2005年 · 第118卷第21期

Hypertension has currently become a centennial epidemic and key public health problem in China. According to an investigation among 15 540 adults from 2000 to 2001 by Gu and co-workers,1 the prevalence of hypertension among people aged 35 to 74 years has reached 27.2%, ranking among the highest rates of hypertension in the world and putting the blood pressure (BP) of nearly 130 million Chinese adults above the normal level。

Abstract：Background　Quantitatively assessing myocardial perfusion and its reserve is of great importance for the diagnosis and stratification of patients with coronary artery disease (CAD), and represents an important goal of myocardial contrast echocardiography. In this study we sought to test the usefulness of low dose dobutamine stress real-time myocardial contrast echocardiography (RT-MCE) in the assessment of CAD, and to explore the relationship between perfusion reserve and contractile reserve.Methods　Twenty-six patients with suspected or clinical diagnosed CAD were enrolled and underwent RT-MCE at baseline and under low dose dobutamine stress, and subsequent coronary angiography. RT-MCE images were analyzed quantitatively from microbubble replenishment curves for myocardial perfusion and its reserve. Results　At baseline, significant differences in beta (0.28±0.12, 0.25±0.09, 0.22±0.06, 0.20±0.07 respectively, P＜0.01) and A×beta (1.37±0.46, 1.28±0.47, 1.13±0.37, 0.91±0.32, respectively, P＜0.01) were observed among four segment groups with graded coronary artery stenosis severity (normal; 30%-69% stenosis; 70%-90% stenosis; and beyond 90% stenosis), but not observed in parameter A. When under stress, significant differences in A (5.73±1.28, 5.63±1.01, 4.96±0.81, 4.57±0.62, respectively, P＜0.01), beta (0.67±0.17, 0.55±0.19, 0.32±0.13, 0.25±0.08, respectively, P＜0.01) and A×beta (3.81±1.20, 3.11±1.17, 1.59±0.82, 1.12±0.37, respectively, P＜0.01) were observed among the formerly mentioned groups. Graded decreases in A reserve (1.20±0.53, 1.11±0.16, 0.98±0.12, 0.99±0.13, respectively, P＜0.01), beta reserve (2.65±1.07, 2.32±0.82, 1.44±0.40, 1.29±0.34,respectively, P＜0.01) and A×beta reserve (3.05±1.63, 2.59±1.01, 1.42±0.44, 1.27±0.34, respectively, P＜0.01) could also be observed with increasing coronary stenosis severity. In five segments groups scored by WMS (1-5), concordance between contractile function and myocardial perfusion could be found both at rest (beta: 0.28±0.11, 0.22±0.08, 0.21±0.05, 0.17±0.05, 0.19±0.06, respectively, P＜0.01; A×beta: 1.29±0.48, 0.98±0.45, 0.94±0.29, 0.76±0.30, 0.92±0.32, respectively, P＜0.01) and under stress (beta: 0.59±0.20, 0.35±0.15, 0.27±0.08, 0.17±0.05, 0.20±0.05, respectively, P＜0.01; A×beta: 3.07±1.38, 1.62±0.82, 1.28±0.40, 0.78±0.24, 0.93±0.22, respectively, P＜0.01). This concordance is also valid in terms of the reserves, and the MCE parameters in segments with ameliorated contractile function are significantly higher than in those without. Conclusions　Quantitative RT-MCE in conjunction with dobutamine stress shows promise in identifying and stratifying CAD and in exploring the perfusion-contractile correlation.

