2017年 · 第130卷第04期

Background: The clinical significance of acute vasoreactivity testing (AVT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains unclear. We analyzed changes in hemodynamics and oxygenation dynamics indices after AVT in patients with CTEPH using patients with pulmonary arterial hypertension (PAH) as controls.　 Methods: We analyzed retrospectively the results of AVT in 80 patients with PAH and 175 patients with CTEPH registered in the research database of Beijing Chao-Yang Hospital between October 2005 and August 2014. Demographic variables, cardiopulmonary indicators, and laboratory findings were compared in these two subgroups. A long-term follow-up was conducted in patients with CTEPH. Between-group comparisons were performed using the independent-sample t-test or the rank sum test, within-group comparisons were conducted using the paired t-test or the Wilcoxon signed-rank test, and count data were analyzed using the Chi-squared test. Survival was estimated using the Kaplan-Meier method and log-rank test.　 Results: The rates of positive response to AVT were similar in the CTEPH (25/175, 14.3%) and PAH (9/80, 11.3%) groups (P > 0.05). Factors significantly associated a positive response to AVT in the CTEPH group were level of N-terminal pro-brain natriuretic peptide (≤1131.000 ng/L), mean pulmonary arterial pressure (mPAP, ≤44.500 mmHg), pulmonary vascular resistance (PVR, ≤846.500 dyn·s−1·m−5), cardiac output (CO, ≥3.475 L/min), and mixed venous oxygen partial pressure (PvO2, ≥35.150 mmHg). Inhalation of iloprost resulted in similar changes in mean blood pressure, mPAP, PVR, systemic vascular resistance, CO, arterial oxygen saturation (SaO2), mixed venous oxygen saturation, partial pressure of oxygen in arterial blood (PaO2), PvO2, and intrapulmonary shunt (Qs/Qt) in the PAH and CTEPH groups (all P > 0.05). The survival time in patients with CTEPH with a negative response toAVT was somewhat shorter than that inAVT-responders although the difference was not statistically significant (χ2 =3.613, P = 0.057). The survival time of patients with CTEPH who received calcium channel blockers (CCBs) was longer than that in the group with only basic treatment and not shorter than that of patients who receiving targeted drugs or underwent pulmonary endarterectomy (PEA) although there was no significant difference between the four different treatment regimens (χ2 =3.069, P = 0.381).　 Conclusions: The rates of positive response to AVT were similar in the CTEPH and PAH groups, and iloprost inhalation induced similar changes in hemodynamics and oxygenation dynamics indices. A positive response to AVT in the CTEPH group was significantly correlated with milder disease and better survival. Patients with CTEPH who cannot undergo PEA or receive targeted therapy but have a positive response to AVT might benefit from CCB treatment.

Background: The optimal timing of surgical revascularization for patients presenting with ST-segment elevation myocardial infarction (STEMI) and impaired left ventricular function is not well established. This study aimed to examine the timing of surgical revascularization after STEMI in patients with ischemic heart disease and left ventricular dysfunction (LVD) by comparing early and late results.　 Methods: From January 2003 to December 2013, there were 2276 patients undergoing isolated coronary artery bypass grafting (CABG) in our institution. Two hundred and sixty-four (223 male, 41 females) patients with a history of STEMI and LVD were divided into early revascularization (ER, <3 weeks), mid-term revascularization (MR, 3 weeks to 3 months), and late revascularization (LR, >3 months) groups according to the time interval from STEMI to CABG. Mortality and complication rates were compared among the groups by Fisher’s exact test. Cox regression analyses were performed to examine the effect of the time interval of surgery on long-term survival.　 Results: No significant differences in 30-day mortality, long-term survival, freedom from all-cause death, and rehospitalization for heart failure existed among the groups (P > 0.05). More patients in the ER group (12.90%) had low cardiac output syndrome than those in the MR (2.89%) and LR (3.05%) groups (P = 0.035). The mean follow-up times were 46.72 ± 30.65, 48.70 ± 32.74, and 43.75 ± 32.43 months, respectively (P = 0.716). Cox regression analyses showed a severe preoperative condition (odds ratio = 7.13, 95% confidence interval 2.05–24.74, P = 0.002) rather than the time interval of CABG (P > 0.05) after myocardial infarction was a risk factor of long-term survival.　 Conclusions: Surgical revascularization for patients with STEMI and LVD can be performed at different times after STEMI with comparable operative mortality and long-term survival. However, ER (<3 weeks) has a higher incidence of postoperative low cardiac output syndrome. A severe preoperative condition rather than the time interval of CABG after STEMI is a risk factor of long-term survival.

