Volume 131 · Issue 12 · 2018

抗血小板治疗是冠状动脉疾病患者管理的基石。近二十年来，随着经皮冠状动脉介入治疗（PCI）的快速增长，个体化抗血小板治疗的研究空前繁荣。^[1]

Residual SYNTAX score (rSS) and its derived indexes including SYNTAX revascularization index (SRI) and clinical rSS had been developed to quantify and describe the extent of incomplete revascularization. This study was conducted to explore the utility of the three scores among real-world patients after percutaneous coronary intervention (PCI).

From January 2013 to December 2013, patients underwent PCI treatment at Fuwai Hospital were included. The primary endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events. The secondary endpoints were myocardial infarction, revascularization, stroke, and stent thrombosis. Kaplan-Meier methodology was used to determine the outcomes. Cox multivariable regression was to test the associations between scores and all-cause mortality.

A total of 10,344 patients were finally analyzed in this study. Kaplan-Meier survival analysis indicated that greater residual coronary lesions quantified by rSS and its derived indexes were associated with increased risk of adverse cardiovascular events. However, after multivariate analysis, only clinical rSS was an independent predictor of 2-year all-cause death (hazard ratio: 1.02, 95% confidence interval: 1.01–1.03, P< 0.01). By receiver operating characteristic (ROC) curve analysis, clinical rSS had superior predictability of 2-year all-cause death than rSS and SRI (area under ROC curve [AUC]: 0.59 vs. 0.56 vs. 0.56, all P< 0.01), whereas rSS was superior in predicting repeat revascularization than clinical rSS and SRI (AUC: 0.62 vs. 0.61 vs. 0.61; all P< 0.01). When comparing the predictive capability of rSS ≥8 with SRI <70%, their predictabilities were not significantly different.

This study indicates that all three indexes (rSS, clinical rSS, and SRI) are able to risk-stratify patients and predict 2-year outcomes after PCI. However, their prognostic capabilities are different.

It remains undetermined whether second-generation drug-eluting stents (G2-DESs) outperform first-generation DESs (G1-DESs) in patients with acute coronary syndrome (ACS). We aimed to compare the efficacy and safety of G1-DES and G2-DES in ACS patients in a high-volume cardiovascular center.

In 2013, 10,724 consecutive patients underwent percutaneous coronary intervention in our institution. We included 4037 patients with ACS who underwent exclusively G1-DES or G2-DES implantation (n = 364 and n = 3673, respectively). We used propensity score matching to minimize the imbalance between the G1-DES and G2-DES groups and followed patients for 2 years. The efficacy endpoints were major adverse cardiac events (MACEs) and its components including target vessel-related myocardial infarction (TV-MI), target vessel revascularization/target lesion revascularization (TVR/TLR), and cardiac death. The safety endpoint was stent thrombosis. Continuous variables were compared by Mann-Whitney U-test, and categorical variables were compared using Pearson’s Chi-square or Fisher’s exact test. Kaplan-Meier curves were constructed to compare the event-free survival rates, and multivariate Cox proportional hazards regression analysis was used to assess whether stent type was an independent risk factor for the efficacy and safety endpoints.

At the 2-year follow-up, the results for MACE and it components, as well as stent thrombosis, were similar for G1-DES and G2-DES (MACE, 5.2% vs. 4.3%, χ² = 0.514, P= 0.474; TV-MI, 0.8% vs. 0.4%, P= 0.407; TVR, 4.9% vs. 3.7％, χ² = 0.939, P= 0.333; TLR, 3.8% vs. 2.5%, χ² = 1.610, P= 0.205; cardiac death, 0.3% vs. 0.5%, P= 0.670; and stent thrombosis, 0.5% vs. 0.4%, P> 0.999). Kaplan-Meier analysis indicated similar event-free survival rates between G1-DES and G2-DES after propensity score matching (all: log-rank P> 0.05). Multivariate analysis demonstrated that stent type was not an independent risk factor for the efficacy and safety endpoints (MACE, hazard ratio [HR] = 0.805, 95% confidence interval [CI]: 0.455-1.424, P= 0.456; TV-MI, HR = 0.500, 95% CI: 0.101- 2.475, P= 0.395; TVR, HR = 0.732, 95% CI: 0.403-1.330, P= 0.306; TLR, HR = 0.629, 95% CI: 0.313-1.264, P= 0.193; cardiac death, HR = 1.991, 95% CI: 0.223-17.814, P= 0.538; and stent thrombosis, HR = 0.746, 95% CI: 0.125-4.467, P= 0.749).

