心包内脂肪与冠状动脉CTA非钙化斑块的相关性

目的 探讨心包内脂肪容积与冠状动脉CTA非钙化斑块的关系。方法 连续收集冠状动脉钙化零评分而冠状动脉CTA提示非钙化斑块的患者31例,选取冠状动脉CTA检查正常的患者93例。应用多因素条件Logistic回归分析心包内脂肪容积与非钙化斑块的相关性;采用ROC曲线评估Framingham评分结合心包内脂肪容积对非钙化斑块的预测价值。结果 采用多因素条件Logistic回归调整年龄、体质量指数(BMI)、糖尿病、高血压、高脂血症史、吸烟、冠心病家族史影响因子后,心包内脂肪容积与冠状动脉CTA非钙化斑块异常相关(OR=1.23,95%CI 1.09~1.40,P=0.01)。Framingham评分结合心包内脂肪容积较单纯应用Framingham评分对非钙化斑块的预测能力明显提高(Z=2.08,P<0.05)。结论 心包内脂肪容积与非钙化斑块密切相关。Framingham评分结合心包内脂肪容积有助于改善对冠状动脉钙化零评分患者非钙化斑块的预测。     

冠状动脉CT血管成像预测冠状动脉斑块患者发生主要不良心脏事件的价值

目的 探讨冠状动脉CT血管成像（CCTA）预测冠状动脉斑块患者发生主要不良心脏事件（MACE）的价值。方法 对256例冠状动脉粥样硬化斑块患者行CCTA检查,于CCTA图像上定量评定冠状动脉管腔狭窄程度,并依据斑块成分进行分型。随访MACE发生情况,建立预测MACE的3个模型（模型1,冠状动脉狭窄程度分级;模型2,冠状动脉狭窄程度分级联合管壁斑块分型;模型3：冠状动脉狭窄程度分级联合管壁斑块分型和临床危险因素指标）,评估3个模型对MACE的预测效能。结果 256例病例中47例失访,最终随访209例患者。随访结束时,46例发生MACE。冠状动脉狭窄程度分级和斑块分型评估MACE发病风险的风险比分别为4.47、3.43,高于临床危险因素指标。模型2、模型3预测MACE的ROC曲线下面积明显大于模型1（P<0.05）,模型2和模型3预测MACE的ROC曲线下面积差异无统计学意义（P=0.076）。结论 CCTA可定量评估冠状动脉管腔狭窄程度并进行斑块分型,联合应用有助于提高MACE的预测效能。     

对比单次屏气与两次屏气法减影冠状动脉CT血管造影评估严重钙化冠状动脉狭窄

目的 对比分析单次屏气与两次屏气方法获得减影冠状动脉CT血管造影(sub-CCTA)对评估严重钙化(Agatston钙化积分＞400)冠状动脉狭窄的价值。方法 回顾性分析60例疑诊冠心病患者CCTA及侵入性冠状动脉造影(ICA)资料,根据扫描方法分为单次屏气组(n=32)及两次屏气组(n=28)。针对CCTA显示严重钙化节段,对比2组常规CCTA(con-CCTA)和sub-CCTA图像质量评分;以ICA结果为标准,绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),评估CCTA诊断目标节段狭窄率≥50%的效能。结果 单次屏气组中,CCTA共检出134个冠状动脉节段存在严重钙化,其中78个节段ICA显示狭窄率≥50%;con-CCTA图像质量评分为3.0(2.0,3.0),低于sub-CCTA 。两次屏气组中,CCTA共检出127个冠状动脉节段存在严重钙化,其中74个节段ICA显示狭窄率≥50%;con-CCTA图像质量评分为3.0(2.0,3.0),低于sub-CCTA 。con-CCTA评估单次、两次屏气组目标节段狭窄率≥50%的AUC(0.780、0.767)均低于sub-CCTA(AUC=0.903、0.898,Z=4.198、3.470,P均＜0.010)。单次屏气sub-CCTA图像质量评分高于两次屏气sub-CCTA(Z=－2.954,P=0.030),而诊断目标节段狭窄率≥50%的准确率差异无统计学意义(Z=0.129,P=0.900)。结论 单次与两次屏气法sub-CCTA评估严重钙化冠状动脉节段狭窄程度效能相仿,但前者图像质量更佳。     

