2008年·第121卷第06期

Reperfusion therapy including primary percutaneous coronary intervention (PCI) and thrombolytic therapy has become the most important strategy for the treatment of acute ST-segment elevation myocardial infraction(STEMI)。

Abstract：Background Primary percutaneous coronary intervention (PCI) has been identified as the first therapeutic option for patients with acute ST-segment elevation myocardial infarction (STEMI).The strategy of transferring patient to a PCI center was recently recommended for those with acute STEMI who were present to PCI incapable hospitals,which include lack of facilities or experienced operators.In China,some local hospitals have been equipped with PCI facilities,but they have no interventional physicians qualified for performing primary PCI.This study was conducted to assess the feasibility,safety and efficacy of the strategy of transferring physician to a PCI-equipped hospital to perform primary PCI for patients with acute STEMI.Methods Three hundred and thirty-four consecutive STEMI patients with symptom presentation ≤12 hours in five local hospitals from November 2005 to November 2007 were randomized to receive primary PCI by either physician transfer (physician transfer group,n=165)or patient transfer(patient transfer group,n=169)strategy.Door-to-balloon time,in-hospital and 30-day major adverse cardiac events(MACE,including death,non-fatal re-infarction,and target vessel revascularization)were compared between the two groups.Results Baseline characteristics between the two groups were comparable.Thrombolysis In myocardial infarction (TIMI) 3 flow was revealed in more patients in the physician transfer group at initial angiography(17.6% vs 10.1%,P＜0.05).The success rate of primary PCI(96.3% vs 95.4%,P＞0.05)and length of hospital stay were similar between the two groups ((15±4)days vs(14±3)days,P＞0.05).In the physician transfer group,door-to-balloon time was significantly shortened ((95±20) minutes vs(147±29)minutes,P＜0.0001)and more patients received primary PCI with door-to-balloon time less than 90 minutes(21.2% vs 7.7%,P＜0.001).During hospitalization,MACE occurred in 6.7% and 11.2% of patients in the physician and patient transfer groups,respectively(P=0.14).At 30-day clinical follow-up,the occurrence rates of death,non-fafal re-infarction,and target vessel revascularization (TVR) were 3.6%vs 5.9%,4.2%vs 8.9%,and 1.2% vs 2.4% in the physician and patient transfer groups,respectively (all P＞0.05).The cumulative composite of MACE was significantly reduced(8.9% vs 17.2%,P=0.03)and MACE free survival(91.0% vs 82.9%,P＜0.05)was significantly improved in the physician transfer group at 30 days.Conclusion The strategy of transferring physician to local hospital to perform primary PCI for patients with acute STEMI is feasible,safe and efficient in reducing the door-to-balloon time and 30-day MACE rate。

Abstract：Background Incomplete stent apposition (ISA) has been demonstrated to be more common after drug-eluting stent (DES)implantation than after bare metal stent(BMS)implantation.Clinical outcomes of ISA remain controversial and the predictive accuracy of previous studies was limited by the short follow-up period of only 12-18 months.In the present study,we present the outcomes of a more than 2-year follow-up in patients with ISA after DES implantation.Methods From the clinical and core intravascular ultrasound(IVUS)database of the hospital,we jdentified 76 patients who had undergone DES implantation In de novo lesions between January 2004 and June 2005 and had received IVUS examination at a scheduled 6-month follow-up.Atotal of 13(17.1%)patients had documented ISA at the follow-up by IVUS.Clinical follow-up was available up to 41 months after DES implantation and up to 33 months after identification of ISA.Results Over a mean follow-up of(34±5)months(range 24-41 months),3 of the 13 patients(23.1%)suffered from ST elevated myocardial Infarction with one death.Angiography confirmed the very late stent thrombosis (ST) in the area with ISA.All the 3 patients were implanted with sirolimus eluting stents in left anterior descending artery(LAD)and the very late ST occurred at 29,31 and 32 months after DES implantation,and separately at 20,23 and 23 months after the identification of ISA.All of the 3 patients had antiplatelet therapy continued before suffering from ST, and had been apparently stable on antiplatelet monotherapy with aspirin for a long period following dual antiplatelet therapy with aspirin and clopidogrel for more than 12 months.Conclusion ISA of DES may be associated with a high incidence of very late stent thrombosis,even in clinically stable patients with dual antiplatelet therapy of at least 12 months after the procedure。

