Successful Coronary Artery Bypass in Ehlers-Danlos Type IV Syndrome Case Report and Review of the Literature

Atherosclerotic coronary artery occlusive disease is very rare in cases of Ehlers-Danlos type IV syndrome. We report what we believe is a unique case of successful coronary artery bypass grafting for atherosclerotic coronary artery disease in a patient with this syndrome and examine the possible implications for the natural progression of the disease through a review of the literature. Nevertheless, we reiterate previous investigators'' advice that any invasive procedure on these patients should be approached with extreme caution and that surgery should be performed as a last resort, considering the significantly elevated risks.Key words: Adult, atherosclerosis, coronary artery surgery, coronary artery disease, Ehlers-Danlos syndrome/classification/genetics/surgery, genetic predisposition to disease, male, vascular diseases/etiologyAtherosclerotic coronary artery occlusive disease is very rare in cases of Ehlers-Danlos type IV syndrome. We report what we believe is a unique case of successful coronary artery bypass grafting (CABG) for atherosclerotic coronary artery disease in an Ehlers-Danlos IV patient and examine the possible implications for the natural progression of Ehlers-Danlos IV—also called vascular Ehlers-Danlos syndrome (v-EDS)—through a review of the literature.     

急性冠状动脉综合征冠状循环炎症标记物的研究进展

炎症反应是导致动脉粥样硬化斑块破裂和血栓形成的重要因素,阐明刺激炎症发生的部位和炎性因子的来源对明确急性冠状动脉综合征的病理机制和有效的防治具有重要意义,对冠状循环内炎性标记物的研究新进展作一综述。     

经皮冠状动脉介入术对冠状动脉微循环的影响

目的分析经皮冠状动脉介入治疗术对冠状动脉微循环的影响。方法回顾性分析2013年1月~2014年12月本院收治的130例冠心病患者临床资料,患者均予以经皮冠状动脉介入术治疗,对比患者手术前后冠状动脉微循环阻力指数(IMR)与高敏C-反应蛋白水平(hs-CRP)。结果患者经皮冠状动脉球囊扩张(PTCA)及支架植入后IMR水平均高于术前,差异均有统计学意义(p0.05),但PTCA后与支架植入后无明显差异(p0.05);患者的股动脉、冠状窦hs-CRP水平在PTCA后与支架植入后均明显升高,前后对比差异有统计学意义(p0.05)。结论经皮冠状动脉介入治疗术可致冠心病患者术后IMR与hs-CRP水平升高,考虑与手术器械压迫冠状动脉血管壁致动脉粥样硬化斑块破裂及血管内皮损伤相关,从而导致冠状动脉的微循环障碍与炎症反应。     

温通煎能预防冠心病患者介入治疗后再狭窄

目的就如何利用中西医两种医学防治心血管病的优势,进一步提高临床疗效。从辨证与辨病、整体观念与综合调控治疗、传统中医理论和现代药理研究相结合等方面,寻找提高中医药防治临床心血管病疗效的具体方法和有效途径。方法500例冠心病介入性治疗后随机分为温通煎组250例,选用由制附子、山楂、决明子、丹参、水蛭、黄芪、麦门冬等组成的温通煎口服与常规温通煎组250例作对照,6个月后观察总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、体质指数、运动平板实验后心电图的变化,临床表现及是否有再狭窄或再堵塞。结果温通煎组与常规用药组血压、总胆固醇和甘油三酯无差异(P>0.05)。高密度和低密度脂蛋白胆固醇、体质指数和空腹血糖有差异(P<0.05)。温通煎组有13例未完成6个月的治疗;常规用药组有14例中途改用中药治疗,另有6例死亡。温通煎组运动平板试验5 min后感心前区不适(心前区闷痛)者11例,但心电图无病理性改变;常规用药组运动平板试验5 min后感心前区不适者46例,心电图S-T段水平压低者29例,斜下压低者12例,5例心电图未改变。经冠状动脉造影证实冠状动脉狭窄与上次比较加重20%以上者16例。温通煎组无再狭窄或再堵塞病例,明显优于常规用药组(P<0.05)。结论温通煎可以预防冠心病介入性治疗后再狭窄及再堵塞。并能调节冠心病人的脂质代谢紊乱,改善冠心病人介入治疗后的生活质量。     