多时相CT影像组学模型预测胸腺瘤风险分类

目的 观察多时相CT影像组学模型预测胸腺瘤风险分类的价值。方法 纳入86例经病理确诊的单发胸腺瘤患者,包括32例高风险及54例低风险胸腺瘤,按照7∶3比例将其分为训练集(n=59)和验证集(n=27);采用单因素及多因素logistic回归分析训练集临床及CT特征,筛选胸腺瘤风险分类的独立预测因素,构建临床-CT模型。分别基于平扫、动脉期(AP)、静脉期(VP)、平扫+AP、平扫+VP、AP+VP及平扫+AP+VP提取并筛选最优影像组学特征,计算影像组学评分(Rad-score);采用受试者工作特征(ROC)曲线选取最佳影像组学模型,以之联合临床-CT特征构建联合模型。绘制ROC曲线,计算曲线下面积(AUC),评估各模型预测胸腺瘤风险分类的效能。结果 周围脂肪浸润是胸腺瘤风险分类的独立预测因素(OR=0.029,P=0.004)。ROC曲线显示,模型_AP+VP为最佳影像组学模型,其与联合模型预测训练集胸腺瘤风险分类的AUC分别为0.860及0.877,均高于临床-CT模型的0.736(Z=1.925、-2.464,P均＜0.05),预测验证集的AUC分别为0.835及0.847,亦高于临床-CT模型的0.641(Z=1.840、-2.137,P均＜0.05);模型_AP+VP与联合模型在训练集和验证集的AUC差异均无统计学意义(Z=-1.180、0.291,P均＞0.05)。结论 多时相CT影像组学模型可有效预测胸腺瘤风险分类。     

超声心动图心肌做功指标预测顽固性高血压患者预后

目的 筛选可预测顽固性高血压(RH)患者预后的超声心动图心肌做功指标。方法 前瞻性纳入67例RH患者,采集超声心动图基线数据;随访至其后4年或发生不良事件时;比较不良事件组与无不良事件组基线超声指标,筛选预测RH患者发生不良事件的心肌做功指标。结果 随访期间3例失访,21例发生(A组)、43例未发生(B组)不良事件。A组左心室壁增厚占比及整体无用功(GWW)均高于,而左心室整体纵向应变(LVGLS)、整体做功效率均低于B组(P均＜0.05)。左心室壁增厚是RH患者发生不良事件的独立危险因素(OR=6.96,P＜0.05;HR=5.026,P＜0.05)。以-14.50%、109.00 mmHg%及12 mm 为LVGLS、GWW及左心室壁增厚的临界值,其预测RH患者发生不良事件的曲线下面积(AUC)分别为0.791、0.732及0.664,三者联合AUC为0.857,优于单一GWW及左心室壁增厚(P均＜0.05)。结论 根据LVGLS、GWW及左心室壁厚度可较好地预测RH患者发生不良事件。     

冠状动脉CTA斑块特征评价支架内再狭窄风险

目的 探讨冠状动脉CTA斑块特征评估植入支架后发生支架内再狭窄（ISR）的风险。方法 对166例患者于支架植入前行冠状动脉CTA检查,观察血管狭窄程度和斑块特征,并于植入支架后6~18个月内复查冠状动脉造影;根据有无ISR,将其分为ISR组（n=16）与无ISR组（n=150）,比较两组间的差异;采用多因素Logistic回归分析获得ISR的危险因素,以ROC曲线评价各因素诊断ISR的效能。结果 ISR组病变长度,非钙化斑块、点状钙化、正性重构比例和正性重构指数均大于无ISR组（P均<0.05）。多因素Logistic回归分析结果显示,非钙化斑块[回归系数（B）=1.89,优势比（OR）=6.63,P=0.01]、点状钙化（B=1.28,OR=3.59,P=0.01）、正性重构（B=2.17,OR=8.71,P<0.01）、病变长度（B=0.05,OR=1.05,P=0.04）是导致ISR的危险因素。病变长度及正性重构指数诊断ISR的ROC曲线下面积（AUC）分别为0.70和0.82（P均<0.01）,联合上述斑块特征预判ISR的AUC为0.87（P<0.01）。结论 病变长度、正性重构、非钙化斑块、点状钙化可用于评估冠状动脉支架植入后发生ISR的风险。     

