【作者】 范秀双；

【导师】 韩树海；

【作者基本信息】 吉林大学 ， 临床医学， 2009， 硕士

【摘要】 扩张型心肌病(DCM)主要特征表现为左心室或双心室心腔扩大和收缩功能障碍,产生心力衰竭。DCM病因至今未明,目前尚缺乏有效而特异的治疗手段。1976年Hoar等首次报道胸段硬膜外阻滞(TEB)用于心脏手术后镇痛,效果满意。此后,世界各地相继开展了TEB在心血管系统方面应用的工作和研究,并取得了较好的疗效。但目前国内外关于TEB治疗DCM的报道较少。本研究旨在观察TEB对DCM患者临床症状、体征、心腔大小及心功能的影响,进一步探讨TEB对DCM的疗效,为DCM的治疗提供参考。应用TEB联合常规药物治疗DCM患者4周,同时配合单纯药物对照组比较,结果显示:治疗后,T组患者临床症状及体征明显好转。T组治疗有效率显著高于C组。心脏超声检查显示:T组FS、LVEF值较阻滞前明显增大(P<0.05);LVDD、RVDD、LA值较阻滞前明显减小(P<0.05);IVS、LVPW值较阻滞前增加(P>0.05)。C组FS、LVEF值较治疗前增加(P>0.05),LVDD、RVDD、LA值较治疗前减小(P>0.05);IVS、LVPW值较治疗前增加(P>0.05);两组间比较,T组FS、LVEF、LVDD、RVDD指标变化情况均较C组显著(P<0.05);T组LA、IVS、LVPW指标变化情况较C组略大(P>0.05)。提示TEB治疗DCM,临床效果较明显,可使心脏收缩功能显著提高,心腔明显缩小,有望为DCM治疗提供一种安全有效的治疗方法。更多还原

【Abstract】 Background: In 1976, Hoar first reported the application of high thoracic epidural blockade (TEB) for analgesia after cardiac surgery with satisfactory results.Since then, researches were carried out all over the world on the application of TEB in the cardiovascular system, and have achieved convincing and efficacy data. The effects of TEB on physiological function of patients with cardiovascular diseases:(1) Adjusting the function of cardiac autonomic nerve, inhibiting over-excitement of the sympathetic nervous, relieving microvascular spasm, increasing blood flow in ischemic site, reducing ischemic injury and improving myocardial energy metabolism.on the premise of not affecting coronary perfusion pressure, TEB can also lower heart rate, reduce pre- and post-load of left ventricle, thereby reduce myocardial oxygen.therefore, TEB increases the anti-ischemic capacity of myocardium by improving myocardial oxygen balance as well as redistributing myocardial blood flow. (2) Improving arrhythmia threshold, increasing the stability of cardiac electrophysiology, reducing arrhythmia and the death resulting from it. (3) improving the body’s hypercoagulable state ,lowering plasma fibrinogen levels and reducing the opportunities of thrombo-embolism formation. (4) no influence on the respiratory function. ( 5)On the premise of insuring coronary perfusion pressure, TEB can inhibit stress response, lower elevated norepinephrine, epinephrine, adrenocorticotropic, cortisol and other stress hormone levels, expand coronary artery effectively to improve myocardial blood supply. Also ,it can reduce the elevated serum TNF-αand IL-6 levels in DCM patients, reduce their toxic effects on the body, to put an end to the vicious cycle and improve the prognosis. (6) Reversing ventricular remodeling, narrowing expanding cavity. (7) improving cardic function, improving exercise tolerance and bettering life quality .Dilated cardiomyopathy (DCM) is characterized by left ventricular or double ventricular dilation and systole function has been damaged. Etiology can be idiopathic, familial / genetic, viral and (or) immune, alcoholic / toxic, or that associated with known cardiovascular disease of which myocardial dysfunction degree can not be explained by abnormal load or the level of myocardial ischemia. The symptom usually shows proeeeding heart failure, arrhythmia, thromboembolism and sudden death, which can occer at any time.In recent ten years, the incidence of DCM is increasing, 5-10/10 million per year, with an average age of about 40 years old. Patients with DCM have poor prognosis in the event of heart failure, which has been reported that 5-year follow-up mortality was 35%, 10-year follow-up mortality was 70%. At present, there is no effective and specific remedy for DCM. Angiotensin-converting enzyme inhibitor,β-receptor blocker, pacing therapy, and so forth which has been used in the treatment did not receive ideal effects. Heart transplantation can be considered for patients with long-term heart failure, for whom medical treatment considered noneffective, however, such facts like donor shortage, high cost, rejection and others have severely limited the wide application of this technology. Since the beginning of the 20th century, 90’s, Fengqi Liu and other scholars have shown that TEB has good efficacy to DCM through a preliminary study,providing a new way of thinking and dealing.In this study, comparing with the conventional treatment group ,we studied the impact of TEB combined with conventional drugs on DCM patients’symptom,sign, cardiac function and cavities, to observe its effect on DCM.Objective:To observe the effect of TEB on DCM.Methods:Forty patients with DCM were selected as subjects. All patients were randomly divided into 2 groups: TEB group (T group, n =20) and conventional treatment group (C group, n = 20). Patients in T group was administered with continuous TEB by intermittent injection of 0. 5% lidocaine in addition to routine medicinal therapy. Patients in C group was administered with routine medicinal therapy. Left ventricular ejection fraction (LVEF), FS (fractional shortening), LVDD (left ventricular diastolic diameter), RVDD (Right ventricular diastolic diameter), LA (Left atrium diameter), IVS (interventricular septum) and LVPW (left ventricular posterior wall) were measured by echocardiography before and 4 weeeks after treatment and the data were compared. Results:1. There were no significant differences in background data between two groups.2. Clinical sign and symptom: 4 weeks after treatment, the patients’sympto- ms in T group were rapidly improved; Palpitations, shortness of breath, chest tightness and other symptoms were alleviated in 5-10 minutes after epidural administration, lower extremity edema gradually relieved, urine gradually increased, hepatomegaly mitigated, appetite improved, wet lung rale decreased to disappear, the capacity of activity enhanced. Comparing with T group, the patients’symptom in C group was not improved so significantly . The treatment efficiency in T group was significantly higher than that in C group (P <0.05).3. Echocardiography results: (1) Four weeks later, in T group, FS and LVEF increased significantly comparing with the data before treatment(P<0.05); LVDD、RVDD and LA were significantly reduced comparing with the data before treatment(P<0.05); IVS and LVPW increased comparing with the data before treatment, however, there were no statistically significant differences (P >0.05); (2) Four weeks later, in C group, comparing with the data before treatment,FS and LVEF increased,LVDD、RVDD and LA were reduced, IVS and LVPW increased, however,there were no statistically significant differences (P >0.05) in all these data; (3) Four weeks later, There was much more improvement of FS、LVEF、LVDD and RVDD in T group than that in C group, there were statistically significant differences (P < 0.05); LA、IVS and LVPW in T group improved more obviously than in C group, however, there were no statistically significant differences(P >0.05). Conclusion: TEB combined with conventional drugs has remarkable clinical effect on DCM.It could improve cardiac systolic function and narrow heart cavity significantly, which provides a safe and effective treatment for DCM.更多还原