冠状动脉分叉病变介入治疗并发症防治进展

<正>冠状动脉分叉处由于受血液涡流及剪切力的影响,发生动脉粥样硬化的风险显著增加,可累及冠状动脉主支和(或)分支血管,约占经皮冠状动脉介入治疗(PCI)的15%左右[1]。冠状动脉分叉病变(简称分叉病变)的介入治疗难度大,并发症发生率较高且具有一定特殊性[2]。因此,对分叉病变各种介入治疗并发症的快速识别并予以及时处理,是提高手术成功率、降低病死率及改善患者预后的关键。     

冠状动脉造影三维重建评估分叉角度对冠状动脉分叉病变介入治疗中分支血管闭塞的影响

目的:利用三维冠状动脉造影定量分析(3D-QCA)探讨分叉角度对冠状动脉分叉病变介入治疗中分支血管闭塞的影响。方法:收集从2012年1月至2012年3月间在阜外医院接受经皮冠状动脉介入治疗(PCI)的冠状动脉分叉病变患者176例,利用3D-QCA对分叉角度等分叉病变的相关参数进行分析。以所得血管分叉角度的中位数(49°)作为分界点,将所有患者分为两组:低角度组(≤49°,n=93)和高角度组(>49°,n=83)。分析两组患者分支血管的闭塞率,并通过多因素Logistic回归分析评价血管分叉角度对冠状动脉分叉病变介入治疗中分支血管闭塞的影响。结果:在176例分叉病变的介入治疗中,有8例(4.5%)出现分支血管闭塞。分支血管闭塞的发生率在高角度组明显大于低角度组(8.4%vs 1.1%,P=0.019)。随着血管分叉角度逐渐增大,分支血管闭塞发生率逐渐增高,第1四分位内为0%,第2四分位内为2.5%,第3四分位内为7.0%,第4四分位内为8.7%(P=0.027)。多因素Logistic回归分析显示,3D-QCA计算所得血管分叉角度大是分支血管闭塞的独立危险因素(OR=1.13,95%CI:1.005~1.271,P=0.041)。结论:3D-QCA证实,高血管分叉角度是主支血管支架置入后分支血管闭塞的独立预测因素。     

冠状动脉分叉病变介入治疗中分支血管闭塞风险评估

<正>冠状动脉分叉病变是经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)中的常见病变,约占PCI治疗总量的15%~20%[1]。冠心病分叉病变介入治疗对术者技术要求高,介入治疗所需时间长,且介入治疗过程中的分支血管闭塞等导致严重后果。冠心病分叉病变介入治疗过程中的分支血管闭塞发生率约为6%~19%[2~4]。分支血管闭塞会引起心     

应用双药物洗脱支架治疗分叉病变的近远期临床疗效

目的探讨应用双药物洗脱支架（DES）治疗分叉病变的临床疗效。方法选择分支开口有严重狭窄且分支口径≥2．50mm的分叉病变患者为本研究的入选对象。2003年10月至2005年6月共入选应用双DES治疗分叉病变的患者112例,113处病变。分叉病变的类型为前降支／对角支62例（54．9％）,左冠状动脉主干分叉病变32例（28．3％）,回旋支／钝缘支18例（15．9％）,右冠状动脉远端分叉病变1例。113处分叉病变中采用Crush技术64处,“T”型支架置入27处;改良“Y”型支架置入11处;对吻支架置入5处;“V”型支架置入和Culotte技术置入各3处。结果入选112例患者113处分叉病变中（226处病变）使用Cypher或Cypher select DES 91个,TAXUS DES 74个,Firebird DES 67个。64处分叉病变采用Crush技术置入双支架后60处（93．7％）完成了最后的对吻球囊扩张技术。手术成功率为100％。住院期间1例发生亚急性血栓致急性心肌梗死（AMI）,再次介入治疗成功。住院期间心脏事件发生率（MACE,包括死亡、AMI、再次血管重建）为0．89％（1／112）。112例均完成了9个月的临床随访,无死亡发生,1例发生AMI由晚期血栓形成所致。48例完成了9个月的冠状动脉造影随访（42．9％）,8例发生了支架内再狭窄,其中1例进行了冠状动脉旁路移植术,5例再次行介入治疗,总再狭窄发生率为16．7％（8／48）。随访期间MACE发生率为8．04％（9／112）。结论本研究结果显示对于分支口径≥2．5mm且口部有严重狭窄性病变的分叉病变,采用双DES治疗是安全的,近、远期临床疗效是满意的。与Cypher DES相比较,TAXUS DES的再狭窄发生率有增加的趋势。     

