Volume 128 · Issue 06 · 2015

植入药物洗脱支架（DESs）的经皮冠状动脉介入治疗（PCI）已成为冠状动脉疾病护理的标准，并极大地推动了器械行业。^[1,2]2013年，中国约有50万冠心病患者接受了PCI治疗，DES渗透率超过95%。^[3]使用DES（包括国产DES）在预防冠状动脉再狭窄方面非常有效，但在支架植入动脉段的延迟愈合或再内皮化以及支架血栓形成的风险方面需要承担附带成本。^[4]因此，中国PCI指南强烈推荐DES植入后至少12个月的阿司匹林和P2Y12受体拮抗剂双重抗血小板治疗（DAPT）。^[5]由于延长DAPT可能会增加大出血和随后的死亡率，因此用DAPT平衡缺血（或血栓事件）和出血对于改善基于DES的PCI后的总体临床结局总是很重要的。^[6]

Studies have suggested that use of prolonged dual antiplatelet therapy (DAPT) following new generation drug-eluting stent implantation may increase costs and potential bleeding events. This study aimed to investigate the association of DAPT status with clinical safety in patients undergoing everolimus-eluting stent (EES) implantation in the SEEDS study (A Registry to Evaluate Safety and Effectiveness of Everolimus Drug-eluting Stent for Coronary Revascularization) at 2-year follow-up.

The SEEDS study is a prospective, multicenter study, where patients (n = 1900) with small vessel, long lesion, or multi-vessel diseases underwent EES implantation. Detailed DAPT status was collected at baseline, 6-month, 1- and 2-year. DAPT interruption was defined as any interruption of aspirin and/or clopidogrel more than 14 days. The net adverse clinical events (NACE, a composite endpoint of all-cause death, all myocardial infarction (MI), stroke, definite/probable stent thrombosis (ST), and major bleeding (Bleeding Academic Research Consortium II-V)) were investigated according to the DAPT status at 2-year follow-up.

DAPT was used in 97.8% of patients at 6 months, 69.5% at 12 months and 35.4% at 2 years. It was observed that the incidence of NACE was low (8.1%) at 2 years follow-up, especially its components of all-cause death (0.9%), stroke (1.1%), and definite/probable ST (0.7%). DAPT was not an independent predictor of composite endpoint of all-cause death/MI/stroke (hazard ratio [HR]: 0.693, 95% confidence interval [CI]: 0.096–4.980, P = 0.715) and NACE (HR: 1.041, 95% CI: 0.145–7.454, P = 0.968). Of 73 patients who had DAPT interruption, no patient had ST at 12-month, and only 1 patient experienced ST between 1- and 2-year (1.4%). There was a high frequency of major bleeding events (53/65, 82.5%) occurred in patients receiving DAPT treatment.

Prolonged DAPT use was not associated with improved clinical safety. The study emphasized that duration of DAPT needs to be shortened in Chinese patients following EES implantation (ClinicalTrials.gov identifier: NCT 01157455).

Recent studies reported that percutaneous coronary intervention with stent implantation was safe and feasible for the treatment of left main coronary artery (LMCA) disease in select patients. However, it is unclear whether drug-eluting stents (DESs) have better outcomes in patients with LMCA disease compared with bare-metal stent (BMS) during long-term follow-up in Chinese populations.

From a perspective multicenter registry, 1136 consecutive patients, who underwent BMS or DES implantation for unprotected LMCA stenosis, were divided into two groups: 1007 underwent DES implantation, and 129 underwent BMS implantation. The primary outcome was the rate of major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), and target lesion revascularization (TLR) at 5 years postimplantation.

