2008年 · 第121卷第23期

Acute coronary syndrome (ACS) represents a continuum of acute myocardial ischemia including non-ST-elevation myocardial infarction and unstable angina, synonymous with non-ST-elevation ACS (NSTE-ACS),and ST-elevation myocardial infarction (STEMI)。

Abstract：Background The clinical outcome of percutaneous coronary intervention (PCI) is poorer in women than that in men.This study aimed at comparing the impact of gender difference on the strategy of primary PCI in patients with acute ST-segment elevation myocardial infarction (STEMI).Methods Two hundred and fifty-nine patients with STEMI who underwent primary PCI within 12 hours of symptom onset were enrolled.The male group consisted of 143 men aged >55 years,and a female group included 116 women without age limitation.Procedural success was defined as residual stenosis <20% with thrombolysis in myocardial infarction flow grade>2 and without death,emergency bypass surgery or disabling cerebral events during the hospitalization.The rate of major adverse cardiac events (MACE),including death,nonfatal myocardial infarction and target vessel revascularization during follow-up,was recorded.Results Female patients were more hypertensive and diabetic and with fewer cigarette smokers than male counterparts.The prevalence of angiographic 3-vessel disease was higher in the female group,but the procedural success rate was comparable between the two groups (94.4% vs 92.2%).The occurrence rate of MACE did not differ during the hospitalization (4.2% vs 6.0%,P=0.50),but was significantly higher in the female group during follow-up (mean (16.0±11.2) months) than that in the male group (5.4% vs 0.7%,P=0.02).Conclusion Despite a similar success rate of primary PCI and in-hospital outcomes in both genders,female patients with acute STEMI still have a worse prognosis during the long-term follow-up。

Abstract：Background Prognosis of patients with acute ST-elevation myocardial infarction (STEMI) and renal dysfunction (RD) who received primary percutaneous coronary intervention (PCI) has not been fully investigated in the drug-eluting stent (DES) era.This study aimed to evaluate the impact of admission serum creatinine level on short-term outcomes in patients with acute STEMI undergoing DES-based primary PCI.Methods Primary PCI with DES implantation was attempted in 619 consecutive STEMI patients within 12 hours of symptom onset.Among them,86 patients had a serum creatinine level >115 μmol/L on admission (RD group),and the remaining 533 patients had normal renal function (non-RD group).The primary endpoint was 30-day major adverse cardiac events (MACE,including death,non-fatal reinfarction,and target vessel revascularization),and the secondary endpoint was subacute stent thrombosis.Results Patients in the RD group were older than those in the non-RD group.There are more female patients in the RD group and they had a history of hypertension,myocardial infarction and revascularization.The occurrence rates of Killip class ≥2 (29.1% vs 18.6%,P=0.02) and multi-vessel (62.8% vs 44.5%,P=0.001) and triple vessel disease (32.6% vs 18.2%,P=0.002),in-hospital mortality (9.3% vs 3.8%,P=0.03),and MACE rate during hospitalization (17.4% vs 7.7%,P=0.006) were higher in the RD group than those in the non-RD group.At a 30-day clinical follow-up,the MACE-free survival rate was significantly reduced in the RD group (76.7% vs 89.9%,P=0.0003).Angiographic stent thrombosis occurred in 3 (3.5%) and 7 (1.3%) of patients in the RD group and non-RD group,respectively (P=0.15).Multivariate analysis revealed that the serum creatinine level≥115 μmol/L on admission was an independent predictor for MACE rate at a 30-day follow-up (Hazard ratio (HR) 3.31,95% CI 1.19-9.18,P<0.001).Conclusion Despite similar prevalence of stent thrombosis at a 30-day clinical follow-up,the short-term prognosis of STEMI patients with elevated serum creatinine on admission undergoing DES-based primary PCI remains unfavorable。

