2009年 · 第122卷第18期

Bifurcation lesions, one of the complex coronary lesion subsets, are usually encountered in around 15%-25% of patients during percutenous coronary intervention (PCI). The treatment of stenoses at a bifurcation poses an ongoing challenge for the interventional cardiologists1-3 as PCI for bifurcation lesions is associated with the reduced procedural success rate and increased angiographic restenosis, especially in the side branch, or even portends a potentially negative impact on long-term clinical outcomes. 4,5

Abstract：Background The mechanisms responsible for the occurrence of a kissing unsatisfied (KUS) result after classical crush stenting remain unclear. The present study aimed at analyzing the mechanisms and clinical significance of KUS. Methods Two hundred and thirteen patients with true bifurcation lesions treated with classical crush stenting and final kissing balloon inflation (FKBI) were assigned to upper, middle, and lower groups according to the position of the side branch re-wiring assessed by visual estimation, quantitative coronary analysis (QCA) and intravascular ultrasound (IVUS). Angiographic follow-up was indexed at 12 months.Results The upper group was characterized by a larger bifurcation angle of 55.53°±95.25° (P=0.030) and a longer procedural time (42.43±93.92) minutes (P=0.015). The overall rate of KUS by visual estimation was 10.48%, with 5.4% in the upper group, 3.9% in middle group, and 36.1% in lower group (P <0.001). For the diagnosis of KUS, visual inspection demonstrated a good correlation with both QCA and IVUS. Smaller stent diameter was the main reason for KUS in the upper group, while extra-stent side wire location, or re-wire in a low position was the main mechanism attributed to KUS in the lower group. The Lower group had more restenosis, with most restenotic lesions at a lower position of the side branch ostium. KUS (HR 1.652, 95% Cl 1.332-2.088, P <0.001) and re-wiring position (HR 2.341, 95% Cl 1.780-4.329, P <0.001) were two independent predictors of side branch restenosis. Re-wiring position (OR 0.458, 95%Cl 0.336-0.874, P=0.001) and side stent expansion (OR 3.122, 95%Cl 2.883-5.061, P=0.014) were factors predicting the findings of KUS.Conclusions Side wire outside side stents resulted in more KUS and restenosis. Different restenotic lesion types reflected individual mechanisms contributing to the development of plaque proliferation。

Abstract：Background The radial artery is currently regarded as a useful approach for coronary intervention procedures. Adequate anatomical information of the radial artery should be helpful in performing transradial coronary procedures. Few data about the Chinese population have been obtained in this field. Therefore, we tried to evaluate the incidence and clinical significance of anomalous patterns, and their influence on the intervention procedure.Methods In an estimated sample of 3000 cases, radial artery and subclavical artery angiography were performed after insertion of the sheath and coronary angiography (CA). The evaluable data including branch anomaly, tortuosity of the radial artery and procedural characteristics were analyzed. The procedure success was defined as CA or percutaneous coronary intervention (PCI) completed with the initial radial artery approach without changing to other routes.Results In this study, 1897 cases of CA was undertaken and 1103 cases of CA combined with PCI were performed.The success rate of transradial intervention (TRI) was 96.6% (2899/3000). The approach in 44 cases was changed to the contralateral radial artery and 57 cases were changed to the brachial artery or femoral artery due to failure with the initial radial artery approach. The angiography of the upper limb artery was performed in all cases. Anatomic variations of upper limb arteries were noted in 610 patients (20.3%), which included tortuous configurations of the radial artery (5.0%), hypoplasias (2.2%), radioulnar loop (1.1%), abnormal origin of the radial artery (7.7%), stenosis of radial artery (1.4%), a tortuous configuration of the brachial artery (0.9%), a tortuous configurations of the subclavian artery (1.9%), lusoria subclavian artery (0.1%), and subclavian artery occlusion (0.03%). The procedural success rate in the normal population was higher than in the variation group (97.6% vs 93.0%, P<0.001). In addition, other procedural outcomes and incidence of complications except radial artery occlusion were also significantly superior to variation group.Conclusions Anatomic variations of the radial artery were common, making up an important limitation in the trans-radial approach. Selection of appropriate instruments and understanding some tips and tricks were helpful to overcome the obstacles and effectively reduce the learning curve。

