2013年 · 第126卷第06期

Since its inauguration in 2003,China Interventional Therapeutics (CIT) congress has witnessed the growth of percutaneous cardiovascular intervention in China.In 2003 the total number ofpercutaneous coronary intervention (PCI) in China was about 40 000 cases,1while by CIT's 10th anniversary in 2012,the annual number of PCI in China had reached 340 000 cases.CIT has grown along with PCI practice in the country;last year the CIT congress hosted 6000 attendees,including 180 international faculty members and over 750foreign participants from 42 countries or regions。

Since the first Palmaz-Schatz bare-metal stent (BMS)was implanted in human body in 1985,coronary stenting successfully resolved problem of the high restenosis rate in balloon dilatation era and soon became the primary means of clinical treatment of coronary artery disease.In order to meet the requirement of further reduction of the restenosis rate,drug-eluting stent (DES)was developed more than a decade later.With the excellent clinical efficacy,DESs established a milestone in the field of percutaneous coronary intervention (PCI).However,since the "stent thrombosis (ST) storm"triggered in 2006,the late ST after DES implantation quickly became a challenging problem.1.2 To solve this problem,a lot of advances have been achieved.Among them,biodegradable polymers and abluminal coating are two new technologies with bright future。

Abstract：Background It has been recently reported that inflammatory mechanisms play an important role in in-stent restenosis (ISR) processes.Inflammatory factors after percutaneous coronary intervention (PCI) for dynamic monitoring can probably predict ISR.Functional polymorphisms in the promoter region of genes coding for inflammatory factors might be important for determining the magnitude of the inflammatory response.Thus,in the present study,we aimed to investigate the serial changes in serum interleukin-6 (IL-6) levels before and after PCI and the relationship between the -572C/G polymorphism in the promoter region of the IL-6 gene and ISR.We also discussed genetic polymorphisms in the inflammatory response to PCI.Methods A total of 437 patients who successfully underwent bare metal stent (BMS) implantation with a follow-up angiography were divided into an ISR group (n=166) and a non-ISR (NISR) group (n=271).The IL-6 gene promoter polymorphism at position-572 was determined by restricted fragment length polymorphism using the polymerase chain reaction (PCR-RFLP) method.The serum IL-6 levels before and one day,five days and 180 days after PCI were determined by the radioimmunoassay method.Results ISR patients showed higher IL-6 serum levels than NISR patients before PCI ((324.42±28.14) ng/L vs.(283.22±47.30) ng/L,P＜0.001),and one day post-PCI IL-6 serum levels in the ISR group also showed a significantly higher level than in the NISR group (P ＜0.001).Increased IL-6 after PCI persisted at a statistically significant level throughout the study in ISR patients,whereas IL-6 levels had normalized five days after the procedure in NISR patients.One day post-PCI serum IL-6 level was the most accurate marker for diagnosis of ISR,the area under the ROC curve being 0.927 (95％ C/0.878-0.977).The cut-off value for IL-6 to predict ISR was over 355.50 ng/L,with a sensitivity of 0.968 and a specificity of 0.865.There were no significant differences in frequencies of-572 genotype and allele between the two groups (P＞0.05).One day post-PCI IL-6 serum levels in patients with the G allele was significantly higher than in patients without the G allele ((366.99±49.37) ng/L vs.(347.20±55.30) ng/L,P＜0.05).In the ISR group,one day post-PCI serum levels of IL-6 in patients with the G allele was also significantly higher than that in patients without the G allele ((405.67±26.56) ng/L vs.(375.69±38.81) ng/L,P ＜0.05).Multivariate Logistic regression analysis revealed positive correlations between male gender,one day post-PCI serum levels of IL-6,the pre-PCI degree of stenosis,the length of the target lesion stenosis,and restenosis; and there were negative correlations between the stent diameter,the diameter of the reference vessel before stent implantation and restenosis.Conclusions IL-6 is an early post-PCI inflammatory cytokine,and one day post-PCI serum IL-6 level is an independent risk factor for restenosis.The frequencies of IL-6 gene-572 genotype and allele are not different between patients with and without ISR in a Chinese Tianjin Han population,but carrying the IL-6-572G allele is likely to increase an individual's susceptibility to ISR by promoting serum IL-6 levels。