Abstract：Background Rapid recanalization of infarct-related artery (IRA) has become the major target during primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (MI),but strategy for treatment of non-IRA lesions in this setting remains unclear.This study aimed to compare long-term effects between PCI for IRA only and that for both IRA and non-IRA in ST-elevation MI patients with multi-vessel disease.Methods A total of 242 eligible patients with ST-elevation MI and at least two diseased coronary arteries (luminal narrowing≥70%) undergoing primary PCI were included.Of them,149 patients underwent primary PCI for IRA only (group 1),and 93 received primary PCI for IRA followed by elective PCI for non-IRA 7 to 15 days after acute myocardial infarction (AMI) (group 2).Drug-eluting stents (DESs) were deployed in more than 90% of the patients.Results The two groups did not differ with respect to baseline clinical and angiographic characteristics.No significant differences were observed in 12-month clinical follow-up results regarding major adverse cardiac events (11.5% vs 15.1%,P>0.05) and target lesion revascularization (8.1% vs 7.6%,P>0.05) between the two groups.However,patients in group 1 had higher rates of recurrent angina (10.1% vs 2.1%,P<0.05) and depressed left ventricular ejection fraction evaluated by echocardiography (0.56±0.22 vs 0.63±0.25,P <0.05).Conclusion With the use of DESs,complete revascularization with elective PCI for non-IRA after primary PCI may exert a beneficial effect on long-term symptomatology and left ventricular function in patients with ST-elevation MI and multi-vessel disease。

Abstract：Background Atrial fibrillation (AF) occurs commonly in patients with acute myocardial infarction (MI) and is associated with an increased long-term mortality.This study aimed to investigate the clinical characteristics and outcomes of AF in in-hospital elderly Chinese patients with acute MI.Methods A total of 967 patients with acute MI,aged≥65 years,were categorized on the basis of the absence or presence of AF.Patients with documented AF were classified into two subgroups: the ongoing AF group and the new-onset AF group.We retrospectively evaluated the clinical profile,in-hospital outcomes,and effects of revascularization on the incidence of AF in elderly patients with acute MI.Results AF was documented in 100 (11.53%) patients and the incidence of new-onset AF was 6.51% during hospitalization.History of old MI and cerebrovascular events were more common in patients with AF than in those without AF (P<0.001,P<0.01,respectively).The incidence of AF was higher in patients with non-ST elevated MI (P=0.014),inferior wall MI (P=0.004) and cardiac function of Killip class III or IV (P=0.008).Patients with AF had more complication of pneumonia (P=0.003) and longer hospital stay.Left circumflex coronary artery involvement was more common in patients with AF (compared with patients without AF,P <0.001).Percutaneous coronary intervention or coronary artery bypass grafting significantly decreased the incidence of new-onset AF from 7.97% to 3.82% (P=0.017).AF depended to heart failure,increased the in-hospital mortality.Conclusions AF is common in elderly patients with acute MI and is associated with poorer clinical outcomes.Revascularization reduces the incidence of AF and thus improves the clinical outcomes in these patients。

Abstract：Background Coronary artery disease (CAD) is generally considered as a disease of middle-aged men.It is widely accepted that the risk for CAD of premenopausal women is low because of hormone protection.Based on our clinical experience，more and more premenopausal women suffer from angina and myocardial infarction without adequate concern.Even now，there are still limited detailed data to describe the characteristics，mechanism and prognosis of premenopausal CAD patients.This article aimed to analyze the clinical and angiographic characteristics of premenopausal women with CAD.Methods A total of 565 premenopausal women and 721 postmenopausal women (56-60 years old) who underwent coronary angiography for the first time from April 2004 to December 2007 were enrolled.The clinical data and coronary angiographic characteristics (presence，localization，length and severity) were compared between the premenopausal and postmenopausal CAD groups.Results Premenopausal CAD patients presented less frequently with hypertension，diabetes mellitus and dyslipidemia compared with postmenopausal CAD patients (55.0% vs 66.0%，15.0% vs 31.5%，23.9% vs 37.4%，respectively; all P<0.05).Although we found more frequent involvement of single vessel in premenopausal CAD (43.2% vs 26.9%，P=0),and triple vessels in postmenopausal (56-60 years old) CAD patients (33.8% vs 20.4%，P=0)，much more severe lesions (≥90%) at left main (2.9% vs 1.1%,P=0.048) and proximal left anterior descending artery (LAD) (28.2% vs 16.6%，P=0) in the premenopausal CAD group were found.Conclusion Premenopausal women with chest discomfort are always found to have obvious atherosclerosis，more inclined to be located at the left main and proximal LAD，which is a strong predictor of an adverse clinical outcome。

