2012年 · 第125卷第06期

Supported by growing evidence from randomized clinical trials and observational or registry studies,percutaneous coronary intervention (PCI) with implantation of drug-eluting stents (DES) has become the standard of care for coronary artery disease,because of reduced repeat intervention and improved clinical outcomes in comparison with bare metal stent.1-3Currently,majority of coronary artery disease patients with complicated lesion subsets or clinical conditions can be successfully treated with DES-based PCI with favorable results.4-6 In 2011,around 300000 PCI procedures have been performed in China,with the penetration rate of DES reaching beyond 90％ in most of the centers。

Since first report by Murry et al1 in 1986,the role of ischemia preconditioning before sustained coronary occlusion in protecting myocardium and reducing infarct size has been identified in animal studies.2-4 The mechanism underlying the endogenous cardioprotective effects of ischemia preconditioning is complex and may involve humoral,neural,or a combination of both,with different signaling pathwaysinvolving adenosine,bradykinin,protein kinases and K(ATP) channels.5,6 In humans,episodes of angina before acute myocardial infarction (AMI) may also confer a preconditioning or protective effect。

Abstract：Background The optimal revascularization strategy in patients with heart failure with preserved ejection fraction (HFPEF) remains unclear.The aim of the present study was to compare the effects of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with HFPEF.Methods From July 2003 through September 2005,a total of 920 patients with coronary artery disease (CAD) and HFPEF (ejection fraction ≥50％) underwent PCI (n=350) or CABG (n=570).We compared the groups with respect to the primary outcome of mortality,and the secondary outcomes of main adverse cardiac and cerebral vascular events (MACCE),including death,myocardial infarction,stroke and repeat revascularization,at a median follow-up of 543 days.Results In-hospital mortality was significantly lower in the PCI group than in the CABG group (0.3％ vs.2.5％,adjusted P=0.016).During follow-up,there was no significant difference in the two groups with regard to mortality rates (2.3％ vs.3.5％,adjusted P=0.423).Patients receiving PCI had higher MACCE rates as compared with patients receiving CABG (13.4％ vs.4.0％,adjusted P ＜0.001),mainly due to higher rate of repeat revascularization (adjusted P ＜0.001).Independent predictors of mortality were age,New York Heart Association (NYHA) class and chronic total occlusion.Conclusion Among patients with CAD and HFPEF,PCI was shown to be as good as CABG with respect to the mortality rate,although there was a higher rate of repeat revascularization in patients undergoing PCI。

Abstract：Background Bare stent implantation in the treatment for native and recurrent coarctation of the aorta (CoA) has become established as an alternative to surgery and balloon angioplasty.However,this modality still encounters significant complications during the procedure and/or follow-up.The covered Cheatham-Platinum (CP) stent commonly used to be chosen as a rescue treatment in these patients.The purpose of this study was to evaluate the use of covered CP stent as the primary modality in the treatment for native CoA.Methods Twenty-five covered CP stents and 2 bare CP stents were implanted in 25 patients with native CoA.All patients after the intervention were invited for follow-up examinations.Results The peak systolic gradient across the lesion decreased significantly from a median value of 67.5 mmHg (quartile range,19.3 mmHg) to 2 mmHg (quartile range,4.0 mmHg) (P ＜0.0001).Stenotic segment diameter increased from a median value of 5.0 mm (quartile range,1.5 mm) to 17.9 mm (quartile range,2.5 mm) (P ＜0.0001).The median ratio of diameter of the coarctation postprocedure to preprocedure was 4.2 (quartile range,1.6).All of the CP stents were placed in the suitable position without any acute complications.During a follow-up period of up to 72 months,no complications were encountered.Most of the patients (21/25) were normotensive,apart from four patients requiring antihypertensive medication during the follow-up.Conclusion The implantation of covered CP stent as the primary modality is safe and effective in the treatment for native CoA in adolescents and adults。