Abstract：Background Catheter ablation for atrial fibrillation (AF) has been demonstrated to be effective in a subsets of patients with AF.However,very few data are available in regard to patients with prior history of stroke undergoing catheter ablation.This study aimed to investigate the outcome of catheter ablation in AF patients with prior ischemic stroke.Methods Between January 2008 and December 2011,of 1897 consecutive patients who presented at Beijing An Zhen Hospital for treatment of drug-refractory AF,172 (9.1％) patients in the study population had a history of ischemic stroke.All patients underwent catheter ablation and were followed up to assess maintenance of sinus rhythm and recurrence of symptomatic stroke.Results Among these 1897 patients,1768 (93.2％) who had complete follow-up information for a minimum of six months were included in the final analysis.Patients in the stroke group (group Ⅰ) and the no-stroke group (group Ⅱ) were similar in regards to gender,body mass index (BMI),history of diabetes,type of AF,and left atrial size.The patients in group Ⅰ were older than those in group Ⅱ,and had a higher incidence of hypertension,chronic heart failure,lower left ventricular ejection fraction (LVEF),and higher CHADS2 scores.Six months after ablation,107 (68.6％) patients in group Ⅰ and 1403 (87.1％) in group Ⅱ had discontinued warfarin treatment (P ＜0.001).During a median follow-up of (633±415)days,65 patients in the group Ⅰ and 638 in group Ⅱ experienced AF recurrence,and five patients in group Ⅰ and 28 in group Ⅱ developed symptomatic stroke.The rates of AF recurrence and recurrent stroke were similar between group Ⅰ and group Ⅱ (41.7％ vs.39.6％,P=-0.611; 3.2％ vs.1.7％,P=0.219; respectively).Conclusion Catheter ablation of AF in patients with prior stroke is feasible and efficient。

Abstract：Background The gender difference on long-term outcome in unselected patients after percutaneous coronary intervention (PCI) has not yet been fully investigated.This study aimed to evaluate the gender difference on five-year outcomes following EXCEL biodegradable polymer-coated sirolimus-eluting stenting in patients with coronary disease.Methods A total of 2077 "all comers",consisting of 1528 (73.6％) men and 549 (26.4％) women,who were exclusively treated with EXCEL coronary stents were enrolled in the prospective CREATE study at 59 centers from four countries.After propensity score matching,the baseline characteristics of the two groups were well matched.Recommended antiplatelet regimen was clopidogrel and aspirin for six months followed by chronic aspirin therapy.The primary outcome that was the rate of major adverse cardiac events (MACE),defined as a composite of cardiac mortality,non-fatal myocardial infarction (MI) and target lesion revascularization (TLR),and stent thrombosis (ST) at five years were compared between the two gender groups.Results In the two groups,women had higher proportions of clinical risk factors,such as being elderly,diabetes mellitus,hypertension and hyperlipidemia,compared to men.Besides,the mean target vessel number per patient was higher and the mean reference vessel diameter smaller for women.Men had higher risks of cardiac death (3.7％ vs.1.6％,P=0.021) and MACE (8.4％ vs.4.7％,P=0.004) at five years compared with women.However,the cumulative hazards of non-fatal MI and TLR were similar between men and women.The incidence of Academic Research Consortium (ARC) definite or probable stent thrombosis was similar between the two groups (1.3％ vs.1.0％,P=0.639).Prolonged clopidogrel therapy (＞6 months) did not reduce the cumulative hazards of ST from six months to five years in both men (x2=0.098,log rank P=0.754) and women (x2=2.043,log rank P=0.153) patients.Conclusions Women had a lower MACE and cardiac death rate than men after biodegradable polymer-coated sirolimus-eluting stenting in long term follow-up.Effects of prolonged dual antiplatelet therapy (DAPT) in preventing stent thrombosis was similar with six-month DAPT after EXCEL stent implantation in both men and women groups。

