者的治疗方式较多且争议较大,因此本文就腰椎滑脱症患者近年来的手术治疗进展综述如下。

目的 观察体外膜氧合器(ECMO)辅助下经皮冠状动脉介入治疗(PCI)用于高危复杂冠心病(CHD)的价值.方法 回顾性分析48例接受ECMO辅助下PCI的高危复杂CHD患者,收集其临床资料、ECMO辅助情况、PCI情况、住院期间病情变化及随访资料,观察ECMO辅助下PCI治疗高危复杂CHD的价值.结果 ECMO辅助时间0.50～3.55 h,平均(1.57±0.65)h;对46例成功完成PCI,2例因导丝、球囊通过困难而转至心脏外科行冠状动脉旁路移植术(CABG)治疗.46例PCI成功患者中,术后肺部感染4例,脑梗死2例,输血治疗2例,支架内急性血栓形成1例,切口感染1例,腹股沟血肿1例,急性心肌梗死1例.其中4例院内死亡,包括1例术后24 h内支架内急性血栓形成、1例术后第10日急性心肌梗死导致心源性休克、2例术后1周肺部感染并发感染性休克,42例出院.随访过程中2例失访,共对40例随访35.5(6,72)个月,期间5例死于其他疾患,35例病情获得改善.结论 ECMO辅助下PCI治疗高危复杂CHD安全、可行.

[目的]探讨老年人腰椎间盘突出症(lumbar disc herniation,LDH)的临床特点,以及开放减压椎间盘切除的临床效果.[方法]1995年12月—2005年12月,共60例60岁以上LDH患者纳入本研究,单项合并病为50.00％(30/60),多种合并病为41.66％(25/60).均行开放减压椎间盘切除,在保证充分减压的前提下,尽量保留骨性结构.[结果]所有患者均顺利完成手术,术中无死亡,无血管和神经损伤;手术见合并腰椎管狭窄56例,占93.33％.术后8例(13.33％)患者出现谵妄等神志异常,经相应处理,均于4 d内恢复.随访6个月～8年,4例患者死于与手术无关的疾病.随时间推移,VAS和ODI评分显著下降(P＜0.05),而JOA评分显著增加(P＜0.05).末次随访时,47完全无痛,恢复病前生活能力,9例患者活动时有不适,生活质量未恢复至病前水平.[结论]老年LDH临床表现不典型,多合并内科病,局部多伴椎管狭窄或脊柱畸形.开放减压椎间盘切除术可取得满意临床效果.

目的 评价PCI对于老年无保护左主干病变合并心力衰竭(心衰)患者的临床疗效和远期预后.方法 选择2016年1月～2019年1月解放军总医院第六医学中心心内科行PCI的老年无保护左主干病变冠心病患者99例,依据术前LVEF分为心衰组44例(LVEF≤50％),心功能正常组55例(LVEF＞50％).收集2组住院各项指标、PCI情况及随访1年结果,分析PCI对患者疗效和远期预后.结果 心衰组高血压、左主干+3支病变、SYNTAX评分、支架总长度明显高于心功能正常组[56.8％vs 34.5％,P＜0.05;43.2％vs 23.6％,P＜0.05;(30.43±5.22)分 vs(26.37±4.91)分,P＜0.01;(41.33±15.35)mm vs(32.86±17.81)mm,P＜0.05].心衰组术后 1 年全因病死率明显高于心功能正常组,有统计学差异(P＜0.05).心衰组术后1年LVEF明显高于术前[(44.83±10.94)％vs(38.35±11.38)％,P＜0.05],B型钠尿肽水平明显低于术前[(1375.76±534.43)ng/L vs(2835.35±898.78)ng/L,P＜0.05].结论 内科PCI可以在患者不愿或不能耐受冠状动脉旁路移植术情况下,作为老年无保护左主干病变合并心衰患者再血管化的一项重要手段.

