目的 探讨基于ProGlide血管闭合装置的后闭合技术在清醒静脉-动脉体外膜氧合(VA-ECMO)拔管中的安全性与有效性.方法 回顾性分析2017年1月至2021年6月于我院行清醒VA-ECMO救治并撤机患者的临床结局.根据使用的血管闭合方式,将患者分为ProGlide后闭合技术组(ProGlide组)和外科修复组.分析患者全因住院死亡率、动脉拔管闭合操作时间、出血相关事件、30 d内血管相关并发症等.结果 共35例患者最终纳入研究,其中21例(60.0％)使用ProGlide后闭合技术,14例(40.0％)使用外科修复技术.全组患者男21例(60.0％)、女14例(40.0％),平均年龄(49.20±10.52)岁,VA-ECMO支持的中位时间为10.0(8.0,12.0)d,全因住院死亡率为11.4％(4/35).多因素logistic回归分析结果显示,校正年龄、性别后,在主要观察终点中,两组的全因住院死亡率差异无统计学意义(OR=0.78,95％CI 0.09～6.89,P=0.826).次要观察终点显示,ProGlide组具有更少的动脉拔管闭合操作时间(β=14.14,95％CI 7.22～21.05,P<0.01)及更短的撤机后ICU停留时间(β=2.11,95％CI 0.20～4.02,P=0.032).两组均无主要出血事件及30 d内主要血管相关并发症发生,但ProGlide组次要出血事件及30 d内次要血管相关并发症发生率均低于外科修复组(OR=0.13,95％CI 0.02～0.88,P=0.036;OR=0.05,95％CI 0.00～0.59,P=0.018).ProGlide组患者撤机时重症监护室疼痛观察工具法(CPOT)评分明显低于外科修复组(β=1.26,95％CI 0.37～2.14,P=0.007),外科修复组动脉缝合时需要额外使用瑞芬太尼的患者比例明显增加(OR=0.06,95％CI 0.01～0.36,P=0.002).结论 在清醒VA-ECMO动脉拔管过程中,采用ProGlide血管闭合装置的后闭合技术是安全、有效的.与外科修复方法相比,ProGlide血管闭合装置的后闭合技术具有操作时间短、出血及血管相关并发症少、患者疼痛感轻的优势,对促进患者快速康复具有一定作用.

目的 评价单侧无名动脉灌注在主动脉全弓置换术中对大脑的保护效果.方法 选取2018年1月—2019年1月在上海长海医院行主动脉全弓置换术时采用无名动脉插管进行大脑灌注的患者120例,所有患者均采用中度低温停循环的体外循环方法.采用上、下腔静脉,或右心房、股动脉插管建立体外循环.大脑保护方法为单侧选择性顺行性脑灌注,即单纯右侧无名动脉灌注.使用近红外光谱脑氧饱和度监测仪行双侧经皮脑组织氧饱和度持续监测.结果 120例患者停循环前左侧脑氧饱和度为(54.9±6.8)％,右侧脑氧饱和度为(58.2±6.1)％;大脑灌注开始后10 min时左侧脑氧饱和度为(52.3±7.3)％,右侧脑氧饱和度为(57.8±7.5)％;大脑灌注开始后20 min时左侧脑氧饱和度为(51.4±7.5)％,右侧脑氧饱和度为(57.5±7.0)％;循环恢复时左侧脑氧饱和度为(63.5±5.6)％,右侧脑氧饱和度为(60.4±6.2)％.左、右侧脑氧饱和度在各时间点的差异均无统计学意义(P值均＞0.05).7例患者发生术后短暂性神经系统功能不全,均于术后2?5 d恢复正常,无1例发生永久性脑损伤.结论 在主动脉全弓置换术中采用单纯右侧无名动脉灌注安全、可靠,能够满足停循环期间大脑的供血、供氧需求,值得在临床推广.

