摘要：目的：探讨低温双极射频消融技术治疗多平面阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea-hypopnea syndrome，OSAHS）的价值。方法：对67例多平面OSAHS患者采用低温双极射频消融治疗，根据术前、术后症状改善情况及多导睡眠监测（polysomnography，PSG）结果的比较判定疗效。结果：67例患者中治愈21例，显效22例，有效15例，无效9例，总有效率86.57%。术前与术后1年AHI和SaO2结果经t检验，差异有显著性(P＜0.01)。所有病例均无并发症发生。结论：低温双极射频消融术治疗阻塞性睡眠呼吸暂停低通气综合征（OSAHS）疗效肯定，特别是同期治疗多平面阻塞安全可靠，具有独特的优势。
【Abstract】Objective To study the mechanisms of enhancing effect of mild hypothermia (MH) to ischemic preconditioning (IP) on hepatic ischemiareperfusion (I-R) injury. Methods To observe the content of the marker enzymes of liver damage (ALT,AST,LDH) and malondialdehyde (MDA), and activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSHPX), total antioxidase (TAX) in inferior vena cava blood above liver in nonischemic control group (n=6), I-R group (n=6), IP group (n=6) and mild hypothermic ischemic preconditioning (MHIP) group (n=6). Results After I-R the content of ALT,AST, LDH and MDA were significantly elevated (P＜0.01), SOD,CAT,GSH-PX,ACT activities were declined obviously (P＜0.01). The content of ALT,AST,LDH and MDA were significantly lower in IP group than those in I-R group, and in MHIP group than those in IP group (P＜0.01,P＜0.05), and the content of SOD, CAT,GSH-PX, ACT activities were significantly higher in IP group than those in I-R group, and in MHIP group than those in IP group (P＜0.01,P＜0.05). Conclusion Ischemic preconditioning may enhance the oxidation-resistance of liver, and reduce the oxygen free radical injury to liver after ischemia-reperfusion. Mild hypothermia may enhance the protective effect of IP on hepatic ischemiareperfusion injury.
【Abstract】Objective To investigate the injury of calcium on the liver. Methods By using collagenase-containing solution to perfuse the rat livers, the rat liver suspension with different viability was prepared, preserved hypothermically, and the cytosolic calcium comcentration was detected with Fura2/AM. Results ① The concentration of cytosolic calcium after 2-hour storage: Experiment group 1(viability 5%) (1055.0±30.79) nmol/L, experiment group 2(viability 10%) (853.0±20.42) nmol/L, experiment group 3(viability 30%) (616.0±13.20) nmol/L, experiment group 4(viability 50%) (562.0 ±26.06) nmol/L, experiment group 5(viability 70%-80%) (318.0±13.01) nmol/L, experiment group 6(viability 90%) (114.6±6.11) nmol/L. ②The concentration of cytosolic calcium after 24hour storage: Experiment group A(viability 10%) (1704.0±70.11) nmol/L, experiment group B(viability 50%) (1125.0±23.22) nmol/L. The results showed that the lower was the viability, the higher was the cytosolic calcium concentration.With the same viability the cytosolic calcium concentration elevated more than two times higher than the original concentration with the time lengthened. Conclusion Calcium overload is one of the main factors which attribute to the ischemiareperfusion injury of the hepatocytes.