冠状动脉分叉病变置入支架后分支狭窄率的变化

目的研究冠状动脉分叉病变的主支经支架治疗后分支闭塞的影响因素。方法回顾性分析2005年9月至2006年1月在我院接受经皮冠状动脉介入治疗(PCI)的92例患者共121处分叉病变,术后进行定量血管造影分析,探讨分支闭塞的相关因素。结果分叉病变主支置入支架后,分支狭窄程度与分支自身的斑块负荷、分支参考直径、分叉角度、主支斑块负荷相关。其中,分支狭窄程度与分支和主支自身的斑块负荷呈正相关,与分叉角度、分支直径呈负相关。逐步回归分析显示:Y=0.48A-11.4B-0.23C 0.22D(Y:主支支架术后分支面积狭窄率,单位:%;A:分支狭窄率;B:分支参考直径;C:分叉角度;D:主支狭窄率)。结论分叉病变置入支架后分支狭窄程度与分支自身的斑块负荷、分支参考直径、分叉角度以及主支斑块负荷相关。分支自身的病变越重、分支越小、分叉角度越小及主支的病变越重,介入治疗后分支闭塞的可能性越大。     

直径分型法及其指导下的冠状动脉分叉病变介入治疗临床观察

目的探讨冠状动脉分叉主支与分支血管的直径关系并提出一种新的分型方法——直径分型法,进而采用直径分型法指导术式选择并观察介入治疗效果。方法入选2011年3月~2015年4月中国部分北方地区包括北京军区总医院在内的5个心脏中心冠状动脉造影或支架术中观察的361例1080处冠状动脉分叉及分叉病变,于术中测量冠状动脉主支近段血管直径(Dp)、主支远段血管直径(Dd)及分支血管直径(Ds),记录所有直径≥2.5 mm的主支及边支血管情况,观察三者的直径关系及其出现的频次,分为4型,直径分型法1型(ZJ1型):Dp=DdDs;直径分型法2型(ZJ2型):Dp=Dd=Ds;直径分型法3型(ZJ3型):Dp=Dd+Ds且Dd=Ds;直径分型法4型(ZJ4型):不符合上述分型条件者。其中189例冠脉分叉病变患者按照直径分型法进行了冠状动脉支架治疗,均采用了双支架策略。直径分型法1型采用DK mini-Crush支架术,直径分型法2型采用DK mini-Culotte支架术,直径分型法3型采用SKS/V支架术,观察3组术后1个月及1年的主要心脏不良事件(MACE)发生率,包括病死率、心肌梗死复发率、冠状动脉支架内血栓发生率及支架内再狭窄发生率。结果 361例患者1080处冠脉分叉及分叉病变按照直径分型法分型:ZJ1型病变469处(43.4%);ZJ2型病变305处(28.2%);ZJ3型病变248处(23%);ZJ4型病变58处(5.4%)。其中189例分叉病变患者行冠状动脉支架置入术,手术成功率为100%。随访结果显示,ZJ1型、ZJ2型、ZJ3型病变患者术后1个月三组MACE发生率分别为12.6%、5.4%、12.7%,其中病死率分别为2.3%、0%、2.1%;心肌梗死复发率分别为4.6%、3.6%、6.4%;支架内血栓发生率分别为3.4%、0%、2.1%;支架内再狭窄发生率分别为2.3%、1.8%、2.1%;术后1年三组MACE发生率分别为28.7%、23.6%、23.4%,其中死亡率分别为8.0%、9.1%、6.4%;心肌梗死复发率分别为10.3%、7.3%、8.5%;支架内血栓发生率分别为4.6%、3.6%、4.3%;支架内再狭窄发生率分别为5.7%、3.6%、4.3%。结论直径分型法简便、直观、操作性强,指导冠状动脉介入术式选择随访心脏事件发生率低,对于分叉病变的介入治疗具有临床意义。     