Abstract：Background Recurrent atrial tachyarrhythmia (ATa) after circumferential pulmonary vein ablation (CPVA) includes atrial tachycardia (AT) and atrial fribrillation (AF). However, whether there are some differences in clinical course and mechanisms between the recurrent AT and the recurrent AF remained unclear. This study was conducted to investigate the incidence, mechanism, clinical course of the recurrent AT and AF in patients under CPVA.Methods One hundred and thirty consecutive patients (M/F=95/35) with highly symptomatic and multiple antiarrhythmic drugs (AADs) refractory paroxysmal (n=91) or persistent (n=39) AF were included. The ablation protocol consisted solely of two continuous circular lesions around the ipsilateral pulmonary veins (PV) guided by CARTO system. The endpoint of CPVA is PV isolation. For patients with recurrent ATa within 2 months after the initial procedure, cardioversion with direct current was attempted if the ATa lasted for more than 24 hours. A repeat ablation procedure was performed only for patients with AADs refractory recurrent ATa and at least followed up for 2 months after the initial procedure.Results Within 2 months after the initial procedure, 52 patients (40.0%) had experienced episodes of symptomatic recurrent ATa. Among them, 23 patients (44.2%) with recurred AT alone (AT group), 14 patients (26.9%) with recurred AF alone (AF group), and 15 patients (28.8%) with recurred AT and AF (AT plus AF group). The delayed cure rate (65.2%) in AT group was significant higher than that in AF group (21.4%, P<0.05) and AF plus AT group (26.7%, P<0.05). A repeat ablation was performed in 21 patients, including 6 patients with recurrent AT alone, 8 patients with recurrent AF alone, and 7 patients with recurrent AF plus AT. The mean number of PV gaps was 1.2±0.4 in AT group, which was significantly lower than that in AF group (2.6±0.7, P<0.05) and AF plus AT group (2.0±0.6, P<0.05). Delayed cure rate and number of PV gaps between AF group and AF plus AT group were comparable (P>0.05).Conclusions Present study indicates that recurrent AT and AF after CPVA have the different clinical course and different electrophysiological findings during repeat procedure as follows: ⑴After CPVA, spontaneous resolution of recurrent ATa was mainly found in patients with recurrent AT alone (about two thirds patients). ⑵The type of recurrent ATa after CPVA is associated with the number of PV gaps。

Abstract：Background Effect of percutaneous transluminal septal ablation (PTSA) with ethanol injection on electromechanical remodeling of left ventricule still remains unknown. This study was conducted to assess the potential significance of cardiac electromechanical mapping (CEMM) in analyzing the left ventricular remodeling before and immediately after percutaneous transseptal myocardial ablation (PTSMA) in patients with hypertrophic obstructive cardiomyopathy (HOCM).Methods Eight patients with drug-refractory HOCM and 6 patients with hypertrophic cardiopathy (HM) without increased left ventricular outtract gradien (LVOTG) were enrolled into the present study. CEMM was undergone in patients with HOCM before and immediately after PTSA procedure, and in patients with HM. Results PTSA was successful in all patients with HOCM, LVOTG significantly decreased from (62.87±21.16) mmHg to (12.73±3.05) mmHg immediately after ablation procedure. Value of UVP in septal-base segment in HM group was higher than that in HOCM group [(22.79±2.34)mV vs (18.54±1.76)mV].In patients with HOCM, lateral-middle and -base segments had lowest value of UVP [(15.93±1.11) mV and (15.83±1.07)mV] before PTSA. Value of UVP at posterior-middle segment decreased from (23.58±2.21)mV pre-PTSA to (18.89±1.91)mV post-procedure, PTSA led to significant increase of UVP at lateral-middle segment. Septal region in patients with HM and septal-middle, septal-base, posterior-base segments in HOCM had lower value of local linear shortening (LLS) among all patients in both HOCM and HM groups. PTSA resulted in significant reduction of LLS in anterior region and at septal-apex segment. Anterior-base and septal-middle segments in patients with HM had lowest value of local active time (LAT), and significantly differentiated from that in patients with HOCM [(-8.57±0.68)ms vs (-18.61±1.02)ms, (-6.75±0.37)ms vs (-21.90±0.96)ms, respectively].LAT at septal-middle and -base segments in patients with HOCM was decreased significantly [(-21.90±0.96)ms vs (-13.80±1.04)ms, P<0.002; and (-15.20±1.06)ms vs (-6.33±0.52)ms, respectively] immediately after PTSA.Conclusions Posterior-lateral and anterior region probably played important roles in electromechanical remodeling. Significant electromechanical remodeling disassociation (uncoupling) was detected in most left ventricular regions, which would be important in differentiating of HOCM from HM, and in predicting the prognosis in patients with HOCM after PTSA procedure.