Abstract：Background CartoXP and CartoMerge have been used to treat atrial fibrillation(AF)for several years.Our randomized prospective study compared clinical outcomes of these two versions of three dimensional electroanatomic mapping system in guiding catheter ablation for paroxysmal atrial fibrillation (PAF).Methods Eighty-one patients with symptomatic,drug refractory PAF were randomly assigned to CartoMerge group (n=42,mean age(54.5±13.1)years,history of AF=3.2 years)or CartoXP group(n=39,mean age(59.8±15.6)years,history of AF=2.9 years).All patients underwent 64-slice computed tomography(MSCT)1 to 3 days prior to ablation procedure.Using CartoMergeTM Image Integration Module,3D anatomical images of the left atrium(LA)and pulmonary veins(PVs)derived from MSCT of CartoMerge group were established and merged with the electroanatomical map.The integrated images were used to guide the procedure of circumferential pulmonary vein isolation (CPVI).In the other group,CPVI was guided just by CartoXP.The endpoint of CPVI in both groups was abolition or dissociation of pulmonary vein potentials(PVPs).Results Mapping points to establish the electroanatomical model of the LA/PVs were 48.7±13.4 in CartoMerge group and 62.5±15.7 in CartoXP group(P＜0.001).Mean distance between mapping points and the MSCT surfaces in CartoMerge group was(1.59±0.33)mm.Accomplishment of abolition or dissociation of PVPs was achieved 95.2% in CartoMerge group and 92.3% in CartoXP group.Durations of procedure and exposure to X-ray were(156±25)minutes,(179±21)minutes(P＜0.001) and(19.6±7.5)minutes,(28.5±12.8)minutes(P＜0.001),respectively.After a follow-up with duration of(11.9±3.1)months vs (12.4±3.6)months post the first ablation procedure,patients free of AF were 33(78.6%)in CartoMerge group and 29(74.4%) in CartoXP group(P＞0.50).No patient suffered pulmonary vein stenosis,alrioesophageal fistula,stroke or death.Conclusion Compared to CartoXP,CartoMerge shortened the catheter ablation procedure and exposure to X-ray,without affecting the clinical outcomes of circumferential pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation in experienced centres。

Abstract：Background Failure of balloon catheter passing through the occluded segment accounts for 10%-15% of all procedures during percutaneous coronary intervention(PCI)for chronic total occlusion(CTO).We sought to investigate an original technique for facilitating balloon catheter passing by multi-wire plaque crushing.Methods Between July 2000 and October 2007,152 patients with 164 CTO lesions who had failed balloon passing were treated by multi-wire plaque crushing technique.The main process of this technique was to insert 1 or 2 wires along with the original wire located in the true lumen of CTO lesions after balloon failure for plaque crushing and then to withdraw the crushing wires to get an enlarged lumen inside of the occlusion segment,thus facilitating the balloon passing.Results Both overall lesion and technique success rates were 91.5%(150/164).A total of 211 crushing wires were used during PCI,including 1 crushing wire for 117(71.3%)lesions and 2 crushing wires for 47(28.7%)lesions.Approximately 57.3%(121/211)of all crushing wires were those already used in the same procedure.Technique failure occurred in 14 lesions(8.5%).Technique failure was due to crushing wires entering false lumen(92.9%,13/14)and coronary perforation(7.1%,1/14).Major procedural complications included coronary perforation(1 case)and severe coronary dissection(2 cases),all of which were successfully treated.Conclusions Multi-wire plaque crushing technique is effective in facilitating balloon catheter passing during CTO PCI.It is feasible,economical and relatively safe with a low rate of procedural complications。