Objective To determine risk factors of delayed recovery of consciousness after aortic arch surgery underdeep hypothermic circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods We retrospectively analyzed clinical data of 113 patients who underwent aortic arch surgery under DHCA＋ASCP in the Affiliated Drum Tower Hospital， Medical School of Nanjing University from October 2004 to April 2012. According to whether they regained consciousness within 24 hours after surgery， all the 113 patients were divided into normal group （73 patients including 55 males and 18 females with their average age of 48.1±10.9 years） and delayed recovery group （40 patients including 29 males and 11 females with their average age of 52.2±11.4 years）. Risk factors of delayed recovery of consciousness after surgery were evaluated by univariate analysis and multivariate logistic regression analysis. Results Nine patients （8.0%） died postoperatively， including 5 patients with multi-organ failure， 2 patients with heart failure， 1 patient with mediastinal infection， and 1 patient with pulmonary hemorrhage. There were 7 deaths （17.5%） in the delayed recovery group and 2 deaths （2.7%） in the normal group， and the in-hospital mortality of the delayed recovery group was significantly higher than that of the normal group （P=0.016）. A total of 94 patients （including 65 patients in the normal group and 29 patients in the delayed recovery group） were followed up for 4-95 months. Eight patients （including 5 patients in the normal group and 3 patients in the delayed recovery group） died during follow-up， including 2 patients with stroke， 3 patients with heart failure， 2 patients with pulmonary hemorrhage and 1 patient with unknown cause. Ten patients were lost during follow-up. Univariate analysis showed that age （P=0.042）， hypertension （P=0.017）， emergency surgery （P=0.001）， cardiopu- lmonary bypass （CPB） time （P=0.007）， aortic cross-clamp time （P=0.021）， and blood transfusion（P=0.012）were risk factors of delayed recovery of consciousness after aortic arch surgery. Multivariate logistic regression showed that emergency surgery （P=0.005） and CPB time＞240 minutes （P=0.000） were independent risk factors of delayed recovery of consciousness after aortic arch surgery. Conclusion Delayed recovery of consciousness after aortic arch surgery is attributed to a combination of many risk factors. Correct patient diagnosis， lesion site and involved scope should be made clear preoperatively in order to choose appropriate surgical strategies. During the surgery， strengthened brain protection， shortened operation time， improved surgical techniques， and perioperative stable circulation maintenance are all important measures to prevent delayed recovery of consciousness after aortic arch surgery.
Objective To observe the influence of edaravone perfusion via the pulmonary artery on postoperative lung tissue and lung function during pulmonary ischemia in deep hypothermic circulatory arrest （DHCA）， and explore its possible mechanism. Methods A total of 24 healthy New Zealand white big-ear rabbits were randomly divided into three groups： （1） control group： DHCA model under cardiopulmonary bypass （CPB） was established； （2）low potassium dextran （LPD）group： LPD solution perfusion via the pulmonary artery after the establishment of DHCA； （3）edaravone group：LPD solution containing edaravone （5 mg/kg） perfusion via the pulmonary artery after the establishment of DHCA. Oxygenation index and lung compliance were observed at the time of baseline condition， recovery of ventilation， 1 hour and 2 hours after recovery of ventilation， and postoperative lung function of the three groups were compared. Malondialdehyde （MDA） and superoxide dismutase （SOD） in pulmonary venous blood were measured. All the rabbits were sacrificed after the operation. HE staining and immunohistochemistry were performed on the lung tissues to investigate lung structure changes and inflammatory reaction. Transmission electron microscopy was used to compare ultrastructural changes of lung.Results There were no statistical difference in oxygenation index， lung compliance， MDA and SOD among the 3 groups under the baseline condition （P＞0.05）. After recovery of ventilation， oxygenation index and lung compliance deteriorated to varying degrees in all 3 groups. Oxygenation index and lung compliance of the control group and LPD group at the time of recovery of ventilation， 1 hour and 2 hours after recovery of ventilation were significantly lower than those of edaravone group （oxygenation index：recovery of ventilation and in control group and edaravone group: 198.25±11.02 mm Hg vs. 244.87±13.05 mm Hg；lung compliance：one hour after recovery ventilation in control group and edaravone group：45.88±1.64 ml/cm H2O vs. 59.75±2.38 ml/cm H2O；P＜0.05）. After CPB removal， MDA levels were increased to varying degrees in all 3 groups. MDA levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly higher than those of edaravone group （P＜0.05）. After CPB removal， SOD levels were decreased to varying degrees in all 3 groups. SOD levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly lower than those of edaravone group （P＜0.05）. HE staining showed clear lung structure， less red blood cell leakage， less inflammatory cell infiltration， and less alveolar fluid accumulation in the edaravone group. Immunohistochemistry showed that integral light density of interleukin 6 （IL-6）in edaravone group was significantly lower than those of the LPD group and control group （14.44±1.75 vs. 20.18±2.22， P＜0.05）. Transmission electron microscopy showed integral basement membrane structure， clear blood gas barrier structure， significantly larger number of type II epithelial cells， abundant but not swollen mitochondria and lamellar bodies in the cytoplasm in the edaravone group， which were destroyed in varying degrees in the LPD group and control group. Conclusion Pulmonary artery perfusion of protective solution in low temperature can significantly reduce lung injury induced by DHCA and CPB. Protective solution containing edaravone in low temperature can better decrease lung injury and protect oxygenation.