Abstract：Background Severe bilateral carotid stenosis caused by atherosclerosis has not been unusual in the elderly.Such patients have high stroke risk.Many studies show that carotid artery stenting (CAS) is an alternative to treat unilateral carotid stenosis.However,the optimal procedural strategy of bilateral carotid stenosis remains unclear.The purpose of our study was to evaluate the safety of simultaneous bilateral carotid artery stenting (SBCAS) compared with unilateral carotid artery stenting (UCAS).Methods In this single-center retrospective study,we analyzed 234 consecutive patients who underwent carotid stenting from January 2005 to December 2009.Thirty-nine patients (16.7％) of them underwent SBCAS,and the others (n=195) underwent UCAS.Indication for CAS was defined as carotid artery diameter reduction ＞60％ (symptomatic) or ＞80％ (asymptomatic).Six-month and 30-day hemodynamic depression (HD),hyperperfusion syndrome (HPS),stroke,death and myocardial infarction (MI) after carotid stenting were assessed.Results SBCAS group had no more HD and HPS compared with UCAS group at 30 days (HD:28.2％ vs.20.0％,P=0.396; HPS:2.6％ vs.2.1％,P=0.262).Moreover,there was no statistically significant difference between SBCAS group and UCAS group in major stroke,death,MI and their combinations within 30 days (major stroke:0 vs.3.6％,P=0.604; death:2.6％ vs.1.5％,P=0.520; MI:2.6％ vs.0.5％,P=0.306; and their combinations:5.1％ vs.4.6％,P=1.000)and 6 months (major stroke:0 vs.3.6％,P=0.604; death:5.1％ vs.2.1％,P=0.262; MI:5.1％ vs.1.0％,P=0.130 and their combinations:7.7％ vs.5.1％,P=0.459).Conclusions The patients undergoing SBCAS had no more events than those undergoing UCAS in 30-day and 6-month follow-up.Our finding suggests that SBCAS appears to be as safe as UCAS。

Abstract：Background Dual-axis rotational coronary angiography (DARCA) was developed as an innovative adaptation of rotational angiography (RA),but it requires a longer coronary injection compared to standard coronary angiography (SA).As the body of the average Chinese patient is smaller than that of most western patients,with the same contrast injection time,the risk of complications from the contrast agent is increased in this population.The purpose of this study was to assess the clinical safety and efficacy of DARCA in the diagnosis of coronary artery disease (CAD) in the Chinese population by directly comparing it to SA.Methods Two hundred Chinese patients were randomized to either the SA group (n=100) or DARCA group (n=100).Contrast utilization,radiation exposure and procedure time were recorded for each modalities.Blood pressure (BP),heart rate (HR) pre and post injection symptoms and any arrhythmias were recorded.Results Compared to the SA group,there was a 42％ reduction in contrast utilization,55％ reduction in radiation exposure and a 31％ shorter procedure time in the DARCA group.In both groups,there were slight declines in the systolic BP values in the left coronary artery (LCA) post injection (P ＜0.01).Moreover,post injection HRs for the LCA were also reduced in the DARCA group (P ＜0.01).But all of these changes were small,transient and without clinical importance.Only one patient (1％) in the DARCA group had an attack of ventricular tachycardia immediately post injection and it resolved by itself during LCA angiography.No arrhythmias occurred in the SA group.Conclusion DARCA is a safe,efficient,and clinically comparable altemative to SA in the diagnosis of coronary artery disease in the Chinese population with less contrast utilized,which is less radiation exposure and a shorter procedure time than SA。

Abstract：Background Baseline white blood cell (WBC) count was correlated with ischemic events occurrence in patients with ST-elevated myocardial infarction (STEMI).However,circulating WBC count is altered after percutaneous coronary intervention (PCI).The aim of this study was to assess the relationship between postprocedural WBC count and clinical outcomes in STEMI patients who underwent PCI.Methods A total of 242 consecutive acute STEMI patients who underwent successful primary PCI were enrolled and followed up for two years.WBC counts were measured within 12 hours after PCI.ST-segment resolution (ST-R) and myocardial blush grades (MBG) were evaluated immediately after PCI.Left ventricular ejection fraction (LVEF) was obtained at baseline and 12-18 months after PCI.Results Postprocedural WBC count was an independent inverse predictor of ST-R (OR 0.80,P ＜0.0001) and MBG 3(OR 0.82,P ＜0.0001).It was negatively correlated with LVEF (baseline r=-0.22,P=0.001; 12-18 months r=-0.29,P＜0.0001).The best cutoff value of WBC for predicting death was determined to be 13.0×109/L.The patients with a postprocedural WBC count above 13.0×109/L showed a significantly lower cumulative survival rate (30 days,82.4％ vs.99.0％,P ＜0.0001 and 2 years 75.0％ vs.96.4％,P ＜0.0001).Multivariate Cox regression analysis showed that a postprocedural WBC count was a strong independent predictor of 30-day mortality (HR 8.48,P=0.019) and 2-year mortality (HR 4.93,P=0.009).Conclusions Increased postprocedural WBC count is correlated with myocardial malperfusion and left ventricular dysfunction,and is an independent predictor of poor clinical outcomes in STEMI patients who underwent PCI。