G1-DES and G2-DES have similar efficacy and safety profiles in ACS patients at the 2-year follow-up.

The Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients (PARIS) bleeding score is a novel score for predicting the out-of-hospital bleeding risk after percutaneous coronary intervention (PCI). However, whether this score has the same value in non-European and American populations is unclear. This study aimed to assess the PARIS bleeding score’s predictive value of bleeding in patients after PCI in the Chinese population.

We performed a prospective, observational study of 10,724 patients who underwent PCI from January to December 2013, in Fuwai Hospital, China. We defined the primary end point as major bleeding (MB) according to Bleeding Academic Research Consortium definition criteria including Type 2, 3, or 5. The predictive value of the PARIS bleeding score was assessed with the area under the receiver operating characteristic (AUROC) curve.

Of 9782 patients, 245 (2.50%) MB events occurred during the 2 years of follow-up. The PARIS bleeding score was significantly higher in the MB group than that of non-MB group (4.00 [3.00, 5.00] vs. 3.00 [2.00, 5.00], Z = 3.71, P < 0.001). According to risk stratification of the PARIS bleeding score, the bleeding risk in the intermediate- and high-risk groups was 1.50 times (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 1.160–1.950; P= 0.002) and 2.27 times higher (HR: 2.27; 95% CI: 1.320–3.900; P= 0.003) than that in the low-risk group. The PARIS bleeding score showed a moderate predictive value for MB in the overall population (AUROC: 0.568, 95% CI: 0.532- 0.605; P< 0.001) and acute coronary syndrome (ACS) subgroup (AUROC: 0.578, 95% CI: 0.530- 0.626; P= 0.001) and tended to be predictive in the non-ACS subgroup (AUROC: 0.556, 95% CI: 0.501- 0.611; P= 0.054).

The PARIS bleeding score shows good clinical value for risk stratification and has a significant, but relatively limited, prognostic value for out-of-hospital bleeding in the Chinese population after PCI.

Very few data have been reported for ST-segment elevation myocardial infarction (STEMI) caused by unprotected left main coronary artery (ULMCA) occlusion, and very little is known about the results of this subgroup of patients who underwent primary percutaneous coronary intervention (PCI). The aim of this study was to determine the clinical features and outcomes of patients with STEMI who underwent primary PCI for acute ULMCA occlusion.

From January 2000 to February 2014, 372 patients with STEMI caused by ULMCA acute occlusion (ULMCA-STEMI) who underwent primary PCI at one of two centers were enrolled. The 230 patients with non-ST-segment elevation MI (NSTEMI) caused by ULMCA lesion (ULMCA-NSTEMI) who underwent emergency PCI were designated the control group. The main indexes were the major adverse cardiac events (MACEs) in-hospital, at 1 month, and at 1 year.

Compared to the NSTEMI patients, the patients with STEMI had significantly higher rates of Killip class≥III (21.2% vs. 3.5%, χ² = 36.253, P < 0.001) and cardiac arrest (8.3% vs. 3.5%, χ² = 5.529, P = 0.019). For both groups, the proportions of one-year cardiac death in the patients with a post-procedure thrombolysis in myocardial infarction (TIMI) flow grade<3 were significantly higher than those in the patients with a TIMI flow grade of 3 (STEMI group: 51.7% [15/29] vs. 4.1% [14/343], P < 0.001; NSTEMI group: 33.3% [3/9] vs. 13.6% [3/221], P = 0.001; respectively]. Landmark analysis showed that the patients in STEMI group were associated with higher risks of MACE (16.7% vs. 9.1%, P = 0.009) and cardiac death (5.4% vs. 1.3%, P = 0.011) compared with NSTEMI patients at 1 month. Meanwhile, in patients with ULMCA, the landmark analysis for incidences of MACE and cardiac death was similar between the STEMI and NSTEMI (all P= 0.72) in the intervals of 1–12 months. However, patients who were diagnosed with STEMI or NSTEMI had no significant difference in reinfarction (all P> 0.05) and TVR (all P> 0.05) in the intervals of 0–1 month as well as 1 month to 1 year. The results of Cox regression analysis showed that the differences in the independent predictors for MACE included the variables of Killip class ≥III and intra-aortic balloon pump support for the STEMI patients and the variables of previous MI, ULMCA distal bifurcation, and 2-stent for distal ULMCA lesions for the NSTEMI patients.