Abstract：Background More and more percutaneous coronary intervention were done from radial artery approach.But the great limitation of radial artery approach and main failure cause of transradial coronary intervention is smaller size and more variations of a radial artery approach.The aim of the study is to explore the features and variations of a radial artery approach in southern Chinese populations and their clinical significance in percutaneous coronary intervention.Methods A total of 1400 patients who underwent scheduled first time transradial coronary angiography between July 2007 and September 2010 were enrolled.Radial arteriography was performed in all patients to detect the anatomical variations of this vessel.All patients' radial and ulnar artery inner diameters were measured using a computer assisted quantification method.A detailed patient history was recorded.Multivariate Logistic regression analysis was performed to evaluate the predictive value of variables (including age,gender,ethnicity,height,weight,body mass index,smoking,diabetes,hypertension and dyslipidemia) in arterial tortuosities and variations of this vessel.Results In southern Chinese populations,there were no significant differences in the diameters of the forearm arteries:the mean radial artery inner diameter was (3.04±0.43) mm in ethnic Han Chinese and (3.05±0.42) mm in ethnic Zhuang Chinese,P ＞0.05),the mean ulnar artery inner diameter was (3.03±0.38) mm in Han Chinese and (3.05±0.36) mm in Zhuang Chinese,P ＞0.05).It was estimated that the inner diameter of the radial artery was not smaller than a 6F Cordis sheath in 86.1％ of male patients and in 57.0％ of female patients,and not smaller than a 7F Cordis sheath in 59.3％ of male patients and 24.9％ of female patients.The factors found to positively affect the size of the radial artery were sex (bj=0.309,P ＜0.01),weight (bj=0.103,P ＜0.01),and diabetes mellitus (bj=-0.088,P ＜0.01) was found to negatively affect radial artery size.Arterial tortuosities occurred in 12.1％ of patients and arterial variations in 4.1％.The incidence of tortuosities and variations included radial artery tortuosity (3.6％),high origin of radial artery (1.7％),radial artery loop (0.6％),double radial artery (0.1％),brachial artery tortuosity (0.4％),double brachial artery (0.1％),subclavian artery tortuosity (5.4％),small subclavian artery (0.4％),right retro-esophageal subclavian artery (0.6％),brachiocephalic trunk tortuosity (2.8％),small brachiocephalic artery (0.1％),and brachiocephalic artery anomaly (0.4％).For people in Guangxi province,tortuosities of the subclavian artery and radial artery are the most common among the vascular tortuosities of the radial artery approach.The overall rate of transradial procedural success was 96.1％.Procedural failure was more common in patients with anomalous radial artery approach than in patients with normal radial artery approach (22.8％ vs.1.8％,P=0.000).According to multivariate Logistic regression analysis,age (OR=2.695,95％ Cl 2.232-3.253,P=0.000),female gender (OR＝5.127,95％ CI 3.000-8.762,P=0.000),height (OR=0.612,95％ Cl 0.465-0.807,P=0.000),body mass index (OR=2.377,95％ Cl 1.834-3.082,P=0.000),hypertension (OR=1.668,95％ CI 1.132-2.458,P=0.010),hyperlipidemia (OR=1.273,95％ CI 1.425-2.049,P=0.034) and smoking (OR=5.750,95％ CI 3.636-9.093,P=0.000),were independently associated with arterial tortuosities of the radial artery approach.Female gender was independently associated with arterial variations of the radial artery approach (OR=3.613,95％ CI 3.208-7.826,P=0.000).Conclusions The diameters of the radial and ulnar arteries between the Han people and the Zhuang people in southern Chinese populations are similar.In a transradial operation,the most southern Chinese populations,the use of a 6F sheath and guiding catheter is safe,and using a 7F sheath and guiding catheter is feasible in some selected patients.Radial arterial tortuosities and variations in southern Chinese populations are relatively common and are a significant cause of the failure of transradial coronary procedure.Old age,female gender,short stature,high body mass index,hypertension,hyperlipidemia and smoking,were independently associated with an increased risk of arterial tortuosity.In addition,female gender was an independent predictor of arterial variations。

Abstract：Background It has been reported that increased red blood cell width (RDW) is a marker associated with the presence and adverse outcomes of various cardiovascular diseases.The aim of the present study was prospectively evaluate the severity of coronary artery disease (CAD) and RDW in a large Chinese cohort.Methods A total of 677 consecutive individuals who underwent coronary angiography due to the presence of angina-like chest pain and/or positive treadmill exercise test were enrolled in this study.All patients received coronary angiography and were then divided into two groups based on the results of coronary angiography (CAD group (n=499) and control group (n=178)).The clinical information including classical CAD risk factors and RDW were analyzed to identify their relationship to CAD.The severity of CAD was evaluated by Gensini score and its relationship with RDW was also analyzed.Results Patients with angiographic CAD had significantly elevated RDW levels compared with controls ((12.95±0.77)％vs.(12.73±0.83)％,P=0.001).There was a significant positive correlation between RDW and the Gensini score (r=0.37,P ＜0.001).In multivariate Logistic regression analysis,RDW was demonstrated to be an independent predictor for both angiographic CAD (OR=1.34,95％ CI.1.02-1.77,P ＜0.05) and for a higher Gensini score (＞13,OR=2.23,95％ CI.1.62-3.08,P ＜0.001).In a receiver operating characteristic (ROC) curve analysis,an RDW value of 12.85％ was identified as an effective cut-point in predicting the presence or absence of CAD with a sensitivity of 50.0％ and a specificity of 65.2％.Conclusion RDW is associated with both presence of CAD and the severity of coronary stenosis,suggesting that it might be a readily available marker for the prediction of CAD and its severity。

