目的 肺及肺外結(jié)核患者是否能使用激素是目前頗有爭議的臨床問題，結(jié)合1 例肺結(jié)核合并結(jié)核性心包炎和結(jié)核性腦膜炎患者的病情，用循證臨床實(shí)踐的方法，就是否使用激素進(jìn)行床旁循證治療。 方法 計(jì)算機(jī)檢索Cochrane圖書館、OVID、MEDLINE、www.guideline.org，查找和評價高質(zhì)量臨床證據(jù)，并根據(jù)患者意愿為患者制定治療方案。 結(jié)果 共納入11 個RCT，2 個Cochrane 系統(tǒng)評價，9 個指南。證據(jù)表明：① 糖皮質(zhì)激素能降低結(jié)核性腦膜炎患者的死亡風(fēng)險，也能降低神經(jīng)系統(tǒng)功能缺損的風(fēng)險；② 潑尼松龍使結(jié)核性心包炎患者總體死亡率降低（P=0.044），同時使心包炎所致的死亡風(fēng)險也顯著降低（P=0.004）；③ 激素能否使肺結(jié)核患者獲益仍有爭議。結(jié)合患者病情和意愿，在抗癆治療的基礎(chǔ)上加用地塞米松等治療7 周后，患者腦脊液基本恢復(fù)正常，心包積液消失。 結(jié)論 對于結(jié)核性腦膜炎和結(jié)核性心包炎患者應(yīng)常規(guī)使用糖皮質(zhì)激素治療，但如何選擇糖皮質(zhì)激素類藥物以及治療療程仍未達(dá)成一致。
目的 探討慢性縮窄性心包炎的外科最佳手術(shù)徑路選擇，總結(jié)臨床經(jīng)驗(yàn)。方法 回顧性分析 1970年9月至 2009年 9月中國醫(yī)科大學(xué)附屬第一醫(yī)院收治 538例慢性縮窄性心包炎患者的臨床資料，按手術(shù)徑路不同將其分為兩組，胸骨正中切口組： 324例，男 204例，女 120例，年齡（ 44.5±10.0）歲；左胸前外側(cè)切口組： 214例，男 130例，女 84例，年齡（ 46.5±6.8）歲。比較兩組患者術(shù)后心功能和并發(fā)癥發(fā)生情況。結(jié)果 胸骨正中切口組死亡 1例，術(shù)后 2 d死于頑固性室性心律失常。左胸前外側(cè)切口組死亡 9例，其中死于多器官功能衰竭 1例，呼吸衰竭 2例，低心排血量綜合征 2例，嚴(yán)重肺部感染 3例；1例于第 3次復(fù)發(fā)手術(shù)中發(fā)生左心室破裂死亡。胸骨正中切口組心功能較左胸前外側(cè)切口組明顯改善，中心靜脈壓較左胸前外側(cè)切口組降低，胸腔積液、肺炎和膿胸發(fā)生率均低于左胸前外側(cè)切口組（ P＜ 0.05）。隨訪 385例（胸骨正中切口組 231例、左胸前外側(cè)切口組 154例），隨訪時間 3個月～ 15年，心功能明顯改善，均恢復(fù)正常工作和學(xué)習(xí)。胸骨正中切口組縮窄性心包炎復(fù)發(fā) 4例，左胸前外側(cè)切口組復(fù)發(fā) 17例，均經(jīng)相應(yīng)的治療治愈或好轉(zhuǎn)。結(jié)論 心包剝脫術(shù)是治療慢性縮窄性心包炎的有效手段，胸骨正中切口徑路是外科治療慢性縮窄性心包炎最佳的手術(shù)徑路。
目的 總結(jié)慢性縮窄性心包炎的外科治療經(jīng)驗(yàn)。方法 78例患者術(shù)前均被明確診斷為慢性縮窄性心包炎，均在全身麻醉下經(jīng)胸部正中切口行心包剝脫術(shù)。結(jié)果 術(shù)后中心靜脈壓6.5～14.0mmHg（1kPa=7.5mmHg），平均8mmHg。死亡1例，再次開胸止血2例，發(fā)生低心排血量綜合征3例。術(shù)后病理檢查：心包纖維結(jié)締組織增生、玻璃樣變性60例，呈于酪樣結(jié)核病變18例（伴結(jié)核肉芽腫形成7例）。隨訪65例，隨訪時間3個月～10年，心功能（NYHA）均為I級，無心包縮窄復(fù)發(fā)和死亡。結(jié)論 手術(shù)是治療慢性縮窄性心包炎惟一有效的方法，胸部正中切口是較佳的手術(shù)徑路，心包切除范圍應(yīng)根據(jù)具體病情而定，力爭將心包徹底松解切除。
目的 探討血漿腎素 -血管緊張素系統(tǒng) (RAS)、一氧化氮 (NO)在心包炎病變過程中的變化及作用。方法 2 1只雄性家兔隨機(jī)分為兩組 ,實(shí)驗(yàn)組 :11只 ,心包腔內(nèi)注入 4 0 %尿素 ,2 ml/ kg;對照組 :10只 ,心包腔內(nèi)注入等量生理鹽水。分別于術(shù)前和術(shù)后 1、4、7、10、15、2 1天采血測定血漿腎素活性 (RA)、血管緊張素 (ANG )和 NO的濃度 ,觀察心包、心肌、肺和肝的病理改變?！〗Y(jié)果 術(shù)后實(shí)驗(yàn)組血漿 RA、ANG 和 NO濃度較術(shù)前均升高 ,術(shù)后 7～ 2 1天與對照組同時點(diǎn)比較差別具有顯著性意義 (Plt;0 .0 1) ;實(shí)驗(yàn)組兔心包增生增厚、心肌變性、肺淤血和肝淤血?！〗Y(jié)論心包炎病變過程中血漿 RAS、NO濃度均升高 ,一方面 NO與 RAS相拮抗 ,另一方面 NO和 RAS共同介導(dǎo)心包、心肌、肺、肝等器官的損傷。