Compared to the NSTEMI patients, the patients with STEMI and ULMCA lesions still remain at a much higher risk for adverse events at 1 year, especially on 1 month. If a successful PCI procedure is performed, the 1-year outcomes in those patients might improve.

Females with ST-segment elevation myocardial infarction (STEMI) have higher in-hospital and short-term mortality rates compared with males in China, suggesting that a sex disparity exists. The age of onset of STEMI is ahead of time and tends to be younger. However, there are relatively little data on the significance of sex on prognosis for long-term outcomes for adult patients with STEMI after percutaneous coronary intervention (PCI) in China. This study sought to analyze the sex differences in 30-day, 1-year, and long-term net adverse clinical events (NACEs) in Chinese adult patients with STEMI after PCI.

This study retrospectively analyzed 1920 consecutive STEMI patients (age ≤60 years) treated with PCI from January 01, 2006, to December 31, 2012. A propensity score analysis between males and females was performed to adjust for differences in baseline characteristics and comorbidities. The primary endpoint was the incidence of 3-year NACE. Survival curves were constructed with Kaplan- Meier estimates and compared by log-rank tests between the two groups. Multivariate analysis was performed using a Cox proportional hazards model for 3-year NACE.

Compared with males, females had higher risk profiles associated with old age, longer prehospital delay at the onset of STEMI, hypertension, diabetes mellitus, and chronic kidney disease, and a higher Killip class (≥3), with more multivessel diseases (P < 0.05). The female group had a higher levels of low-density lipoprotein (2.72 [2.27, 3.29] vs. 2.53 [2.12, 3.00], P< 0.001), high-density lipoprotein (1.43 [1.23, 1.71] vs. 1.36 [1.11, 1.63], P= 0.003), total cholesterol (4.98 ± 1.10 vs. 4.70 ± 1.15, t= −3.508, P< 0.001), and estimated glomerular filtration rate (103.12±22.22 vs. 87.55±18.03, t= −11.834, P< 0.001) than the male group. In the propensity-matched analysis, being female was associated with a higher risk for 3-year NACE and major adverse cardiac or cerebral events compared with males. In the multivariate model, female gender (hazard ratio [HR]: 2.557, 95% confidence interval [CI]: 1.415–4.620, P= 0.002), hypertension (HR: 2.017, 95% CI: 1.138–3.576, P= 0.016), and family history of coronary heart disease (HR: 2.256, 95% CI: 1.115–4.566, P= 0.024) were independent risk factors for NACE. The number of stents (HR: 0.625, 95% CI: 0.437- 0.894, P= 0.010) was independent protective factors of NACE.

Females with STEMI undergoing PCI have a significantly higher risk for 3-year NACE compared with males in this population. Sex differences appear to be a risk factor and present diagnostic challenges for clinicians.

The prevalence, presentation, management, and prognosis of coronary heart disease differ according to sex. Greater understanding on the differences between men and women with acute aortic dissection (AAD) is needed. We aimed to investigate whether sex disparities are found in patients with AAD, and to study sex differences in complications, mortality in-hospital, and long-term.

We included 884 patients enrolled in our institute between June 2002 and May 2016. Considering psychosocial factors, treatments, and the outcomes in men versus those in women with AAD, we explored the association of sex with psychosocial characteristics and mortality risk. For categorical variables, significant differences between groups were assessed with the Chi-square test or Fisher’s exact test, and continuous parameters were assessed with Student’s t-test. Univariate and stratified survival statistics were computed using Kaplan-Meier analysis.