Abstract：Background Patients presenting with severe left ventricular dysfunction (SLVD) undergoing conventional coronary artery bypass grafting (CCABG) are at an increased risk of perioperative mortality and morbidity.The aim of this study was to assess the risk factors responsible for mortality and morbidity among patients with SLVD by comparing CCABG and off-pump coronary artery bypass surgery (OPCAB).Methods We retrospectively evaluated 186 consecutive patients with SLVD who underwent coronary artery bypass grafting (CABG),including 102 by CCABG and 84 by OPCAB.Registry database,medical notes,and charts were studied for preoperative and postoperative data of the patients.Different variables and risk factors (preoperative,intraoperative,and postoperative) were evaluated and compared.The morbidity and mortality outcomes were compared in the two groups.The follow-up results and quality of life were assessed after surgery.Results The two groups had similar percentage of patients with preoperative high-risk profiles and no significant differences were found between groups in baseline variables such as age or comorbidities.There was a significant difference in the number of grafts used between the two groups.CCABG patients received (3.6±0.5) grafts per patient,while OPCAB patients had (2.7±0.6) grafts (P <0.05).Completeness of revascularization was also significantly different between the two groups (CCABG 91.1% vs OPCAB 73.8%,P <0.05).The hospital mortality was similar in the two groups (4.8% in OPCAB vs 5.9% in CCABG).The risk-adjusted mortality,according to the calculated propensity score,did not reach statistical significance in the two groups.In this study,OPCAB seemed to have a beneficial effect on reducing reoperation for bleeding,blood transfusion requirement,and the length of stay at ICU.But the incidence of perioperative myocardial infarction was more common in the off-pump group (P <0.05).The degree of improvement in angina and quality of life did not differ significantly between the two groups.Conclusions Using cardiopulmonary bypass is not an independent predictor of mortality and morbidity in patients with SLVD.Isolated CABG can be safely performed in SLVD patients with acceptable postoperative morbidity and mortality in addition to encouraging home discharge rates and higher quality of life.Therefore,CCABG remains a viable option in selected patients with SLVD。