Abstract： Objective To evaluate the clinical safety and neurological outcomes of right axillary artery cannulation with a side graft compared with a direct approachin aortic arch replacement for patients with acute Stanford type A aortic dissection. Methods Between July 2008 and July 2010， 280 consecutive patients with acute Stanford type A aortic dissection underwent right axillary artery cannulation for cardiopulmonary bypass （CPB） in total arch replacement and stented “elephant trunk” implantation in our hospital.These 280 patients were divided into two groups according to the method of axillary artery cannulation in operation:direct arterial cannulation was used in 215 patients（direct arterial cannulationgroup， DG group， mean age of 43.1±9.5 years）， while cannulation with a side graft was used in 65 patients（ indirect cannulation group， IG group， mean age of 44.7±8.3 years）. Clinical characteristics of both groups were similar except their axillary artery cannulation method. Patient outcomes were compared as to the prevalence of clinical complications， especially neurological deficits and postoperative morbidity. Results The overall hospital mortality was 3.6% （10/280）， 3.3% （7/215） in DG group and 4.6% （3/65） in IG group respectively.Right axillary artery cannulation was successfully performed in all cases without any occurrence of malperfusion. Postoperatively， 25 patients（8.9%）developed temporaryneurological deficits， 19 cases in DG group（8.8%）， and 6 cases in IG group （9.2%）， and all these patients were cured after treatment. The incidence of postoperative complications directly related to axillary artery cannulation was significantly lower in IG group than that in DG group（1 case vs. 19 cases， P=0.045）. There were no statistical differences in arterial perfusion peak flow， peak pressure，antegrade cerebral perfusion time， deep hypothermic circulatory arrest time， and CPB time between the two groups（P ＞ 0.05）. Conclusion Right axillary artery cannulation with a side graftcan significantly reduce the postoperative complications of axillary artery cannulation. It is a safe and effective method for patients undergoing surgery for acute Stanford type A aortic dissection.
Abstract： Objective To investigate the cerebral protective effects of hyperoxia management during deep hypothermia circulatory arrest（DHCA） rabbit by the blood gas indexes, superoxide dismutase（ SOD） activity and malondialdehyde （MDA） levels of brain, and ratio of water to brain. Methods A DHCA and antegrade selective cerebral perfusion （ASCP） rabbit model was established. Twenty-four 11-13 week-old male New Zealand rabbits（ weighing 2.7 to 3.4 kg） were assigned to three groups with a random number table: a sham operation group （Sham group）, an ASCP group （S group）, and an ASCP ＋ hyperoxia management group （SH group）. There were eight rabbits in each group. We recorded the intraoperative values for arterial oxygen pressure （PaO2）, arterial oxygen saturation （SaO2）, jugular venous oxygen pressure（PjvO2）, jugular venous oxygen saturation（ SjvO2） and blood lactate level. The brain SOD activity, MDA levels, and ratio of water to brain were measured after the operation. Results Before initiating circulatory arrest, before initiating reperfusion and five minutes of reperfusion, levels of PaO2 , PjvO2 , and SjvO2 in the SH group were significantly higher than those of the S group and Sham group. SOD activity in the SH group was not significantly different from that of the S group[（213.53±33.52） U/mg. prot vs. （193.02±27.67） U/mg. prot] and Sham group[（213.53±33.52） U/mg. prot vs.（244.38±35.02）U/mg. prot], but the SOD activity in the S group was lower than that in the Sham group（ P ＜ 0.05）. MDA levels in the SH group were lower than that in the S group[（1.42±0.30） nmol/mg. prot vs. （2.37±0.55） nmol/mg. prot, P ＜ 0.05]. Conclusion Our data show that hyperoxia management during DHCA＋ASCP improves rabbits’PjvO2 and SjvO2, maintains brain SOD activity, and decreases brain MDA levels, demonstrating the neuroprotective effects of hyperoxia mangagement.