Abstract：Background As an adipocytokine,resistin has been proposed as a link between inflammation,metabolic disorder and atherosclerosis.The aim of the study is to evaluate whether serum resistin is associated with acute coronary syndrome (ACS) and major adverse cardiovascular events (MACEs) among postmenopausal women with ACS undergoing percutaneous coronary intervention (PCI).Methods A total of 106 consecutive postmenopausal women who underwent coronary angiography for evaluation of suspected myocardial ischemia were enrolled.Pre-procedure serum resistin,inflammatory and metabolic biomarkers were measured.All participants were followed for seven years for MACEs,including cardiovascular death,recurrent nonfatal myocardial infarction,and re-PCI.Results Patients with ACS (n=69) had significantly higher resistin levels than those without coronary artery disease (CAD) (n=37) (4.61 (1.79-10.80) ng/ml vs.2.36 (0.85-4.15) ng/ml,P=0.002).Correlation analysis revealed positive correlations between resistin levels and inflammatory and metabolic factors (P ＜0.05).A follow-up of a mean of 83.4months showed that patients with ACS suffered more MACEs than those without (13.0％ vs.2.7％,P=0.05).Adjusted for cardiovascular risks,inflammatory and metabolic factors,multiple Logistic regression analysis indicated that an elevated resistin level was an independent predictor of ACS onset (OR=1.139,95％ CI 1.024-1.268,P=0.017) and of MACEs after PCI (OR=1.099,95％ CI 1.015-1.189,P=0.019).To clarify the association between resistin levels and MACEs,ACS patients were divided into two subgroups on the basis of resistin levels.Compared with the low resistin subgroup (≤4.35ng/ml,n=32),patients in the high resistin subgroup (＞4.35 ng/ml,n=37) were more prone to suffer MACEs (21.6％ vs.3.1％,P=0.015).Kaplan-Meier analysis showed a significantly lower event-free survival rate in ACS patients with high resistin levels than in the low resistin subgroup (78.4％ vs.96.9％,Log rank 5.594,P=0.018).Conclusion An elevated serum resistin level is associated with ACS and cardiovascular events and acts as a predictor in progression of ACS in postmenopausal women。

Abstract：Background Transradial access has been increasingly used during primary percutaneous coronary intervention (PCI)for patients with acute ST-segment elevation myocardial infarction (STEMI) in last decade.Clinical benefits of upstream use of tirfiban therapy in STEMI patients treated by primary PCI have been reported.We investigated the merits of transradial vs.transfemoral access in primary PCI for STEMI patients with upstream use of tirofiban.Methods Patients with STEMI treated with tirofiban between December 2006 and October 2012 then by primary PCI were compared between transradial (n=298) and transfemoral (n=314) access.Baseline demographics,angiographic and PCI features and primary endpoint of major adverse cardiac events (MACE) at 30-day clinical follow-up were recorded.Results Baseline and procedural characteristics were comparable between the two groups,apart from more patients in transradial group had hypertension and were treated by thrombus aspiration during primary PCI.Significantly fewer MACE occurred in the transradial group (5.4％) compared with the transfemoral group (9.9％) at 30-day clinical follow-up.Major bleeding events at 30-day clinical follow-up were 0 in transradial group and in 2.9％ of transfemoral group.Multivariate analysis confirmed transradial approach as an independent negative predictor of 30-day MACE (HR 0.68;95％ CI 0.35-0.91; P=0.03).Conclusions Using transradial approach in primary PCI for acute STEMI infarction patients treated with tirofiban was clearly beneficial in reducing bleeding complications and improving 30-day clinical outcomes。

Abstract：Background The CYP2C19 G681A single polymorphism has been proven to affect clopidogrel responsiveness.However,the effect of coexisting polymorphisms of other genes has not yet been reported in the Chinese population.This study investigated the effect of coexisting polymorphisms of CYP2C19 and P2Y12 on clopidogrel responsiveness and adverse clinical events in Chinese patients.Methods In 577 Han Chinese patients undergoing stent placement because of acute coronary syndrome had platelet reactivity assessed by thromboelastography,and the CYP2C19 G681A and P2Y12 C34T polymorphisms were detected by the ligase detection reaction.Primary clinical endpoints included cardiovascular death,nonfatal myocardial infarction,target vessel revascularization,and stent thrombosis.The secondary clinical endpoints were thrombolysis in myocardial infarction bleeding.The follow-up period was 12 months.Results Genotyping revealed 194 carriers of the wild type GG genotype of CYP2C19 and the wild type CC genotype of P2Y12 (group 1),102 carriers of the wild type GG genotype of CYP2C 19 and the mutational T allele of P2Y12 (group 2),163 carriers of the mutational A allele of CYP2C19 and the wild type CC genotype of P2Y12 (group 3),and 118 carriers of the mutational A allele of CYP2C19 and the mutational T allele of P2Y12 (group 4).Group 4 had the lowest ADP-inhibition (49.74±32.61) and the highest prevalence of clopidogrel low response (29.7％) of the four groups.The rate of the composite of primary clinical endpoints increased more in group 4 (8.5％) than in the other three groups; the rate of composite primary endpoints in group 2 (2.9％) and group 3 (3.7％) were not significantly different than that of group 1 (1.5％).Conclusion Coexisting polymorphisms of different genes affected clopidogrel responsiveness and clinical outcome more than single polymorphism in Chinese patients with acute coronary syndrome undergoing percutaneous coronary intervention。