目的 探讨胸主动脉腔内修复术(TEVAR)后持续疼痛对B型主动脉夹层患者中长期预后的影响.方法 回顾性分析2012年1月至2016年12月解放军总医院第六医学中心连续收治并进行TEVAR的B型主动脉夹层患者的临床资料32例,并进行随访.按照术后是否出现疼痛分为疼痛组和非疼痛组.结果 30例患者完成了平均5.25年随访,疼痛组13例,非疼痛组17例.两组患者的性别、年龄、合并疾病、住院天数、住院费用及发病至手术间隔时间比较,差异均无统计学意义(均P>0.05).疼痛组手术所用时间短于非疼痛组[(83.46±10.37)min比(92.59±9.36)min,P=0.017],支架平均直径大于非疼痛组[(37.62±3.93)mm比(33.35±2.50)mm,P=0.001],差异均有统计学意义.疼痛组患者支架平均长度虽较非疼痛组偏长,但差异无统计学意义[(183.38±31.25)mm比(172.00±28.10)mm,P=0.304].疼痛组死亡1例,再发夹层1例;非疼痛组死亡2例,再发夹层1例,再次介入治疗1例.疼痛组与非疼痛组患者复合终点事件发生率比较,差异无统计学意义[2(2/13)比4(4/17),P=0.655].结论 尚无法得出TEVAR术后持续疼痛对B型主动脉夹层长期预后是否产生不利影响.

目的 探讨性别对老年急性心肌梗死(AMI)患者住院病死率的影响.方法 选择在解放军总医院第六医学中心心血管内科住院的老年AMI患者605例,男性382例,女性223例,收集入选者基线资料、院内结局等临床资料,以院内死亡为终点构建多因素logistic回归模型.结果 老年AMI患者住院病死率为9.1％.女性住院心源性死亡、高血压、糖尿病、甲状腺功能减退比例明显高于男性,血红蛋白、血肌酐、血尿酸、估算肾小球滤过率(eGFR)水平明显低于男性,TG、TC、LDL-C、HDL-C、随机血糖水平明显高于男性(P＜0.05,P＜0.01).性别、年龄、KillipⅢ～Ⅳ级、血钾＞5.5 mmol/L、血钾＜3.5 mmol/L、血尿酸＞357 μmol/L、eGFR＜60 ml/(min·1.73 m2)、PCI及冠状动脉旁路移植术为老年AMI患者院内心源性死亡的独立危险因素(P＜0.05,P＜0.01).ST段抬高型心肌梗死、血运重建是影响老年女性AMI患者院内死亡的独立危险因素(95 ％CI:1.037～13.914,P=0.044;95％CI :0.058～0.708,P=0.012).结论 性别是影响老年AMI患者住院病死率的独立危险因素.

目的 分析年龄≥60岁女性左主干病变血运重建患者5年生存情况.方法 收集解放军总医院第六医学中心2013年1月～2015年12月收治的年龄≥60岁连续女性左主干病变患者46例,根据血运重建方法分为PCI组14例和冠状动脉旁路移植术(CABG)组32例,收集入选者一般临床资料,观察主要不良心血管事件(MACE)发生情况.结果 PCI组2例死亡,1例因脑梗死卧床,3例偶有心悸、胸闷,口服药物好转,不影响日常生活.CABG组2例失访,3例随访到2018年,3例术后院内死亡,1例随访期间乳腺癌死亡,1例术后5年行PCI.PCI组与CABG组MACE发生率及生存时间比较,无统计学差异[21.4％ vs 20.0％,P=0.955;(75.3±3.1)个月vs (81.2±5.5)个月,P=0.974].结论 对于左主干病变患者,CABG仍是首选的血运重建方式,对于经过选择的老年女性左主干病变患者,PCI是一种可接受的血运重建方式.