Abstract： Objective To determine the risk factors for acute kidney injury (AKI) after thoracic aortic arch replacement surgery under deep hypothermic circulatory arrest (DHCA). Methods We retrospectively analyzed the clinical data of 139 patients who underwent thoracic aortic arch replacement surgery under DHCA between January 2004 and December 2008 in Beijing Anzhen Hospital Affiliated to Capital University of Medical Sciences. The patients were divided into two gro-ups according to whether AKI occurred after thoracic aortic arch replacement surgery. In the AKI gro-up (n=48), there were 39 males and 9 females with an age of 57.67±9.56 years. In the normal renal function gro-up (n=91), there were 69 males and 22 females with an age of 41.30±13.37 years. We observed the clinical data of the patients in both gro-ups, including left ventricular ejecting fraction (LVEF) before operation, diameter of the left ventricle, diameter of the ascending aorta, renal function, cardiopulmonary bypass time, aortic crossclamp time, and DHCA time. The risk factors for AKI and death after operation were evaluated by univariate analysis and stepwise logistic regression analysis. Results Among all the patients, AKI occurred in 48 (34.53%), 17 (12.23%) of whom underwent continuous renal replacement therapy (CRRT). Respiratory failure occurred in 27 patients (19.42%). Twentynine patients (20.86%) had cerebral complications, including temporary cerebral dysfunction in 26 patients and permanent cerebral dysfunction in 3 patients. In all the patients, 14 (10.07%) died, including 4 patients of heart failure, 9 patients of multiple organ failure, and 1 patient of cerebral infarction. There were 3 (3.30%)deaths in the normal renal function gro-up and 11 (22.92%) deaths in the AKI gro-up with a significant difference of mortality rate between the two gro-ups (P=0.011). A total of 118 patients were followed -up and 7 were lost. The follow-up time was from 5 to 56 months with an average time of 42 months. During the follow-up period, 7 patients died, including 3 patients of heart failure, 2 patients of cerebral apoplexy, and 2 patients of unknown reasons. The logistic regression analysis revealed that creatinine level was greater than 13260 μmol/L before operation (OR=1.042, P=0.021) and respiratory failure (OR=2.057, P=0.002) were independent determinants for AKI after the operation. Conclusion AKI is the most common complication of thoracic aortic arch replacement surgery under DHCA, and is the risk factor of mortality after the surgery. It is important to enhance perioperative protection of the renal function.
Objective To investigate the clinical effects and the brain protection effect of different cardiopulmonary bypass in treating descending aortic aneurysms. Methods From January 2001 to December 2008, 65 patients were diagnosed to have descending aortic aneurysm with magnetic resonance imaging (MRI) in our hospital. Among them, there were 56 males and 9 females whose age was between 15 and 71 years old with an average of 48.1 years. The disease process ranged from 6 days to 4 months (19.0±6.5 d ). Preoperative diagnosis showed that there were 41 cases of DeBakey type Ⅲinterlayer, 9 cases of Marfan syndrome with postoperative complications of type Ⅲ interlayer, 7 cases of pseudoaneurysm and 8 cases of true aneurysm. We adopted artificial blood vessel repair patch to repair the damaged point of the descending aorta in 2 cases, performed vascular aneurysm resection and artificial vessel replacement on 63 patients, and carried out descending aorta replacement and intercostal artery grafting in 18 cases. Results Among the 65 cases of cardiopulmonary bypass patients, there were 13 cases of left heart bypass, 12 cases of heart bypass, 30 cases of deep hypothermic circulatory arrest (DHCA) with total body retrograde perfusion (TBRP) and 10 cases of modified separate perfusion of upper and low body. Cardiopulmonary bypass time, DHCA time, retrograde perfusion time, upper body circulatory arrest time and low body circulatory arrest time were respectively 51-212 min, 18-75min, 18-73 min, 21-31 min, and 39-67 min. No death occurred during the operation, and there were no brain complications or complications of paralysis among all the patients. Two patients died after operation because of renal failure. Conclusion Good results can be achieved by selecting different method of cardiopulmonary bypass based on the anatomical location and range of the thoracic descending aortic aneurysms. The selection criteria should be favorable to the surgical operation and organ protection.