Background: Lymph node status of patients with early-stage nonsmall cell lung cancer has an influence on the choice of surgery. To assess the lymph node status more correspondingly and accurately, we evaluated the relationship between the preoperative clinical variables and lymph node status and developed one model for predicting lymph node involvement.　 Methods: We collected clinical and dissected lymph node information of 474 patients with clinical stage T1aN0-2M0 nonsmall cell lung cancer (NSCLC). Logistic regression analysis of clinical characteristics was used to estimate independent predictors of lymph node metastasis. The prediction model was validated by another group.　 Results: Eighty-two patients were diagnosed with positive lymph nodes (17.3%), and four independent predictors of lymph node disease were identified: larger consolidation size (odds ratio [OR] = 2.356, 95% confidence interval [CI]: 1.517–3.658, P < 0.001,), central tumor location (OR = 2.810, 95% CI: 1.545–5.109, P = 0.001), abnormal status of tumor marker (OR = 3.190, 95% CI: 1.797–5.661, P < 0.001), and clinical N1–N2 stage (OR = 6.518, 95% CI: 3.242–11.697, P < 0.001). The model showed good calibration (Hosmer–Lemeshow goodness-of-fit, P < 0.766) with an area under the receiver operating characteristics curve (AUC) of 0.842 (95% [CI]: 0.797–0.886). For the validation group, the AUC was 0.810 (95% CI: 0.731–0.889).　 Conclusions: The model can assess the lymph node status of patients with clinical stage T1aN0-2M0 NSCLC, enable surgeons perform an individualized prediction preoperatively, and assist the clinical decision-making procedure.

Background: The laryngeal mask airway (LMA) is the most commonly used rescue airway in obstetric anesthesia. The aim of this retrospective cohort study was to evaluate the application of the LMA in parturients undergoing cesarean delivery (CD) for 5 years in our hospital. As a secondary objective, we investigated the incidence of airway-related complication in obstetric general anesthesia (GA).　 Methods: We collected electronic data for all obstetric patients who received GA for CD between January 2010 and December 2014 in Peking University First Hospital. Based on the different types of airway device, patients were divided into endotracheal intubation (ET) group and LMA group. The incidences of regurgitation and aspiration, as well as maternal and neonatal postoperative outcomes were compared between groups.　 Results: During the 5-year study, GA was performed in 192 cases, which accounted for 2.0% of all CDs. The main indications for GA were contraindication to neuraxial anesthesia or a failed block. Among these, ET tube was used in 124 cases (68.9%) and LMA in 56 cases (31.1%). The percentage of critical patients above the American Society of Anesthesiologists’ Grade II was 24/124 in ET group and 4/56 in LMA group (P = 0.036). The emergent delivery rate was 63.7% for ET group and 37.5% for LMA group (P = 0.001). None of the patients had regurgitation or aspiration. There were no significant differences in terms of neonatal Apgar scores, maternal and neonatal postoperative outcomes between the two groups.　 Conclusions: Our results suggested that GA was mainly used for contraindication to neuraxial anesthesia or a failed block, and emergent CDs accounted for most cases. The second-generation LMA could be used for obstetric anesthesia, but correct position to achieve a good seal is the key to prevent reflux and aspiration. Whether they could replace the tracheal tube in routine practice needs further large prospective studies.

