中国肥厚型心肌病患者血栓栓塞事件风险预测模型的构建研究

背景 血栓栓塞（TE）事件是肥厚型心肌病（HCM）的重要并发症。目前针对HCM患者TE事件的风险预测,仅国外学者构建了两个模型：HCM Risk-CVA及French HCM score,然而,现有研究发现HCM Risk-CVA模型对于中国HCM患者的临床价值较为有限。目的 本研究拟构建适合中国HCM患者的TE事件风险预测模型。方法本研究系回顾性队列研究,收集2010—2018年在四川大学华西医院就诊的537例HCM患者的病例资料。本研究通过电话随访或电子病历系统查询患者就诊记录,每6～12个月随访1次,直至出现终点事件或死亡或研究拟定的评估日期（2019-12-31）,终点事件定义为复合性TE事件。采用单因素和多因素Cox回归分析构建风险预测模型,并使用自助重抽样的方法进行内部验证。结果 537例患者中,24例患者有不同程度的数据缺失,最终纳入513例患者。中位随访时间为4.2(1.3,6.2)年,随访过程中42例（8.18%）发生TE事件,年发病率为2.10%[95%CI(1.47%,2.73%)]。根据多因素Cox回归模型构建TE事件风险预测模型,最终纳入年龄、既往TE事件、心...     

心房颤动治疗的未来发展方向——混合消融

心房颤动是临床常见的心律失常,已有研究证明其与严重不良心脑血管事件(心力衰竭、脑卒中和心肌梗死)有关,目前全球心房颤动的患病人数超过了3 300万,预计未来40年内其患病率将增加1倍以上。多年来,医学相关人员在探究心房颤动的病理生理机制及开创改进其治疗方法等方面付出了大量努力。目前心房颤动的治疗管理仍是临床医学上的一个难题,尽管心房颤动治疗的手术消融和导管消融技术已逐渐趋于成熟,但对于心房颤动最佳的治疗方式、消融能量的选择尚无统一定论。导管消融通常需要多次手术且成功率低,而手术消融术后不良事件发生率较高。近年来,鉴于心脏外科医生和电生理学家之间的密切合作,结合导管及微创手术消融诞生了一种治疗心房颤动的新型策略——混合消融模式。混合消融克服了导管消融和微创手术消融的缺点,减少了不良结局,在治疗持续性心房颤动,尤其是长期持续性心房颤动上取得了可观的成效。本文主要通过回顾心房颤动消融的研究进展,对比分析目前混合消融模式治疗心房颤动的现有研究成果,归纳总结这种新型心房颤动治疗策略的优势与挑战,以期为临床心房颤动的治疗提供更多选择。     

基于FT-CMR的心脏功能评估参数对心房颤动冷冻球囊消融患者治疗后复发的预测效能分析

目的 探讨分析基于心脏磁共振特征追踪技术(FT-CMR)的心脏功能评估参数对心房颤动冷冻球囊消融患者治疗后复发的预测效能。方法 选取2019年6月至2020年12月收治的126例预行冷冻球囊消融术的心房颤动患者为研究对象,术前均进行心脏磁共振检查,根据术后6个月内患者有无复发将其分为窦性心律组72例和房颤复发组54例。比较两组患者左心房应变及应变率参数,采用FT-CMR评估患者心脏功能,并进行单因素、多因素logistic回归分析,探讨FT-CMR心脏功能评估参数对心房颤动冷冻球囊消融术后复发的预测价值。结果 房颤复发组患者女性、高血压、糖尿病、非阵发性心房颤动比例显著高于窦性心律组(P<0.05)。房颤复发组患者左心房总应变(Es)、左心房正向应变率峰值(SRs)、左心房被动应变(Ee)、心室舒张早期负向应变率峰值(SRe)、左心房整体纵向应变(PLAS)参数值低于窦性心律组(P<0.05)。Logistic多因素回归分析结果显示,性别(OR=3.511,95%CI:1.036～11.906)、PLAS(OR=1.089,95%CI:1.039～1.141)是心房颤动冷冻...     