Abstract：Background Increased renal sympathetic nerve activity can result in diuretic resistance in patients with chronic congestive heart failure.We investigated the effect of regional renal nerve blockade on the patients with chronic refractory heart failure and diuretic resistance.Methods Eighteen patients with chronic refractory heart failure were enrolled (mean age (64±11) years).The patients were randomly divided into two groups (renal nerve blockade group and standard therapy group,n=9 each).Renal nerve blockade was performed by percutaneous injection of local anaesthetic under computed tomographic guidance.Heart rate,mean arterial blood pressure,plasma and urine electrolytes,neurohormones,factional excretion of sodium (FENa),24-hour urine volume were monitored at baseline and the first 24 hours after therapy.Dyspnea and oedema were also evaluated.The major adverse cardiovascular events (MACE),plasma brain natriuretic peptide (BNP) level and left ventricular ejection fraction (LVEF) were compared between the two groups during the 3-12 months follow-up period.Results No complication was observed during the acute phase of renal nerve blockade.After renal nerve blockade,the 24-hour urine volume and FENa were significantly increased,while the level of plasma rennin,angiotensin Ⅱ,aldosterone,BNP and atrial natriuretic peptide as well as dyspnea and oedema were significantly reduced in renal nerve blockade group compared with baseline and standard therapy group.During three to 12 months of follow-up,the rate of MACE and plasma BNP level were significantly lower,while LVEF was significantly higher in renal nerve blockade group than those in standard therapy group.Conclusion Regional renal nerve blockade may be a safe and effective treatment for patients with chronic refractory heart failure。

Abstract：Background Sirolimus-eluting stents (SES) are reported to be associated with reduced late lumen loss (LLL),resulting in less frequent restenosis when compared to bare-metal stent.The current study aimed to assess the difference in LLL between SES with biodegradable and with permanent polymer.Methods From March 2010 to June 2011,300 consecutive patients having only biodegradable polymers or permanent polymer SES for all diseased vessels were included.Serial quantitative coronary analysis was performed on both the "in-stent" and "segment" area,including the stented segment,as well as both five mm margins proximal and distal to the stent.The primary endpoint was the LLL defined as the minimal lumen diameter (MLD) post-stenting minus the MLD at nine-month after the indexed procedure.Results LLL was comparable between the two stents.Importantly,LLL for the distal segment (median 0.05 mm,interquartile 0 to 0.09 mm) was less severe compared with i n-stent (median 0.13 mm,interquartile 0.08 to 0.18 mm) and proximal segment LLL (median 0.12 mm,interquartile 0.06 to 0.14 mm,all P＜0.001).In general,the LLL was associated with the post-procedure MLD (b=0.28,P=0.002),hyperlipidemia (b=0.14,P=0.021),and calcified lesions (b=0.58,P=0.001).The R2 and Radj of the multiple regression model were 0.651 and 0.625,respectively.Conclusions SES with either biodegradable or permanent polymer had lower value of LLL.The small amount of LLL at the distal seoment oossiblv contributed to the less distal edge stenosis。

Abstract：Background Transcatheter aortic valve implantation (TAVI) has emerged as the treatment choice for non-operable patients with severe symptomatic aortic stenosis (AS) and may be a good alternative to surgery for those at very high or prohibitive surgical risk.We performed a meta-analysis to evaluate the comparative benefits of TAVI versus surgical aortic valve replacement (SAVR) in patients with severe AS.Methods A comprehensive literature search of PubMed,Embase,ScienceDirect and Cochrane Central Register of Controlled trials was performed,and randomized trials as well as cohort studies with propensity score analysis were included.Results One randomized trial (n=699) and six retrospective cohort studies (n=781) were selected for meta-analysis.Mortality at 30-day and 1-year follow-up was comparable between TAVI and SAVR.Despite similar incidences of stroke,myocardial infarction,re-operation for bleeding,and renal failure requiring dialysis,TAVI was associated with a lower occurrence rate of new-onset atrial fibrillation (OR 0.51,95％ CI 0.33-0.78) and shorter procedural time (mean difference -67.50 minutes,95％ CI-87.20 to-47.81 minutes).Post-operative aortic regurgitation and permanent pacemaker implantation were more common in patients after TAVI than in those with SAVR (OR 5.53,95％ CI 3.41-8.97; OR 1.71,95％ Cl 1.02-2.84,respectively).Conclusion In patients with severe symptomatic AS,TAVI and SAVR did not differ with respect to short-and mid-term survival,but the incidence of permanent pacemaker implantation and post-procedural aortic regurgitation remain relatively high after TAVI。