目的:比较Del Nido停搏液与含血停搏液在急性主动脉夹层外科手术中的心肌保护效果及对肾功能的影响.方法:回顾性分析2019年6月至2020年6月因急性主动脉夹层Stanford A型在海军军医大学附属第一医院手术的69例患者,根据术中使用的心脏停搏液分为Del Nido停搏液组(DN组,n=35)和含血停搏液组(CBC组,n=34).对两组患者术前一般资料、体外循环资料、预后进行比较.结果:两组患者术前一般资料如年龄、性别、心功能、肾功能、高血压及糖尿病患病率的差异无统计学意义.两组患者体外循环时间、主动脉阻断时间、停循环时间、自动复跳率、术后血清肌钙蛋白和肌红蛋白水平的差异无统计学意义.DN组术后死亡3例,需要血液透析9例,CBC组术后死亡4例,需要血液透析5例.DN组中单侧肾受累患者共14例,其中术后死亡3例,需要血液透析8例;CBC组中单侧肾受累患者共11例,其中术后死亡2例,需要血液透析3例.DN组停搏液灌注次数显著低于CBC组(P<0.05).两组中单侧肾脏有血供患者的术后透析率、住院天数、死亡率的差异无统计学意义.结论:Del Nido停搏液在急性主动脉夹层Stanford A型外科手术中可以提供较好的心肌保护作用,未对肾功能产生不利影响.

目的 根据多学科合作制订的上海市体外膜氧合(ECMO)技术临床质量控制标准对ECMO技术在上海各医院的开展现状进行督查以推进此项技术规范有序开展.方法 确定ECMO技术临床质量控制督查工作的主体.通过前提调研结果,多学科合作制订临床质量控制督查的标准,针对以心血管外科或心血管外科/重症医学科合作模式为主导的上海市15家医院ECMO技术的临床实施工作进行现场督查,形成督查工作报告.结果 8家医院工作出色达到所有要求的指标.另有7家医院发现存在不同程度的问题需要持续整改.结论 ECMO技术临床规范性是保证ECMO质量的必要条件.通过质控督查,将ECMO技术的临床开展制订一系列准入标准,并加强制度建设,团队合作和培训工作将是下一步工作的重点.

Objective To analyze the recent clinical results and experience of extracorporeal membrane oxygenation (ECMO) in treating critical patients, so as to summarize the methods, timing and indications of ECMO treatment. Methods We retrospectively analyzed the clinical data (primary disease, supportive mode, adjuvant time and so on) of 18 critical patients treated with ECMO from Jan. 2014 to Nov. 2016 in our hospital, compared the offline rate and success rate of different kinds of critical patients, and analyzed the survival factors and causes of death of the patients. Results Among the 18 critical patients, 12 cases were treated with vein-artery ECMO, four with vein-vein ECMO and two with vein-artery-artery ECMO. Totally seven (38.9%) cases were successfully offline and five (27.8%) cases survived. The offline rate and success rate of the patients with circulatory failure were 62.5% (5/8) and 37.5% (3/8), respectively, while those of the patients with respiratory failure were both 20% (2/10). None of the six patients with adult respiratory distress syndrome (ARDS) secondary to severe burn, trauma or operation survived. The survival rates of patients with ARDS secondary to pulmonary disease (HR=12.3, 95%CI: 2.2-69.9; P<0.01) and patients with circulatory failure (HR=4.6, 95% CI: 1.1-19.5; P<0.05) were significantly higher than that of patients with ARDS secondary to non-pulmonary causes, while there was no significant difference in survival rate between the patients with circulatory failure and ARDS secondary to pulmonary disease. Conclusion Prompt selection of ECMO treatment time, improvement of the treatment procedure, active treatment of primary disease, and prevention of complications are the keys of ECMO treatment. The establishment of hospital emergency channel and the formation of ECMO treatment team with multidisciplinary and multisectoral cooperation should be carried out to insure the success of ECMO treatment.