Background: Double outlet right ventricle (DORV) is a group of complex congenital heart abnormalities. Preoperative pulmonary hypertension (PH) is considered an important risk factor for early death during the surgical treatment of DORV. The aim of this study was to report our experience on surgical treatment of DORV complicated by PH.　 Methods: From June 2004 to November 2016, 61 patients (36 males and 25 females) aged 2 weeks to 26 years (median: 0.67 years and interquartile range: 0.42–1.67 years) with DORV (two great arteries overriding at least 50%) complicated by PH underwent surgical treatment in our center. All patients were categorized according to surgical age and lesion type, respectively. Pulmonary artery systolic pressure (PASP), pulmonary artery diastolic pressure (PADP), and mean pulmonary artery pressure (mPAP) were measured directly before cardiopulmonary bypass (CPB) was established and after CPB was removed. An intracardiac channel procedure was performed in 37 patients, arterial switch procedure in 19 patients, Rastelli procedure in three patient, Senning procedure in one patients, and Mustard procedure in one patient. The Student’s t-test and Chi-squared test were performed to evaluate clinical outcomes of the surgical timing and operation choice.　 Results: Fifty-five patients had uneventful recovery. PASP fell from 55.3 ± 11.2 mmHg to 34.7 ± 11.6 mmHg (t = 14.05, P < 0.001), PADP fell from 29.7 ± 12.5 mmHg to 18.6 ± 7.9 mmHg (t = 7.39, P < 0.001), and mPAP fell from 40.3 ± 10.6 mmHg to 25.7 ± 8.3 mmHg (t = 11.85, P < 0.001). Six (9.8%) patients died owing to complications including low cardiac output syndrome in two patients, respiratory failure in two, pulmonary hemorrhage in one, and sudden death in one patient. Pulmonary artery pressure (PAP) dropped significantly in infant and child patients. Mortality of both infants (13.9%) and adults (33.3%) was high.　 Conclusions: PAP of patients with DORV complicated by PH can be expected to fall significantly after surgery. An arterial switch procedure can achieve excellent results in patients with transposition of the great arteries type. Higher incidence of complications may occur in patients with ventricular septal defect (VSD) type before 1 year of age. For those with remote VSD type, VSD enlargement and right ventricle outflow tract reconstruction are usually required with acceptable results. The degree of aortic overriding does not influence surgical outcome.

Background: Electroconvulsive therapy (ECT) can alleviate the symptoms of treatment-resistant depression (TRD). Functional network connectivity (FNC) is a newly developed method to investigate the brain’s functional connectivity patterns. The first aim of this study was to investigate FNC alterations between TRD patients and healthy controls. The second aim was to explore the relationship between the ECT treatment response and pre-ECT treatment FNC alterations in individual TRD patients.　 Methods: This study included 82 TRD patients and 41 controls. Patients were screened at baseline and after 2 weeks of treatment with a combination of ECT and antidepressants. Group information guided-independent component analysis (GIG-ICA) was used to compute subject-specific functional networks (FNs). Grassmann manifold and step-wise forward component selection using support vector machines were adopted to perform the FNC measure and extract the functional networks’ connectivity patterns (FCP). Pearson’s correlation analysis was used to calculate the correlations between the FCP and ECT response.　 Results: A total of 82 TRD patients in the ECT group were successfully treated. On an average, 8.50 ± 2.00 ECT sessions were conducted. After ECT treatment, only 42 TRD patients had an improved response to ECT (the Hamilton scores reduction rate was more than 50%), response rate 51%. 8 FNs (anterior and posterior default mode network, bilateral frontoparietal network, audio network, visual network, dorsal attention network, and sensorimotor network) were obtained using GIG-ICA. We did not found that FCPs were significantly different between TRD patients and healthy controls. Moreover, the baseline FCP was unrelated to the ECT treatment response.　 Conclusions: The FNC was not significantly different between the TRD patients and healthy controls, and the baseline FCP was unrelated to the ECT treatment response. These findings will necessitate that we modify the experimental scheme to explore the mechanisms underlying ECT’s effects on depression and explore the specific predictors of the effects of ECT based on the pre-ECT treatment magnetic resonance imaging.