目的 比较国产雷帕霉素与依维莫司或佐他莫司药物洗脱支架治疗冠状动脉左主干开口及体部病变的效果.方法 选取本院2014年5月～2015年12月收治的44例冠状动脉左主干开口及体部病变行药物洗脱支架介入治疗的患者作为研究对象,按支架的类型分为国产雷帕霉素药物洗脱支架组(雷帕霉素支架组,FIREWARK、NANO)16例和依维莫司或佐他莫司药物洗脱支架组(依维莫司、佐他莫司支架组,Promus element、Xince V、Resolute)28例并随访观察.对比两组的心因性死亡(无明确的其他原因的死亡)情况,靶血管血运重建的事件发生率.结果 所有患者平均随访33个月,雷帕霉素支架组的事件发生率为6.25％,依维莫司、佐他莫司支架组的事件发生率为7.14％,两组的事件发生率比较,差异无统计学意义(x2=0.01,P=0.922).结论 国产雷帕霉素药物洗脱支架治疗左主干开口及体部病变的效果不劣于依维莫司或佐他莫司药物洗脱支架.

目的探讨体外膜肺氧合（ECMO）联合主动脉内球囊反搏（IABP）预防性应用于高危经皮冠状动脉介入治疗（HR-PCI）患者的短期临床疗效。方法选择2018年5–8月10例HRPCI患者,术中应用ECMO联合IABP循环支持。结果 10例患者中男性8例,女性2例,年龄51～84（70.3±11.1）岁,平均左心室射血分数（35.7±10.2）%。10例患者均为严重三支病变,左主干病变7例,其中合并右冠状动脉（RCA）慢性完全闭塞（CTO）病变5例,前降支CTO病变2例;剩余3例中2例为RCA和左前降支（LAD）近/中段CTO病变,1例为RCA CTO病变合并LAD/左回旋支（LCX）严重狭窄。在ECMO联合IABP支持下7例左主干病变中先处理左主干病变6例,1例处理了RAC CTO病变和LAD重度狭窄;剩余3例中2例RCA和LAD近/中段CTO病变均先处理了LAD CTO病变,另1例RCA CTO病变合并LAD/LCX严重病变患者先处理了RCA CTO病变。术中ECMO平均灌注流量（1.80±0.30）L/min,总运转时间（3.4±0.7）h。PCI平均手术时间（2.2±0.5）h。1例PCI术中发生血流动力学崩溃,ECMO灌注流量提高到3.0 L/min维持血流动力学,直到循环正常。术后所有患者ECMO均成功撤机。2例患者IABP穿刺部位血肿,其中1例术后发现假性动脉瘤;1例术后于ICU发生室性心动过速和心室颤动;无ECMO管道机械性问题、下肢缺血和感染并发症发生。结论对不适合行外科血管重建术的HR-PCI术患者,ECMO联合IABP循环支持下行PCI术是可行的。

Objective To assess the feasibility,safety and efficacy of primary PCI in elderly patients with AMI.Methods Three hundred and sixty-four AMI patients were divided into ≥75 years old group (n=90) and ＜75 years old group (n=274).The successful operation rate,preoperative complication rate,mortality and incidence of major adverse cardiovascular events (MACE) were recorded during their hospital stay time.Results The successful operation rate was 94.4％,the postoperative TIMI 3 blood flow rate was 87.8％,and the preoperative complication rate was 10.0 ％ in ≥75 years old group.The mortality and incidence of MACE were significantly higher in ≥75 years old group than in＜75 years old group during the hospital stay time (12.2％ vs 2.9％,P =0.001;16.7 ％ vs 5.1％,P =0.000).Conclusion Transradial primary PCI is a safe,feasible and effective therapy for ≥75 years old AMI patients.

Objective To assess the safety of PCI and risk of death in ≥85 years old patients.Methods Ninety ≥85 years old coronary heart disease patients after PCI were included in this study.The risk of death on day 30 after PCI and during the follow-up period was assessed according to their surgical access,preoperative and postoperative estimated glomerular filtration rate (eGFR) and bleeding events,NCDR risk score of CHD.The patients were followed up for 693±510 days.Results Eighty-four patients (93.3％) underwent PCI via the radial artery.The dose of contrast media was 128.3±55.8 ml.No significant difference was found in preoperative and postoperative eGFR (55.53 ± 19.58 ml/min · 1.73 m2 vs 55.40± 18.84 ml/min · 1.73 m2,t =0.095,P=0.925).Bleeding occurred in 4 patients (4.4％) with no life-threatening massive bleeding occurred.The risk of death increased in patients with their NCDR risk score ＞45 on day 30 after PCI (P=0.013).Conclusion PCI is a safe and feasible procedure and NCDR risk score can predict the risk of death in ≥85 years old patients on day 30 after PCI.