Abstract：Background Brachial-ankle pulse wave velocity (baPWV) is a reliable method for measuring arterial elasticity, but the absence of reference value for baPWV has limited its wide use. We conducted an epidemical study in north China to investigate the reference value of baPWV for Chinese people and its influential factors.Methods A total of 974 identified healthy subjects were recruited in this study. The values of baPWV were evaluated noninvasively with an automatic device.Results For healthy population, the mean value of baPWV was higher for male (P <0.001). Multiple regression analysis demonstrated that both age and systolic blood pressure were positively associated with baPWV for male and female (P <0.001). BaPWV value was higher in male than in female in younger group (<50 years) but not in older group (P≤0.001). The upper limits of baPWV were 1394/1264 cm/s, 1435/1361 cm/s, 1552/1433 cm/s, 1597/1609 cm/s and 1798/1915 cm/s for healthy male/female at 10 years interval (age range 20-70 years).Conclusions Aging is the most important reason of arterial stiffness, but the effect of age on baPWV augmentation is greater for healthy female than their male counterpart. The reference values of baPWV by sex and age are very useful for clinical and preventive medicine。

Abstract：Background The time of onset of myocardial infarction shows seasonal and daily variation. We aimed to investigate whether the number of hours with daylight has an effect on the seasonal variation of heart attack, and whether the time of sunrise has an effect on the diurnal rhythm of myocardial infarction.Methods We carried out a retrospective database study covering all patients admitted to any acute care hospital with the diagnosis of myocardial infarction in Hungary between January 2004 and December 2005 (n=32 329). Data were collected from the National Health Insurance Fund Administration (OEP) according to the International Classification of Diseases (ICD 121,122) and National Meteorology Service (OMSZ). In case of patients who occurred in the database several times the events have been considered as a separate case.Results With consideration to seasonal variation, the peak period of heart attack was found in the spring, with the lowest number of events in the summer. The number of hours with daylight showed a weak negative correlation with the occurrence of myocardial infarction (r=-0.108, P <0.05). With respect to diumal variation, the peak period of daily events was between 6-12 in the morning (35.57%). We have found a positive correlation between the time of sunrise and sunset and the occurrence of myocardial infarction (P<0.01).Conclusion Based on our findings, the number of hours with daylight and the time of sunrise may be connected with the chances of having heart attack; however other factors, such as high blood pressure, diabetes or smoking may also have an influence。

Abstract：Background The breathhold contrast-enhanced three-dimensional magnetic resonance angiography (MRA) using T1-weighted gradient-echo imaging sequence is the standard technique for MRA of the thorax. However, this technique is not desirable for certain patients with respiratory insufficiency, serious renal impairment, or allergy to contrast agents. The objective of this study was to optimize and evaluate a non-contrast-enhanced free-breathing pulmonary MRA protocol at 3 Tesla.Methods The time-of-flight protocol was based on a two-dimensional T1-weighted turbo field echo sequence with slice-selective inversion recovery and magnetization transfer preparation together with respiratory navigator gating, cardiac gating, and parallel imaging. Optimal values for time of inversion delay, flip angle and slice thickness were experimentally determined and used for all subjects.Results Excellent pulmonary MRA images, in which the 7th order branches of pulmonary arteries could be reliably identified, were obtained in the 12 free-breathing healthy volunteers. TI of ～300 ms provides the best suppression of background thoracic and cardiac muscles and effective inflow enhancement. With increasing flip angle, the pulmonary vessels gradually brightened and exhibited optimal contrast at 20°-30°. The 2 mm slice thickness and 0.5 mm slice overlap is suitable for visualization of the peripheral pulmonary vessel.Conclusions The MRA protocol at 3 Tesla may have clinical significance for pulmonary vascular imaging in patients who are not available for contrast-enhanced 3D MRA and CT angiography examination or are unable to sustain a long breath-hold。

Abstract：Background The genetic variations in VKORC1 modulate the stable responses to warfarin administration. But the role of VKORC1 polymorphisms during the initial anticoagulation and elimination period in the Han Chinese population is not clear.Methods Twenty-four healthy Chinese volunteers were grouped according to their VKORC1 genotype. Twelve subjects were in the 3 mg group and 12 in the 6 mg group. VKORC1 genotypes were determined by a polymerase chain reaction (PCR) based restriction fragment length polymorphism (RFLP) assay and sequencing. The international normalized ratio (INR) was measured with an ACL9000 coagulation analyser. Plasma free warfarin concentration was measured with LC/MS/MS.Results In the initial anticoagulation period, the -1639AG and 1173TC carriers compared with the -1639AA and 1173TT carriers had a low INR value. The differences between genotypes with regard to INR values were more obvious in the 3 mg subjects (P<0.05), and were not significantly different among the 6 mg subjects (P >0.05). On the contrary, no significant difference of plasma free warfarin concentration between genotypes was observed in each dosage group. It took 96 hours for the INR value and 144 hours for the free warfarin plasma concentration to come back to baselines after the last dose. No significant difference among genotypes and dosing groups was detected in the elimination phase (P>O.05).Conclusion VKORC1 polymorphisms are associated with differences in the initial response to warfarin when given at fixed doses, without affecting, as expected, its plasma concentration。