Background: The treatment of the condylar fractures is difficult. Factors that result in the fractures are complex. The objective of this morphometric study was to investigate the relationship between condylar fracture patterns and condylar morphological characteristics.　 Methods: We conducted a retrospective analysis of 107 patients admitted to the West China Hospital of Stomatology for bilateral condylar fractures caused by parasymphyseal impact. The patients were divided into five groups according to the type of condylar fracture. Ten parameters were evaluated on three-dimensional (3D) reconstruction mandible models through the Mimics 16.0 (Materialize Leuven, Belgium) anthropometry toolkit. Each parameter of the 3D models was analyzed using multivariate analysis. Multinomial logistic regression analyses were used to examine the relationships between the five groups.　 Results: The results showed that the differences of condylar head width (M1), condylar neck width (M3), the ratio of condylar head width to condylar anteroposterior diameter (M1/M2), the ratio of condylar head width to condylar neck width (M1/M3), the ratio of condylar height to ramus height (M8/M7), and mandibular angle (M10) were statistically significant (p < 0.05). Type A condylar head fractures were positively associated with M1 (compared to Type B: OR =1.627, 95% CI: 1.123, 2.359; compared to Type C: OR = 1.705, 95% CI: 1.170, 2.484) and M1/M2 (compared to Type B: OR =1.034, 95% CI: 0.879, 2.484). Type B condylar head fractures were negatively associated with M10 (compared to Type C: OR = 0.909, 95% CI: 0.821, 1.007). Condylar neck fractures were negatively associated with M3 (compared to condylar head: OR = 0.382, CI: 0.203, 0.720 ; compared to condylar base: OR = 0.436, 95% CI: 0.218, 0.874), and positively associated with M1/M3 (compared to condylar head: OR = 1.229, 95% CI: 1.063, 1.420 compared to condylar base: OR = 1.223, 95% CI: 1.034, 1.447). Condylar base fractures were positively associated with M10 (OR = 1.095, 95% CI: 1.008, 1.189) and negatively associated with M8/M7 (OR = 0.855, 95% CI: 0.763, 0.959) as compared with condylar head fractures.　 Conclusions: Condylar fracture pattern is associated with the anatomical features of the condyles when a fracture occurs from parasymphyseal impact.

Background: The association between the previous history of endometriosis and obstetric outcomes is still ambiguous. This study aimed to evaluate the effects of previous history of operatively diagnosed endometriosis on pregnancy outcomes.　 Methods: A total of 98 primiparous women who had been diagnosed with endometriosis by previous laparoscopic surgery were included in this retrospective cohort study. Pregnancy outcomes were compared between these women (study group) who had a live birth and 300 women without endometriosis (control group) who had a live birth. In the study group, the pregnancy outcomes of 74 women who conceived naturally (no assisted reproductive technology [ART] subgroup) were simultaneously compared with 24 women who conceived by ART (ART subgroup).　 Results: Miscarriage was observed in 23 of 98 women with endometriosis (23.5%). There were 75 women who had a live birth after laparoscopic diagnosis of endometriosis in the study group eventually. On multivariate analysis, the postpartum hemorrhage rate increased significantly in the study group when compared with the control group (adjusted odds ratio: 2.265, 95% confidence interval: 1.062, 4.872; P = 0.034). There was an upward tendency of developing other pregnancy-related complications, such as preterm birth, placental abruption, placenta previa, cesarean section, fetal distress/anemia, and others in the study group than in the control group. However, the differences showed no statistical significance. Within the study group, the occurrence rate of postpartum hemorrhage and preterm birth was both higher in the ART subgroup than in the no ART subgroup. The differences both had statistical significance (44.4% vs. 17.5%, P = 0.024 and 27.8% vs. 1.8%, P = 0.010, respectively). At the same time, median (interquartile range) for gestational age at delivery in the ART subgroup was significantly shorter than that in the no ART subgroup (38 weeks [36–39 weeks] vs. 39 weeks [38–40 weeks]; P = 0.005).　 Conclusions: Endometriosis may affect obstetric outcomes. Women with endometriosis have a higher risk of postpartum hemorrhage. Women with endometriosis who conceived by ART may have a higher risk of postpartum hemorrhage and preterm birth than those conceived naturally.