Abstract：Background Aspirin and clopidogrel can improve myocardial reperfusion and alleviate myocardial injury during percutaneous coronary intervention (PCI).Whether the addition of intravenous tirofiban during this procedure produces further benefit has not been clarified in ST segment elevation myocardial infarction(STEMI)patients.We evaluated this on STEMI patients who underwent primary PCI(p-PCI)via transradial artery approach.Methods Consecutive patients were randomized into tirofiban group(n=72)or placebo group(n=78).Angiographic analysis included initial and final thrombolysis in myocardial infarction(TIMI)flow grade(TFG),corrected TIMI frame count(CTFC)and TIMI myocardial perfusion grade(TMPG)of the thrombotic vessel.Platelet aggregation rate(PAR),creatine phosphokinase(CPK),CPK isoenzyme MB(CPK-MB)and troponin I levels were measured and TIMI definitions were used to assess bleeding complications.Left ventricular performance parameters were investigated with equilibrium radionuclide ventrjculography.Major adverse cardiac events(MACE)were followed up for 6 months.Results The cases of TFG 0 and 1 before PCI,TFG 0 when first crossing of guide wire were less,and the cases of TFG 3 after PCI was more in tirofiban group than those in placebo group.The final CTFC was fewer and the incidence of no reflow phenomenon was lower,as well the percentage of final TFG 3 was higher in tirofiban group than those in placebo group (all P＜0.05).Mean peak CPK-MB was significantly lower,while the left ventricular performance parameters 1 week after PCI were much more improved in tirofiban group than those in the placebo group.PAR was significantly decreased shortly after tirofiban infusion.The incidence of 6-month MACE in tirofiban group was obviously lower than that in the placebo group.No statistical difference was noted between the two groups with regard to bleeding complications.Conclusions Intravenous tirofiban infusion,in addition to aspirin and clopidogrel in STEMI patients with P-PCI via transradial artery access,can quickly inhibit platelet aggregation,loosen occlusive thrombus,improve myocardial reperfusion and reduce incidence of MACE with few complications of vessel access and bleeding。

Abstract：Background The identification of vulnerable plaques before rupture is an important clinical goal.The purpose of the present study was to assess the difference in plaque composition among patients with acute coronary syndrome(ACS) and stable coronary artery disease(SCAD)by intravascular ultrasound virtual histologic analysis.Methods One hundred and thirty-nine patients were divided into ACS group and SCAD group according to clinical presentation.A total of 229 de novo lesions with＞50% stenosis in native coronary arteries with diameters ＞2.5 mm were studied with intravascular ultrasonography.Geometric and compositional data were obtained using intravascular ultrasound virtual histology software.Results There were no significant differences in overall lesions for fibrous((52.0±11.9)%vs(54.3±8.5)%,P＞0.05),fibrolipidic((12.3±10.1)%vs(13.8±9.5)%,P＞O.05),calcium((14.0±9.1)%vs(19.3±13.1)%,P＞0.05),or necrotic core ((22±0±11.1)%vs(19.7±5.4)%,P＞0.05)percentages in ACS and SCAD patients,respectively.There were also no significant differences in culprit lesions for fibrous((46.4±12.0)%vs(53.6±8.8)%,P＞0.05),fibrolipidic((9.1±9.0)% vs (12.9±9.7)%,P＞0.05),calcium((16.6±9.7)%vs(21.8±26.3)%,P＞0.05),or necrotic core((28.0±12.6)%vs(20.6±5.2)%,P＞0.05)percentages in ACS and SCAD patients,respectively.High density lipoprotein-cholesterol levels＞1.04 mmol/L were associated with more fibrolipidic((14.5±10.4)%vs(7.1±6.5)%,P＜0.05)and less necrotic core((20.6±9.7)%vs (27.9±12.6)%,P＜0.05)percentages in the cohort with ACS.Conclusions In this study,coronary plaque composition assessed by intravascular ultrasound virtual histologic analysis was not significantly different between ACS and SCAD patients.The anatomic relationship of the specific plaque components to the lumen of the vessel was more important than the quantitative information of plaque composition for plaque stability。