诱导多能性干细胞（ induced pluripotent stem cells，iPSCs）是一种类似于胚胎干细胞（ embryonic stem cells， ESCs）的、具有自主增殖和分化能力的多能性干细胞。 iPSCs可以由各种不同动物的不同体细胞重编程转化而来，能增殖并分化成各种体细胞，其中包括具有收缩和兴奋功能的心肌细胞。截止目前，iPSCs分化的心肌细胞主要用于以下几个方面：通过细胞移植治疗缺血性心肌病及心肌梗死；在体外建立遗传性心脏病模型，研究其发病机制；检测药物心脏毒性，筛选患者特异性个体化药物；构建心脏生物起搏器。

OBJECTIVE To investigate the role of protein kinase C(PKC) in mediation of ischemic preconditioning(IPC) against myocardial reperfusion injury by using PKC inhibitor polymyxin B(Poly B) and PKC activator 4β-phorbol-12-myristate-13-acetate(PMA) during cardiopulmonary bypass(CPB) in feline.METHODS One hundred and twenty felines were randomized into five groups: control group(n=24),in which CPB was conducted without aortic cross-clamping(ACC);IR group(n=24),with 60 min cardiac arrest by ACC followed by 30 min reperfusion,and cardioplegia used during the period of ACC;IPC group(n=24),with protocol similar to that of IR group except for three-round 15 min IPC applied before ACC;Poly B group(n=24),with protocol similar to that of IPC group except for polymyxin B administered after starting of IPC;PMA group(n=24),with protocol similar to that of IR group except for PMA administered before ACC.Membrane and cytosol fraction of PKC activity was assessed by biochemical assays,and myocardial Ca~(2+)content was determined simultaneously.RESULTS PKC activity in both membrane and cytosol fractions was significantly reduced after 60 min cardiac arrest with ACC and during myocardial reperfusion in IR group while the Ca~(2+)content in myocardium was significant increased.However,IPC enhanced the activation and translocation of PKC to the membrane and significantly reduced the rise in myocardial Ca2 +content.Although mem-brane and cytosol fraction of PKC activity were also both inhibited by Poly B after ACC,the increase ofmyocardial Ca2 +contentwas markedly attenuated which was comparable with thatin IPC group,whereasthe change patterns of PKC activities and myocardial Ca2 +content were similar to IPC in PMA group.CONCLUSION Cardioprotection by IPC is mediated through enhanced translocation of PKC to the membrane.PKC in-hibitor Poly B cannot completely abolish IPC-induced cardioprotection.PKC activator PMA mimics at least partially theprotective effect of IPC against myocardial calcium overload.

OBJECTIVE To evaluate the effect of modified ultrafiltration(MUF) on inflammatory response and alteration of hemodynamics during extracorporeal circulation(ECC).METHODS 30 patients who underwent double valves replacement(DVR) were randomly divided into modified ultrafiltration group(groupⅠ,n=14)and control group(groupⅡ,n=16)without MUF.Blood samples were taken before surgery,30 minutes after aortic occlusion,immediately after ECC or beginning of MUF,at 15 minutes after ECC or the end of MUF,30 minutes,2 hours,8 hours,24 hours after ECC to measured the concentrations of Interleukin-6(IL-6),Interleukin-8(IL-8),Endothelin-1(ET-1).Lung function and alteration of hemodynamics are measured during perioperation.RESULTS All patients' concentrations of IL-6,IL-8 and ET-1 increased after beginning of ECC.The difference between 2 groups at all time points after ECC were significant(P0.05).In the MUF group,the changes of CO,CI,MAP,LVSWI is significant(P0.05),the difference of CI,LVSWI between 2 groups were significant at 15 minutes after ECC(P0.05),and the lung function is far better than that in control group at every time point after ECC(P0.05).CONCLUSION MUF can filter out the supernumerary water and concentrat the blood.Also the inflammatory mediators can be removed by ultrafiltration.Alleviate the inflammatory response after operations with ECC,condition the cardiopulmonary function of patients and decrease occurrence of multiple organ failure(MOF)after operations.