冠状动脉介入治疗术中的微循环灌注及其检测手段

临床广泛应用的再灌注治疗评价指标主要针对的是心内膜下冠状动脉,近年来越来越多的证据表明,冠状动脉微循环在心肌的血供中起着重要作用。有些急性心肌梗死患者,虽然通过血流重建治疗使梗死相关冠脉开通。但由于相关的冠脉微循环出现微栓塞,使近远期心血管事件发生率和死亡率增加;相反,另外一些急性心肌梗死患者虽然相关冠脉仍闭塞,但其灌注区的心肌微循环却可通过侧支循环得到灌注,预后良好。因此越来越多的临床医生开始关注微循环的灌注,出现了一系列针对微循环的评价指标。但是目前的技术尚无法在人体内直接观察微血管,微血管血流的测定也非常复杂,现回顾和展望微循环灌注的检测手段以及应用。     

计算机断层摄影术冠状动脉造影诊断冠心病和评价冠状动脉病变的价值

目的:研究计算机断层摄影术冠状动脉(冠脉)造影(CTCA)在急性胸痛患者中诊断冠心病和评价冠脉病变程度的价值.方法:回顾性入选133例临床诊断为不稳定性心绞痛的急性胸痛患者,分别接受64排CTCA和冠脉造影检查.以定量冠脉造影(QCA)为诊断标准,评价CTCA诊断冠心病和冠脉病变程度的准确性.结果:CTCA诊断冠心病的敏感性93.4%,阳性预测值94.2%.Pearson相关分析示:CTCA和冠脉造影评价的冠脉直径狭窄程度显著相关(P<0.001).Logistic回归分析示,钙化程度是CTCA诊断冠心病敏感性的独立影响因素(RR=2.37,95%CI:1.35-4.18,P=0.003).ROC曲线分析显示,钙化积分对预测冠脉三支血管存在≥50%或≥75%狭窄有预测作用,P均<0.05.结论:CTCA在急性胸痛患者中对冠心病的筛查和冠脉病变程度的评价有较高价值.     

经皮冠状动脉内多普勒超声技术对冠状动脉血液动力学的研究

目的 :评价冠状动脉 (冠脉 )内多普勒血流钢丝测量冠脉血流速度和血流储备 (CFR)的应用价值。　　方法 :在 2 1例冠脉狭窄患者 (冠脉狭窄组 )和 12例正常冠脉者 (对照组 )中 ,利用冠脉内多普勒血流钢丝和冠脉内注射罂粟碱测量了冠脉的血流速度和 CFR。　　结果 :左前降支冠脉狭窄远端的平均最大血流速度、舒张期最大血流速度、舒张期与收缩期流速比值和 CFR均显著低于对照组测值。　　结论 :应用冠脉内多普勒超声技术可准确测量正常和冠脉狭窄患者的冠脉血流速度和 CFR,冠脉内注射罂粟碱安全、可靠 ,这一方法的临床应用对冠心病患者冠脉血液动力学的评价提供了可靠的方法。     

Coronary Stenting Without Predilatation in Acute Coronary Syndromes

We report on the procedural outcome in 30 patients with acute coronary syndromes in whom stent implantation was attempted without predilatation. Elective stent implantation in infarct related coronary arteries after myocardial infarction might be superior to agioptasty alone. We retrospectively analyzed the result from 88 patients who had stent implantation for myocardial infarction or unstable angina. In 30 of these patients we attempted to implant a stem without predilating the vessel. Successful stent deployment was possible in 26 (87%). In four patients where it was not possible to cross the lesion, we could withdraw the stent to predilate the lesion. We did not attempt direct stent implantation if the lesion was calcified, long, involved major side branches or a tortuous proximal segment, or where the length of the lesion and diameter of the distal vessel could not be measured. A low profile, premounted stent was used. Procedural success was 100% in the group of 30 patients with direct stent implantation— not significantly different from the 93% success in the group of 58 patients whose lesions were predilated first but had more complex lesions. The incidence of complications did not differ significantly between the two groups and no instances of stent loss or displacement occurred in the direct implantation group. Stent implantation without predilatation is feasible and not associated with a higher incidence of complications, provided lesions that allow easy positioning of the stent are selected. It can shorten the procedure and duration of ischemic occlusion of the vessel, which would be of particular advantage in unstable patients or where a large area of myocardium is jeopardized.     