Abstract：Background Mesenchymal stem cells (MSCs) transplantation provides a new approach for myocardial repair.However,many important fundamental questions about MSCs transplantation remain unanswered.There is an urgent need to identify MSCs from the beating heart and analyze the efficacy of this new approach.This study aimed to localize the magnetically labeled MSCs(MR-MSCs)and monitor the restorative effects of MR-MSCs with magnetic resonance(MR) imaging.Methods Acute myocardial infarction(AMI)was created in swine by a balloon occlusion of the left anterior descending coronary artery.Cells were delivered via intracoronary infusion after myocardial infarction.Infarct size change and cardiac function were assessed with 3.0T MR scanner.The results were then confirmed by histological and western blot analysis.All statistical procedures were performed with Systat (SPSS version 12.01).Results A total of 26 swine were divided into four groups(sham-operated group,n=6;AMI group with PBS transplantation,n=6;labeled MSCs group,n=7;unlabeled MSCs group,n=7).MSCs,MR-MSCs(107 cells)or PBS were delivered by intracoronary injection after MI and serial cardiac MR imaging studies were performed at 0,4 and 8 weeks after transplantation.MR imaging demonstrated MI size decreased after MSCs transplantation in labeled and unlabeled groups,however,increases were seen in the AMI group at 8 weeks after MI.The left ventricular eiection fraction(LVEF) was slightly increased in the AMI group((41.87±2.45)%vs(39.04±2.80)%,P＞0.05),but significantly improved in the MR-MSCs group((56.85±1.29)%vs(40.67±2.00)%,P＜0.05)and unlabeled group((55.38±1.07)%vs(41.78±2.08)%,P＜0.05) at 8 weeks after treatment.MR-MSCs were further confirmed by Prussian blue and immunofluorescent staining.Western blot analvsis demonstrated that there was an increased expression of cardiomyocyte markers such as myosin heavy chain and troponin T in the MSCs treatment groups and the ratio of matrix metalloproteinase 2 to tissue inhibitor of metalloproteinase 1 decreased in the labeled group and unlabeled group compared with the AMI group and sham-operated group.Conclusion Transplanted MR-MSCs can regenerate new myocardium and prevent remolding In an MI model at 2-month follow-uD and represent a preferred method to better understand the mechanisms of stem cell therapy in future clinical studies。

Abstract：Background Recent studies have revealed that pretreatment with statin is effective in preventing armythmia,but its electrophysiological mechanism is unclear.This study was conducted to investigate the cardioprotective effects of simvastatin on reversing electrical remodeling in left ventricular myocytes of rabbit heart undergoing ischemia-reperfusion.so as to explore the ionic mechanism responsible for the anti-arrhythmic effect of statin.Methods Forty-five rabbits were randomly divided into three groups:ischemic-reperfusion group(I-R),simvastatin intervention group (Statin) and sham-operated control group(CON).Anesthetized rabbits were subjected to 30-minute ischemia by ligation of the left anterior descending coronary artery and a 60-minute reperfusion after a 3-day administration of oral simvastatin of 5 mg·kg-1·d-1 in the Statin group or a placebo in the I-R group.Single ventricular myocytes were isolated enzymatically from the epicardial zone of the infracted region derived from the hearts in the I-R and Statin group and the same anatomical region in the CON animals.The whole cell patch-clamp technique was used to record membrane ionic currents,including sodium current(Ina),L-type calcium current(Ica-L)and transient outward potassium current(Ito).Simultaneously,the level of serum cholesterol was examined.Results There was no significant difference in the serum cholesterol concentration among the three groups.The peak Ina current density(at-30 mV)was significantly decreased in I-R((-22.46±5.32)pA/pF,n=12)compared with CON ((-42.78±5.48)pA/pF,n=16,P＜0.01)and Statin((-40.66±5.89)pA/pF,n=15,P＜0.01),while the peak Ina current density in the Statin group was not different from CON(P＞0.05).The peak Ica-L current density(at 0 mV)was significantly increased in I-R((-4.34±0.92)pA/pF,n=15)compared with CON((-3.13±1.22)pA/pF,n=13,P＜0.05)and Statin ((-3.46±0.85)pA/pF,n=16,P＜0.05),while the Peak Ica-L current density in Statin was not different from CON(P＞0.05).The Ito current density(at+60mV)was significantly decreased in I-R((9.49±1.91)pA/pF,n=11)compared with CON ((17.41±3.13)pA/pF,n=15,P＜0.01)and Statin((14.54±9.41)pA/pF,n=11,P＜0.01),although there was a slight reduction in the Statin group compared with CON(P＜0.05).Conclusions It is implied that ischemia-reperfusion induces significant down-regulation of Ina and Ito and up-regulation of Ica-L,which may underlie the altered electrical activity and long abnormal transmembrane action potential duration of the surviving ventricular myocytes,thus contributing to ventricular arrhythmias during acute ischemia-reperfusion period.Pretreatment with simvastatin could attenuate these changes and reverse this electrical remodeling without lowering the serum cholesterol level,contributing to the ionic mechanism of statin in treatment of arrhythmia independent of a decrease in cholesterol。