Primary percutaneous coronary intervention(PPCI)is the best treatment strategy for ST-segment elevation myocardial in-farction(STEMI).About 50%of patients with STEMI have multivessel disease and 2011 ACC/AHA guidelines on PPCI,and the PPCI sec-tion of the ACC/AHA guidance on STEMI in 2013,are not recommended(ClassⅢrecommendations)for patients with hemodynamic stabili-ty at the same time in the treatment of non-infarct-related artery in PPCI.However,the 2014 ESC guidelines and the ACC/AHA in 2015 have recommended that PPCI is simultaneously treated with non-infarct-related artery from class Ⅲrecommendations(not recommended)to classⅡB.The article describes the progress of emergency treatment strategy for coronary multivessel disease.

Objective The retrospective study was designed to assess the safety and effectiveness of percutaneous femoral artery access for thoracic endovascular aortic repair (TEVAR) of type B aortic dissection. Methods Retrospectively analysis the clinical database of our hospital between January 2012 to December 2016,the total of 32 patients,that were undergone TEVAR because of type B aortic dissection,were included.According to the approach of building vascular access,they were divided into open femoral-exposure access group and percutaneous femoral access group,and then analysis the safety and effectiveness in both two groups.Result Open femoral-exposure access group has 20 cases,and percutaneous femoral access group has 12 cases.The procedures were successfully completed among total of 32 cases.There are no significantly difference between both groups in gender,age,BMI and access-oriented complication. Compared with the open femoral-exposure access group, percutaneous femoral access group has a shorter operative time. Conclusion During the procedure of TEVAR for type B aortic dissection, using percutaneous femoral access with an adjunctive pre-close technique is safe and effective, with minimally and is worthy of clinical promotion.

Objective:To investigate the efficacy of plasma D-dimer in distinguishing fatal chest pain caused by acute myocardial infarction (AMI),acute pulmonary embolism (APE) or aortic dissection (AAD).Methods:155 patients complained of chest pain or dyspnea sent to the cardiac centre of our hospital from January 1st 2013 to January 1st 2016,finally diagnosed as ST elevation AMI and received PPCI,APE or AAD were retrospectively analyzed.D-dimer levels were assessed and compared among different groups.The ROC curves were utilized to evaluate different value of D-dimmer levels in differential diagnosis of AMI,APE/AAD.Results:Finally,151 cases were enrolled in this study,including 103 cases of AMI,23 APE and 25 AAD.The D-dimer levels in AMI group [291.3 (190.3,392.4) μg · L-1] were significantly lower than those in APE group [4103.2(2533.5,5672.8) μg · L-1,Z =-7.134,P ＜0.001],AAD group [4885.3(608.7,9161.9) μg · L-1,Z =-6.813,P ＜0.001] and APE/AAD group [4510.53(2240.2,6780.9) μg · L-1,Z =-9.043,P ＜ 0.001].The area under ROC curves(AUC) to distinguish AMI from APE/ADD was (0.958 ± 0.015) and the optimal value was 428 μg · L-1,with a sensitivity of 87.4％,specificity 95.8％,positive predictive value (PPV) 78.0％,positive likelihood ratio (PLR) 7.60,negative predictive value (NPV) 97.8％,and negative likelihood ratio (NLR)0.05.Conclusion:D-dimer can be used as an indicator to distinguish AMI from APE/AAD,and avoid misdiagnosis of APE/AAD as AMI,which provide a safety guarantee for the emergency PCI treatment of AMI.

