2018年 · 第46卷第10期

Recently, I was inspired by the book "Understanding Value-Based Healthcare" published by Peking University Medical Press (Christopher Moriates et al., translated by Yang Li, reviewed by Wu Ming). It is worth taking some time and carefully reading by leaders in charge of medical and health reform departments, managers of medical institutions, people who want and want to invest in health care or industries, leaders and teachers of medical education departments, medical staff and medical students. Its main content has a lot of resonance with my original intention of studying medicine and practicing medicine, and my thinking, reflection and exploration on how to understand medicine and how to be a good doctor in the practice of studying medicine for more than half a century.

"Chinese Heart Failure Diagnosis and Treatment Guidelines 2018" published in this issue^[1](abbreviated as the new guidelines) is in the "Chinese Heart Failure Diagnosis and Treatment Guidelines 2014"^[2]Based on the latest research evidence in the field of heart failure (heart failure) in recent years, refer to the latest European and American heart failure guidelines^[3,4]Combined with China's national conditions and clinical practice, the update made a comprehensive and clear elaboration and recommendation on the classification, diagnosis, prevention, treatment and management of heart failure, in order to improve the overall prevention and treatment level of heart failure in China.

Coronary artery dilatation refers to dilatation-like changes in the coronary artery caused by various reasons that exceed 1.5 times or more the diameter of the adjacent normal coronary artery^[1,2]。 Coronary artery dilatation is classified into localized dilatation (i.e., coronary aneurysm) and diffuse dilatation, where diffuse dilatation refers to dilatation exceeding 50% of the length of the coronary artery^[3]。 The main cause of coronary artery dilatation is atherosclerosis (50%)^[4]Other causes include Kawasaki disease, Takayasu arteritis and infectious diseases. Atherosclerotic coronary artery dilatation usually involves multiple vessels^[5]Among them, the right coronary artery is the most common (40% ~61%), followed by the left anterior descending artery (15% ~32%), left circumflex artery (15% ~23%) and left main artery (0.1% ~3.5%)^[1,6,7]。 The mechanism of coronary artery dilatation has not been clarified at present, but it may be related to the destruction of the middle layer of the artery, thinning of the arterial wall and increased shear force of the arterial wall^[8]。 Lam and Ho^[9]It is reported that more than 80% of patients with atherosclerotic coronary artery dilatation are complicated with proximal clinically significant coronary artery stenosis, and coronary artery dilatation is considered to be a manifestation of the entire continuous pathophysiological process of obstructive coronary atherosclerosis^[10]。 However, for coronary artery dilatation without clinically significant stenosis, its formation may be associated with positive remodeling of atheromatous plaque^[10]Inflammatory response^[3]And risk factors^[11]Relevant. Some studies have also shown that the more severe the coronary artery dilation, the greater the shear force on the artery wall, which will further promote the coronary artery dilation^[12]。

Since "Chinese Heart Failure Diagnosis and Treatment Guidelines 2014"^[1]Since its release, there have been many new advances in the diagnosis, treatment, prevention and comprehensive management of heart failure (heart failure). For this reason, the Heart Failure Group of the Cardiovascular Branch of the Chinese Medical Association, the Heart Failure Professional Committee of the Chinese Medical Association, and the Editorial Committee of the Chinese Journal of Cardiovascular Diseases organized an expert group, according to the latest clinical research results at home and abroad, with reference to the 2017 American College of Cardiology (ACC) /American Heart Association (AHA)^[2]and the European Society of Cardiology (ESC) 2016^[3]The relevant guidelines issued by etc., combined with China's national conditions and clinical practice, updated the "Chinese Guidelines for the Diagnosis and Treatment of Heart Failure 2014".