Patients in the DES group were older and more likely to have hyperlipidemia and bifurcation lesions. They had smaller vessels and longer lesions than patients in the BMS group. In the adjusted cohort of patients, the DES group had significantly lower 5 years rates of MACE (19.4% vs. 31.8%, P = 0.022), CV death (7.0% vs. 14.7%, P = 0.045), and MI (5.4% vs. 12.4%, P = 0.049) than the BMS group. There were no significant differences in the rate of TLR (10.9% vs. 17.8%, P = 0.110) and stent thrombosis (4.7% vs. 3.9%, P = 0.758). The rates of MACE (80.6% vs. 68.2%, P = 0.023), CV death (93.0% vs. 85.3%, P = 0.045), TLR (84.5% vs. 72.1%, P = 0.014), and MI (89.9% vs. 80.6%, P = 0.029) free survival were significantly higher in the DES group than in the BMS group. When the propensity score was included as a covariate in the Cox model, the adjusted hazard ratios for the risk of CV death and MI were 0.41 (95% confidence interval [CI]: 0.21–0.63, P = 0.029) and 0.29 (95% CI: 0.08–0.92, P = 0.037), respectively.

DES implantation was associated with more favorable clinical outcomes than BMS implantation for the treatment of LMCA disease even though there was no significant difference in the rate of TLR between the two groups.

We investigated whether and to what extent the ratio between circulating fibrinogen (Fg) and its degradation products (FDP) reflects the severity of coronary artery disease (CAD) in type 2 diabetic patients.

Plasma levels of Fg and FDP were determined, and Fg/FDP ratio was calculated in 344 consecutive patients with type 2 diabetes and chest pain on exertion undergoing coronary angiography. The severity of CAD was evaluated by the number of significant CAD (>50% luminal diameter narrowing) and Gensini score.

Plasma Fg was higher, but Fg/FDP ratio was lower in patients with significant CAD (n = 255) compared with those without (n = 89), due to a disproportionate increase in FDP. Fg and FDP correlated positively, while Fg/FDP ratio negatively, with the number of diseased coronary arteries and the tertile of Gensini score (all P values for trend < 0.01). After adjusting for age, sex, risk factors for CAD, lipid profiles, glycosylated hemoglobin A1c, creatinine, leukocyte count, and high-sensitivity C-reactive protein, Fg/FDP ratio remained an independent determinant for multivessel coronary disease (MVD) (odds ratio [OR], 0.869; 95% confidence interval [CI], 0.788–0.958, P = 0.005) and high tertile of Gensini score (OR, 0.797, 95% CI, 0.682–0.930, P = 0.004). The area under the curve of Fg/FDP ratio was larger than that of Fg for predicting the presence of MVD (0.647 vs. 0.563, P = 0.048) and Gensini score ≥ 30 (0.656 vs. 0.538, P = 0.026).

Elevated plasma Fg and FDP level and reduced Fg/FDP ratio are associated with presence of CAD, and Fg/FDP ratio is superior to Fg in reflecting severe coronary atherosclerosis for patients with type 2 diabetes.

Whether final kissing balloon (FKB) dilatation after one-stent implantation at left-main (LM) bifurcation site remains unclear. Therefore, this large sample and long-term follow-up study comparatively assessed the impact of FKB in patients with unprotected LM disease treated with one-stent strategy.

Total 1528 consecutive patients underwent LM percutaneous coronary intervention in one center from January 2004 to December 2010 were enrolled; among them, 790 patients treated with one drug-eluting stent crossover LM to left anterior descending (LAD) with FKB (n = 230) or no FKB (n = 560) were comparatively analyzed. Primary outcome was the rate of major adverse cardiovascular events, defined as a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR).

Overall, The prevalence of true bifurcation lesions, which included Medina classification (1,1,1), (1,0,1), or (0,1,1), was similar between-groups (non-FKB: 37.0% vs. FKB: 39.6%, P = 0.49). At mean 4 years follow-up, rates of major adverse cardiovascular events (non-FKB: 10.0% vs. FKB: 7.8%, P = 0.33), death, MI and TVR were not significantly different between-groups. In multivariate propensity-matched regression analysis, FKB was not an independent predictor of adverse outcomes.

For patients treated with one-stent crossover LM to LAD, clinical outcomes appear similar between FKB and non-FKB strategy.

Lack of fluoroscopic landmarks can make valve deployment more difficult in patients with absent aortic valve (AV) calcification. The goal of this article was to evaluate the feasibility and effectiveness of transcatheter implantation of a valved stent into the AV position of a goat, assisted with a microcatheter which provides accurate positioning of coronary artery ostia to help valved stent deployment.