Abstract：Background Several kinds of intercellular adhesion molecules closely relate to hepatitis B.The complex of CD2 and CD58 plays an important role in enhancing the adhesion of T lymphocytes to target cells,hyperplasia and activation of T lymphocytes.In this study,we explored the relationship between the expression of CD58 in liver tissue and chronic hepatitus B infection.Methods We determined the expression of the CD58 molecule on the surface of hepatocytes by using immunohistochemistry and the levels of serum HBV DNA from patients with HBV infection and from normal controls.The biochemical parameters of hepatic function were analyzed as well.Results CD58 expression in hepatocytes significantly increased with the severity progression of chronic HBV infection.The IOD levels(1og10)of CD58 in the control,mild,moderate,and severe chronic HBV infection groups were O,(7.20±4.64)×103,(25.63±7.41)x103 and(37.47±11.17)×103 respectively(P＜0.05 compared with the control group,respectively)Conclusion CD58 probably increases cell mediated immunity to eliminate hepatitis B virus and leads to damage of hepatocytes。

Abstract：Background The pathogenesis of hypersplenism and the immune function of the spleen in patients with portal hypertension(PH)remain obscure.This study aimed to evaluate the morphological changes of blood spleen barrier in spleen with hypersplenism due to PH and provide evidence for an in-depth investigation of the immune function of the spleen with hypersplenism and the mechanism of hypersplenism.Methods Spleen samples from 12 portal hypertensive patients and 4 patients with traumatic ruptures of spleen were examined.The samples of spleen were made into pathological sections,stained with Masson trichrome stain,Gomori stain,and CD68,CD34 immunohistochemistry,and were examined microscopically for the changes in the distribution of collagen fibers,reticular fibers,macrophages,and vascular endothelial cells.The changes in ultrastructure of macrophages and endothelial cells in marginal zone were also evaluated by transmission electron microscopy.Results As compared to the normal spleen,the density of macrophage in the PH spleen was decreased,but the macrophages were mainly located in the marginal zone and distributed around the splenic corpuscle,with many villi and pseudopodium-like protrusion on the cell surface.The accrementition of collagen fibers was obvious around the splenic corpuscle and central artery.The increased reticulate fibers encircled the splenic corpuscle with more connection between the fibers.The vascular endothelial cells were in diffused distribution,without any regionality in PH spleen,but the vessel with enlarged lumina increased in red pulp.Conclusions The morphological changes of the blood spleen barrier can be one of the pathological fundaments for the abnormality of the immune function and the increased destruction of blood cells located in the spleens of patients with PH.However,this still entails clarification。

