主动脉气囊反搏术在冠状动脉支架术围手术期心源性休克患者中的应用价值

目的 :小结主动脉气囊反搏术 (IABP)在冠状动脉支架术围手术期合并严重心源性休克患者中的应用结果。方法 :14例心肌梗死患者 (平均年龄 62 .3岁 )在冠状动脉支架术围手术期发生心源性休克而经股动脉行IABP。监测平均动脉压 (MBP)、心脏指数 (CI) ,同时在IABP前后测量肱动脉收缩压及舒张压力 ,并进行院内和出院后心功能以及股动脉并发症随访。结果 :8例在IABP支持下行直接或补救性冠状动脉支架术 ,3例在直接冠状动脉支架术后、3例在术中发生心源性休克而行IABP。 11例患者心功能得到迅速改善 ,在术后 8周内出院 ;3例患者术中死亡。门诊随访 6个月以上 ,3例心功能 (NYHA)Ⅱ级 ,6例心功能Ⅰ级。结论 :IABP通过增加冠状动脉舒张期灌注和降低左心室收缩期后负荷而使心源性休克患者受益 。

超声技术、运动试验、冠脉造影诊断冠状动脉疾患的对照研究

本文100例临床以心前区疼痛疑诊冠心病住院患者,经彩色多普勒超声心动图的二维超声观察和测量左冠状动脉(LCA)主干的结果与活动平板运动试验.并和其中37例冠脉造影进行对照。结果表明:(1)LCA 主干内经越小.硬化程度越高.P<0.01.(2)LCA硬化程度越高.运动试验阳性率亦越高 P<0.001、(3)冠脉内径越小,冠脉造影狭窄越重.运动试验阳性率亦越高。

基于病例研究冠状动脉扭曲对血流动力学的影响

目的探讨扭曲冠状动脉血流动力学的改变,从而阐明扭曲对冠状动脉血流灌注和壁面切应力（wall shear stress,WSS）的影响。方法选取冠状动脉左前降支（left anterior descending,LAD）扭曲和无扭曲两例个体病例,在Mimics软件中重建出LAD扭曲和无扭曲血管模型,并将模型导入ANSYS Fluent软件中进行血流动力学模拟计算,比较两种不同LAD模型的血流动力学情况。结果扭曲的冠状动脉在最大曲率大于1 mm^-1的弯曲处WSS下降较为明显,这种情况可能导致下游供血不足;弯曲外侧具有较低WSS（0～26 Pa）,而弯曲内侧WSS相对较高（〉100 Pa）;无扭曲和扭曲血管WSS均值分别为10.79、36.12 Pa,相比于无扭曲血管,扭曲血管整体WSS增高。结论扭曲冠状动脉整体WSS增高,从而可能延缓冠状动脉粥样硬化的进展。

冠状动脉内支架置入术的临床应用（附三例报告）

作者报告了３例冠状动脉血管成形术（ＰＴＣＡ）术中发生急性血管闭塞，或严重内膜剥脱致血管夹层，形成威胁性闭塞时，采用冠状动脉内支架置入术治疗的结果。３例病人均为术中决定置人冠脉内支架，经快速抗凝等准备，一次放置成功。支架置入后残余狭窄为０～１０％，获得了满意的管径增大效果。３例病人均无急性或慢性血栓形成的严重并发症，术后无心绞痛发作，临床经过顺利。作者认为冠脉内支架置入术，是处理ＰＴＣＡ术中急性血管闭塞的有效而快速安全的手段。作者还讨论了紧急情况下冠脉内支架置入术的具体操作及注意事项，认为充分适度的抗凝治疗是保证支桑置入成功的关键。

0D-1D coupling model and 3D fluid-structure interaction model based on coronary CT angiography for displaying hemodynamic characteristics of coronary artery stenosis