Outcome of Coronary Bypass Surgery Versus Coronary Angioplasty in Diabetic Patients With Multivessel Coronary Artery Disease

Objectives. This study sought to compare the outcome of percutaneous transluminal coronary angioplasty (PTCA) (n = 834) and coronary artery bypass graft surgery (CABG) (n = 1805) in diabetic patients with multivessel coronary disease from an observational database.Background. There is concern about selection of revascularization in diabetic patients with multivessel coronary artery disease.Methods. Data were collected prospectively and entered into a computerized database. Follow-up was by letter or telephone or additional events resulting in readmission.Results. After CABG there were more in-hospital deaths (0.36% vs. 4.99%, p < 0.0001) and a trend toward more Q wave myocardial infarctions than after PTCA. Five- and 10-year survival rates were 78% and 45% after PTCA and 76% and 48% after CABG, respectively (p = 0.47). At 5 and 10 years, insulin-requiring patients had lower survival rates of 72% and 31% after PTCA and 70% and 48% after CABG, respectively (p = 0.54). Multivariate correlates of long-term mortality were older age, low left ventricular ejection fraction, heart failure and hypertension. In the total group, insulin requirement was a correlate of long-term mortality. For the total group, choice of therapy had a multivariate hazard ratio close to 1. In the insulin-requiring subgroup, the multivariate hazard ratio was 1.35 (95% confidence interval 1.01 to 1.79) for PTCA versus CABG. Corrected for baseline differences, 5- and 10-year survival rates were 68% and 36% after PTCA and 75% and 47% after CABG, respectively, in the insulin-requiring subgroup. Nonfatal events were more common after PTCA, especially additional revascularization.Conclusions. This study reveals a high incidence of events in diabetic patients and raises further questions about angioplasty in insulin-requiring diabetic patients with multivessel disease.     

冠状动脉内膜剥脱术在冠心病外科治疗中的运用

目的 探讨冠状动脉内膜剥脱术在冠心病外科治疗中的运用,评估其临床疗效。方法 19例冠心病患者接受非体外循环冠状动脉旁路移植术,术中运用冠状动脉内膜剥脱术,分析围手术期临床资料,中期随访不良事件的发生率,总结冠状动脉内膜剥脱术的技术要点。结果 19例病例术中共行冠状动脉内膜剥脱35处,其中前降支系统7支（37%,其中前降支5支、对角支2支）,回旋支系统2支（10%）,右冠状动脉系统10支（53%,其中主干4支、后降支6支）;4例患者同时行2支血管内膜剥脱。患者无围术期心肌梗死和手术死亡;中期随访无心绞痛发作,术后1年冠状动脉CTA提示所有吻合口通畅率为92.5%。结论 冠状动脉内膜剥脱术能安全、有效地实现冠状动脉完全再血管化,近中期效果满意,是治疗弥漫性冠状动脉病变的有效方法。     

Percutaneous Coronary Revascularization in Patients With Single Coronary Artery

IntroductionSingle coronary artery (SCA) is a rare congenital coronary anomaly. Its incidence in various angiographic series is from 0.024% to 0.066%. Percutaneous coronary intervention (PCI) of coronary artery disease (CAD) in these patients is technically challenging.MethodsWe retrospective analyzed the cardiac catheterization procedures of last 15 years and found 12 cases of SCA (incidence 0.084%). To determine the course of anomalous coronaries, angiographic “dot and eye” method and computed tomography (CT) were used. The course of the SCA was classified as per the modified Lipton criteria. PCI was performed as per the standard protocol for a significant epicardial coronary artery stenosis.ResultsOut of total 12 patients of SCA, 9 patients had PCI of significant CAD. The mean age of 9 PCI patients was 63.8 ± 8.2 years (5 males, 4 females). The origin of the SCA was from the right sinus of Valsalva in 6 cases and from left sinus of Valsalva in 3 cases. Eleven successful PCI procedures were performed, which included PCI of left main, coronary bifurcation lesion, chronic total occlusion, and multi-vessel disease. Four patients had intravascular imaging and 3 patients had rotablation of calcified lesions.ConclusionPCI of SCA is technically challenging, which requires considerable expertise and experience. An appropriate selection of hardware along with technical expertise can make the procedure simpler with optimal end results.     