基于非小细胞肺癌双能CT表现及影像组学列线图模型预测其血管生成拟态

目的 基于非小细胞肺癌(NSCLC)双能CT (DECT)表现及影像组学构建联合列线图模型,分析其预测NSCLC血管生成拟态(VM)的价值。方法 回顾性分析137例经手术病理证实的单发NSCLC患者,以7 ∶ 3比例将其分为训练集和验证集。基于肺窗CT提取及筛选最优影像组学特征,计算影像组学评分。以单因素分析及多因素logistic回归分析筛选NSCLC表达VM的独立预测因素,分别以之构建临床、能谱及影像组学模型;基于独立预测因素构建联合列线图模型。采用受试者工作特征曲线评估各模型预测NSCLC VM的效能,以校准曲线分析模型的拟合度,以决策曲线分析评估模型的临床获益。结果 最终筛选出6个最优影像组学特征。病灶最大径、毛刺征、CT_{140 keV}及影像组学评分为NSCLC VM的独立预测因素(OR=2.25、9.69、0.99、-14.44,P均＜0.05)。临床、能谱及影像组学模型预测验证集NSCLC VM的曲线下面积(AUC)分别为0.83、0.85、0.87,均低于联合列线图模型(AUC=0.95,Z=2.14、2.10、2.07,P均＜0.05)。联合列线图模型预测结果与实际结果的一致性较好,且其临床获益较高。结论 基于DECT及影像组学构建的联合列线图模型能可有效预测NSCLC VM。     

CT预测急性肠系膜缺血继发性肠坏死

目的 评估CT预测急性肠系膜缺血(AMI)继发性肠坏死的价值。方法 回顾性分析78例经手术病理证实AMI患者的腹部CT资料,根据是否发生继发性肠坏死将其分为肠坏死组(n=26)及无肠坏死组(n=52)。采用单因素分析和多因素logistic回归分析筛选CT预测AMI继发性肠坏死的独立因素,并建立联合模型,绘制受试者工作特征(ROC)曲线,评估其单一CT参数及联合模型预测AMI继发性肠坏死的效能,计算其曲线下面积(AUC)。结果 组间血管狭窄或闭塞、肠壁积气、肠系膜静脉积气、"缆绳征"及肠壁异常强化差异均有统计学意义(P均＜0.05)。CT所示肠系膜血管3级及以下分支狭窄或闭塞、肠壁积气和肠系膜静脉积气为预测AMI继发性肠坏死的独立预测因素(P均＜0.05);其预测AMI继发性肠坏死的AUC分别为0.66、0.73及0.72,联合模型的AUC为0.89。结论 CT对于预测AMI继发性肠坏死具有一定临床应用价值。     

3.0T无对比剂MR冠状动脉造影图像质量的影响因素

目的 分析影响3.0T无对比剂MR冠状动脉造影（MRCA）图像质量的因素。方法 前瞻性对170例疑诊冠状动脉疾病患者行3.0T全心无对比剂MRCA检查，针对冠状动脉主要分支包括左前降支（LAD）、左回旋支（LCX）及右冠状动脉（RCA）进行主观评分，计算其信噪比（SNR）；根据3支总得分将图像分为优、良、中或差；采用单因素分析及有序logistic回归分析筛选MRCA图像质量的影响因素。观察回归分析结果显示差异有统计学意义的参数与MRCA图像质量的相关性，并以受试者工作特征（ROC）曲线分析其评估图像质量的效能。结果 MRCA主观评分结果为优、良、中（以上可用于诊断）及差者（不可用于诊断）分别为36、46、57及31例；其间LAD、LCX及RCA的SNR总体差异具有统计学意义（P均<0.01）。患者体质量指数（BMI）（OR=0.64）、心率（OR=0.96），以及采集效率（OR=1.06）和体位（OR=0.33）均为MRCA图像质量的影响因素（P均<0.05），且均与图像质量评分相关（r=－0.604、－0.250、0.500、0.407，P均<0.001）；分别以≤25.5 kg/m²、≤70次/分、≥37%及手下摆为阈值，BMI、心率、采集效率及手上举或下摆判断MRCA图像可否用于诊断的曲线下面积（AUC）为0.802、0.704、0.955及0.686。结论 患者BMI、心率，以及采集效率和体位为3.0T无对比剂MRCA图像质量的影响因素。     