Objective To observe value of 0D-1D coupling model and 3D fluid-structure interaction(FSI)model based on coronary CT angiography(CCTA)for displaying hemodynamic characteristics of coronary artery stenosis.Methods Based on CCTA data of the stenosed left anterior descending branch(LAD)in a patient with coronary heart disease,an 0D-1D coupling model and 3D FSI model were built,respectively.Then hemodynamic characteristic indexes,including the pressure,flow velocity and wall shear stress(WSS)were obtained in every 0.01 s during 1 s at 5 sampling points(i.e.sampling point 1—5)using these 2 models,respectively,and the consistencies of the results between models were evaluated with Spearman correlation coefficient r s.Results The time consuming for construction of 0D-1D coupling model and 3D FSI model was 0.033 min and 704 min,respectively.Both models showed basically distribution of the pressure,flow velocity and WSS of the stenosed LAD.For more details,the pressure at the stenosed segment of LAD and the proximal segment of stenosis were both higher,which gradually decreased at the distal segment of stenosis,and the flow velocity at the proximal segment of stenosis was in a relatively slow and uniform condition,with significantly increased flow velocity and WSS at the stenosed segment.Compared with 3D FSI model,0D-1D vascular coupling model was relatively unrefined and lack of distal flow lines when displaying blood flow velocity.For sampling point 2 at the stenosed segment of LAD,no significant consistency for pressure between 2 models was found(P=0.118),but strong consistency for the flow velocity and WSS(r s=0.730,0.807,both P<0.05).The consistencies of pressure,flow velocity and WSS between 2 models at the proximal and distal segment of stenosis,i.e.1,3—5 sampling points were week to moderate(r s=0.237—0.669,all P<0.05).Conclusion 0D-1D coupling model exhibited outstanding computational efficiency and might provide relatively reasonable results,while 3D FSI model showed higher accuracy for details and streamline when simulating LAD stenosis.

Comparison of very-high-frequency ultrasound assessment of radial arterial wall layers after first and repeated transradial coronary procedures

Background Transradial coronary procedure （TRP） traumatizes the radial artery （RA）, especially resulting in changes to arterial wall morphology. This study explored the significance of the early onset of traumatic effects to wall layers of the RA following the first TRP （FTRP） and repeat TRP （RTRP） using very-high-frequency ultrabiomicroscopy （VHFUBM）. Methods A total of 1431 patients that re- ceived TRP were divided into the FTRP group that comprised 781 patients and the RTRP group that comprised 650 patients depending on the number of procedures. Two-dimensional RA images were acquired by 30-55 MHz ultrasound one day before and one day after the pro- cedure. Results After TRP, the incidence of intimal tears, medial dissections and external elastic lamina fracture were greater in the RTRP （P 〈 0.001）. The RTRP group showed significantly thicker intimal thickness （IT）, media thickness （MT）, adventitia thickness and all complex layer thicknesses as compared with the FTRP group （P 〈 0.001）. Conclusions Multivariate linear regression analysis discovered that repeated TRP and other observations were independent predictors of increased IT in post-operative RA. VHFUBM provides an approach to study structural and histopathological injury in the wall layers of RA which showed increased trauma to the RA following RTRP.

Is there any link between homocysteine and atherosclerosis？

I have read with interest the paper by Hart, et al. re- porting that homocysteine （Hey） is an independent risk fac- tor for non-culprit coronary lesions progression after 12 months of follow-up in elderly patients who has undergone percutaneous coronary stenting. Hcy-mediated increased lipid peroxidation and generation of free radicals results in in- flammation and endothelial dysfunction, which triggers atherosclerotic process. Coronary artery disease is also as- sociated with higher levels of Hcy.

Cardiac evaluation of liver transplant candidates

Physicians previously thought that heart disease was rare in patients with end stage liver disease. However, recent evidence shows that the prevalence of ischemic heart disease and cardiomyopathy is increased in transplant candidates compared to most other surgical candidates. Investigators estimate that up to 26% of all liver transplant candidates have at least one critical coronary artery stenosis and that at least half of these patients will die perioperatively of cardiac complications. Cardiomyopathy also occurs in greater frequency. While all patients with advanced cardiac disease have defects in cardiac performance, a larger than expected number of patients have classical findings of dilated, restrictive and hypertropic cardiomyopathy. This may explain why up to 56% of patients suffer from hypoxemia due to pulmonary edema following transplant surgery. There is considerable controversy on how to screen transplant candidates for the presence of heart disease. Questions focus upon, which patients should be screened and what tests should be used. This review examines screening strategies for transplant candidates and details the prognostic value of common tests used to identify ischemic heart disease. We also review the physiological consequences of cardiomyopathy in transplant candidates and explore the specific syndrome of "cirrhotic cardiomyopathy".