Abstract：Background Little is known about the prognosis of coronary artery disease (CAD) in Chinese patients with abdominal aortic aneurysm (AAA).The aim of this study was to evaluate the predictors of in-hospital all-cause mortality of severe CAD in Chinese patients who were hospitalized for AAAs.Methods From January 2003 to August 2009,368 patients were operated on for AAAs.The clinical characteristics were retrospectively collected.The primary outcome was the in-hospital all-cause mortality.The clinical risk factors were subjected to a multivariate analysis to determine the predictors of in-hospital all-cause mortality.Results During their hospitalization,23％ (85/368) of the patients underwent coronary angiography,which revealed significant lesions in 93％ (79/85) of the patients.In 25 cases,coronary artery bypass grafting (CABG) was performed before the AAA repair and in 16 cases of percutaneous coronary intervention (PCI) was performed.Ten patients with AAA alone died before discharge,and eight patients diagnosed with AAA combined with CAD died.There was no statistical difference in the postoperative death between the two groups.The logistic analysis showed that age ＞70 years and CAD (vessels ≥2) were the significant factors in predicting the adverse clinical outcome.Conclusions The prevalence of severe CAD in Chinese patients with AAAs seemed lower than those that were reported.Myocardial evaluation and subsequent revascularization before AAA surgery could improve the clinical outcome for these patients who have severe CAD。

Abstract：Background Stenting strategies and clinical outcomes of bifurcation lesions in a chronic total occlusion (CTO) vessel after successful recanalization remain to be unknown.Methods Between January 2001 and December 2009,195 (41.1％) patients with 254 (47.0％) bifurcation lesions in CTO vessels from a pool of 564 patients with 659 CTO lesions were included and divided into proximal (n=134) and distal (n=120) groups,according to the location of the bifurcation lesions.The primary endpoint was the occurrence of major adverse cardiac events (MACE) at the end of clinical follow-up,including cardiac death,myocardial infarction,or target vessel revascularization (TVR).Results Collaterals with Rentrop class 3 were seen more in distal group (100％ and 68.3％),compared to proximal group (76.9％ and 45.6％).Two-stent technique for proximal bifurcation lesions was used in 24.6％,significantly different from the distal group (6.7％,P ＜0.001),without significant difference in composite MACE between proximal and distal groups,or between one- and two-stent subgroups in proximal group.The composite MACE after 1-year in complete revascularization subgroup was 17.9％ relative to 29.6％ in the incomplete revascularization group (P=-0.044).Stents in long false lumen in main vessel were mainly attributive to decreased TIMI grade flow,with resultant increased in-stent restenosis,total occlusion,TVR and coronary aneurysms.Imcomplete revasculzarization (HR 2.028,P=0.049,95％ CI 1.002-4.105) and post-stenting TIMI flow (HR 6.122,P=0.020,95％ CI 1.334-28.092) were two independent predictors of composite MACE at the 1-year follow-up.Conclusions Two-stent was more used for proximal bifurcation lesions.No significant difference was observed in MACE between proximal and distal,or between one- and two-stent subgroups in the proximal group.Placement of a safety wire was critical for proximal bifurcation lesions.Complete revascularization was mandatory to improve clinical outcomes。