钙化斑块特征预测经皮冠状动脉介入治疗术中旋磨

目的 探讨钙化斑块特征预测经皮冠状动脉介入治疗（PCI）术中是否需要旋磨的可行性。方法 对157例有症状并先后接受冠状动脉CT血管成像（CCTA）、冠状动脉造影及血管内超声检查（IVUS）的疑诊冠心病患者（224个靶血管病变）均成功实施PCI，观察钙化斑块特征可否预测PCI术中旋磨。结果 24例（28个靶血管病变）PCI术中实施旋磨，133例（196个靶血管病变）未旋磨，前者SYNTAX积分更高（P=0.02），且在血管水平及病变水平上具有更高的Agatston钙化积分（P<0.01）。病变处钙化积分≥313、管腔狭窄率≥75%及钙化弧度≥270°提示需要旋磨。校正后，病变处钙化积分[OR=1.03，95%CI（1.015，1.053），P<0.001）及钙化弧度≥270°[OR=1.17，95%CI（1.025，1.231），P<0.001）是需要旋磨的独立预测因子。结论 CT所示钙化积分及弧度分级是对钙化病变进行旋磨的独立预测因子。     

Changes in the way diagnostic coronary arteriography is performed due to the interventional prospect: the clinical impact

Our study was aimed at assessing whether diagnostic coronary angiography has changed in the interventional era. We have studied consecutive 1073 patients with coronary artery disease that was detected by a first angiographic study 2 years prior to (group 1: 545 patients) and after (group 2: 528 patients) the start of an interventional cardiology program in our catheterization laboratory. Radiological data and the use of intracoronary nitrates were recorded as well as demographic data and angiographic results. Pre- and post-interventional era comparison demonstrated: a significant increase in cranial, caudal and left anterior oblique angles, 19.3 degrees +/- 14.8 degrees vs. 24.3 degrees +/- 15.4 degrees, -18.4 degrees +/- 17.4 degrees vs. -23.3 degrees +/- 13.9 degrees, and 29.0 degrees +/- 23.3 degrees vs. 36.2 degrees +/- 25.4 degrees, respectively; a decrease in mean number of angiographic views and mean fluoroscopy time, 9.5 degrees +/- 1.6 degrees vs. 8.9 degrees +/- 1.8 degrees (p = 0.04) and 4.1 +/- 4.2 vs. 3.6 +/- 3.2 min (p = 0.008), respectively. The percentage of patients with normal coronary arteries on coronary arteriography decreased from 9.78 to 8.07% in the pre- and post-interventional era comparison. The way coronary arteriography is performed has changed, thanks to the new interventional attitude of invasive cardiologists. Trainees and young fellows should be trained right from the start of their fellowship to assess coronary artery disease from an interventional point of view.     

冠状动脉造影对心肌桥的检测及临床意义

目的 探讨冠脉造影中心肌桥的检出率及其临床意义。 方法 根据冠状动脉造影显示冠状动脉管腔收缩期狭窄判定心肌桥，并根据收缩期狭窄程度分为3级。 结果 1447例行冠状动脉造影的患者中共检出心肌桥10例，检出率2．2％，全部位于左前降支。2例在心肌桥近端有粥样硬化病变，管腔固定狭窄达70％以上，置入支架。其他有症状病例经药物治疗，临床症状消失。 结论 冠状动脉造影时收缩期狭窄是判定心肌桥的惟一依据，心肌桥可导致缺血性心脏事件，对有缺血症状者应予适当治疗。     

Successful implantation of a coronary sinus lead after stenting of a coronary vein stenosis

Dislodgment of the coronary sinus lead was observed in a 79-year-old patient 8 months after implantation of a biventricular pacing system. A severe stenosis in the posterolateral branch, in which the lead was previously positioned, prohibited reinsertion of the lead. Because no other branches with adequate anatomy for lead insertion were available in the targeted area, the stenosis was dilated and stented. Subsequently, the left ventricular lead could be reimplanted in the same vessel.     

Echocardiographic Diagnosis of a Right Coronary Artery-Coronary Sinus Fistula

In this case report, we describe a 67-year-old woman with right coronary artery-coronary sinus fistula. This woman had complaints of chest pain. Ischemic ECG changes and a ventricular tachycardia were detected on her electrocardiogram. Transthoracic echocardiography showed a large right coronary artery and a dilated coronary sinus. Drainage of the coronary artery to the coronary sinus was detected by colour flow mapping during transesophageal echocardiographic examination, and a 94 mmHg peak gradient was recorded by continuous wave Doppler at the drainage site. These findings were confirmed by cardiac catheterization. Transthoracic and transesophageal echocardiography can provide definitive confirmation of the right coronary artery-coronary sinus fistula, and can be the diagnostic procedure of choice when this anomaly is suspected.     