Abstract：Background Although some certain infectious pathogens could be detected in the patients with coronary artery disease, the roles of these infectious factors in the development of coronary artery diseases remain largely unknown. Since the number of infectious pathogens has been argued to be relative to the coronary artery diseases, we therefore examined whether there is a link between the number of infections and the incidence of in-stent restenosis after stent implantation.Methods One hundred and eighty-one patients were enrolled in this study. Infectious pathogens including serum anti-Chlymydia pneumoniae, cytomegalovirus, Helico pylori, human herpes simplex virus-1, human herpes simplex virus-2 antibodies and hepatitis B virus antigen were measured in all patients before coronary stent implantation. Coronary angiography was performed before, immediately after and 6 months after stent implantation. Results Restenosis rate 6 months post stent implantation was similar in patients with low pathogen burden (<3 pathagens, 33.3%) to those with high pathogen burden (≥3 pathogens, 29.1%). Conclusions Previous infections with Chlymydia pneumoniae, cytomegalovirus, Helico pylori, human herpes simplex virus-1, human herpes simplex virus-2 and hepatitis B virus do not contribute to the incidence of restenosis after stent implantation.

Abstract：Background Foetal echocardiography has become a diagnostic method to detect foetal congenital heart disease with high probability. However, it is not only time consuming and but also difficult to visualize outflow tract of foetus early in the second trimester of pregnancy, even for an experienced obstetric ultrasonographer. Recently, many methods for screening foetal cardiac anomalies were explored, but much more work is needed to develop an effective and suitable screening method. The aim of this study was to investigate the clinical significance of utilising the ductus venosus (DV) Doppler examination and the four-chamber view of heart to screen for foetal cardiac malformation in early second trimester of pregnancy.Methods Heart and DV of 401 consecutive foetuses in early second trimester (12+1-17+6 weeks) in high risk pregnancies were examined with Acuson 128 xp/10 or Sequoia 512 ultrasound diagnostic systems. Absent or reversed flow during atrial contraction (A-wave) in the DV was defined as sufficiently abnormal to screen for foetal cardiac malformations. The foetal echocardiographic diagnosis was confirmed by postnatal echocardiography (or postmortem). The sensitivities of screening tests were compared among the three methods: DV Doppler examination, four-chamber view alone, and the combination of both techniques.Results Satisfactory examinations were obtained in 383/401 foetuses (95%). Thirty foetuses with cardiac abnormalities were confirmed by neonatal echocardiography (or postmortem). The sensitivity of DV Doppler examination or four-chamber view alone is 63 % ( 19/30) and 60 % ( 18/30), respectively. The sensitivity of combining information, DV Doppler flow waveform and four-chamber view, to screen for foetal cardiac malformation is 83% (25/30) and significantly better than that of either DV Doppler flow waveform or four chamber view alone (P<0.05).Conclusion Doppler flow waveform of DV can be used to screen for foetal cardiac malformation early in the second trimester. Combining information from Doppler flow waveform of DV and four-chamber view will improve the overall sensitivity of the screening。

Abstract：Background The ADRA2B gene insertion/deletion (I/D) polymorphism is associated with various cardiovascular and metabolic phenotypes. Large (C1) and small (C2) artery compliance, assessed by pulse wave analysis, is considered as sensitive markers or risk factors for cardiovascular disease. Therefore whether the ADRA2B I/D polymorphism is associated with C1 and C2 need to be investigated. Methods A total of 227 men and 243 women were enrolled in a Chinese family-based study. C1 and C2 were measured by pulse wave analysis. ADRA2B genotypes were determined by polymerase chain reaction. Statistical methods included generalized estimation equations and quantitative transmission disequilibrium test.Results The II (31.9%), ID (46.8%) and DD (21.3%) genotype frequencies were in Hardy-Weinberg equilibrium (P=0.73). The covariates selected by stepwise regression for C1 and C2 were age, systolic pressure and gender. The population based association analysis showed that C1 and C2 were not associated with ADRA2B genotype both before (C1: P=0.28; C2: P=0.27) and after (C1: P=0.58; C2: P=0.18) the adjustment. The family-based analyses of 128 informative offspring showed that transmission of the D-allele was not associated with C1 or C2, both before (C1: P=0.42; C2: P=0.85) and after (C1: P=0.31; C2: P=0.82) the adjustment.Conclusion The study do not support that the ADRA2B gene I/D polymorphism has a major gene effect on C1 or C2 in the Chinese population of current sample size。