Abstract：Background The effectiveness and influence of surgery followed by adjuvant chemoradiotherapy (CRT) on the survival of patients with resectable esophageal carcinoma are still under debate.The outcomes of clinical trials have not been consistent.This study aimed to perform a meta-analysis of eligible published clinical trials to compare CRT with surgery without adjuvant chemoradiotherapy (non-CRT) for resectable esophageal carcinoma.Methods Computerized bibliographic and manual searches were undertaken to identify all eligible literature between 1990 and 2012.PubMed,EMBASE,Chinese National Knowledge Infrastructure,and Wanfang databases were our primary sources for published clinical trials.The quality of the methodology and reliability of the data from all of the clinical trials were assessed.All data were extracted by three independent researchers.Results Seven studies that included a total of 523 patients were selected.It was found that CRT significantly improved survival.The odds ratio (OR) in comparing CRT and non-CRT groups was 1.75 (95％ confidence intervals (CI):1.17-2.60,P=0.006) for 1-year survival,2.07 (95％ Cl:1.45-2.96,P ＜0.0001) for 3-year survival,and 2.17 (95％ CI:1.45-3.26,P=0.0002) for 5-year survival.There have been no CRT treatment-related deaths reported in the literature.The incidence of related complications was high in the cases with CRT.Patients treated with CRT had a lower incidence of local-regional cancer recurrence (OR:0.49,95％ Cl:0.31-0.76,P=0.002) and a similar incidence of distant cancer recurrence (OR:0.90,95％ CI:0.60-1.34,P=0.60).Conclusions It was found that patients with resectable esophageal carcinoma could gain a survival benefit from CRT.However,CRT was associated with a high incidence of related complications。

Abstract：Background Previous studies indicated that long coronary lesions are one of the key predictors of drug-eluting stent (DES) failure.The purpose of this study was to evaluate the efficacy and the safety of the long length FIREHAWK(R) stent in long coronary artery disease.Methods The long cohort of TARGET I was a prospective,multicenter,single arm trial.It was planned to enroll 50 patients undergoing percutaneous coronary intervention (PCI) for the treatment of de novo long lesions in a native coronary artery.The major inclusion criteria of the trial was that patients were intended to undergo the treatment of a long target lesion(s) with diameter stenosis ≥70％ and reference vessel diameter 2.5 mm to 4.0 mm by visual estimate,that needed to be covered by at least one 33 mm or 38 mm stent or multiple long stents overlapped.The angiographic follow-up was planned at 9-month and the clinical follow-up will be up to 5 years.The primary end point was in-stent late lumen loss at 9-month.Results Fifty patients (mean age (57.6±10.2) years) with 59 de novo long lesions (reference vessel diameter (2.85±0.44) mm,lesion length (35.2±9.4) mm,and stent length (41.8±11.3) mm) were enrolled.The angiographic follow-up rate was 92％ at 9-month.The in-stent late loss was (0.16±0.16) mm.Proximal edge,distal edge and in-segment late loss (mm) were 0.21±0.35,0.03±0.33,and 0.07±0.26,respectively.No in-segment binary restenosis was observed.At 1-year no death,Q wave myocardial infarction (MI),or stent thrombosis occurred.Non-Q-wave MI occurred in two patients (4％) due to procedural complications.Conclusions Treatment of long coronary lesions with the FIREHAWK(R) stent is able to produce similar results as observed in the FIREHAWK(R) FIM clinical trial.Based on this result,we are confident in the treatment prospect of the FIREHAWK（R） for long coronary lesions。

Abstract：Background Severity scoring systems are useful tools for measuring the severity of the disease and its outcome.This pilot study was to verify and compare the prognostic performance of the Simplified Acute Physiology Score Ⅱ (SAPS Ⅱ)and Glasgow Coma Scale (GCS) in neuro-intensive care unit (N-ICU) patients.Methods A total of 1684 patients consecutively admitted to the N-ICU at Xuanwu Hospital between January 1,2005and December 31,2011 were enrolled in this study.The data-base included admission data,at 24-,48-,and 72-hour SAPS Ⅱ and GCS.Repeated measure data analysis of variance,Logistic regression analysis,the Hosmer-Lemeshow goodness-of-fit statistic,and the area under the receiver operating characteristic were used to evaluate the performance.Results There was a significant difference between the SAPS Ⅱ or GCS score at four time points (F=16.110,P=0.000or F=8.108,P=0.000).The SAPS Ⅱ scores or GCS score at four time points interacted with the outcomes with significant difference (F=116.771,P=0.000 or F=65.316,P=0.000).Calibration of the SAPS Ⅱ or GCS score at each time point on all patients was good.The percentage of a risk estimate prediction corresponding to observed mortality was also good.The 72-hour score have the greatest consistency.Discriminations of the SAPS Ⅱ or GCS score at each time were all satisfactory.The 72-hour score had the greatest discriminative power.The cut-off value was 33 (sensitivity of 85.2％ and specificity of 74.3％) and 6 (sensitivity of 70.6％ and specificity of 65.0％).The SAPS Ⅱ at each time point on all patients showed better calibration,consistency and discrimination than GCS.The binary Logistic regression analysis identified physiological variables,GCS,age,and disease category as significant independent risk factors of death.After the two variables including underlying disease and type of admission were excluded,we built the simplified SAPS Ⅱ model.A correlation was suggested between the simplified SAPS Ⅱ score at each time point and outcome,regardless of the diagnosis.Conclusions The GCS scoring system tends to be a little weaker in the predictive power than the SAPS Ⅱ scoring system in this Chinese cohort of N-ICU patients.The advantage of SAPS Ⅱ scoring system still exists that it dose not need to take into account the diagnosis or diseases categories,even in the special N-ICU.The simplified SAPS Ⅱ scoring system is considered a new idea for the estimation of effectiveness。