A total of 884 patients (76.1% male, mean age 51.4±11.8 years) were included in this study. There were fewer current smokers in female compared with male (17.5% vs. 67.2%, χ² = 160.06, P< 0.05). The percentage of men who reported regular alcohol consumption was significantly higher than that in women (40.6% vs. 3.8%, χ² = 100.18, P< 0.05). About 6.2% (55 of 884) of patients with AAD died before vascular or endovascular surgery was performed, 34.4% (304 of 884) of patients underwent surgical procedures, and 52.7% (466 of 884) and 12.8% (113 of 884) of patients received endovascular treatment and medication. Postoperative mortality similar (6.0% vs. 5.6%, respectively, χ² = 0.03, P = 0.91) between men and women. Follow-up was completed in 653 of 829 patients (78.8%). Adjustment for age, history of coronary disease, hypertension, smoking and drinking, Type A and use of beta-blocker, angiotensin II receptor blockers, angiotensin converting enzyme (ACE) inhibitor, calcium-channel blockers and statins by multivariate logistic regression analysis suggested that age (odds ratios [ORs], 1.04; 95% confidence interval [CI], 1.01–1.07; P< 0.05), using of calcium-channel blockers (OR, 0.37; 95% CI, 0.18- 0.74; P< 0.05), at discharge were independent predictors of late mortality, ACE inhibitors (OR, 1.91; 95% CI, 1.03–3.54; P = 0.04) was independent risk factor of late mortality.

In Chinese with AAD, sex is not independently associated with long-term clinical outcomes. Age, the intake of calcium-channel blockers at discharge might help to improve long-term outcomes.

Recent advances in extracorporeal membrane oxygenation (ECMO) have led to increasing interest in its use during cardiopulmonary resuscitation (CPR). However, decisions regarding extracorporeal CPR (ECPR) in children are difficult as a result of limited studies, especially in Asia Pacific. The objective of this study was to investigate trends in survival and demographic details for children with ECPR in Asia Pacific recorded in the Extracorporeal Life Support Organization (ELSO) registry from 1999 to 2016 and identify the risk factors associated with in-hospital mortality.

The data of children younger than 18 years of age who received ECPR over the past 18 years in Asia Pacific were retrospectively analyzed. The data were extracted from the ELSO registry and divided into two 9-year groups (Group 1: 1999- 2007 and Group 2: 2008- 2016) to assess temporal changes using univariate analysis. Then, univariate and multiple logistic regression analyses were performed between survivors and nonsurvivors to identify factors independently associated with in-hospital mortality.

A total of 321 children were included in final analysis, with an overall survival rate of 50.8%. Although survival rates were similar between Group 1 and Group 2 (43.1% vs. 52.5%, χ² = 1.67, P = 0.196), the median age (1.7 [0.3, 19.2] months for Group 1 vs. 5.6 [0.8, 64.9] months for Group 2, t= −2.93, P = 0.003) and weight (3.7 [3.0, 11.5] kg for Group 1 vs. 6.0 [3.4, 20.3] kg for Group 2, t= −3.14, P = 0.002) of children increased over time, while the proportion of congenital heart disease (75.9% for Group 1 vs. 57.8% for Group 2, χ² = 6.52, P = 0.011) and cardiogenic shock (36.2% for Group 1 vs. 7.2% for Group 2, χ² = 36.59, P< 0.001) decreased. Patient conditions before ECMO were worse, while ECMO complications decreased across time periods, especially renal complications. Multiple logistic regression analysis of ECMO complications showed that disseminated intravascular coagulation (DIC), myocardial stunning, and neurological complications were independently associated with increased odds of hospital mortality.

The broader indications and decreased complication rates make EPCR to be applicated more and more extensive in children in Asia Pacific region. ECMO complications such as myocardial stunning are independently associated with decreased survival.

Acute coronary syndrome (ACS) is closely related to unstable plaques and secondary thrombosis. The inflammatory cells in plaques and their inflammatory products may be the cause for plaque instability and ruptures. The study aimed to disclose the changes of inflammatory factors including serum intracellular adhesion molecule-1 (ICAM-1), chitinase-3-like protein 1 (YKL-40), and lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with ACS and its clinical significance.