Search for Optimal Frequencies and Amplitudes of Therapeutic Electrical Carotid Sinus Nerve Stimulation by Application of the Evolution Strategy

In humans, electrical, bipolar, bilateral carotid sinus nerve stimulation (CSNS; impulse duration 0.35 ms) was applied, using frequencies between 10 and 110 Hz and voltages between individual thresholds and maximal amplitudes of stimulation. Ten anginal patients and two hypertensive patients were studied at an interval of up to 12 years after implantation of electrodes and a radiofrequency receiver for chronic therapeutic CSNS. In search of combinations of frequency and voltage of CSNS, eliciting largest ("optimal") depressor responses of blood pressure and heart rate in the individual patient, Rechenberg's evolution strategy was applied. This strategy simulates mutation and selection of biological evolution. In each patient and on each test stimulation, a value of quality was computed from actual heart rate and blood pressure values as a selection criterion for the strategy. Either responses to uninterrupted CSNS were investigated, while stimulation parameters were adjusted every 3 min, according to the strategy, or responses to 3 min of CSNS after a change in stimulation parameters were compared to intercalated 3-min control periods. In each patient, one or more combined settings of frequency and voltage elicited "optimal" responses. In principle, "optimal" CSNS frequencies ranged between 35 and 105 Hz with large interindividual differences. Due to chronic implantation of electrodes and technical features of radiofrequency transmitted stimulation energy, interindividually different voltages led to an optimal response to CSNS. Also according to the present results, the frequency of CSNS has to be determined individually. It is concluded that the evolution strategy was applied successfully, because voltage and frequency settings leading to "optimal" responses were found within 90-180 min, whereas intraindividual systematic investigations would not be feasible due to their necessarily very long duration. So far, only short-term responses have been evaluated. A broader use of the strategy in other applications is encouraged, as for example in pacemaker optimization and especially in functional electrostimulation.     

Effects of short-duration transients on cardiac rhythm

Cardiac stimulation thresholds of short-duration large-amplitude electrical transients were studied. An isolated rabbit heart model was used and transients were applied directly to the heart through electrodes of 1 mm² and 1 cm² surface area. A variety of oscillatory waveforms and pulse configurations were studied and indicated that, for transients shorter than 100 μs, stimulation thresholds approach a constant charge-transfer density of 3·4 μC cm⁻².     

Mapping location of excitation during magnetic stimulation: Effects of coil position

We determined the location of excitation for different positions of a round and butterfly coil duringin vitro magnetic stimulation of cut peripheral nerves. We analyzed the conditions under which excitation occurs, either at the termination or at the peak of the field gradients (first spatial derivative of the electric field). These results were then compared to predictions about the location of excitation sites from a theoretical model of magnetic stimulation of finite neuronal structures. Excitation along a straight nerve occurred at terminations when 1) a coil was positioned close to the end of a nerve (at least one diameter length from the end), 2) a nerve ended in a finite terminating impedance much greater than the axial resistance of the nerve, 3) the induced electric field was of sufficient magnitude, pointing in a direction away from the axis of a nerve. Excitation occurred at the negative peak of the field gradients along a nerve when 1) a coil was positioned far away from the ends of a nerve, 2) there were no geometric or volume conductor inhomogeneities around a nerve, and 3) it was of sufficient magnitude. Threshold strengths for excitation at terminations were significantly lower than that for field gradient excitation and comparable to that due to geometric and volume conductor inhomogeneities.     