Abstract：Background Drug-eluting stents(DES)have been shown to significantly reduce clinical events and angiographic restenosis in the treatment of coronary artery disease(CAD).This study was conducted to assess the long-term efficacy and safety of the polymer-based sirolimus-eluting cobalt-chromium Firebird 2TM stents in the treatment of patients with CAD.Methods This first-in-man study using the Firebird 2TM stent is a prospective,historically-controlled multicenter clinical study,which enrolled 67 patients with CAD who were treated with the sirolimus-eluting cobalt-chromium stent(Firebird 2TM,Microport Shanghai,Firebird 2 group),compared to another 49 patients treated with a bare cobalt alloy stent(Driver,Medtronic,control group).Continued 2-year clinical follow-up was performed after getting the initial 6-month angiographic and 1-year clinical follow-up.The incidence of major adverse cardiac events(MACE)including cardiac death,reinfarction and target lesion revascularization(TLR)and stent thrombosis were compared between the two groups.Results All patients in the Firebird 2 group(100.0%)and 48 patients in the control group(98.O%)completed the 2-year clinical follow-up.At the 1-year follow-up the use of the Firebird 2 stent was highly effective,resulting in a significant 94% decrease of TLR (26.5%in the control group and 1.5%in the Firebird 2 group,P＜0.0001).A significant difference in TLR was maintained at 2-year follow-up,Firebird 2 group 1.5%and the control group 31.3%(P＜0.0001).Between 1-and 2-year post-stenting.no more TLR occurred in the Firebird 2 group compared with two cases in the control group (P＞0.05).There was a 1.5%incidence of MACE at 1-and 2-year follow-up in the Firebird 2 group,compared with 26.5% and 33.3%in the control group,respectively(all P＜0.0001).The cumulative 1-and 2-year MACE free survival rates were 98.5%in the Firebird 2 group vs 73.5%and 66.7% in the control group (log rank P＜0.0001).No case of stent thrombosis occurred during 2-year follow-up in the Firebird 2 group,compared with one case that suffered a definite stent thrombosis in the control group at 19-month post-stenting:this patient presented with unstable angina pectoris and was treated by balloon angioplasty.Conclusions Compared with the bare cobalt alloy stent,the Firebird 2TM sirolimus-eluting cobalt-chromium stent is safe and effective in treating patients with CAD.The use of this stent was associated with a sustained clinical benefit and significantly lower rate of TLR and MACE up to 2 years post-stenting。

Abstract：Background Optical coherence tomography (OCT)is a new imaging modality with resolution of approximately 10 μm and can be employed to visualize intracoronary characteristics.Sirolimus-eluting stents(SES)are susceptible to late thrombosis due to delayed re-endothelialization over the stent struts,which may result in acute myocardial infarction or death.This study was designed to evaluate the re-endothelialization and neointimal coverage of SES with OCT 6 months and 12 months after implantation.Methods A total of 36 patients enrolled in the study underwent OCT examination 6 months(17 patients)and 12 months (19 patients)after SES implantation.The strut apposition to the vessel wall and neointimal coverage on SES struts were evaluated by OCT.Results Forty-six SES and 6561 struts were analyzed.At 6 months,3041 struts(98.7%)were well-apposed and 39 struts(1.3%)were malapposed.At 12 months,3434 struts(98.6%)were well-apposed and 47 struts(1.4%)were malapposed.Furthermore,only 4 SES at 6 months(18.2%)and 10 SES at 12 months(41.7%)were fully covered by neointimal growth.The average neointimal thicknesses covering the analyzed struts at 6 months and 12 months were (42±28)μm and (88±32) μm,respectively.There were 1989 struts at 6 months(72.1%)and 1461 struts at 12 months (45.6%)with neointimal thickness ＜100 μm.Conclusions OCT was able to visualize the strut apposition to the vessel wall and neointimal coverage on SES struts.At 6-month and 12-month follow-up examinations most struts were covered with thin neointima,but few of the entire SES showed full coverage.To prevent late-stent thrombosis in the presence of uncovered stent struts,longer dual antiplatelet drugs therapy should be recommended。