目的探讨建立山羊心肌缺血预适应(IPC)实验模型的方法及其影响因素.方法将12只雄性山羊,麻醉、气管插管接呼吸机后均由右侧开胸,升主动脉插主动脉供血管,上下腔静脉插腔静脉引流管,建立体外循环(CPB),阻断升主动脉(ACC)5 min,开放恢复灌注5 min,共行3轮IPC实验,随后ACC 60 min,心脏停搏,后开放升主动脉心脏再灌注90 min.CPB前及再灌注后30、60、90 min监测血流动力学及心功能.结果12只山羊中9只顺利脱离CPB机,停机后血流动力学逐渐稳定;一只麻醉时死亡,一只心脏复跳后反复出现室颤,经多次除颤无效死亡;一只术后出现急性肺水肿死亡.平均转机时间1 26±14 min,平均预充胶体(6%贺斯代血浆或血)量6 50±1 50 ml,平均追加胶体量16 5±50 ml.再灌注后与CPB前比较,血流动力学及心功能恢复满意.结论正确的实验方法可模拟临床顺利完成山羊的IPC实验,把握好几个关键的技术,可有效的提高山羊IPC实验模型的成功率.

目的:探讨合并降主动脉内膜破口的A型胸主动脉夹层的手术新方法.方法:3例急性A型胸主动脉夹层患者在深低温停循环、经上腔静脉逆灌下行升主动脉和半弓置换,同时直视下探查降主动脉近端的内膜破口.用卵圆形毛毡片分别置于裂口处内膜的外侧和内侧,用4-0丙烯线作连续缝合修补破口.结果:3例患者均顺利出院.术后2～3个月行螺旋CT结果显示:3例患者胸部降主动脉夹层均已形成血栓;其中2例假腔消失,另1例假腔明显缩小,但仍有少量血流与真腔相通,可能为降主动脉内膜破口修补处渗漏.结论:对同时合并有降主动脉内膜破口的A型胸主动脉夹层患者行降主动脉内膜破裂口修补具有良好的临床效果,避免了二期降主动脉手术.

目的:探讨体外循环(CPB)技术对建立山羊心肌缺血预适应(IPC)模型的影响.方法:12只雄性山羊右侧开胸,升主动脉插主动脉供血管,上、下腔静脉插腔静脉引流管,建立CPB,阻断升主动脉(ACC)、肺动脉5 min,开放恢复灌注5 min,并重复3次,随后ACC 60 min,心脏停搏,后开放升主动脉心脏再灌注90 min.CPB前及再灌注后30、60、90 min监测血流动力学及心功能.结果:12只山羊中10只顺利脱离CPB机,停机后血流动力学逐渐稳定;1只复跳后反复出现室颤,经多次除颤无效死亡;1只术后出现急性肺水肿死亡.平均转机时间(136.0±13.0) min,平均预充胶体(6%贺斯代血浆或血)(550.0±150.0) ml,平均追加胶体(175.0±50.0) ml.再灌注后与CPB前相比较,血流动力学及心功能恢复满意.结论:CPB保证下可模拟临床顺利完成山羊的IPC实验.把握好几个关键的CPB技术,可有效地提高山羊IPC模型的成功率.

目的:探讨改良超滤对成人心脏瓣膜替换术后左心功能的影响.方法:22例成人心脏瓣膜替换术患者随机分为改良超滤(MUF)组(n=10)和无超滤对照组(n=12), 动态观察体外循环(CPB)前、CPB停时及MUF结束时(对照组CPB停后15 min)3个时间点心排量(CO)、心排指数(CI)、每搏输出量(SV)、每搏指数(SVI)、平均动脉压(MAP)、左室每搏做功指数(IVSWI)等心功能指标.结果:MUF组超滤后CO、CI、SV、SVI、LVSWI均较CPB停时明显升高(P<0.05);对照组停CPB时与CPB停后15 min相比,各项指标无显著性差异.MUF组超滤后与对照组CPB停后15 min相比,CI和LVSWI升高显著(P<0.05).结论:在成人心脏瓣膜替换术中,应用改良超滤技术可以减轻心肌水肿,提高心脏指数,改善术后早期心功能.