Abstract：Background Weight gain following smoking cessation increases cardiovascular risk,but its effects on prognosis after percutaneous coronary intervention (PCI) remain unclear.This study aimed to investigate the relationship between weight gain post smoking cessation and one-year clinical outcome in patients who underwent PCI with drug-eluting stent (DES).Methods A total of 895 consecutive male smoking patients were divided into quitters (n=437) and continuers (n=458)according to their smoking status after PCI.Weight gain,major adverse cardiac events (MACE,including cardiac deaths,myocardial infarction and revascularization),and recurrent angina were recorded during follow-up for one year.Results Average weight gain in quitters was more than that in continuers (1.5 kg vs.-0.03 kg,P＜0.001).Weight was unchanged or increased by more than 1.5 kg in 78.17％ of continuers,while 50.57％ of quitters had a weight gain of less than 1.5 kg.Compared with continuers,MACE in quitters was significantly reduced after PCI (6.12％ vs.4.81％,P=0.049),especially recurrent angina (13.97％ in continuers vs.9.84％ in quitters,P=-0.027).After adjusting for weight gain and other factors,smoking cessation was independently associated with a lower risk of MACE and recurrent angina (OR=0.73,P=0.035).However,weight gain ＞1.5 kg (OR=1.55,P=0.026) could curtail the benefits from smoking cessation.Conclusions Weight gain may reduce the benefits of smoking cessation after PCI with DES implantation.Thus,although smoking cessation is recommended after PCI,weight control should also be highly encouraged for these patients。

Abstract：Background Edge dissections after coronary stent implantation are associated with increased short-term risk of major adverse cardiovascular events.The incidence and outcome of edge dissections after coronary stent implantation were reportedly different using different imaging techniques.We used optical coherence tomography (OCT) to assess the incidence,morphological findings and related factors of edge dissections after drug-eluting stent (DES) implantation.Methods Totally 42 patients with 43 de novo lesions in 43 native arteries undergoing DES implantation with OCT imaging were enrolled in this study.Results Nine edge dissections were detected in 43 arteries after DES implantation.There were four morphological patterns of stent edge dissections indentified in this study:(1) superficial intimal tears (n=3),(2) subintimal dissections (n=4),(3) split of media (n=1),(4) disruption of the fibrotic cap of plaque (n=1).Stent edge expansion and stent expansion were both higher in the group with dissections than those in the group without dissections (1.682±0.425 vs.1.229±0.285,P=0.0290; 1.507±0.445 vs.1.174±0.265,P=0.0072).Conclusions The incidence of stent edge dissections detected by OCT was 21％.Stent edge dissection is related with stent edge expansion and stent expansion。

Abstract：Background Contrast induced acute kidney injury (CIAKI) is an important complication in the use of iodinated contrast media (CM).Our study was to evaluate the neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C for early diagnosis of CIAKI.Methods The patients with established or suspected coronary artery disease (CAD) with the estimated glomerular filtration rate (eGFR) was more than 30 ml.min-1.1.73 m-2 and nor more than 90 ml·min-1·1.73 m-2 were continuously enrolled.The blood samples of the first 50 patients were obtained before and at 2,4,8,24 and 48 hours after procedure to identify the time points at which the biomarkers reached peaks and at which the blood samples of the rest of patients were obtained.The plasma NGAL and cystatin C measure used enzyme-linked immunosorbent assay (ELISA) kit.The diagnostic characteristics of absolute and relative increasing NGAL and cystatin C for CIAKI were evaluated.Results Total 311 patients were enrolled,among whom 39 (12.5％) developed CIAKI.Plasma NGAL increased at 2hours and reached peak at 4 hours after procedure,while plasma cystatin C increased at 2 hours and reached peak at 24hours after procedure.Thus,we determine rational point of time at 4 hours for NGAL and at 24 hours after procedure for cystatin C,respectively.The plasma NGAL at 4 hours after CM exposure showed largest area under curve (AUC) of 0.662 (95％ confidence interval (C/):0.565-0.758,P=0.002) with 51.5％ sensitivity and 80.6％ of specificity.The relative increasing 25％ of NGAL showed the best sensitivity and specificity of 0.872 and 0.808,respectively,with maximum Youden index of 0.680,while cystatin C with relative increasing more than 25％ had 76.9％ of sensitivity and 81.2％ of specificity.Combined two biomarkers might get more than 90％ of specificity.Conclusions Single measurement of NGAL or cystatin C had poor sensitivity and specificity; however,the relative increasing 25％ of NGAL at 4 hours after CM exposure demonstrated higher diagnostic values for CIAKI.Combining relative increasing plasma NGAL with relative increasing plasma cystatin C might perform better for early diagnosis of CIAKI。