It is well recognized that any disruptive innovation in medicine looks at first unfeasible and unacceptable.It has been the case for transcatheter aortic valve implantation (TAVI) as the project appeared totally unrealistic in the early 1990s.It is quite thrilling,therefore,to observe the current expansion of this technology worldwide,20 years after the birth of the concept and 10 years after the first-in-man TAVIprocedure performed in Rouen on April 16,2002.To date,more than 80 000 patients have benefitted from TAVIworldwide and the number is consistently increasing。

It is now more than two decades since Nico Pijls and Bernard DeBruyne introduced fractional flow reserve (FFR) as a way to assess stenosis severity in the catheterization laboratory and since Paul Yock invented grayscale intravascular ultrasound (IVUS) that then spawned many second-generation intravascular imaging techniques such as (1) Virtual histology-IVUS (VH-IVUS) that uses both amplitude and radiofrequency ultrasound information to classify plaque as necrotic core,fibrofatty,fibrotic,or calcific;(2) Optical coherence tomography (OCT) that is the light analogue of IVUS with a 10-fold increase in resolution and better tissue characterization,but at the expense of decreased penetration;(3) Near infrared spectroscopy (NIRS) that detects lipid within the vessel wall within 0.45 mm of the neointimal surface and that has been recently combined with grayscale IVUS in a single catheter。

The role of drug-eluting stent (DES),which prevents acute or subacute recoil and elutes drugs to prevent smooth muscle cell proliferation,is temporary and limited within a few weeks after its implantation.Beyond that,there is no utility or advantages but only limitations just like foreign materials in patients' body.All of these problems can be solved with the use of fully bioabsorbable stent (BAS),which will disappear from the vessel wall after complete degradation and leave a "clean" vessel.Numerous BASs are currently undergoing pre-clinical and clinical trials.1'2 The purpose of the present study was to assess the short-term effects of a novel,fully bioabsorbable poly-L-lactic acid (PLLA)sirolimus-eluting stent (SES) made in China compared with a metallic durable polymer-coated sirolimus-eluting Cypher stent in healthy porcine coronary arteries。

Multiple primary cancers (MPC) are specific malignant tumors type,manifesting as more than one primary tumor diagnosed in the same patient,either simultaneously or sequentially.The diagnostic criteria include:the cancer must be clearly malignant as determined by histological evaluation;each cancer must be geographically separate and distinct;and the possibility that the second tumor represents a metastasis should be excluded.1 The mechanism of pathophysiology remains poorly understood but cancer survivors are at increased risk of second cancer.With increased availability of methods with greater sensitivity for screening organs susceptible to cancers,there may be an increase of frequency in the identification of multiple malignities in the coming years.The association of multiple myeloma with solid tumors is rare.In this study,we presented a multiple myeloma case accompanying to lung,colon and gastric cancer。

In most adults,the conus medullaris ends at around the inferior margin of the first lumbar (L1) vertebral body)However,location of terminus of the conus medullaris is variable and even extends more distally in patients with diseases such as tethered cord syndrome (TCS).Here,we reported a conus medullaris injury following combined spinal and epidural anesthesia (CSEA) in a pregnant woman with unknown TCS。

Transcatheter aortic valve implantation (TAVI) is a promising alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis (AS) who were deemed at a high surgical risk.This novel technique has kept evolving rapidly throughout the world in the past decade,but was not introduced to China until recently.Here we report our clinical experience in TAVI based on the largest cohort of Chinese patients in a single center。