1 临床资料例1 男性,7岁,17 kg.择期行室间隔缺损修补术.术前配血发现冷凝集试验阳性,冷凝集素效价呈高滴度.体外循环(CPB)采用常温不停跳,大剂量地塞米松预充(3 mg/kg).

Objective To assess the efficacy of warm blood and mannitol reperfusion in extracorporeal circulation for patients with severe valvular heart diseases. Methods Eighty patients with valvular heart diseases between 1998-6 and 1999-6 were selected and randomly divided into test group and control group. Mitral valve replacement, aortic valve replacement or double valve replacement was performed in those patients. All the patients were given continuous mild hypothermia(28±3℃) blood myocardial protection, while only the patients in test group were exposed to warm blood and mannitol reperfusion before unclamping the aortic artery. The auto-beating ratio, assistant time after unclamping aortic artery, trend of cardiac index and creatine kinase change after operation, supporting time by respirator, time in ICU and mortality of two groups were compared. Results The patients in test group performed better in auto-beating ratio, assistant time after unclamping aortic artery and velocity of cardiac index resumed and creatine kinase descending after operation than the patients in control group (P＜0.05). There was no significant differences in the supporting time by respirator, time in ICU and mortality between two groups (P＞0.05). Conclusion Warm blood and mannitol reperfusion is benefit to the myocardial protection in patients with severe valvular heart diseases.

Leukocyte depletion filter (LDF) was used in a cardiopulmonary bypass (CPB) model in cat, and its protective effect of leukocyte depletion on the pulmonary functions was evaluated. In the control group LDF was not used. Sequestration of leukocytes in the lung and the ratio of dry/wet weight of the lung were measured. Oxygen free radicals in lung tissue was determined By ESR, and the levels of serum MDA, as well as ultrastructural changes in the lung tissue were also examined. The filtration efficiency rate for white blood cells was 0.93±0.05( vs before the filtration P<0.01), the ratio of dry/wet weight was 0.258±0.011 in control group and 0.612±0.023 in experimental group(P<0.01),respectively.It was found that oxygen free radical levels were lower in the experimental group than control group(P<0.01) consistantly. MDA level increased from 0.574±0.051nmol/mg before bypass to 1.371±0.078nmol/mg(P<0.01) after bypass,while it was 2.089±0.108nmol/mg in control group; it was 0.523±0.048nmol/mg before bypass and 0.587±0.056nmol/mg 60min after bypass in experimental group. The difference was significant(P<0.01). Electronmicroscopic studies demonstrated that lung tissue was well arranged with the clearly demonstrated myomeres, and the mitochondrial structures were relatively well preserved. The electron density was reduced during the reperfusion period,and it was more pronounced in the experimental group (P<0.05). It suggested that LDF can significantly attenuate lung reperfusion injury and has protective effect on the pulmonary functions.

目的 研究滤除白细胞含血心肌保护液对心肌再灌注损伤的保护作用. 方法 随机选择20例心肺转流术患者,采用中度低温含血心肌保护液持续顺行灌注,分为对照组与实验组,每组10例.对照组:未用白细胞滤过器;实验组:于含血心肌保护液通路加用白细胞滤过器.测定实验组滤过前、后血细胞的变化,升主动脉阻断前5分钟、升主动脉开放后30分钟、1小时两组血清丙二醛水平,心肌超微结构变化;应用持续左心功能监测术后血流动力学变化. 结果 实验组滤过后白细胞滤除率为0.91±0.05(P＜0.05),红细胞滤除率为0.08±0.03(P＞0.05),血小板滤除率为0.88±0.06(P＜0.05);丙二醛水平两组增高趋势相同,但对照组增高幅度明显高于实验组(P＜0.05);主动脉阻断前两组患者心肌电子显微镜显示肌原纤维排列整齐,肌节、肌带清楚,线粒体形态、结构完整,再灌注后可见电子密度降低,以对照组降低明显(P＜0.05);持续左心功能结果显示术后实验组左心功能较对照组恢复快. 结论 滤除白细胞含血心肌保护液能明显地减轻心肌再灌注损伤,起到了较好地心肌保护作用,使术后左心功能恢复加快.