The subjects were 10 healthy goats in this study. A microcatheter was introduced into the distal site of right coronary artery (RCA) through femoral artery sheath. A minimal thoracic surgery approach was used to access the apex of the heart. The apex of the left ventricle was punctured; a delivery catheter equipped with the valved stent was introduced over a stiff guidewire into the aorta arch. We could accurately locate the RCA ostia through the microcatheter placed in the RCA under fluoroscopy. After correct valve position was confirmed, the valved stent was implanted after rapid inflation of the balloon. The immediate outcome of the function of the valved stents was evaluated after implantation.

All ten devices were successfully implanted into the AV position of the goats. Immediate observation after the procedure showed that the valved stents were in the desired position after implantation by angiography, echocardiogram. No obstruction of coronary artery ostia occurred, and no moderate to severe aortic regurgitation was observed.

When the procedure of transcatheter implantation of a balloon-expandable valved stent into the AV position of goats is assisted with microcatheter positioning coronary artery ostia, the success rate of operation can be increased in those with noncalcified AV.

Coronary artery perforation (CAP) is a rare but severe complication of percutaneous coronary intervention (PCI). The aim of our study was to evaluate the effect and safety of transcatheter embolization by autologous fat particles in the treatment of CAP.

Once the CAP was confirmed, a little autologous subcutaneous fatty tissue was obtained from the groin of the patient and then was made into 1 mm × 1 mm fat particles. The perforated vessel was embolized by fat particles via a micro-catheter. There were eight patients undergoing transcatheter embolization by autologous fat particles in the treatment of CAP during PCI in Peking University Third Hospital from February 2009 to June 2014, and the clinical data of these patients were collected and analyzed retrospectively.

The lesion morphology of the patients was classified based on the American College of Cardiology/American Heart Association Task Force classification, there were one patient with Class B2 lesion and seven patients with Class C lesions (there were five patients with chronic total occlusion lesions). According to the Ellis classification of CAP, there were six patients with Class II perforations and two patients with Class III perforations. The causes of perforation included that seven patients induced by guide wire and one patient by balloon predilation. Three patients had pericardial effusion. All of the eight patients with CAP underwent transcatheter embolization by autologous fat particles. Coronary angiography confirmed that all of them were embolized successfully. There was no severe complication after the procedure. The coronary angiography of one patient at 1 week and another patient at 2 years after the embolization showed that the embolized arteries had recanalized. The median follow-up time was 20.3 months (8.8–50.2 months), the event-free survival rate was 100%.

Transcatheter embolization by autologous fat particles was an effective, safe, cheap, and easy way to treat the perforation of small vessels during PCI.

The decrease of glomerular filtration rate has been theoretically supposed to be the result of low perfusion in renal artery stenosis (RAS). But the gap between artery stenosis and the glomerular filtration ability is still unclear.

Patients with selective renal artery angiogram were divided by the degree of renal artery narrowing, level of estimated glomerular filtration rate (eGFR), respectively. The different levels of eGFR, renal microcirculation markers, and RAS severity were compared with each other, to determine the relationships among them.

A total of 215 consecutive patients were enrolled in the prospective cohort study. Concentrations of microcirculation markers had no significant difference between RAS group (RAS ≥ 50%) and no RAS group (RAS < 50%) or did not change correspondingly to RAS severity. The value of eGFR in RAS group was lower than that in the no RAS group, but it did not decline parallel to the progressive severity of RAS. The microcirculation markers presented integral difference if grouped by different eGFR level with negative tendency, especially that plasma cystatin C (cysC) and urinary microalbumin to creatinine ratio (mACR) increased with the deterioration of eGFR, with strong (r = −0.713, P < 0.001) and moderate (r = −0.580, P < 0.001) correlations. In the subgroup analysis of severe RAS (RAS ≥ 80%), the levels of plasma cysC and urinary mACR demonstrated stronger negative associations with eGFR, (r = −0.827, P < 0.001) and (r = −0.672, P < 0.001) correlations, respectively.

Severity of RAS could not accurately predict the value of eGFR, whereas microcirculation impairment may substantially contribute to the glomerular filtration loss in patients with RAS.