Abstract：Background Resection of tumors arising from the tongue base and the parapharyngeal space is difficult for exposure and manipulation because of their obscure location. The aim of this study was to evaluate the surgical approach of the pre-mental foramen mandibulotomy for resecting the tumors of tongue base and parapharyngeal space.Methods Fifty-one patients with tumors of tongue base and parapharyngeal space were treated using the mandibulotomy approach on the pre-mental foramen. In the present study, this technique was described in detail. The patients were followed up for three months to six years with a mean of 26 months. Results The tumors of tongue base and parapharyngeal space could be exposed clearly and be resected radically by surgical approach of pre-mental foramen mandibulotomy. The surgical complications were reduced. Conclusions Compared to other surgical approaches, such as lateral mandibulotomy, midline mandibulotomy, the suprahyoid parapharyngeal approach, and paramedian mandibulotomy, we found that the pre-mental foramen mandibulotomy is the ideal choice for resecting the tumors of tongue base and parapharyngeal space。

Abstract：Background Coma after cardiopulmonary resuscitation (CPR) is commonly seen in daily clinical practice. How to objectively evaluate brain function after CPR is essential to the following treatment. Coma patients after CPR had been studied prospectively at the Neuro-Intensive Care Unit of Xuanwu Hospital since 2002. In this study, we focused on the topic of how to evaluate the severity of coma after CPR .Methods From April 2002 to November 2004, patients in coma 24 hours after CPR were monitored, the evaluation methods included Glasgow coma score (GCS),brain stem reflection, and spinal reflection. Laboratory evaluation included electroencephalography (EEG),brainstem auditory evoked potential (BAEP), short latency somatosensory evoked potential (SLSEP), and transcranial Doppler (TCD) .Results Twenty-four of 35 patients(68.57%)were in deep coma. The GCS was 3 except for 2 patients;EEG was evaluated not less than grade Ⅳ except for 4 patients, BAEP was evaluated as grade Ⅲ except for 3 patients, and SLSEP was evaluated as grade Ⅲ except for 1 patient.Twenty-four patients died within 1 month and 11 of them(45.83%)were determined as brain death. Glasgow outcome score (GOS) was evaluated as grade Ⅰ. Eleven of the 35 patients survived and their consciousness changed from deep coma to coma vigil. EEG was evaluated as gradeⅠin 5 patients, BAEP and SLSEP were evaluated as grade Ⅰ in 3 patients, and GOS was all evaluated as grade Ⅱ among the 11 patients.Two patients(18.18%)regained consciousness in 35 and 90 days after cardiopulmonary resuscitation and GOS was evaluated as grade Ⅳ and Ⅲ, respectively.Conclusion Combined or continuous evaluation of clinical examinations and laboratory tests can accurately and objectively determine brain function after CPR。

Abstract：Background Although transient ischemic attacks (TIA) is a clinical diagnosis, imaging findings are important for its diagnosis and treatment. This study evaluated the value and limitations of conventional CT, CT cerebral perfusion imaging and transcranial Doppler sonography (TCD) in patients with TIA.Methods Conventional CT, CT cerebral perfusion imaging and TCD were performed in 20 patients with TIA. After regular CT examination, 40-second dynamic scans were performed on selected slice, while 40 ml of non-ionic contrast materials was bolus-injected through antecubital vein with power injector. These dynamic images were processed with the perfusion software package on workstation. Cerebral blood flow (CBF) and time to peak (TTP) were measured in specific regions of the brain. TCD was also performed in 20 patients with TIA. Comparative analysis was made on the basis of the results of conventional CT, CT cerebral perfusion imaging and TCD. Results In the 20 patients with TIA, conventional CT turned out to be normal. However, persisting abnormal perfusion changes corresponding to clinical symptoms were found in 13 cases with the prolonged TTP. The other 7 cases were normal. TTP of the affected side (11.6±3.0)s was significantly prolonged (t=4.782,P<0.01) in comparison with the contralateral side (8.8±1.5)s. The difference in CBF was not statistically significant (t=1.912, P=0.073) between the affected side [(223.9±19.6) ml*min-1*L-1] and the contralateral side [(227.7±19.8) ml*min-1*L-1] . TCD revealed severe stenosis or occlusion of the carotid artery in 10 patients, arteriosclerosis in 6 patients, blood speed decrease in 2 patients, vasospasm in 1 patient. Conclusions Conventional CT can exclude intracerebral diseases. Perfusion CT provides valuable hemodynamic information and shows the extent of perfusion disturbances. TCD can demonstrate abnormalities of the involved arteries in patients with TIA. The combination of these three imaging methods can provide more diagnostic information.Conclusions Conventional CT can exclude intracerebral diseases. Perfusion CT provides valuable hemodynamic information and shows the extent of perfusion disturbances. TCD can demonstrate abnormalities of the involved arteries in patients with TIA. The combination of these three imaging methods can provide more diagnostic information。

Although atherosclerosis has been considered to be multi-factorial disease in which genetic, environmental, metabolic factors have been implicated, the gaps remain in our knowledge of the etiopathogenesis of atherosclerosis. There is mounting evidence that inflammation plays an important role in the initiation, development as well as evolution of atherosclerosis, suggesting that atherosclerosis is an inflammation disease.1,2 Although triggers and pathways of inflammation are probably multiple and different in different clinical settings, the data from animals as well as humans including our groups indicated that an inflammatory process was involved in all stages of atherosclerosis appeared in different clinical entities.