Abstract：Background With the advent of drug-eluting stents(DES)and much lower rates of target vessel revascularization (TVR),whether adjunctive balloon postdilatation can further optimize outcome is still unknown.The present study was to compare the outcomes of postdilatation with un-postdilatation following deployment of DES.Methods From April 2004 to September 2006,6479 consecutive Chinese patients who underwent DES implantation,including 1769 with postdilatation(1454 male,(57.9 ±10.8)years old)and 4710 without postdilatation(3819 male,(57.9±10.6)years old)were analyzed.Clinical and angiographic follow-up was performed at 7 months.Results Compared with the un-postdilatation group,the postdilatation group had more complex lesions and larger relevant vessel diameter(RVD).In the postdilatation group,in-stent residual restenosis was significantly improved right after the procedure((16.80±5.88)%vs(19.60±6.07)%;P=0.000).There was no statistical difference in the major adverse cardiac events(MACE)rate between the groups(2.9%vs 3.3%;P=0.420),and there were also no statistical differences in death,acute myocardial infarction(AMI)and target lesion revascularization(TLR)rates in the two groups(0.1%vs 0.4%,P=0.127;1.7%vs 1.3%,P=0.229;and 1.5%vs 2.0%,P=0.206,respectively).The in-stent thrombosis rate was almost the same in both groups(0.5%vs 0.5%;P=1.000).Seven months angiographic follow-up results showed that both in-stent and in-segment restenosis rates were lower in the postdilatation group(8.8%vs 15.6%,P=0.000;and 10.5%vs 17.3%,P=0.000),and so were in-stent and in-segment late loss((0.32±0.12)mm vs(0.491±0.13)mm,P=0.000;and (0.24±0.08)mm vs(0.36±0.09)mm,P=0.001).Conclusion Postdilatation after DES deployment was safe and could reduce the restenosis rate,especially for more complex lesions。

Abstract：Background Because no data regarding the comparison of crush stenting with pactitaxel(PES)or sirolimus eluting stents(SES)for coronary bifurcate lesions have been reported,we compared the clinical outcomes of these two types of stents.Methods Two hundred and thirty patients with 242 bifurcate lesions were enrolled in a prospective,nonrandomized trial.Primary endpoints included myocardial infarction,cardiac death and target vessel revascularization at 8 months.Results All patients were followed up clinically and 82%angiographically at 8 months.Final kissing balloon inflation was performed in 72%in the PES and 75%in the SES groups(P＞0.05).Compared to the SES group,PES group had a higher late loss and incidence of restenosis(P=0.04)in the prebifurcation vessel segment.The postbifurcation vessel segment in the PES group had a greater late loss((0.7+0.6)mm vs(0.3±0.4)mm,P＜0.001)and higher restenosis in the side branch(25.5%vs 15.6%,P=0.04)when compared to the SES group.There was significant difference of insegment restenosis in the entire main vessel between PES and SES groups (P=0.004).Target lesion revascularization was more frequently seen in the PES group as compared to the SES group(P=0.01).There was significant difference in the accumulative MACE between these two groups(P=0.01).The survival rate free from target lesion revascularization was significantly higher in the SES group when compared to the PES group(P＜0.001).Conclusion SES is superior to PES in reducing restenosis and target lesion revascularization by 8-month follow-up after crush stenting for bifurcate lesions。

Abstract：Background The association between vulnerability of plaque assessed with intravascular ultrasound (IVUS) and plasma levels of fibrinolytic biomarkers was determined in patients with acute coronary syndrome(ACS).However,few data are available on the relationship between the levels of tissue type plasminogen activator(t-PA)and virtual histological intravascular ultrasound(VH-IVUS)signs of plaque instability.Methods Eighty-nine patients with ACS were enrolled in the study.Blood was collected to measure t-PA levels by liquid phase bead flow cytometry.Eighty-nine nonbifurcate lesions(identified by coronary angiography and ECG)were investigated using IVUS before catheterization.IVUS radiofrequency data Obtained with a 20 MHz catheter were analyzed with IVUS virtual histological software.The areas of plaque and media were calculated and lesions were classified into two groups:VH-IVUS derived thin cap fibroatheroma(VH-TCFA)and non-VH-TCFA plaque.Results Plasma t-PA levelin the patients with TCFA was significantly lower than that with non-TCFA ((1489±715) pg/ml vs(2163±1004)pg/ml).Decreased plasma levels of t-PA were associated with plaque vulnerability.Plasma levels of t-PA correlated negatively with plaque plus media and necrotic core in plaque in patients with ACS.Conclusions t-PA is an independent risk factor and a powerful predictor of vulnerable plaques.Decreased levels of t-PA may reflect instability of atherosclerotic plaques and might therefore serve as noninvasive determinants of those at high risk for consequent adverse events。

Transcatheter closure of congenital perimembranous ventricular septal defect (VSD) has always been a problem for cardiologists in the past decade because of the risks for interference with the valves and conduction system。