As an acute phase protein, α1-antitrypsin (AAT) has been extensively studied in acute coronary syndrome, but it is unclear whether a relationship exists between AAT and stable angina pectoris (SAP). The purpose of the present study was to investigate the association between AAT plasma levels and SAP.

Overall, 103 SAP patients diagnosed by coronary angiography and clinical manifestations and 118 control subjects matched for age and gender were enrolled in this case-control study. Plasma levels of AAT, high-sensitivity C-reactive protein (hsCRP), lipid profiles and other clinical parameters were assayed for all participants. The severity of coronary lesions was evaluated based on the Gensini score (GS) assessed by coronary angiography.

Positively correlated with the GS (r = 0.564, P < 0.001), the plasma AAT level in the SAP group was significantly higher than that in the control group (142.08 ± 19.61 mg/dl vs. 125.50 ± 19.67 mg/dl, P < 0.001). The plasma AAT level was an independent predictor for both SAP (odds ratio [OR] = 1.037, 95% confidence interval [CI]: 1.020–1.054, P < 0.001) and a high GS (OR = 1.087, 95% CI: 1.051–1.124, P < 0.001) in a multivariate logistic regression model. In the receiver operating characteristic curve analysis, plasma AAT level was found to have a larger area under the curve (AUC) for predicting a high GS (AUC = 0.858, 95% CI: 0.788–0.929, P < 0.001) than that of hsCRP (AUC = 0.665, 95% CI: 0.557–0.773, P = 0.006; Z = 2.9363, P < 0.001), with an optimal cut-off value of 137.85 mg/dl (sensitivity: 94.3%, specificity: 68.2%).

Plasma AAT levels correlate with both the presence and severity of coronary stenosis in patients with SAP, suggesting that it could be a potential predictive marker of severe stenosis in SAP patients.

Percutaneous coronary intervention (PCI) through transradial approach (TRA) has shown to be safe and effective as transfemoral approach (TFA) among unselected patients. However, very few studies have compared the outcomes between TRA and TFA specifically in patients with a history of coronary artery bypass grafting surgery (CABG).

A total of 404 post-CABG patients who had undergone angiography or PCI were included in the study. The primary endpoint was defined as angiographic success and procedure success. The secondary endpoint was defined as in-hospital net adverse clinical events (NACEs), which included all cause of death, myocardial infarction (MI), stroke, repeat revascularization, and major bleeding. Patients were followed-up for 1-year. Major adverse cardiovascular events (MACEs), which included death, MI, and repeat revascularization, at 1-year follow-up were also compared.

The angiographic success was reached by 97.4% in the TRA group compared with 100% in the TFA group (P= 0.02). The procedure success was achieved in 99.1% in the TRA group and 97.9% in the TFA group (P = 0.68). The incidence rates of in-hospital NACE (2.7% vs. 2.7%, P = 1.00) and 1-year MACE (11.5% vs. 12.0%, P = 0.88) were similar between TRA and TFA. Meanwhile, TRA was associated with a lower rate of Bleeding Academic Research Consortium ≥2 bleeding (P = 0.02). In patients undergoing graft PCI, the procedure success was similar between TRA and TFA (100.0% vs. 98.7%, P = 1.00). The procedure time (25.0 min vs. 27.5 min, P = 0.53) was also similar. No significant difference was detected between TRA and TFA in terms of in-hospital NACE (0 vs. 0, P = 1.00) and 1-year MACE (21.4% vs. 10.3%, P = 0.19).

Compared with TFA, TRA had lower angiographic success but had a similar procedure success in post-CABG patients. TRA was also associated with decreased bleeding and shortened hospital stay.

Despite great reduction of in-stent restenosis, first-generation drug-eluting stents (DESs) have increased the risk of late stent thrombosis due to delayed endothelialization. Arsenic trioxide, a natural substance that could inhibit cell proliferation and induce cell apoptosis, seems to be a promising surrogate of sirolimus to improve DES performance. This randomized controlled trial was to evaluate the efficacy and safety of a novel arsenic trioxide-eluting stent (AES), compared with traditional sirolimus-eluting stent (SES).