Objective To estimate the relationship of methods and drugs for management of constrictive pericarditis during pericardiectomy. Methods We reviewed the records of 45 patients (mean age, 40.24±15.34 years) with a diagnosis of constrictive pericarditis who underwent pericardiectomy in our hospital from 2012 through 2014 year. During operation, inotropic agents, vasodilators and diuretics were used. According to the diuretics, patients were divided into two groups including a furosemide group(group F) with 38 patients and a lyophilized recombinant human brain natriuretic peptide (lrhBNP) group with 7 patients(group B). Results Preoperatively, 30 patients were pulmonary congestion, which was diagnosed by chest radiographs. Pericardiectomy was finished by off pump in 43 patients. Another 2 patients required cardiopulmonary bypass (CPB) for pericardiectomy. In the group F 52.6% of the patients needed vasodilators to reduce cardiac preloading following pericardiectomy. None of other vasodilators were used in the group B. After pericardiectomy, the fluctuation of systolic and diastolic pressure decreased significantly in the group B (P=0.01, respectively). In the group F, the fluctuation of diastolic pressure decreased significantly (P＜0.05). Low cardiac output was the most common postoperative problem. One patient accepted postoperative extracorporeal membrane oxygenation (ECMO) support. Postoperative poor renal function was found in 42.2% of the patients. Three of them needed hemofiltration. Postoperative poor renal function accompanied by poor hepatic function was found in 15.6% of the patients. One of them used dialysis and artificial liver. Three patients were respiratory failure with longer mechanical ventilation and tracheotomy. The overall perioperative mortality rate was 6.7% (3 patients). All patients, who died or used with hemofiltration, artificial liver and ECMO were found in the group F. Conclusion More stable haemodynamics after pericardiectomy may occur with using lrhBNP. lrhBNP may reduce postoperative major morbidity and mortality. Because of the small group using lrhBNP in our study, more patients using lrhBNP for pericardiectomy need to be studied.