Abstract：Background The necrosis of a large number of myocardial cells after acute myocardial infarction (AMI) results in a decrease of cardiac function and ventricle remodeling.Stem cell transplantation could improve cardiac function after AMI,but the involving mechanisms have not been completely understood.The present study aimed to investigate the effects of transplantation of autologous bone marrow mononuclear cells (BM-MNC) and rnesenchymal stem cells (MSCs) via the coronary artery on the ventricle remodeling after AMI as well as the mechanisms of the effects of transplantation of different stem cells on ventricle remodeling.Methods A total of 36 male pigs were enrolled in this study,which were divided into 4 groups: control group,simple infarct model group,BM-MNC transplantation group,and MSCs transplantation group.At 90 minutes when a miniature porcine model with AMI was established,transplantation of autologous BM-MNC ((4.7±1.7)×107) and MSCs ((6.2±1.6)×105) was performed in the coronary artery via a catheter.Ultrasound,electron microscope,immunohistochemical examination and real time reverse transcdptase-polymerase chain reaction were used respectively to observe cardiac fun~ons,counts of blood vessels of cardiac muscle,cardiac muscle nuclear factor (NF)-KB,myocardial cell apoptosis,and the expression of the mRNA of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in cardiac muscles.Multivariate Logistic regression was used to analyze the correlation factors of left ventricular end-diastolic diameter (EDD).Results The number of blood vessels in the infarct zone and around its border in the BM-MNC transplantation group was more than those in the infarct model group and MSCs group (P=0.0001) and there was less myocardial cell apoptosis in the stem cell transplantation group than that in the infarct model group (all P <0.01).The positive rate of NF-KB in the stem cell transplantation group was lower than that in the infarct model group (P=0.001).The gene expression of VEGF in the infarct border zone of the BM-MNC group was higher than that in the MSCs group (P=0.0001).The gene expression of bFGF in the infarct border zone in the MSCs transplantation group was higher than that in the infarct model group and the BM-MNC group (P=0.0001).Left ventricular ejection fraction was inversely proportional to the apoptotic rate of myocardial cells and cardiac muscle NF-KB but positively correlated with the number of blood vessels and the expression of VEGF and bFGF in the infarct zone and infarct border zone.The Multivariate Logistic regression analysis on the factors influencing the left ventricular end-diastolic diameter after stem cell transplantation showed that the expression of VEGF mRNA in the cardiac muscles in the infarct zone,the number of apoptotic myocardial cells and the expression of NF-KB in the infarct border zone were independent factors for predicting the inhibitory effect on the dilation of left ventricular EDD after stem cell transplantation.Conclusions Transplantation of autologous BM-MNC and MSCs in pigs can improve the condition of left ventricular remodeling and recover the cardiac functions after AMI.The improvement of cardiac functions is related to the increase of blood vessels,the increased expression of VEGF and bFGF,the reduction of myocardial cell apoptosis,and the decrease of NF-KB level in cardiac muscle tissues after stem cell transplantation。

Abstract：Background This study evaluated the clinical application of CT guided 125iodine implantation in patients with portal vein tumor thrombus in primary hepatocellular carcinoma.Methods The ten patients (9 males and 1 female,aged from 36 to 72 years) with portal vein tumor thrombus accompanying hepatocellular carcinoma had been treated with comprehensive therapy including surgery,transcatheter arterial chemoembolization,radiotherapy ablation,microwave ablation or percutaneous ethanol injection.The average diameter of each tumor thrombus was 21.5 mm×30.5 mm.Seeds of 30 MBq 125I were implanted 5 mm apart within the portal vein tumor thrombus.The follow-up after 4 months included enhanced spiral CT.Results CT screening of the tumours indicated that 4 out of 10 patients showed complete response to the therapy,5 partial response and 1 stable disease.Adverse effects included aggravated abdominal dropsy and temporarily increased transaminase,which were controlled by medical management.Severe complications such as haemorrhage,biliary fistula,hepatic abscess,pancreatic fistula and hepatic function failure were not observed.Implanted seeds migrated to lung and left hepatic lobe in 1 case.Conclusion CT guided implantation of 125iodine seeds,can effectively treat portal vein tumor thrombus accompanying hepatocellular carcinoma with minimal damage and few complications。

Abstract：Background Using magnetic resonance imaging,diagnosis of malignant meningioma from benign meningioma with atypical features is uncertain.We evaluated the value of lipid signal in differentiating intracranial meningiomas.Methods 1H-magnetic resonance spectroscopy (MRS) using a point resolved spectroscopy (TR/TE 1000/144 ms)sequences were performed on 34 patients on a 3.0 T scanner.Lipid peak located at 1.3 ppm was evaluated.MRS data from these tumours were compared with histopathological findings (including hematoxylin and eosin staining and KP-1 staining).Results Twenty-nine meningiomas were histologically benign (eleven meningothelial,thirteen fibrous,four transitional and one microcystic),three were atypical,and two were anaplastic.Lipid signal was detected in ten cases: two anaplastic,three atypical,two fibrous and three meningothelial meningiomas.All voxels with lipid peak in the spectrum from the tumour were evaluated.With creatinine peak in the normal white matter chosen as internal standard,lipid/creatinine ratios of anaplastic,atypical and benign meningiomas were 0.844±0.027 (range from 0.725 to 0.994),0.465±0.023 (range from 0.239 to 0.724),and 0.373±0.016 (range from 0.172 to 0.571) respectively.Highly significant differences were noted between anaplastic and the other two subtypes.Patchy necrosis was observed in anaplastic meningioma,while focal necrosis was noted in atypical meningioma with HE stain.However,no necrosis was found in benign group.KP-1 stain demonstrated histocytes containing lipids in the necrotic region of anaplastic and atypical meningioma.Conclusion The lipid signal at 1.3 ppm is a useful marker in evaluating the malignancy of intracranial meningiomas,especially in the differential diagnosis of anaplastic meningioma。