Patients with symptoms of angina pectoris were enrolled and randomized to AES or SES group. The primary endpoint was target vessel failure (TVF), and the second endpoint includes rates of all-cause death, cardiac death or myocardial infarction, target lesion revascularization (TLR) by telephone visit and late luminal loss (LLL) at 9-month by angiographic follow-up.

From July 2007 to 2009, 212 patients were enrolled and randomized 1:1 to receive either AES or SES. At 2 years of follow-up, TVF rate was similar between AES and SES group (6.67% vs. 5.83%, P = 0.980). Frequency of all-cause death was significantly lower in AES group (0 vs. 4.85%, P = 0.028). There was no significant difference between AES and SES in frequency of TLR and in-stent restenosis, but greater in-stent LLL was observed for AES group (0.29 ± 0.52 mm vs. 0.10 ± 0.25 mm, P = 0.008).

After 2 years of follow-up, AES demonstrated comparable efficacy and safety to SES for the treatment of de novo coronary artery lesions.

The purpose of this article was to clarify the optimal management concerning transjugular intrahepatic portosystemic shunts (TIPSs) and surgical shunting in treating portal hypertension.

All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed and Cochrane up to February 2014, were searched for randomized controlled trials (RCTs) comparing TIPS with surgical shunting. Four RCTs, which were extracted by two independent investigators and were evaluated in postoperative complications, mortality, 2- and 5-year survival, hospital stay, operating time and hospitalization charges.

The morbidity in variceal rehemorrhage was significantly higher in TIPS than in surgical shunts (odds ratio [OR] = 7.45, 95% confidence interval [CI]: (3.93–14.15), P < 0.00001), the same outcomes were seen in shunt stenosis (OR = 20.01, 95% CI: (6.67–59.99), P< 0.000001) and in hepatic encephalopathy (OR = 2.50, 95% CI: (1.63–3.84), P< 0.0001). Significantly better 2-year survival (OR = 0.66; 95% CI: (0.44–0.98), P = 0.04) and 5-year survival (OR = 0.44; 95% CI: (0.30–0.66), P < 0.00001) were seen in patients undergoing surgical shunting compared with TIPS.

Compared with TIPS, postoperative complications and survival after surgical shunting were superior for patients with portal hypertension. Application of surgical shunting was recommended for patients rather than TIPS.

To evaluate the response rate to vaccination in different treatment groups (nonimmunosuppressants and immunosuppressants).

We completed an online systematic search using PubMed to identify all articles published in English between January 1990 and December 2013 assessing the effect of the response rate to vaccination in different treatment groups (with and without immunomodulators). The following terms were used: "inflammatory bowel disease (IBD)" OR "Crohn’s disease" OR "ulcerative colitis" AND ( "vaccination" OR "vaccine" ) AND ( "corticosteroids" OR "mercaptopurine" OR "azathioprine" OR "methotrexate [MTX]" ) AND "immunomodulators."

The inclusion criteria of articles were that the studies: (1) Randomized controlled trials which included patients with a diagnosis of IBD (established by standard clinical, radiographic, endoscopic, and histologic criteria); (2) exposed patients received immunomodulators for maintenance (weight-appropriate doses of 6-mercaptopurine/azathioprine or within 3 months of stopping, 15 mg or more MTX per week or within 3 months of stopping; (3) exposed patients received nonimmunomodulators (no therapy, antibiotics only, mesalazine only, biological agent only such as infliximab, adalimumab, certolizumab or natalizumab or within 3 months of stopping one of these agents). The exclusion criteria of articles were that the studies: (1) History of hepatitis B virus (HBV), influenza or streptococcus pneumoniae infection; (2) patients who had previously been vaccinated against HBV, influenza or streptococcus pneumoniae; (3) any medical condition known to cause immunosuppression (e.g. chronic renal failure and human immunodeficiency virus infection); (4) individuals with positive hepatitis markers or liver cirrhosis; (5) patients with a known allergy to eggs or other components of the vaccines and (6) pregnancy.

Patients treated with immunomodulators were associated with lower response rates to vaccination.