Abstract：Background In both the seventh edition of the International Union Against Cancer (UICC) staging system for gastric cancer and the 14th edition of the Japanese Gastric Cancer Association (JGCA) system,T4a is defined as "Tumor perforates serosa (visceral peritoneum) without invasion of adjacent structures." The aim of this study was to investigate the differences in prognosis between patients with serosa-penetrating and serosa-invading T4aN0M0 gastric carcinomas.Methods Data were collected from 221 patients with T4aN0M0 gastric carcinoma who underwent D2 resection at our cancer center between January 1990 and December 2008.The cohort included 42 patients with serosa-penetratingtumors and 179 patients with serosa-invading tumors.The average follow-up time was 85.5 months.Spearman's rank correlation,Kaplan-Meier plots,and Cox proportional hazards regression models were used to analyze the data.Results The 5-year survival rate of patients with serosa-penetrating and serosa-invading gastric cancers were 31％and 62％ respectively (P ＜0.05).The relapse rates after D2 radical surgery were 16.2％ in patients with serosa-invading gastric cancer versus 59.5％ in those with serosa-penetrating tumors (P ＜0.05).Peritoneal dissemination and distant organ/lymph node metastatic rates were 76.0％ and 24.0％ respectively in patients with penetrating tumors,versus 44.8％and 55.2％ respectively in patients with invading tumors (P ＜0.05).Multivariate analysis showed that penetration of the serosa was an independent prognostic indicator of overall survival.Conclusions Our findings provide a basis for the concept that serosa-penetrating T4aN0M0 gastric carcinoma represents a more aggressive cancer than serosa-invading T4aN0M0 gastric carcinoma.Serosa penetration is an independent factor for poor prognosis of patients with gastric carcinoma。

Abstract：Background It is unclear whether a history of paroxysmal atrial fibrillation (PAF) would impact the effect of catheter ablation on persistent atrial fibrillation (AF).This study aimed to compare the effect of catheter ablation on persistent AF with and without a history of PAF.Methods One hundred and eighty-three patients underwent catheter ablation of persistent AF lasting for ＞1 month and were reviewed.Patients were divided into two groups according to whether they had a history of PAF or not.Group Ⅰ consisted of persistent AF patients with a history of PAF,and group Ⅱ consisted of persistent AF patients without such a history.All patients received catheter ablation focused on pulmonary vein isolation and were observed for arrhythmia recurrences,which were defined as documented episodes of AF or atrial tachycardia after a blanking period of 3 months.Results One hundred and three patients (60.9％) in group Ⅰ and sixty-six patients (39.1％) in group Ⅱ were successfully followed and included in analysis.There were no significant differences in clinical and echocardiographic characteristics between both groups except for a younger age and more male patients in group Ⅱ.After (15.5±10.7) months of follow-up,59 (57.3％) patients in group Ⅰ and 49 (74.2％) patients in group Ⅱ maintained sinus rhythm free of anti-arrhythmia drugs (P=0.025).Multivariate analyses found left atrial anteroposterior diameter (P=0.006) and persistent AF with a history of PAF (OR 1.792,95％ CI 1.019-3.152; P=0.043) as the only independent statistical predictors of arrhythmia recurrences.Conclusion The arrhythmia recurrence rate of catheter ablation based on pulmonary vein isolation in persistent AF with a history of PAF was higher than those without a history of PAF

Abstract：Background The transseptal puncture technique has been widely used in therapeutic left atrium catheterization.But this technique may lead to some life-threatening complications.It can not be used widely because it is restricted by economy and deferring the transseptal puncture procedure.The aim of this study was to introduce a simple and safe transseptal puncture procedure.Methods The distal of coronary sinus (CS) electrode was positioned close to the lateral margin of heart,which was about at 3 O'clock at left anterior oblique (LAO) 30° referred to whole cardiac profile.It was then used as the marker for the level of fossa ovalis at posterior-anterior projection to guide the pull of transseptal needle.The midpoint between the distal CS and the posterior margin of heart at right anterior oblique (RAO) 45° view was considered as the location of fossa ovalis.Once the puncture was succeeded,the guidewire was introduced to the left superior pulmonary vein via puncture sheath after the needle was retrieved.The end of outer sheath was introduced into left atrium with the protection of guidewire.It was applied in 539 patients (316 male,223 female; (53±16) years old) who underwent catheter ablation of atrial fibrillation or left-sided atrioventricular accessory pathway.Results This transseptal approach reached 100.0％ success and was succeeded in 98.9％ with the first attempt.The first attempt puncture was aborted due to greater resistance to needle advancement or smaller needle curve in six patients.However,the second attempts were all succeeded after the needle curve was reshaped.There was no tamponade and embolism occurred.Conclusion The atrial septum puncture approach using the location of distal CS electrode as important marker and the guidewire for protection when sending outer sheath into left atrium is reliable and safe。