Objective:To investigate the clinical significance of serum levels of glycated protein (GSP),endogenous se- cretory receptor for advanced glycated end products (esRAGE)and GSP/esRAGE ratio in assessing the presence and severity of coronary artery disease(CAD) in patients with and without type 2 diabetes mellitus(T2DM).Methods:Serum levels of GSP and esRAGE were measured and GSP/esRAGE ratio was calculated in 48 patients with angiographic CAD and T2DM,52 with angiographic CAD only,and 35 controls.All patients with angiographic CAD then were divided into three subgroups(one-vessel group 24 patients,two-vessel 29 and three-vessel 47) based on the number of diseased coronary vessel o Results:Serum level of GSP and GSP/esRAGE ratio in patients with CAD and T2DM were significantly higher than those in patients with CAD only (all P<0.01) and in controls (all P<0.01),Serum level of GSP and GSP/esRAGE ratio in patients with CAD only were sig- nificantly higher than those in controls (P<0.01);Serum level of esRAGE in patients with CAD and T2DM was significantly lower than in patients with CAD only (P<0.01)and in controls (P<0.01),Serum level of esRAGE in CAD only was signifi- candy lower than in controls(P<0.01);Serum level of GSP (spearman correlate coefficient,rs=0.460,P<0.01) and es- RAGE (rs=4)-0.542,P<0.001),GSP/esRAGE ratio (rs=0.536,P<0.001) were significantly eorrelated with thenumber of diseased vessel.Conclusion:Serum levels of GSP and esRAGE,and GSP/esRAGE ratio maybe valuable parameters for predicting the presence and severity of CAD in patients with and without T2DM.

Objective To identify the factors influencing the response to clopidogrel.Methods Seventy-two patients with acute coronary syndrome who were treated at Beijing Tongren Hospital from September,2005 to April,2006 were eligible for this study.10 μmol/L ADP induced platelet aggregation was measured before and 7 days after clopidogrel treatment by the traditional optical aggregometry.According to the inhibition of platelet aggregation(ΔA),the population was divided into low response group and normal response group.Then some factors possibly influencing the response to clopidogrel were analyzed by specific statistical methods.Results Baseline characteristic showed that compard with that of normal response group,the body mass index and the percentage of obesity and STEMI were lower in low response group,while its percentage of hypertension and diabetes were higher(P<0.05).The further independent-sample T test also proved the impact of hypertension,diabetes and kinds of ACS except obesity on the response to clopidogrel(P<0.05).Logistic multivariable regression found that hypertension and Apre were the main factors influencing the response to clopidogrel(OR=15.757 and 1.131 respectively,P<0.01).Conclusion Hypertension and Apre are the main factors influencing the response to clopidogrel.

Objective:To investigate the effects of blocking the rennin-angiotensin system on expression of protain kinase C isoforms in the heart of diabetic rats,investigate the machanisma of decreasing cardiovascular evants of diabetes by bloching RAS.Methods:Hyperglycemia was induced with streptozotocin and diabetic rats were randomized to 4 group:normal control, diabetic control,benazepril group(10mg·kg~(-1)·day~(-1)),irbesartan group(40mg·kg~(-1)·day~(-1)).After 4 weeks,expression of pkcαpkcβⅡin the heart were assessed by immunohistochemistry.Results:The expression of pkcαpkcβⅡwas significantly highter in the heat of diabetic rats than that in normal ones.Treatment with benazepril,irbesartan partially corrected the abnor- malities of expression,irbesartan decrease the expression of pkcβⅡmore than benazepril.Conclusion:①PKC pathway was one of mechanisms for cardiovascular complications of diabetes.②Decreasing cardiovascular evants of diabetes by bloching RAS perhaps associates with its effects on regulating PKC.

目的:研究复方鳖甲软肝片的稳定性并测算其有效期.方法:根据<新药临床前研究指导原则汇编>,在模拟市售包装条件下,通过室温贮存24个月,对其性状、含量测定等项指标进行定期考察.结果:在考察期间,各项指标均符合规定.结论:本品常温放置二年,其质量稳定,故有效期定为2年.