於忠伟

[摘要] 目的 探討胸段硬膜外阻滞对扩张型心肌病心力衰竭的临床治疗价值。 方法 选择2015年1月～2017年6月浙江省湖州市德清医院收治的扩张型心肌病合并心力衰竭者80例，根据治疗方案分为对照组和观察组，各40例。对照组入组者实施常规内科保守治疗，观察组实施有创胸段硬膜外主观内穿刺并给予局部麻醉药，所有入组者观察时间点均以治疗疗程内为起点，比较干预后3 d，两组应激相关因子：血浆肾上腺素（E）及去甲肾上腺素（NE）水平变化；干预后1个月，超声心动图指标左室内径及左室射血分数变化；干预后1 d及干预后1周，两组脑钠肽（BNP）变化趋势。 结果 干预前两组血浆E及NE水平比较差异无统计学意义（P > 0.05），干预后3 d，两组血浆E及NE水平均显著低于干预前（P < 0.05），且干预后观察组血浆E及NE水平显著低于对照组（P < 0.05）。干预前两组超声心动图指标中左室内径及左室射血分数等比较，差异无统计学意义（P > 0.05）；干预后1个月，观察组超声心动图指标中左室内径及左室射血分数优于干预前，且干预后观察组超声心动图指标中左室内径及左室射血分数优于干预后对照组，差异均有统计学意义（P < 0.05）；干预前两组BNP水平比较差异无统计学意义（P > 0.05），两组干预后1 d及干预后1周，其BNP水平均低于干预前，干预后1 d及干预后1周，观察组BNP水平均显著低于同时间点对照组，差异均有统计学意义（P < 0.05）。 结论 针对扩张型心肌病合并心力衰竭患者，实施胸段硬膜外阻滞，对降低机体应激反应，延缓心肌扩张，改善心肌氧耗，促进心衰恢复有重要价值。

[关键词] 胸段硬膜外阻滞；扩张型心肌病；心力衰竭；超声心动图；应激反应

[中图分类号] R541.6 [文献标识码] A [文章编号] 1673-7210（2018）04（b）-0127-04

[Abstract] Objective To investigate the clinical value of thoracic epidural blockade for heart failure with dilated cardiomyopathy. Methods From January 2015 to June 2017， 80 cases with heart failure with dilated cardiomyopathy in Deqing Hospital in Huzhou City were selected and divided into control group and observation group， each group with 40 cases. The control group was received routine medical conservative treatment， the observation group were underwent invasive thoracic epidural subjective intrathecal anesthesia and local anesthesia. All patients were observed during hospitalization. All participants were observed at the time point within the course of treatment as a starting point， 3 days after intervention the two group with stress related factors： plasma levels of epinephrine （E） and norepinephrine （NE） were compared. One month after intervention， the echocardiographic parameters of left ventricular diameter and left ventricular ejection fraction changes were compared， one day and one week after intervention， brain natriuretic peptide （BNP） trends were compared also. Results There was no significant difference in plasma E and NE levels between the two groups before intervention （P > 0.05）. Three days after intervention， plasma E and NE levels in both groups were significantly lower than those before intervention （P < 0.05）. After intervention， the levels of plasma E and NE in the observation group were significantly lower than control group （P < 0.05）. Before the intervention， the left ventricular diameter and the left had no statistically significant difference （P > 0.05）. After intervention， the left ventricular ejection fraction and left ventricular ejection fraction of echocardiography in observation group were better than before intervention， and the left ventricular diameter and left ventricular ejection fraction of echocardiography in observation group after intervention were better than control group after intervention， the differences were statistically significant （P < 0.05）. There was no significant difference in BNP levels between the two groups before intervention （P > 0.05）. The levels of BNP in the two groups were lower than those before the intervention， the levels of BNP in observation group were significantly lower than those in control group， the differences were statistically significant （P < 0.05）. Conclusion For patients with dilated cardiomyopathy complicated with heart failure， the implementation of thoracic epidural block has important value in reducing stress response， delaying myocardial expansion， improving myocardial oxygen consumption and promoting heart failure recovery.

[Key words] Thoracic epidural block； Dilated cardiomyopathy； Heart failure； Echocardiography； Stress response

扩张型心肌病随着病程的延长，将可能出现心力衰竭，当患者出现交感神经兴奋性的增高、细胞及神经因子水平的改变而出现交感神经重构[1]。一旦发展为心力衰竭后将导致支配心脏交感与副交感神经水平的功能失衡，进一步加重冠状动脉阻力增加、血小板激活、血栓形成[2]，导致心肌再灌注损伤、钙离子超载等影响心脏稳定性的因素，导致心律失常甚至猝死发生[3]。扩……