2017年 · 第45卷第07期

Catheter ablation of atrial fibrillation (referred to as atrial fibrillation for short) in China started in 1998, and it has shown a rapid growth trend in the past 10 years. In 2016 alone, more than 30,000 cases were completed. Recent studies have supported that catheter ablation can improve prognosis. Data from the Swedish AF catheter ablation registry were matched by applying propensity score to 2 836 catheter ablation and 2 836 non-ablation patients, with an average follow-up of more than 4 years. The results showed that catheter ablation could reduce stroke and mortality by more than 50%. The AATAC-AF study randomized 102 patients with catheter ablation and 101 patients treated with medication. The results suggest that catheter ablation can significantly reduce the hospitalization rate and mortality rate of patients with persistent atrial fibrillation and heart failure compared with amiodarone. As a result, the indications for catheter ablation of atrial fibrillation, including high-risk complex cases, will be further expanded, and higher requirements for the safety of ablation treatment will also be put forward.

unprotected left main disease (UPLM) is a class of high-risk coronary artery disease. The main revascularization therapies include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Due to the importance of UPLM in the anatomy of myocardial blood supply, there has been controversy over which revascularization strategy to choose in clinical decision-making^[1,2]。

A 72-year-old female was admitted to the hospital on December 14, 2016 due to "chest tightness and asthma after repeated activities for 5 years, aggravated with syncope for 1 d". Five years before admission, the patient repeatedly experienced chest tightness, asthma, and fatigue after activity. When the condition was severe, the above symptoms appeared after climbing a floor, and he was diagnosed with hypertrophic cardiomyopathy. Usually taking a large dose of metoprolol succinate (95 mg/d), the symptoms have worsened recently, and chest tightness and asthma appear after walking 100 m on a flat road. One day before admission, the patient fainted once, had a heart rate of 30 beats/min and a blood pressure of 60/40 mmHg (1 mmHg =0.133 kPa) at admission. Considering syncope caused by bradyarrhythmia, a temporary pacemaker was implanted immediately. After implantation, the blood pressure rose to 100/60 mmHg, and metoprolol was suspended. The heart rate was above 80 beats/min for 2 days, and the temporary cardiac pacing electrode was removed. Color echocardiography on admission showed hypertrophic cardiomyopathy with basal hypertrophy with a maximum thickness of about 21 mm, left ventricular outflow tract stenosis (severe) and maximum left ventricular outflow tract pressure difference (LVOTG) of 167 mmHg. Combined with chest tightness and shortness of breath after activity, the patient was diagnosed as severe obstructive hypertrophic cardiomyopathy with a 6-min walking distance of only 100 m. Surgical myocardial resection or percutaneous endoventricular septal ablation to alleviate LVOTG was the option for treatment. The patient was older and at high risk for myocardial resection. The patient refused surgical treatment and performed percutaneous endoventricular septal ablation. The patient signed informed consent.

A 55-year-old male was admitted to the hospital on 21 August 2016 due to "repeated palpitations and chest tightness for 1 year and syncope once 10 days ago". After admission, the clinical diagnosis was pre-excitation syndrome complicated with paroxysmal ventricular tachycardia and atrial fibrillation (AF), and elective radiofrequency ablation under three-dimensional mapping was performed. Physical examination showed no obvious abnormalities and no history of surgical trauma. Cardiac CT angiography (CTA) and left atrial appendage imaging were performed before operation to observe the presence or absence of coronary artery disease and thrombosis in the left atrial appendage. CTA cross-section, multiplanar reconstruction and volumetric reconstruction of the heart showed absence of the left atrial appendage and intact and smooth endocardium at the attachment of the left atrial appendage (Figure 1)。 Digital subtraction angiography (DSA) was performed before radiofrequency ablation to examine the left atrial appendage without development (Figure 2)。 The imaging diagnosis was congenital absence of left atrial appendage. The patient's atrial fibrillation disappeared after transcatheter radiofrequency ablation. After discharge, he was routinely given warfarin anticoagulation for 6 months, and the international standardized ratio of prothrombin time (INR) was monitored regularly. He was given gastric protection treatment for 2 months, and the electrocardiogram was reviewed regularly.

Coronary heart disease is an important cause of death in patients. Studies have shown that plaque composition and properties determine its progress and affect patient prognosis^[1]。 At present, coronary angiography, which is widely used in clinical practice, can only provide a two-dimensional assessment of lumen size, but cannot effectively detect the characteristics of plaque. With the miniaturization of medical devices, advances in imaging and data signal processing technologies, endovascular imaging technology has been used in the clinic and can assess atherosclerotic plaque burden and vulnerability^[2,3]。 However, recent histological and related studies have shown that intravenous ultrasound (IVUS) has a positive predictive value of 41% for detecting lesion progression and evaluating revascularization strategies among clinically applied imaging techniques^[4]。 optical coherence tomography (OCT) is unable to detect thin neointimal membranes and to distinguish between fibrin and thrombus. In the pig model, the drug-eluting stent was completely covered by fibrin 1~3 days after placement, and the false coverage rate of OCT due to low discrimination ability could reach 45% ~76%^[5]。

von Willebrand factor (VWF), a multimeric glycoprotein mainly produced by vascular endothelial cells, is a risk factor for assessing bleeding and thrombotic status^[1]。 In high shear environments, VWF is involved in platelet adhesion and aggregation and triggers thrombosis. acute myocardial infarction (AMI) is a thromboembolic disease characterized by thrombosis induced by rupture of atherosclerotic plaque, which leads to coronary artery occlusion and myocardial ischemia. Statistics in 2015 show that cardiovascular deaths rank first among the total causes of death among urban and rural residents, and the mortality rates of AMI in urban and rural areas have reached 55.32 people/100,000 and 68.60 people/100,000 respectively^[2]The incidence of the disease is a younger trend^[3]。 Studies have shown that the level of VWF is elevated in patients with AMI, and this change in VWF plays an important role in coronary thrombosis, so VWF has become a hot spot in the research of new antithrombotic targets. This paper reviews the relationship between VWF and AMI.

At present, the incidence of coronary heart disease in China is on the rise. At the same time, due to the maturity and popularity of percutaneous coronary intervention (PCI) technology, the number of coronary heart disease patients receiving PCI is also increasing. Perioperative anticoagulants such as heparin and antiplatelet drugs such as aspirin, clopidogrel, and platelet glycoprotein Ⅱb/Ⅲa receptor antagonists are required. Thrombocytopenia after PCI is not uncommon, and some patients even have severe consequences. This article introduces the etiology and management of thrombocytopenia after PCI.