目的:评价主动脉内球囊反搏(IABP)在心脏手术后救治低心排血量(低心排)的效果.方法:28例术后应用中等剂量心脏活性药物支持不能改善的低心排患者,均立即使用KAATⅡPlus IABP(40 ml).监测桡动脉和主动脉压力波形,持续监测左心功能,记录尿量,观察末梢循环状况.结果:全组患者IABP辅助时间为(48±32) h,早期生存率为75.0%.所有患者在应用IABP后,桡动脉压力(基础收缩压)均在早期有所下降(P<0.01);基础舒张压上升(P<0.01);平均动脉压增加;尿量明显增加,术前2例肌酐水平高的患者20 h后恢复正常;持续左心功能监测结果见CO、CI于应用IABP后2 h明显恢复,48 h已经恢复到术前水平,MAP于应用后即明显提高,外周阻力明显降低.结论:IABP对救治心脏手术后低心排起到了重要作用,大大降低了死亡率.

白细胞和感染、再灌注损伤、器官移植的排斥反应密切相关.体外循环(CPB)时血液与大量人工物质接触,使血液中的补体激活,产生白细胞脱颗粒,大量氧自由基产生,释放花生四烯酸(AA)代谢产物,粒细胞微栓形成等[1].主动脉阻断及开放过程中,心肌出现再灌注损伤,而这些损伤性物质的产生均起自白细胞.

目的:研究白细胞滤过器(LDF)在体外循环手术中的作用,探讨LDF心肌保护的效果.方法:随机选择20例病人,心肌保护采用中度低温含血心肌保护液持续顺行灌注,实验组(10例)于含血心肌保护液通路加用LDF,对照组(10例)未用LDF.测定滤过前后血细胞的变化、主动脉阻断前后血清乳酸脱氢酶(LDH)、血清丙二醛、心肌超微结构的变化;应用持续左心功能监测术后左心功能的变化.结果:滤过后白细胞滤除率为0.91±0.05(与滤过前比较P＜0.05).对照组LDH由103±24 U/L升至365±89 U/L(P＜0.01),实验组由110±34 U/L升至199±35 U/L(P＜0.05).血清丙二醛对照组由5.55±0.34 nmol/ml增至17.31±0.58 nmol/ml(P＜0.01),实验组由4.98±0.56 nmol/ml增至7.98±0.21 nmol/ml(P＜0.05).主动脉阻断前全组病人心肌电镜显示肌原纤维排列整齐,肌节、肌带清楚,线粒体形态、结构尚完整,再灌注后可见电子密度降低,以对照组降低明显(P＜0.05).持续左心功能结果显示术后左心功能实验组较对照组恢复佳.结论:应用LDF能明显减轻再灌注损伤,起到了较好地心肌保护效果;使术后左心功能恢复加快.

目的:研究主动脉内球囊反搏(IABP)对冠状动脉旁路移植术(CABG)后冠状动脉近侧段血流速度和左心功能的影响.方法:经食管彩色多普勒超声监测11例患者CABG术后应用IABP在1∶1气囊搏动情况下冠状动脉近侧段血流速度的变化,同时应用持续左心功能监测仪观察血流动力学的变化.结果:应用IABP后冠状动脉血流均值和峰相血流速度明显增加,舒张期流速和主动脉内平均流速明显加快(P<0.05);应用IABP后心排血量(CO)和心排血指数(CI)即有增加的趋势,2 h明显恢复,48 h已经恢复到术前水平.结论:IABP可显著增加冠状动脉近侧段血流速度,并加速CABG术后左心功能的恢复.