A total of 120 patients with coronary heart disease (CHD) were categorized into 2 groups: 69 with ACS and 51 with stable angina pectoris (SAP); 20 patients with chest pain and normal angiography served as a control group. The 120 patients with CHD were categorized into single-vessel disease group, double-vessel disease group, and three-vessel disease group based on the number of coronary artery stenosis. The severity of coronary artery stenosis was quantified based on coronary angiography using Gensini score. They were further divided into mild CHD group with its Gensini score <26 (n = 36), moderate CHD group with its Gensini score being 26–54 (n = 48) and severe CHD group with its Gensini score >54 (n = 36). Serum levels of ICAM-1, YKL-40, and Lp-PLA2 of different groups were determined by enzyme-linked immunosorbent assay. Correlation between ICAM-1, YKL-40, Lp-PLA2, and Gensini score was analyzed.

The levels of serum inflammatory factors ICAM-1, YKL-40, and Lp-PLA2 were significantly higher in the ACS group than those in control group and SAP group (all P< 0.05); and compared with control group, no significant difference was observed in terms of the serum ICAM-1, YKL-40, and Lp-PLA2 levels in the SAP group (P > 0.05).The levels of serum ICAM-1, YKL-40, and Lp-PLA2 were not significantly different among control group, single-vessel disease group, double-vessel disease group, and three-vessel disease group (all P> 0.05). The levels of serum ICAM-1, YKL-40, and Lp-PLA2 were not significantly different among control group, mild CHD group (Gensini score <26), moderate CHD group (Gensini score 26–54), and severe CHD group (Gensini score >54) (all P> 0.05). Nonparametric Spearman correlation analysis showed that the levels of serum ICAM-1, YKL-40, and Lp-PLA2 were not correlated with the Gensini score in CHD patients (r = 0.093, r= –0.149, and r= –0.085, all P> 0.05; respectively).

The serum levels of ICAM-1, YKL-40, and Lp-PLA2 were correlated with different clinical types of CHD, but not well correlated the severity and extent of artery stenosis, suggesting that ICAM-1, YKL-40, and Lp-PLA2 might be involved in occurrence of instability of atherosclerotic plaque, and might reflect the severity of CHD mostly through reflecting the plaque stability.

Cardiotoxicity is one of the most serious chronic complications of anthracyclines therapy. Assessment of the left ventricular ejection fraction (LVEF) fails to detect subtle cardiac dysfunction of left ventricular (LV). This study aimed to detect and evaluate new parameters of subclinical anthracyclines’ cardiotoxicity in children with solid tumor.

A detailed echocardiographic examination was performed in 36 children with hepatoblastoma or rhabdomyosarcoma after receiving anthracyclines’ chemotherapy and 36 healthy controls from January 2015 to December 2016. The LVEF, ratio of early diastolic peak velocity of transmitral flow (E) and septal diastolic e’ mitral annular peak velocity (e’), tricuspid annular plane systolic excursion (TAPSE), and LV global longitudinal strain (GLS) were evaluated using M-mode, tissue Doppler imaging (TDI), and two-dimensional speckle tracking echocardiography (2D-STE), respectively. Echocardiographic parameters were compared between patient group and healthy controls. All patients were divided into two subgroups based on their anthracyclines’ cumulative dosage (<300 mg/m² subgroup and ≥300 mg/m² subgroup).

All patients had no presentation of heart failure and LVEF within normal range (65.7±5.1%). Compared with healthy controls, the mean E/e' increased significantly (7.9±0.7 vs. 10.2±3.5, t = 3.72, P< 0.01), mean TAPSE decreased significantly (17.2±1.3 mm vs. 14.2±3.0 mm, t= −4.03, P< 0.01), and mean LV GLS decreased significantly(−22.2% ±1.9% vs. −17.9% ±2.9%, t=-5.58, P< 0.01) in patient group. Compared with subgroup with anthracyclines' cumulative dosage < 300 mg/m², mean LV GLS decreased significantly(−18.7±2.7% vs. −16.5±2.1%, t = 2.15, P= 0.04), the mean E/e’ increased significantly (9.1±1.5 vs. 11.5±4.9, t= −2.17, P= 0.04), and mean TAPSE decreased significantly (14.2±2.1 mm vs. 12.5±2.2 mm, t= −2.82, P= 0.02) in subgroup with anthracyclines’ cumulative dosage ≥300 mg/m².