Abstract：Background Macro- and microvascular diseases are the leading cause of morbidity and mortality in diabetic patients, but their mechanisms remain unclear. Recent reports provide evidence that the levels of CD55 and CD59 are decreased in diabetic microvascular diseases. However, very little is known about the levels of CD55 and CD59, the relationship between them and carotid artery intima-media thickness, and the effects of statins on CD55 and CD59 in diabetic macrovascular diseases.Methods The mean fluorescence intensity (MFI) of CD55 and CD59 expression on peripheral blood leucocyte subsets (lymphocytes, monocytes and neutrophils) was studied using flow cytometry, and carotid artery intima-media thickness was measured using B-mode ultrasonography in 23 healthy subjects (controls), 19 patients with type 2 diabetes (T2DM), and 43 patients with type 2 diabetes and macrovascular diseases (T2DM-M). The patients with T2DM-M were assigned to two subgroups based on whether statins were used: group with statins (n=23) and group without statins (n=20).Results Compared with the controls and T2DM, the MFI of CD55 positive neutrophils was significantly lower in T2DM-M (P=0.049 vs controls and P=0.033 vs T2DM); similarly, the MFI of CD59 positive monocytes was also lower in T2DM-M (P=0.038 vs controls and P=0.043 vs T2DM). The MFI of CD59 positive neutrophils in T2DM-M was lower than in T2DM (P=0.032). The levels of CD55 and CD59 were negatively associated with age and blood pressure (r=-0.245--0.352, P=0.041-0.003), but not acute-phase reactants and carotid artery intima-media thickness. The levels of CD55 and CD59 increased after treatment with statins, but the results were not significantly different (P >0.05).Conclusions CD55 and CD59 expressions on peripheral blood leucocytes are decreased in T2DM patients with macrovascular diseases. The results suggest that the decreased levels of complement regulatory proteins might play an important role in diabetic macrovascular diseases。

Abstract：Background The response of patients with chronic hepatitis B (CHB) to antiviral therapy against hepatitis B virus (HBV) is related to the base line level of HBV DNA, but the mechanism is not clear. The present study aimed to understand the possible relationship between the level of HBV DNA and HBV-specific, nonspecific cytotoxic T lymphocytes (CTL) and natural killer (NK) cells of CHB patients and the mechanism how the HBV DNA level influences the antiviral therapeutic effect.Methods Totally 100 adult patients with CHB who were positive for HBV DNA, HBeAg and (HLA)-A2 were enrolled into this study. HBV DNA was tested by real time fluorescence quantitative polymerase chain reaction (PCR). HBV specific and nonspecific CTL and NK cells were tested by flowcytometry. Serum alanine aminotransferase (ALT) and total bilirubin (Tbil) were determined for each patient using routine biochemical tests. The 100 cases were assigned to two groups based on their HBV DNA level: group A had 48 cases, their HBV DNA level was 104-105 copies/ml, group B had 52 cases, their HBV DNA level was 106-107 copies/ml. HBV specific CTL, nonspecific CTL, NK cells, ALT and Tbil of the two groups were compared.Results HBV DNA level of groups A and B was (4.81±0.39) log10 copies/ml and (6.81±0.40) log10 copies/ml, respectively (t=25.32, P <0.001). HBV specific CTL and NK cells of group A were significantly higher than those of group B (P <0.001 for both). Nonspecific CTL of group A was significantly lower than that of group B (P <0.01). ALT and Tbil of group A were significantly lower than those of group B (P <0.01 and P <0.05, respectively).Conclusions Serum HBV DNA level of patients with CHB is related to HBV specific CTL, nonspecific CTL and NK cells, which might result in inflammatory reaction of liver and cause more damage to liver function. Mechanism of HBV DNA level affecting the efficacy of anti-viral treatment may be related to the levels of HBV specific CTL and NK cells。