Background: In patients with nonvalvular atrial fibrillation (NVAF), embolic stroke is thought to be associated with left atrial appendage (LAA) thrombi. The WATCHMAN LAA Occlusion Device has been shown to be noninferior to conventional oral anticoagulation with warfarin for stroke prevention in patients with NVAF. This study aimed to evaluate the procedural feasibility, safety and 12-month outcomes of the WATCHMAN LAA Occlusion Device in NVAF patients with high risk for stroke in China.　 Methods: The clinical data of 106 NVAF patients, who were consecutively underwent LAA closure with the WATCHMAN Device between April 2014 and May 2015, were collected. Patients were followed up at 1, 3, 6, and 12 months after discharge. A transesophageal echocardiograph was performed at 45 days after implantation and repeated in case of an unexpected event during the follow-up period.　 Results: This study included 106 NVAF patients with a mean age of 64.2 ± 8.6 years (ranging from 50 to 88 years), and the mean CHA2DS2-VASc score of all patients was 3.6 ± 1.6 (ranging from 2 to 9). Among those 106 NVAF patients, 100 (94.3%) patients were implanted with the device successfully. The procedural success rate was 94.3% (100/106), and the occlusion rate was 100.0% (100/100). There were one tamponade, one ischemic stroke, and eight minor pericardial effusions during hospitalization. During 12-month follow-up period, two patients developed a thrombus layer on the device that resolved with additional anticoagulation: one with visible device-thrombus experienced transient ischemic stroke, and one had a hemorrhagic stroke. There were no deaths in this study. The overall survival rate was 100.0%, and nonmajor adverse event rate was 95.0% (95/100). In this study, the expected annual rate of ischemic stroke risk in these patients according to the CHA2DS2-VASc score was 4.0%, while the observed ischemic stroke rate was 2.0% per year.　 Conclusions: LAA closure with the WATCHMAN Device was feasible, efficient, and safe for NVAF to prevent the accidence of stroke in Chinese patients. During the 12-month follow-up period, the observed ischemic stroke rate (2.0% per year) in our study was lower than the predicted annual stroke risk (4.0%) using the CHA2DS2-VASc score.

Background: Sacral neuromodulation (SNM) has become an effective method for treating lower urinary tract voiding dysfunction during the past 20 years. Because of the expensive cost, the number of implantable pulse generator (IPG) implantations per year in China is far lower than that in Western developed countries since 2012. This study was to summarize the effects of the appropriate prolonged SNM testing time in improving the implantation rate of a permanent IPG in patients with refractory lower urinary tract symptoms (LUTS) in mainland China.　 Methods: From January 2013 to June 2016, 51 patients with refractory LUTS received SNM therapy. In this study, we compared the conversion rate 2 weeks after the Stage I test and final actual conversion rate. We also observed the complications (such as pain, infection, and electrode displacement) and effectiveness. We tried to improve an appropriate prolonged test time which was favorable for improving the SNM conversion rate while ensuring safety and effectiveness.　 Results: Among 51 patients receiving SNM therapy, 19 patients (mean age 45.0 ± 16.9 years) had poor Stage I test results, and on an average, the electrode was removed 27.4 ± 9.6 days after the surgery. In one patient, the electrode was removed within 2 weeks; when the remaining 18 patients were questioned 2 weeks after testing, none of the patients wanted to terminate the test, and all the 18 patients desired to prolong the testing time to further observe the treatment effect. The remaining 32 patients (mean age 46.7 ± 15.3 years) received Stage II permanent implantation at 19.6 ± 10.4 days after the surgery. The overall Stage I–II conversion was 62.7% (32/51) in this study. Within 2 weeks after the surgery, only eight patients received Stage II permanent implantation, and the conversion rate was only 15.7% (8/51 ), which was much lower than the overall conversion rate of 62.7%. Nearly 84.4% (27/32) of the patients received Stage II implantation within 4 weeks. None of the patients had incision infections. In one patient, the entire system was removed 1 month after Stage II implantation due to pain in the implantation site.　 Conclusions: Appropriate extension of the Stage I testing time of an SNM-barbed electrode could significantly improve the Stage II permanent implantation rate in Chinese refractory LUTS patients; there were no wound infections, and the postoperative complication rate was low. This study recommended that Stage I period of SNM therapy should be 4 weeks according to safety and successful conversion rate.