LV GLS is helpful in the early detection of subclinical LV dysfunction using 2D-STE. E/e’ and TAPSE are other sensitive parameters in detecting subclinical cardiac dysfunction of both ventricles by TDI. These parameters show significant change with different anthracyclines’ cumulative dosage, so cumulative dosage should be controlled in clinical treatment.

Outflow tract (OFT) septation defects are a common cause of congenital heart disease. Numerous studies have focused on the septation mechanism of the OFT, but have reported inconsistent conclusions. This study, therefore, aimed to investigate the septation of the aortic sac and the OFT in the early embryonic human heart.

Serial sections of 27 human embryonic hearts from Carnegie stage (CS) 10 to CS19 were immunohistochemically stained with antibodies against c-smooth muscle actin (α-SMA) and myosin heavy chain.

At CS10–CS11, the OFT wall was an exclusively myocardial structure that was continuous with the aortic sac at the margin of the pericardial cavity. From CS13 onward, the OFT was divided into nonmyocardial and myocardial portions. The cushion formed gradually, and its distal border with the OFT myocardium was consistently maintained. The aortic sac between the fourth and sixth aortic arch arteries was degenerated. At CS16, the α-SMA-positive aortopulmonary septum formed and fused with the two OFT cushions, thus septating the nonmyocardial portion of the OFT into two arteries. At this stage, the cushions were not fused. At CS19, the bilateral cushions were fused to septate the myocardial portion of the OFT.

Data suggest that the OFT cushion is formed before the aortopulmonary septum is formed. Thus, the OFT cushion is not derived from the aortopulmonary septum. In addition, the nonmyocardial part of the OFT is septated into the aorta and pulmonary trunk by the aortopulmonary septum, while the main part of the cushion fuses and septates the myocardial portion of the OFT.

Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG.

The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization.

Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings.

https://clinicaltrials.gov (NCT02432469).

在儿童/青少年精神病学（CAP）人群中，非典型抗精神病药物（AAPs）的使用非常普遍，以解决各种适应症。除了食品药品监督管理局批准用于精神分裂症、双相情感障碍、自闭症谱系障碍中的易怒和妥瑞氏综合征之外，AAP通常用于智力残疾或注意力缺陷/多动障碍中的攻击性、抑郁症和强迫症中的增强、边缘型人格障碍、神经性厌食症、创伤后应激障碍、失眠等的适应症外处方。

致编者：冠状动脉瘘（CAF）是一种不寻常的冠状动脉异常，于1841年首次被描述，其定义为冠状动脉与心腔或大血管之间的异常交通。^[1]大多数CAF是先天性的，但也有获得性形式的报道。^[2]CAFs的传统诊断工具是常规冠状动脉造影（CAG），接受CAG的患者CAF发生率为0.06-0.13%。^[3,4]然而，CAG是一种侵入性检查，异常血管的复杂构型及其与周围结构的解剖关系在二维血管造影图像上可能会被掩盖，这可能会限制CAG对CAF患病率的精确评估。^[5]近年来，已经开发了心脏病诊断成像中的其他技术，例如经胸超声心动图、经食道超声心动图、磁共振血管造影和多层计算机断层扫描(MSCT)。^[6]最近，MSCT改变了冠状动脉诊断。MSCT提供了很高的空间分辨率，可以执行弯曲多平面重建、最大强度投影（MIPs）和体绘制（VR）。复杂的冠状动脉解剖结构可以很容易地用MSCT可视化。^[7]迄今为止，很少有报道关注MSCT评估CAFs的价值。本研究旨在评估来自单个中国三级转诊医疗中心的患者在MSCT上检测到的CAF的患病率、形态特征和分类。

致编者：获得性左心室假性动脉瘤是一种罕见的疾病，通常发生在跨壁心肌梗死后或心脏手术后。左心室假性动脉瘤有破裂的倾向，如果不进行手术治疗会导致死亡。^[1,2]心肌梗塞是左心室假性动脉瘤最常见的原因，其次是心脏手术、创伤和感染。^[3]本研究回顾性分析了左心室假性动脉瘤的手术经验。

致编者：Crouzon综合征（CS），又称颅缝早闭，是一种常染色体显性遗传疾病，与成纤维细胞生长因子受体2（FGFR2).^[1,2,3]某些颅骨的过早融合导致一系列畸形特征，包括不发达的上颌骨、突出的下颌骨、浅眼眶、眼球突出和喙状鼻。其他异常报告为视力损害、听力问题和气道阻塞。CS表现为先天性心脏异常并不常见，迄今为止全世界仅有4例。^[4,5,6,7]