A critique of impedance measurements in cardiac tissue

The specific impedance of cardiac tissue cannot be measured directly. Instead, the investigator obtains voltage and current measurements and places them into a model of the tissue's structure to infer the impedances of elements of the model. If the model fails to describe major aspects of the real tissue, the results may be worthless, although possibly self-consistent. In the literature of impedance measurement in cardiac tissue, only rarely is the model explicitly described; more commonly, the tissue model is adopted implicitly when equations giving the impedance in terms of voltage and current measurements are adopted. This paper examines the series of models that have been used in specific impedance measurements of cardiac tissue and shows how the same or similar measurements can accurately describe tissue impedivity or can lead to significant errors when inadequate models such as isotropic and anisotropic monodomains (although a part of work of historical merit) are used.     

Role of Purkinje cells in the ventral paraflocculus in short-latency ocular following responses

We describe the simple-spike activity of Purkin je cells (P cells) in the ventral paraflocculus (VPFL) of behaving monkeys in association with movements of the visual scene that evoke short-latency ocular following re sponses. One group of P cells discharged maximally for downward motion, and the other for motion toward the side of the recording. The onset of the simple-spike re sponse was measured in relation to the onset of ocular following in 24 P cells. The majority of P cells (79%) led by 1–9 ms. At the site of each recording, electrical stimuli (single negative pulses, 1.5–45 A; 0.2 ms in width) were applied and 60% (18/30) of the sites elicited eye movements in the preferred direction of the P cells. The latency of the single-pulse-evoked response in the ipsilateral eye ranged from 8.6 to 10.9 ms. These data suggest that the P cells in the VPFL play a role in ocular following; some discharge early enough to generate the very earliest eye movements.     

Electrical properties of implant encapsulation tissue

The purpose of this study was to determine the electrical properties of the encapsulation tissue that surrounds electrodes chronically implanted in the body. Two four-electrode arrays, fabricated from either epoxy or silicone rubber, were implanted in each of six adult cats for 82 to 156 days.In vivo measurements of tissue resistivity using the four-electrode technique indicated that formation of the encapsulation tissue resulted in a significant increase in the resistivity of the tissue around the arrays.In vitro measurements of tissue impedance using a four-electrode cell indicated that the resistivity of the encapsulation tissue was a function of the tissue morphology. The tight layers of fibroblasts and collagen that formed around the silicone rubber arrays had a resistivity of 627±108 Ω-cm (mean ± SD; n=6), which was independent of frequency from 10 Hz to 100 kHz, and was significantly larger than the resistivity of the epoxy encapsulation tissue at all frequencies between 20 Hz and 100 kHz. The combination of macrophages, foreign body giant cells, loose collagen, and fibroblasts that formed around the epoxy arrays had a frequency-dependent resistivity that decreased from 454±123 Ω-cm (n=5) to 193±98 Ω-cm between 10 Hz and 1 kHz, and was independent of frequency between 1 kHz and 100 kHz, with a mean value of 195 ±88 Ω-cm. The results indicate that the resistivity of the encapsulation tissue is sufficient to alter the shape and magnitude of the electric field generated by chronically implanted electrodes.     

In vivo electrical characteristics of human skin, including at biological active points

The aim is to compare the mean values of the in vivo electrical characteristics of bioiogical active points (BAPs) with those of the surrounding human skin. The impedance measurements at BAPs and on the surrounding skin are carried out in vivo on ten young, healthy people. The results of the measurements show that the BAP resistance R_P is smaller, and the capacitance C_P is higher, than the corresponding values for skin, R_S and C_S, respectively, these differences are larger at low frequencies (at f=3 Hz, R_S/R_P=3.19 and C_P/C_S=3.2). The mean values of the impedance measurements at the BAPs are different from those measured on the skin. The dependence of R_P and C_P on the pressing force, in the range of about 1–5 N, for the BAPs, has a smaller slope than that observed for the surrounding skin. An equivalent circuit for the BAPs is proposed that describes sufficiently well the experimental results obtained. These results show that the large dispersion in the observed impedance characteristics of the human body measurements in different body regions can be related to the influence of the BAPs present under the electrodes.