Coronary CT Angiography in Heavily Calcified Coronary Arteries: Improvement of Coronary Lumen Visualization and Coronary Stenosis Assessment With Image Postprocessing Methods

To compare the diagnostic value of coronary CT angiography (CCTA) with use of 2 image postprocessing methods (CCTA_S) and (CCTA_OS) and original data (CCTA_O) for the assessment of heavily calcified plaques.Fifty patients (41 men, 9 women; mean age 61.9 years ± 9.1) with suspected coronary artery disease who underwent CCTA and invasive coronary angiography (ICA) examinations were included in the study. Image data were postprocessed with “sharpen” and smooth reconstruction algorithms in comparison with the original data without undergoing any image postprocessing to determine the effects on suppressing blooming artifacts due to heavy calcification in the coronary arteries. Minimal lumen diameter and degree of stenosis were measured and compared between CCTA_S, CCTA_OS, and CCTA_O with ICA as the reference method. The area under the curve (AUC) by receiver-operating characteristic curve analysis (ROC) was also compared among these 3 CCTA techniques.On a per-vessel assessment, the sensitivity, specificity, positive predictive value and negative predictive value, and 95% confidence interval (CI) were 100% (95% CI: 89%, 100%), 33% (95% CI: 22%, 45%), 41% (95% CI: 30%, 53%), 100% (95% CI: 85%, 100%) for CCTA_O, 94% (95% CI: 79%, 99%), 66% (95% CI: 54%, 77%), 57% (95% CI: 43%, 70%), and 95% (95% CI: 85%, 99%) for CCTA_S, 94% (95% CI: 79%, 99%), 44% (95% CI: 32%, 57%), 44% (95% CI: 32%, 57%), and 97% (95% CI: 79%, 99%) for CCTA_OS, respectively. The AUC by ROC curve analysis for CCTA_S showed significant improvement for detection of >50% coronary stenosis in left anterior descending coronary artery compared to that of CCTA_OS and CCTA_O methods (P < 0.05), with no significance differences for detection of coronary stenosis in the left circumflex and right coronary arteries (P > 0.05).CCTA with “sharpen” reconstruction reduces blooming artifacts from heavy calcification, thus, leading to significant improvement of specificity and positive predictive value of CCTA in patients with heavily calcified plaques. However, specificity is still moderate and additional functional imaging may be needed.     

杂交手术治疗多支冠状动脉疾病的研究进展

多支冠状动脉疾病显著影响冠心病患者的预后,但最佳血运重建策略尚不明确。杂交手术治疗多支冠状动脉疾病安全和可行,具有良好的短中期效果。深入探讨杂交手术的目标人群、疗效和不同手术策略特点,对冠心病患者的临床治疗很有必要。     

Efficacy of Coronary Stenting Versus Balloon Angioplasty in Small Coronary Arteries

Objectives. The goal of this study was to compare the efficacy of elective stent implantation and balloon angioplasty for new lesions in small coronary arteries.Background. Palmaz-Schatz stents have been designed and approved by the Food and Drug Administration for use in coronary arteries with diameters ≥3.0 mm. The efficacy of elective stent placement in smaller vessels has not been determined.Methods. By quantitative coronary angiography, 331 patients in the Stent Restenosis Study (STRESS) I–II were determined to have a reference vessel <3.0 mm in diameter. Of these, 163 patients were randomly assigned to stenting (mean diameter 2.69 ± 0.21 mm), and 168 patients were assigned to angioplasty (mean diameter 2.64 ± 0.24 mm). The primary end point was restenosis, defined as ≥50% diameter stenosis at 6-month follow-up angiography. Clinical event rates at 1 year were assessed.Results. Baseline clinical and angiographic characteristics were similar in the two groups. Procedural success was achieved in 100% of patients assigned to stenting and in 92% of patients assigned to angioplasty (p < 0.001). Abrupt closure within 30 days occurred in 3.6% of patients in both groups. Compared with angioplasty, stenting conferred a significantly larger postprocedural lumen diameter (2.26 vs. 1.80 mm, p < 0.001) and a larger lumen at 6 months (1.54 vs. 1.27 mm, p < 0.001). Restenosis (≥50% diameter stenosis at follow-up) occurred in 34% of patients assigned to stenting and in 55% of patients assigned to angioplasty (p < 0.001). At 1 year, event-free survival was achieved in 78% of the stent group and in 67% of the angioplasty group (p = 0.019).Conclusions. These findings suggest that elective stent placement provides superior angiographic and clinical outcomes than balloon angioplasty in vessels slightly smaller than 3 mm.