Catheter ablation of atrial fibrillation in the elderly

Background Atrial fibrillation （AF） catheter ablation has emerged as a promising treatment strategy for AF, but has not been widely adopted in the elderly population. The present study aimed to determine the safety and efficacy of AF catheter ablation in the elderly popula-tion. Methods and Results The study population consisted of 316 patients with paroxysmal AF who underwent left atrial ablation. Ninety-five patients were≥65 years （48 males, mean age 68.9 ± 3.0 years old） and 221 patients were〈65 years old （130 males, mean age 52.5 ± 10.4 years old）. After a mean follow-up period of 34.0 ± 15.1 months, 55 （57.9%） patients in the elderly group were free from ar-rhythmia recurrence compared with 149 （67.4%） patients in the younger group （P=0.169）. Procedural complications were uncommon in both study groups. In logistic regression analysis, left atrial diameter （P=0.003）, hypertension （P=0.001）, dyslipidemia （P=0.039）, and coronary artery disease （P=0.018） were independent predictors of AF recurrence in the elderly population. Conclusions Catheter ablation of AF is safe and effective in older patients. Invasive strategies should be considered as an alternative choice in symptomatic elderly patients with AF.

The impact of optimal medical therapy at discharge on mortality in patients with coronary artery disease

Objective To analyze the current usage of optimal medical therapy （OMT）, influencing factors, and the predictive value of OMT for all-cause mortality in coronary artery disease （CAD） patients with different subgroups. Methods A total of 3176 CAD patients confirmed by coronary angiography were included. OMT was defined as the combination of anti-platelet drugs, statins, beta blockers, and angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Factors for OMT and its prognostic value were analyzed in CAD patients across different subgroups. Results Out of 3176 patients, only 39.8% （n = 1265） were on OMT at discharge. Factors associated with OMT at discharge were pre-admission OMT and discharge department. All-cause mortality occurred in 6.8% （n = 217） of patients. Multivariate analyses indicated that OMT was significantly associated with reduced all-cause mortality （HR： 0.65, 95% CI： 0.45~0.95; P = 0.025）. Sub-group analyses indicate that male acute coronary syndrome （ACS） patients were more likely to receive survival benefits with OMT at discharge. The positive impact of OMT at discharge was more apparent after 24 months, regardless of revascularization therapy. Four-drug combination of OMT was superior to 3-drug combination therapy in ACS patients but not in stable patients. Conclusions OMT was asso- ciated with significant improvement in survival in patients with CAD. The positive impact of OMT was distinct in the CAD patients with different characteristics.

Retrospective analysis of exercise capacity in patients with coronary artery disease after percutaneous coronary intervention or coronary artery bypass graft

Objectives:To describe the current state of exercise capacity as well as to identify its predictors in patients with coronary artery disease (CAD) following percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in the mainland of China.Methods:A retrospective study design was employed.We evaluated 230 CAD patients following PCI or CABG in a cardiac rehabilitation center from January 2019 to October 2019.The patients were referred to undergo incremental cardiopulmonary exercise testing with a cycle ergometer.The Zung Self-Rating Anxiety Scale and the Zung Self-Rating Depression Scale were used to evaluate patients' mental health.Statistical analysis was performed using the chi-square test,Fisher's exact test,t-test,Mann-Whitney U test,and binary logistic regression.Results:Among the 230 patients,223 patients demonstrated reduced exercise capacity.Resutlts of the logistic regression analysis showed that anxiety (OR =1.13,95% CI 1.01-1.32,P =0.029) was an independent risk factor for reduced exercise capacity in patients following the PCI or CABG.Conclusions:Exercise capacity of Chinese CAD patients after PCI or CABG was relatively poor.Alleviating symptoms of anxiety and making exercise prescriptions according to the results of the cardiopulmonary exercise test should be considered during the intervention to improve CAD patients' exercise capacity.

Acute coronary syndrome in the older adults

Coronary heart disease remains the leading cause of death in the developed world. Advanced age is the single strongest risk factor for coronary artery disease （CAD） and independent predictor for poor outcomes following an acute coronary syndrome （ACS）. ACS refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction due to various degrees of reduction in co- ronary blood flow as a result of plaque rupture/erosion and thrombosis formation or supply and demand mismatch.