Abstract：Childhood leukemia bottleneck phenomenon is the most mysterious corollary of the prenatal origin discovery of leukemogenic chromosome translocations.The bottleneck is evidence that leukemia initiation,by in utero acquired chromosome translocations that generate functional fusion genes,is far more common than the incidence rate of corresponding leukemia.For childhood TEL-AML1+ acute lymphoblastic leukemia (ALL) this equates to approximately 100 times.Practically this means that among a hundred children born with TEL-AML1 fusion gene,only one child will later in its life develop ALL.The key data necessary for unraveling of this mystery were discovered in 2002.It was the level of TEL-AML1 + cells' frequency.The bottleneck is caused by the very low body TEL-AML1 + cell count.Only one out of a thousand B cells carries TEL-AML1 fusion gene.TEL-AML1+ body cell count is low because TEL-AML1 fusion is generated at cell level of 10a to 10-4 just during the late fetal lymphopoiesis i.e.after the 36th gestational week。

Abstract：Very late stent thrombosis is a life-threatening complication of implantation of drug-eluting stent (DES).The mechanisms are still unidentified.Stent malapposition is supposed to be one debated reason.Here we report a case of 33 months after DES implanted.Observed by optical coherence tomography,we detected a lipid-rich plaque with defective fibrous cap within the neointima and many local aneurysmal dilatations between stent struts,which mimic "malapposition" on the angiogram.These indicated that vulnerable plaque hidden in the neointima at the stent segment might be a potential mechanism of very late stent thrombosis after DES implantation。

Abstract：Post-partum hemolytic uremic syndrome (PHUS) is a severe thrombotic microangiopathy clinically characterized by hemolytic anemia,renal dysfunction,and low platelets after birth with rapid progression and poor prognosis.Here,we reported a rare case of severe preeclampsia diagnosed as hemolytic uremic syndrome after birth.The patient was diagnosed with PHUS and underwent intermittent plasma exchange with supportive treatment including glucocorticoid injections and transfusion of suspended red blood cells.After these treatments,the patient experienced no apparent remission and chronic renal dysfunction occurred on her.PHUS is a severe emergency with acute onset,rapid progress,and poor prognosis.Early detection,diagnosis,and treatment can significantly improve the prognosis。

Abstract：Ectopic Cushing's syndrome caused by pheochromocytoma is rare.We reported a 15-year-old female patient who was admitted to hospital with typical Cushing's syndrome.She had not started menstruation.Her plasma adrenocorticotropic hormone (ACTH) and 24-hour urinary free cortisol levels were extremely high.Gonadal and progestational hormone levels were also abnormal.Abdominal computed tomography scans and enhanced scans revealed multiple irregular tumors in the right adrenal.Pelvic echogram showed an infantile uterus,while the ovaries were at an immature stage of development.Retroperitoneal laparoscopic right adrenalectomy was performed without intraoperative complications.Histology and immunohistochemistry of the tumor were consistent with pheochromocytoma.Retroperitoneal laparoscopic adrenalectomy is a safe procedure with satisfactory outcomes and allows for rapid recovery。

Abstract：Pulmonary vein thrombosis is a rare disease and is usually represented as a complication of atrial fibrillation,pulmonary tumors,and Iobectomy.Although it is a potentially life threatening condition,the venous disease is easy to misdiagnose because of the non-specific symptoms.In this article,we present a 30-year-old patient who suffered from pulmonary vein thrombosis without any causes.He was diagnosed with other pulmonary disorders till the thrombus within the pulmonary vein extended into the left atrium.Left atrium mass resection and a left lower Iobectomy were undertaken with relative urgency.The postoperative course was uneventful.The patient received a long course of oral anticoagulant therapy。