编辑：治疗难治性精神分裂症(TRS)表明，患者的阳性精神分裂症症状已被证明具有耐药性，即使对至少两种不同类别的抗精神病药物（足够的剂量、持续时间和依从性）进行充分治疗，约占精神分裂症病例的15-30%。根据精神分裂症治疗指南，改良电休克疗法（mECT）是治疗TRS和其他顽固性幻听、严重妄想、昏迷、高度兴奋等难治性症状通常采用的主要方法。然而，很少有研究报道mECT诱导的大脑改变。

致编者：在临床上，抗抑郁药的应用非常广泛。由于眼内压（IOP）升高，目前三环类抗抑郁药的使用较少。然而，在急性青光眼存在的情况下，新型抗抑郁药也是可能的。在此，我们报告一例与文拉法辛相关的双侧急性闭角型青光眼。

编辑：植入性胎盘（植入性、子宫内膜或percreta）具有挑战性：努力降低其发病率至关重要。我们已经很清楚剖宫产(CS)会增加随后妊娠中植入的风险；然而，我们不太清楚哪种CS更/更不可能导致植入。我们饶有兴趣地阅读了施的文章等人.:^[1]无临产（选择性）CS比临产后（紧急）更容易引起前置胎盘植入。我们有一些澄清。

编辑：粘膜下鼻咽癌（NPC）非常罕见，仅占鼻咽所有肿瘤的8.8%。^[1]然而，鉴于组织取样的困难，NPC中粘膜下生长模式的病理学诊断不容易获得。在这里，我们描述了鼻咽内超声引导下经鼻咽针抽吸（ENUS-TNNA）与实时超声支气管镜在诊断粘膜下生长型鼻咽肿瘤中的成功临床应用。

致编辑：空气栓塞是手术中公认的并发症。虽然有数千篇关于术中静脉空气栓塞(VAE)的出版物，但在眼科手术中，它很少发生，因此可能不会被外科医生注意到。由于缺乏诊断方法和标准护理，很容易被忽视。最初是由Ledowski报道的等人.^[1]2005年，一名接受三孔玻璃体切割术的55岁男性在气液交换过程中突然心动过速。然而，在这项研究中，我们在此报告的病例是明确的，显示了患者检查、诊断和复苏的准确记录数据。

致编者：朗格汉斯细胞组织细胞增生症（LCH）是一种罕见的疾病，通常发生在生命的前二十年。^[1]多系统-LCH（MS-LCH）主要影响青少年。骨、肺和皮肤是最常见的系统。^[2]在此，我们报告一例来自中国的MS-LCH病例，患者为79岁，骨髓、肝、脾和肺受累，但无骨和皮肤受累。

首先，我们要感谢读者对我们研究设计的评论。他们关于选择性（分娩）剖宫产（CS）导致前置胎盘植入风险较高的可能原因的观点非常有价值，也很有意义。其次，我们对他们减少选择性CS后植入发生率的策略印象深刻。第一种策略是延迟CS的时机或进行催产素给药，将分娩（−）CS改为分娩（+）CS。这一策略与降低非医学指征CS的发生率是一致的。然而，CS前催产素给药仍有许多注意事项。有些患者在催产素给药后可能反应不佳，仍然缺乏子宫收缩。另一方面，催产素引产应基于严格的医学指征，并不是所有的患者都有催产素指征，有些患者甚至是禁忌的。^[1,2]此外，催产素已被证明对女性有副作用，如心动过速、胸痛、心悸、呼吸困难和恶心。^[3]我们目前的结果还不足以得出催产素适用于CS前所有患者的结论。然而，这可能为临床医生提供有价值的参考。此外，正如读者所提到的，子宫收缩对子宫下段的影响尚未确定，仍需进一步研究。总之，CS前催产素给药仍有争议，但值得进一步研究。第二种策略是在下段做更多的“尾部”下切口，这可能会减少对子宫的损伤。为了验证这一构想，需要更多的临床和超声数据来证明更多的“尾部”下切口导致更薄的子宫下段。