Delayed asymptomatic progressive aortic dissecting aneurysm in patient with STEMI

An 80-year-old woman visited emergency room because of resting chest pain for one hour. She had history of hypertension for 10 years. The blood pressure was 80/50 mmHg and the pulse rate was 51 beats/min. The electrocardiogram demonstrated Junctional bradycardia and ST elevation in lead Ⅱ, Ⅲ and aVF. Chest X-ray indicated cardiomegaly （Figure 1A）. Coronary angiography revealed near total occlusion of proximal right coronary artery （RCA）. She underwent percutaneous coronary intervention （PCI） for the RCA lesion successfully. Echocardiography showed hypokinesia of RCA territory （Figure 2A）.

Feasibility and Diagnostic Accuracy for Assessment of Coronary Artery Stenosis of Prospectively Electrocardiogram-gated High-pitch Spiral Acquisition Mode Dual-source CT Coronary Angiography in Patients with Relatively Higher Heart Rates: in Comparison wit

Objective To prospectively investigate the diagnostic accuracy for coronary artery stenosis of prospectively electrocardiogram-triggered spiral acquisition mode (high pitch mode) dual-source computed tomography coronary angiography (CTCA) in patients with relatively higher heart rates (HR) compared with catheter coronary angiography (CCA). Methods Forty-seven consecutive patients with relatively higher HR (>65 and <100 bpm) (20 male, 27 female; age 55±10 years) who both underwent dual-source CTCA and CCA were prospectively included in this study. All patients were performed CTCA using high pitch mode setting at 20%-30% of the R-R interval for the image acquisition. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a three-point scale (1: excellent to 3: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). Considered CCA as the standard of reference, the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Radiation dose values were calculated using the dose-length product. Results Image quality was rated as being score 1 in 92.4% of segments, score 2 in 6.1% of segmentsand score 3 in 1.5% of segments. The average image quality score per segment was 1.064±0.306. The HR variability of patients with image score 1, 2 and 3 were 2.29±1.06 bpm, 5.17±1.37 bpm, 8.88±1.53 bpm, respectively. The average HR variability of patients with different image scores were significantly different (F=170.402, P=0.001). The sensitivity, specificity, positive and negative predictive values were 92.6%, 97.0%, 87.6%, 98.3%, respectively, per segment and 90.0%, 95.2%, 85.3%, 96.9%, respectively, per vessel and 100%, 63.6%, 90.0%, 100%, respectively, per patient. The effective radiation dose was on average 0.86±0.16 mSv. Conclusion In patients with HR more than 65 bpm and below 100 bpm without cardiac arrhythmia, the prospectively electrocardiogram-gated high-pitch spiral acquisition mode with image acquired timing set at 20%-30% of the R-R interval provides a high diagnostic accuracy for the assessment of coronary stenoses combined with a 1.5% of non-diagnostic coronary segments and a radiation dose below 1 mSv.

Cardiac rehabilitation and exercise therapy in the elderly： Should we invest in the aged？

Coronary heart disease （CHD） is the leading cause of death worldwide and becomes increasingly prevalent among patients aged 65 years and older.Elderly patients are at a higher risk for complications and accelerated physical deconditioning after a cardiovascular event,especially compared to their younger counterparts.The last few decades were privy to multiple studies that demonstrated the beneficial effects of cardiac rehabilitation （CR） and exercise therapy on mortality,exercise capacity,psychological risk factors,inflammation,and obesity among patients with CHD.Unfortunately,a significant portion of the available data in this field pertains to younger patients.A viable explanation is that older patients are grossly underrepresented in these programs for multiple reasons starting with the patient and extending to the physician.In this article,we will review the benefits of CR programs among the elderly,as well as some of the barriers that hinder their participation.