Abstract：Background Thumb web contracture is a common complication after hand injury, and can markedly affect whole hand function. Therefore, surgery involving thumb web reconstruction is often necessary to restore normal function of the involved hand. In this study, we present the application of the lateral tarsal artery (LTA) flap in first web reconstruction.Methods From November 1, 2005 to October 31, 2007, seven patients with severe post trauma or bum contractures around the first web space were treated with a LTA flap. All the patients were followed up.Results All flaps survived, with an average size of 6.7 cm×4.8 cm. There were no complications or recurrent contractures during follow-up. All patients were satisfied with the esthetic appearance and functional outcome of the reconstruction.Conclusion The LTA flap could be an excellent option for covering various defects in the thumb web space, serving as an excellent alternative for the thumb web space reconstruction。

Abstract：Background Mesh reconstruction has been proved to be an effective method in incisional hernia repairment. This study was designed to evaluate the effect of reconstructing the pelvic floor with the high-inlay expanded polytetrafluoroethylene (ePTFE) GORE-TEX Dual Mesh (WLGore And Associates, Flagstuff, USA) in abdominoperineal resection.Methods Sixty patients who underwent abdominoperineal resection for rectal cancer were assigned to 2 groups. The pelvic peritoneum was closed by routine sutures in group 1 and reconstructed with ePTFE in group 2. Postoperative complications and related items were evaluated and the patients were followed up.Results Time of confining to bed, bowel function recovery, fasting, and detaining drainage were significantly different between two groups (P <0.05). In group 1, three patients developed bowel obstruction (10%), while no bowel obstruction was observed in group 2.Conclusion Reconstruction of the pelvic floor using ePTFE results in quicker postoperative recovery and could decrease the risk of postoperative intestinal obstruction。

Abstract：Background Stenting a bifurcation lesion is technically challenging. No study has reported the clinical outcome of a dedicated bifurcation stent in China. We aimed to analyze the safety and clinical outcome of a novel side branch ostial stent (BIGUARDTM) stent in treating coronary bifurcation lesions.Methods Forty-seven patients were enrolled in this first-in-man study, with 61.7% true bifurcation lesions (0,1,1 and 1,1,1) and 26.7% diabetes. A two-stent technique was used in 27.6% of the patients, and 64.7% of patients crossed from the one-stent technique to the two-stent arm. Clinical and angiographic follow-up data at 12 months were available in all the 47 patients and in 43 patients (91.9%), respectively. The study endpoint was the occurrence of major adverse cardiac events (MACE) at 12 months.Results Only one patient had a non-ST segment elevation myocardial infarction, which led to 2% of the in-hospital composite MACE. Notably, the target lesion revascularization at 12 months was 8.6%, with a 10.6% composite MACE at 12 months. Neither cardiac death nor stent thrombosis was seen during the follow-up. By quantitative coronary analysis, the restenosis rate at the main vessel and ostium of the side branch was 9.4% and 2.1%, respectively. Four of 12 patients (33.3%) treated with one-stent and kissing balloon inflation had restenosis in the main vessel.Conclusion BIGUARDTM stent was safe and feasible in treatment of bifurcation lesions。

Percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) has revolutionized the management of atherosclerotic coronary artery disease. However, in-stent restenosis (ISR) has been the downside of all coronary interventions with the devices that have been tested so far, even in the DES era。

Atrial fibrillation (AF) is one of the most common arrhythmias in clinical practice. AF results in electrophysiological alterations which involve increased atrial effective refractory period and atrial effective refractory period dispersion, reduced rate adaptation of atrial effective refractory period, and slowed atrial conduction。

Aortico-cameral tunnel is a rare congenital cardiac anomaly, which arises from the fight coronary sinus and enters the left ventricle, occasionally the right ventricle and fight atrium. However, more than one tunnel are seldom seen simultaneously in one patient. Here we present a case of multiple aortico-cameral tunnels associated with the bicuspid aortic valve in a 63-year-old man。

Drug-eluting stent thrombosis has become a major safety concern after percutaneous coronary intervention (PCI) because of its close association with sudden death or ST-elevation myocardial infarction。

From September 2006 to January 2007, 2 patients with end-staged heart and lung disease (congenital disease, Eisenmenger's syndrome, severe pulmonary artery hypertension and heart failure) underwent heart and lung transplantation (HLT) at the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China。

Adrenal pheochromocytomas is a rare catecholamine-secreting tumor that originates from chromaffin cells in the adrenal medulla。

Non-compaction of the ventricular myocardium (NVM) is a rare congenital genetic heart defect that was initially reported 17 years ago by means of autopsy;1 few cases have been published since then。

To the editor: WANG and his colleagues provided the evidence that "both melanopsin-containing and superior collicular retinal ganglion cells were damaged by chronic ocular hypertension, indicating that glaucomatous neural degeneration involves the non-image-forming visual pathway"。