The term vulnerable patient has been proposed to define subjects susceptible to an acute coronary syndrome (ACS) or sudden cardiac death based on plaque characteristics, blood abnorma-lities, or myocardial vulnerability.1 It will be important in the future to identify both vulnerable patients and vulnerable plaques. Atherosclerotic arteries obtained at autopsy from patients who died suddenly of cardiac causes indicate that pregnancy-associated plasma protein-A (PAPP-A) was abundantly expressed in plaque cells and in the extracellular matrix of ruptured and eroded unstable plaques, but not in stable plaques.2 Here we examined circulating PAPP-A levels in patients with ACS in order to evaluate its potential use in identifying vulnerable patients.

Animal experimental systems are particularly useful for the study of human breast cancer.1,2 An ideal model should be easy to use, closely mimicking human physiopathology and has a stable tumor morbidity. The cell line MA891 was established from a spontaneous TA2 mouse mammary carcinoma by Cancer Institute of Chinese Academy of Medical Sciences.3 Some researches indicated that MA891 had a very low immunogenecity and maintained a high metastatic potential in vivo. So it has been used as a better grafted mouse tumor model for studying cancer physiopathology and metastasis in human for years. However, about the biological characteristic and the histopathologic feature of this model there has been a lack of investigations.

Digestive tract hemorrhage is a common disease of the digestive system, but about 0.4%-5% intestinal bleeding can not be detected with gastroscope or colonscope.1 Since the intestine is long, tortuous, far away from both ends of the digestive tract and unfixed in position, clinical diagnosis of the bleeding is relatively difficult. Yamamoto and Sugano2 reported the clinical application of double-balloon enteroscope at American DDW in 2003。

Ventricular septal defect (VSD) is one of the most common congenital heart malformation. As an isolated lesion, it accounts for 20%-30% of patients with congenital heart disease.1 Eighty percent of these defects are perimembranous involving the membranous septum and the adjacent area of muscular septum. At least 80% of these defects are small and close spontaneously,2,3 the larger defects often persist to cause significant shunt and right ventricular hypertension. Although conventional surgical repair of perimembranous ventricular septal defects (PMVSDs) is a safe, widely accepted procedure with negligible mortality. It is associated with morbidity, discomfort and a thoracotomy scar.1 As an alternative to surgery, a variety of devices for transcatheter closure of VSD have been developed. However, these devices were not specifically designed for this purpose and none has gained wide acceptance. Large delivery sheaths, inability to recapture and reposition, structural failure, dislodgement and embolization of the device, interference with the aortic valve resulting in aortic insufficiency and a high rate of residual shunting are the major limitations of the previously described techniques.2,3 The initial experiences with transcatheter closure of PMVSDs in patients with a new device that was especially designed for non-surgical occlusion of these defects, the Amplatzer asymmetric VSD occluder (AAVSDO, AGA Medical Co., USA) were encouraging.4-6 But the long-term results are not known.

Lutembacher syndrome, a combination of congenital atrial septal defect (ASD) complicated by acquired mitral stenosis,1 has been traditionally treated by open-heart surgery.2 With the introduction of transcatheter closure of ASD3 and percutaneous balloon mitral valvuloplasty,4 then Lutembacher syndrome can be treated percutaneously. Percutaneous management of Lutembacher syndrome can obviate the morbidity and mortality associated with cardiac surgery, the psychological trauma of a thoracotomy scar and the possibility of repeat thoracotomy for mitral restenosis. So the technique may be ideal for treatment of Lutembacher syndrome.

Although unilateral spatial neglect, global processing deficit, or prosopagnosia following brain damage has been usually reported separately, to our knowledge, a report on a patient with the three mentioned syndromes has not been reported. We now present a case that developed unilateral spatial neglect, global processing deficit and prosopagnosia after right hemisphere stroke in September 2004.