Abstract：Background The one-stage pull-through procedures for Hirschsprung's disease (HD) have become popular because it is well accepted by surgeons and mothers with no visible scar and a short hospital stay.It represents the latest development in the concept of a minimally invasive surgery for HD.We introduce a new method of transanal one-stage pull-through for Hirschsprung's disease,different from the transanal Soave procedure.Methods One hundred and thirty-four patients aged 9 days to 5 years underwent a transanal one-stage pull-through procedure.The diagnosis was definite by barium enema or rectal biopsies preoperatively.The patients were anesthetized and placed in the lithotomy position.A urinary catheter was optional.Giving anorectal dilatations for half a minute,a pull-through of the rectum above the peritoneal reflection and into the intussusception was performed.Fine silk suturing was performed circumferentially at the level of that point which was used for traction for the distal end.Another circumferential suture was performed parallel 0.5 cm distance above the odginal one and used for traction for the proximal intestines.The full-thickness rectal wall was truncated between the above two circumferential sutures with cautery.The proximal intestines were pulled down and the mesenteric vessels were dissected with ligation until normal intestines were accessed; the presence of ganglion cells was determined by intraoperative rapid frozen section.The distal end was dissected anteriorly 2.5-3.5 cm above the dentate line.The posterior rectal wall was split longitudinally and dissected to a point 0.5-1.0 cm above the dentate line.The segment of the lesion was resected.The length of bowel resected ranged from 12 to 50 cm (median 16.5 cm).An oblique anastomosis was made.Results The mean operating time was 70 minutes.Postoperative rectal dilation was not required.The patient tolerated feeding on the first postoperative day.Eighty-eight patients were followed-up.All these patients had 2-3 bowel movements per day at postoperative month 1.They were discharged within 4.5 days after the operation.Six patients presented with complications.All recovered by reoperation or conservative treatments.Conclusion The modification of the transanal Swenson pull-through procedure for Hirschsprung's Disease is an easy adaptation to a well-established technique and has a reasonable result。

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia, myocardial infarction and sudden cardiac death.1-10 This disease mainly occurs in young women with oral contraceptive or during the peripartum period,without risk factors for coronary artery disease。

Areversible cardiomyopathy triggered by psychologically stressful events occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome.This condition is characterized by a distinctive form of systolic dysfunction that predominantly affects the distal left ventricle chamber and a favourable outcome with appropriate medical therapy。

Meningeal malignant melanosis is a meninges tumor that can produce melanin.Primary intracranial neurocutaneous melanosis is rare.It grows fast with a high degree of malignancy and is associated with earlier intracranial hypertension and meningeal irritation。

Laparoscopic procedure as a minimally invasive surgery had been introduced into many abdominal surgery.Smaller incisions of the abdominal wall reduce postoperative pain and the risk of wound complications,and provide an excellent cosmetic result compared with open surgery。

Recently,scarless surgery has become a widely used surgical technique,which has made considerable progress owing to extensive animal model studies and clinical trials.Here,we report the first case of transumbilical single-port laparoscopic cholecystectomy in mainland China,on 28th May,2008。