老年冠心病及血运重建对QT离散度的影响

目的 观察老年冠心病患者经皮冠状动脉介入治疗(PCI)术前后QT离散度(QTd)的变化特点与趋势,并与正常对照组进行对比,探讨QTd与冠状动脉狭窄程度和范围的关系及经皮冠状动脉腔内成形术和PCI对其的影响,以期为临床寻找一种评价PCI术预后的有效无创方法.方法 已行冠状动脉造影术的≥60岁冠心病患者679例,分为冠心病组(经冠状动脉造影证实有单支或多支病变,狭窄程度≥50％)536例.对照组(同期住院冠状动脉造影狭窄程度＜50％)143例.术前分别描记两组的常规12导联心电图,测量QTd、校正QT离散度(QTcd).经冠状动脉造影证实狭窄程度≥75％的393例冠心病患者行PCI术,并再分为3个亚组:单支病变组176例,双支病变组118例,3支病变组99例.对照组:同期住院冠状动脉造影狭窄程度＜50％患者143例.PCI各组术前、术后1天、7天,分别检测QTd、QTcd,进行比较.结果 冠心病组胆红素明显低于对照组(P＜0.01).冠心病组的总胆固醇 (TC)、低密度脂蛋白胆固醇(LDL-C)和血尿酸明显高于对照组(P＜0.01),QTd和QTcd明显比对照组延长(P＜0.01),冠心病3个亚组的QTd和QTcd在术前、术后1天和术后7天均呈逐渐下降趋势,3个亚组在组间、不同时点以及组间和不同时点的交互作用中差异均有统计学意义.单支病变组术前QTd(48.52±12.35)ms,术后1天(41.23±13.35) ms,术后7天(41.12±12.61) ms,术前QTcd(55.34±15.81)ms,术后1天(48.62±14.93) ms,术后7天(48.23±13.65) ms;双支病变组术前QTd(53.26±16.95) ms,术后1天(44.54±14.63)ms,术后7天(43.96±15.32) ms,术前QTcd(59.41±16.72)ms,术后1天(50.35±15.43) ms,术后7天(49.94±15.35)ms;3支病变组术前QTd(58.43±13.72) ms,术后1天(52.82±13.66)ms,术后7天(52.76±13.32)ms,术前QTcd(65.91±18.53)ms,术后1天(60.21±16.38) ms,术后7天(60.19±15.74) ms.结论 QTd、QTcd在冠心病患者明显升高,PCI术后明显降低,并与冠状动脉狭窄的程度和范围有关.说明QTd、QTcd可以作为临床上预测心肌缺血,评估PCI术后预后的有效无创指标.     

冠状动脉介入治疗后痉挛的原因分析及护理对策

回顾分析了2003年1月-2005年1月行冠状动脉支架植入术后4例发生冠状动脉痉挛的原因,认为可能与血管的狭窄、术中造影剂或机械刺激、精神紧张等因素有关。针对冠状动脉支架植入术后发生冠状动脉痉挛的时间和规律,认真做好术前评估,尤其是高危患健康教育和心理护理,术后严格床头交接班,了解介入治疗血管及未治疗血管狭窄的情况．并对患发作冠状动脉痉挛时的心电图变化进行分析,加强围手术期的病情观察。     

Whole blood versus plasma measurements of glutamate and alanine across the human myocardium

Comparisons of whole blood and plasma aorto-coronary sinus concentration differences of glutamate and alanine were made before, during and after coronary sinus pacing in seven patients with normal and six patients with stenotic coronary arteries. Mean differences between duplicate analyses were greater in whole blood than plasma both of glutamate (7.5±5.8 vs. 3.3±3.0 μmol/l, p<0.001) and of alanine (7.9±7.0 vs. 3.8±3.4 μmol/l, p<0.001). Concentrations of glutamate were 3.4 and of alanine 1.4 times higher in whole blood than in plasma. Blood cells were calculated to be responsible for about 20% of glutamate and alanine blood exchanges across the heart. Plasma and whole blood fluxes were closely positively correlated (glutamate:r=0.81, alanine:r=0.88) and had always the same direction. Differences in myocardial exchanges of amino acids between the patients with and without coronary artery disease, as well as rapid changes during pacing, could be demonstrated in plasma analyses but were not significantly reflected in whole blood glutamate determinations. This seemed to be due to the greater variations in whole blood analysis. In conclusion, differences in aorto-coronary sinus plasma concentrations reflected, although underestimated, whole blood fluxes. Because of considerable gains in precision of analysis, plasma should be preferred to whole blood for evaluations of glutamate and alanine exchanges across the human heart.     

Revascularization strategies in patients with Type 2 diabetes mellitus

This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.