Immunomodulators may impair the immune response to vaccination in patients with IBD. Vaccination should be made at the time of diagnosis or before starting immunosuppressed therapy.

非传染性疾病（NCD）已成为全球死亡的主要原因。一个令人担忧的例子是，中国的非传染性疾病正在加速流行。与其他地方一样，高血压、糖尿病、心脏病、中风和肥胖症是这一增长趋势的主要原因。一组常见的上述风险因素是导致这些不同状况的原因，包括缺乏身体活动、不健康的饮食习惯、睡眠模式改变、环境污染以及烟草和酒精滥用。在某种程度上，这些问题是由中国成功的经济增长、快速的城市化和加入全球化经济引发的。反过来，非传染性疾病及其并发症给个人和医疗保健系统带来了沉重的负担。此外，这种沉重的慢性病负担破坏了健康公平，阻碍了人力资本的增长。

颅咽管瘤是一种罕见的良性上皮肿瘤，约占所有颅内肿瘤的5%。颅咽管瘤主要局限于鞍内和鞍上区域，以鞍上位置最常见。不累及鞍区的单纯鞍下颅咽管瘤极为罕见。^[1,2]我们报告一位16岁女孩累及蝶窦及斜坡的鞍下颅咽管瘤，并讨论此肿瘤的临床特征及处理。

导管室中心脏骤停伴室性心动过速或室颤并不少见，但心脏骤停需要长时间心肺复苏的患者并不少见，并且仍然是一个主要问题，因为在经皮冠状动脉介入治疗（PCI）期间基本上不可能进行有效的手动胸外按压。^[1]最近，使用一种新的机械胸部按压装置，隆德大学心肺辅助系统（LUCAS，Jolife AB，Lund，Sweden），已被证明在心脏骤停的情况下维持冠状动脉和脑循环，并且可能允许在人工持续循环的情况下继续进行PCI，尽管正在进行的心脏或循环骤停。^[2]我们在此报告一例急性心肌梗死并发心脏骤停的病例，在使用LUCAS装置进行持续机械胸外按压时成功接受PCI。

致编者：患者，65岁，因“阵发性胸痛13年，复发加重5天”，于2014年6月10日入住一附院冠心病科。13年前，患者在没有任何明显诱因的情况下经历了心前区挤压痛，伴有胸腔充血、心悸和过度出汗，但没有任何扩散、恶心和呕吐。这些症状可能会在休息20分钟后缓解。患者在当地医院诊治为急性前壁心肌梗死（MI），经二级预防药物治疗好转后出院。5 d前胸痛复发加重，入院进一步治疗。既往病史包括8年II型糖尿病病史。辅助检查示心电图为窦性心律，无心电轴偏移；心率57次/分；导联II、III、aVF和V3-V6有异常Q波，无平坦或倒置T波。入院后的主要诊断为：（1）冠心病（CHD）、不稳定型心绞痛（UA）和陈旧性MI（下壁和前壁）；（2）Ⅱ型糖尿病。血生化检查结果为：空腹血糖11.04 mmol/L;总胆固醇1.5 g/L，甘油三酯1.65 g/L，高密度脂蛋白（LP）-胆固醇0.35 g/L，低密度LP-胆固醇0.88 g/L，LP（a）2.07 g/L；载脂蛋白：ApoA 0.99 g/L，ApoB 0.83 g/L；心脏标志物：肌酸激酶（CK）-37 U/L，高敏肌钙蛋白I-0.361µg/L，CK-MB-0.70µg/L。彩色超声心动图（2014.6.11）示房室腔大小及比例正常。心室壁不厚。左室前壁、前分壁中段及心尖运动减少。心尖扩张部分地挤出心脏轮廓，尺寸约为25mm × 13mm。各瓣膜形态和运动正常，左心室射血分数（LVEF）为35%。未显示心内膜钙化。

编者：结节病是一种全身性肉芽肿性疾病，最常影响年轻或中年女性。结节病可与多种自身免疫性疾病和其他肉芽肿性疾病共存。^[1]在这里，我们描述了一个罕见的结节病与另一种肉芽肿性自身免疫性疾病大动脉炎（TA）共存的病例。