N-terminal pro-brain natriuretic peptide but not high-sensitivity C-reactive protein is related to severity of coronary artery stenosis in patients with acute coronary syndrome

Objective Biochemical indicators such as N-terminal pro-brain type natriuretic peptide（NT pro-BNP）and high-sensitivity Creactive protein（hsCRP）predict mortality in acute coronary syndrome（ACS）.However,little is known about the relationship of these factors with severity of coronary artery stenosis in patients with.Methods Three hundred and thirty-one subjects including 246 unstable angina pectoris patients and 85 myocardial infarction patients were recruited and classified into two groups：single-vessel disease group（1-vessel disease,n=93）and multiple-vessel disease group（≥2-vessels disease,n=238）according to selective coronary angiography.Plasma levels of NT pro-BNP and hsCRP were measured and severity of coronary stenosis was determined by Gensini score.Results NT pro-BNP but not hsCRP level was higher in patients with myocardial infarction than in patients with unstable angina pectoris.The patients with multiple-vessel disease had significantly higher NT pro-BNP level but not hsCRP compared with those with single-vessel disease.NT pro-BNP levels increased significantly as left ventricle（LV）function decreased,and only NT proBNP but not hsCRP level was related to Gensini score of severity of coronary stenosis in ACS.Conclusion NT proBNP but not hsCRP level is related to severity of coronary artery stenosis in patients in ACS.

RELATIONS OF ENDOTHELIAL FUNCTION AND BLOOD FLOW IN BRACHIAL ARTERY AND CORONARY ARTERY

Objective:To determine the relations between endothelium-dependent vasodilator function and blood flow in the brachial and coronary arteries in patients with suspected coronary artery disease.Methods:Twenty-eight patients with suspected coronary artery disease underwent brachial artery endothelial function test by using high-resolution B-mode ultrasound before coronary angiography(CAG)and coronary flow reserve(CFR)test by using intracoronary Doppler technique.The correlation of coronary artery dilatation induced by an increase in blood flow after intracoronary adenosine infusion and brachial artery flow-mediated dilatation(FMD) following reactive hyperemia was evaluated.The relation between the change of brachial artery blood flow and CFR was also studied.Results:There was a positive correlation between brachial FMD and percent change of coronary diameter after adenosine infusion(12.50%±9.35% vs 11.38%±7.55%,r=0.425,P=0.02).There was also a weak negative relation between brachial flow change following reactive hy-peremia and CFR(r=-0.397,P=0.04).Conclusion:There is a correlation between the coronary endo-thelial function and the CFR by ultrasonic determination of brachial flow changes following reactive hyperemia.

The effect of slow deep breathing relaxation exercise on pain levels during and post chest tube removal after coronary artery bypass graft surgery

Objectives:This study aimed to evaluate the effectiveness of slow deep breathing relaxation exercise(SDBRE)in reducing patients’pain levels during chest tube removal(CTR)post coronary artery bypass grafting(CABG)surgery.Methods:In 2019,fifty post-CABG patients were conveniently selected from a cardiac intensive care unit in Jordan’s major referral heart institute.The patients were randomly assigned to either an intervention group or a control group.A total of 25 patients were assigned into the experimental group who received slow deep breathing relaxation Exercise(SDBRE)alongside the conventional care before CTR.The remaining 25 patients constituted the control group(50%)that had CTR following conventional care.The Visual Analogue Scale(VAS)was used to measure the participants’pain levels during three phases:before CTR(Time 1),5-min post CTR(Time 2),and 15-min post CTR(Time 2)to compare the intervention effect between the two groups.Results:The data analysis findings for the control and intervention group of patients showed that there was a statistically significant decline in their pain level across time for both groups(H¼32.71,P<0.01;H=47.23,P<0.01)respectively.The intervention group had significantly lower pain levels than the control group at Time 2(3.50[1.20,5.30]vs.7.90[7.00,9.00],P<0.01)and Time 3(0.00[0.00,1.30]vs.3.60[2.40,4.10]P<0.01).Conclusions:Using SDBRE during CTR is an effective technique for reducing pain which can minimize the need for analgesics and their associated adverse effects.

Delayed post-dilated stenting to treat an embolic myocardial infarction

Thromboembolism infrequently occurs in coronary arteries. In contrast to an in situ thrombosis, a thrombus is not fresh and floating. There has been no recommended treatment strategy for this rare condition, especially for large thrombi in main arteries. Here, we report a modified stenting strategy to treat thromboembolism in the left main coronary artery.