冠心病分叉病变介入治疗中边支闭塞的预防及处理

目的分析冠心病介入治疗中边支闭塞发生机制,并探讨其预防处理方法。方法回顾性分析1999年~2004年350例冠心病分叉病变患者行介入治疗后并发边支闭塞的原因和处理过程。结果在350例冠心病分叉病变中共有53例术中发生边支闭塞,发生率为15.1%。分叉病变部位:前降支和对角支处分叉病变29例,回旋支和钝缘支处分叉病变16例,左心室后侧支与后降支处分叉病变8例。闭塞边支血管直径<2mm 15例;直径2~2.5mm 20例;直径>2.5mm 18例。分叉病变类型Ⅰ型2例;Ⅱ型12例;Ⅲ型39例。其中16例仅行药物治疗(闭塞边支血管直径<2mm),14例行边支球囊扩张术,23例行边支支架置入术。术中1例发生急性左心功能衰竭,1例出现心源性休克。住院期间非Q波心肌梗死18例,Q波心肌梗死1例。无死亡、急诊冠状动脉旁路移植术(CABG)等其它并发症。结论冠心病分叉病变介入治疗中边支闭塞较为常见,其发生率约为15.1%,以Ⅲ型分叉病变多见。常见原因为斑块移位、痉挛、血栓形成等所致。细小分叉病变可不必处理或予药物治疗,大的分支应积极介入治疗。     

冠状动脉分叉病变介入治疗策略

<正>冠状动脉分叉病变,是指冠状动脉狭窄毗邻和(或)累及重要分支血管的开口。血管分叉处由于血流涡流及切变力的增加,容易发生动脉粥样硬化。分叉病变占所有介入治疗的8%～20%。分叉病变分型的不同,决定了介入治疗策略选择和技术应用有所不同。     

根据冠状动脉分支参考直径和病变对称性评价分叉病变的价值研究

目的探讨具有介入操作指导意义的冠状动脉分叉病变分型方法。方法根据冠状动脉分支参考直径和病变对称性对分叉病变进行分型,并在此基础上设计介入治疗原则。(1)首先根据分支参考直径将分叉病变分为分支对等型和分支优势型。(2)然后根据分叉处病变是否对称分为对称型和非对称型两个亚类。(3)对于分支优势型非对称分叉病变再根据病变部位分为A、B两个亚型。(4)对等对称型分叉病变原则上采用双支架术,全部对吻扩张;其他类型原则上采用单支架术,非支架分支开口70%残余狭窄者对吻扩张。结果按照新分型法的使用时间将连续300例老年冠心病分叉病变分为传统分型组(Lefevre组)和新分型组(ERDALS组)各150例,两组手术成功率都是100%,与Lefevre组相比,分叉病变支架使用率(1.2%比1.5%)、双支架率(23.3%比52%)、操作时间(15.3min比21.6min)和随访心脏事件率(1.3%比3.3%)明显优于Lefevre组(P0.05)。结论按照分支参考直径和病变对称性设计分叉病变分型法具有简便、直观、系统和操作性强的优点,对临床介入治疗具有指导意义。     

国产雷帕霉素药物洗脱支架在冠状动脉分叉病变介入治疗中的应用

目的探讨国产雷帕霉素药物洗脱支架[DE(SFirebirdTM)]在冠状动脉分叉病变介入治疗中应用的安全性和有效性。方法对47例冠心病患者的53处冠状动脉分叉病变行介入治疗,共置入FirebirdTM68枚。结果46例介入治疗成功,失败1例。分叉病变部位:左主干远端前降支和回旋支分叉病变2处,前降支和对角支分叉病变23处,回旋支和钝缘支分叉病变17处,左心室后侧支和后降支11处。术中发生边支血管闭塞4例,边支血管狭窄加重6例,边支血管发生慢血流3例。住院期间发生急性非ST段抬高型心肌梗死3例,ST段抬高型心肌梗死1例,心绞痛5例,1例于术后2天死于心源性休克。随访6个月,7例复发心绞痛而再次住院治疗,无其余主要不良心脏事件发生。结论DE(SFirebirdTM)在冠状动脉分叉病变介入治疗中应用是可行、安全有效的。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.