Essential tremor (ET) is one of the most common neurological degenerative disorders.Increased evidences indicated that ET is a hereditary of disease.Furthermore,this age-related,progressive disorder is thought to be associated with neuronal loss.1 It has been reported that the sensitivity and specificity of family history given by ET patients are 43.3％ and 94.4％,respectively.2 Recently,deep brain stimulation (DBS) of ventral intermediate nucleus of the thalamus (Vim) has become an established treatment for ET and is widely used in the world,however,so far,no more than dozens of cases have been reported to be treated with this method in the mainland of China.Hereby,we report a Chinese patient with family essential tremor (FET),who was treated with Vim-DBS and had good outcome。

To the editor:Airway foreign body (AFB) is a common condition which may be easily misdiagnosed when specific symptoms are lacking.Flexible bronchoscopy can accurately identify and locate foreign bodies within the airway,and is generally the first-line for the removal of AFB.1 We report a successful application of bronchoscopy for AFB in a patient which was misdiagnosed for 19 years。

To the editor:Left ventricular diverticulum is a rare congenital anomaly,and poorly understood.The first patient was described by O'Bryan in 1838) Here we report a case of a 19-year-old young man with isolated huge left ventricular divertivulum He was admitted to our hospital for heart assessment.He had no connective tissue disorders or other systemic anomalies,and there was no signification family history of disease.Transthoracic echocardiography and magnetic resonance imaging (MRI) showed a large outpouching lesion that contained full-thickness myocardium at the anterolateral wall of the left ventricle without any other cardiac defects (Figure 1).Computed tomography angiography showed no significant coronary artery stenosis.This established the diagnosis of isolated left ventricular diverticulum.The man's cardiac function was within normal limits,and a surgical procedure was not indicated。

To the editor:Cutis laxa is a rare connective tissue disorder which is manifested by loose,redundant and inelastic skins.1Occasionally,pulmonary parenchyma will be involved,resulting in emphysema.Here we present two rare cases of emphysema associated with acquired cutis laxa.First is a 48-year-old woman who began to suffer from chronic urticaria seven years ago,and her whole body skin became slack and wrinkling two years later.She had never smoked,but progressive dyspnea developed two years ago.Coughing and some white sputum were also noticed。

To the editor:Accessory ovary is an uncommon congenital anomaly of the female reproductive tract.Tumors arising in accessory ovaries are extremely rare.In this report we described a case of a giant fibrothecoma at accessory ovary in a pregnant woman in her first trimester.A 27-year-old G1P0 woman,pregnant at 9 weeks' gestation,presented persistent abdominal pain for 28 hours.She denied fever,vaginal bleeding,dysuria or bloody stools.Her ultrasonography revealed a right-side pelvic solid mass measured 6.5 cm×5.8cm×4.5 cm 20 days ago。

To the editor:A 44-year-old man presented to our department with intermittent chest and back pain.He had a past medical history of having undergone aortic valve replacement and ascending aortic aneurysm repair (Bentall) in the same operation 12 years ago.The Bentall operation was performed due to the diagnosis of severe aortic valve regurgitation together with an aneurysm of the ascending aorta measuring 70 mm in diameter.The diameter of the remaining aortic arch had previously been measured as 40 mm at the time。

To the editor:Pulmonary arterial hypertension (PAH) is an infrequent but nevertheless,serious life threatening complication of human immunodeficiency virus (HIV) infection.People infected with HIV have a high prevalence of chronic hepatitis B virus (HBV) and/or hepatitis C virus (HCV).Bosentan is effective in patients with HIV-related PAH (HRPH);1 but hardly used on Chinese patients so far.In this rare case,we present successful,long-term coadministration of bosentan and antiretroviral therapy in an HIV/HBV/HCV coinfected Chinese patient with HRPH。

To the editor:We report a case of aortoduodenal fistula presenting as right lower limb ischemia and infection after endovascular aortic repair (EVAR) of an infected abdominal aortic aneurysm (AAA).A right above knee amputation was performed for the septic embolism of the ilio-femoral arteries before the stent-graft infection was finally diagnosed.Then an extra-anatomic revascularization of the left lower limb,following by explantation of the infected stent-graft and rebuilding of the gastro-intestinal continuity were done.To our knowledge,this is the first case successfully treated by this method in China。

To the editor:Synovial sarcoma (SS) of the head and neck is extremely rare.We present a male of 44 years old with SS extending from hypopharynx to the thoracic segment of esophagus.A man of 44 years old was admitted to the hospital because of progressive disphagia and dyspnea.The fibrolaryngoscopy demonstrated a round mass at the oropharynx and hypopharyx,the larynx was obscured under the mass.The cervicothoracic X-ray film and CT revealed a lesion extending from the hypopharynx to the aorta arch level of esophagus (Figure 1A).Emergent tracheotomy was performed before total laryngectomy,partial pharyngoesophagectomy,bilateral selective neck dissection including Ⅰ,Ⅱ,Ⅲ,V areas and esophageal reconstruction。