Case 1: excimer laser coronary atherectomy (ELCA) in stent restenosis. The patient was hospitalized in Beijing Anzhen Hospital on March 19, 2015 due to "chest pain for 2 months". The patient had previous history of hypertension and smoking. Physical examination: blood pressure 140/80 mmmHg (1 mmHg =0.133 kPa); No murmur was heard in the auscultation area of each valve; The breathing sounds of both lungs were clear, and no rales were heard; Soft abdomen, no tenderness and rebound pain. Echocardiography showed a left ventricular ejection fraction of 59%. Diagnosis of unstable angina pectoris. Coronary angiography after admission showed reocclusion of left anterior descending (LAD) and left circumflex artery (LCX). optical coherence tomography (OCT; Abbott, USA) showed fibrous tissue hyperplasia in the stent with red thrombus and marked luminal stenosis (Figure 1）。 It is proposed to use the CVX-300 ELCA system manufactured by Spectranetics, USA (the other three cases are the same) to perform ELCA on LCX. Select 1.4 mm diameter catheter with initial setting of 50 J/cm²Frequency 40 Hz, set again to 50 J/cm²Frequency 40 Hz. The ELCA operated for 2 min 5 s and fired a total of 4 810 pulses. After ELCA, OCT examination was performed again, which showed a significant improvement in intravascular stenosis after operation (Figure 2）。 The stenotic lesions were then dilated using a 2.75 mm ×20 mm balloon and a 3.0 mm ×30 mm drug-eluting balloon (Sequent Braun, Germany), and the vascular occlusion was improved.

Coronary artery dilatation refers to the dilatation of coronary arteries caused by various causes that exceed 1.5 times or more the diameter of adjacent normal coronary arteries^[1,2]。 The main treatment options for coronary artery dilatation include pharmacotherapy, interventional therapy, and surgery, but the best treatment options are currently controversial. This article reviews the research and treatment progress of coronary artery dilatation.

Paravalvular leakage refers to suture cracking between prosthetic valve annulus and autologous tissue after surgical heart valve replacement. It is a common postoperative complication, and its incidence rate is 2.3% ~5.0%^[1,2]。 The mechanisms of paravalvular leakage include calcification and deformation of the autologous annulus, mismatch between the selected prosthetic valve and the patient's annulus, tissue inflammatory reaction, infection and insufficient space in the suture area, etc^[3,4]。 Most patients with paravalvular leakage have no obvious clinical symptoms, but a few patients with paravalvular leakage will have serious consequences and need active treatment. Secondary surgical repair or secondary valve replacement is still the gold standard for the treatment of paravalvular leakage, but secondary surgery is technically difficult, risky and mortality, so many surgeons and patients are reluctant to choose secondary surgery^[5,6]。 1992, Hourihan et al.^[7]The application of transcatheter intervention for closure of paravalvular leakage was reported for the first time. Following the continuous development of interventional therapy techniques and devices for more than 20 years, this technique has been widely carried out abroad. In the American Heart Association (AHA) /American College of Cardiology (ACC) guidelines for the management of valvular heart disease updated in 2017, for patients with repeated hemolysis and/or New York Heart Association (NYHA) cardiac function grades III to IV and high surgical risk of paravalvular leakage, if anatomical conditions are suitable for occlusion, it is recommended that the first choice of interventional treatment (recommended grade IIA)^[8]。 However, this technology has not been widely used in China. This article reviews the current status of interventional therapy for paravalvular leakage.

The pathophysiological basis of myocardial infarction is insufficient blood supply to the myocardium, which leads to apoptosis and ventricular remodeling, which eventually develops into heart failure and death. Therefore, promoting angiogenesis is the key to contain ventricular remodeling and decline in cardiac function after myocardial infarction. The pathological mechanism of coronary microvascular after myocardial infarction is a complex process. Hypoxia and inflammatory stimulation first cause endothelial activation and disability, and then subendothelial tissue damage, resulting in the destruction of microvascular structure. As a compensation, endogenous vascularization mainly includes in situ coronary endothelial vascularization and vascular differentiation and repair of self-stem cells. Among them, the former has three ways^[1]: First, mesothelial cells at the epicardium migrate to the myocardium, and autocrine or paracrine secretion makes them eventually develop into coronary endothelium, forming subepicardial blood vessels; Second, the coronary sinus endothelium is directly connected with the coronary artery branch endothelium. The former can extend to the subadventitia and atrioventricular septum and communicate with the latter, forming collateral circulation in the myocardium; Third, based on the action of oxygen molecules, some special endocardial cells differentiate into the coronary endothelium, and are surrounded by smooth muscle and endocardial cells in the shape of flower clusters, which are called "endocardial flowers"^[2], forming subendocardial blood vessels. However, whether it is in situ coronary endothelium or the body's own stem cells, the function and number of differentiated new blood vessels are limited, and it is difficult to effectively reverse ventricular remodeling. Therefore, a large number of studies have explored new methods to promote coronary microcirculation regeneration, including cell transplantation, biological induction and tissue engineering, etc. The following will explain their research progress from the perspective of mechanism or methodology.