单导管射频消蚀预激综合征患者的左侧旁路

以单导管法对3例体表心电图有delta波的预激综合征患者行射频消蚀。据心电图定位旁路后,将一根消蚀导管经右股动脉插入左室,在二尖瓣环左室侧标测到旁路电位后以该导管放电,全部成功。平均放电5次,平均操作时程1.3小时。本观察提示,单导管是消蚀部分显性预激患者房室旁路的简便、安全和有效的方法。     

射频消蚀房室旁路治疗预激综合症

17例预激综合症共17条房室旁路(其中左侧12条、右侧5条)行射频消蚀术。2例并有房室结双径路。12例左侧分路和1例右侧旁路消蚀成功(成功率77％)。1例随访6个月时心动过速复发(1／13)。第二次消蚀后出现3°房室阻滞。射频消蚀旁路是治疗房室折返性心动过速的有效方法．今后应加强对右侧旁路消蚀的研究。     

射频消蚀治疗老年室上性心动过速2例报告

射频消蚀治疗老年室上性心动过速２例报告郭兴城，李占全，彭云龙，毛文珍，胡芯茹，赵晓君，顾东红（辽宁省人民医院沈阳１１００１５）我们应用经皮穿刺心腔内电极导管射频电消蚀（ＲＦＣＡ）成功地阻断了１例隐匿性左后厕房室旁路（左侧旁路）所致的折返性室上性心动过...     

射频消蚀右侧房室旁路的体会

以导管射频消蚀右侧房室旁路患者２２例，占同期消蚀旁路总数的２２％；其中包括显性者１３例（５９％），隐性者９例（４１％）。２例合并有Ｍａｈａｉｍ氏束，１例合并有隐性左侧旁路。全部消蚀成功，随访１～１１个月，３例复发（１４％），均已再次消蚀成功。我们认为准确的旁路定位及消蚀导管与靶组织的接触是成功的关键。     

561例快速心律失常射频消蚀经验

对５６１例快速心律失常患者进行射频导管消蚀治疗，其中房室旁路折返性心动过速（ＡＶＲＴ）４１３例（４２９条旁路），房室结折返性心动过速（ＡＶＮＲＴ）１４２例，房性心动过速３例，心房扑动２例，心脏正常的室性心动过速１例。显性旁路消蚀成功靶点心电图特征为：ＡＶ≤４０ｍｓ，Ｖ波较体表心电图最早的ｄｅｌｔａ波提前≥２０ｍｓ，Ａ／Ｖ＜１。隐匿旁路成功的靶点心电图特征为：心室起搏时ＶＡ≤４０ｍｓ，Ａ／Ｖ＜１。对左前旁路患者、合并主动脉瓣狭窄者、动脉迂曲的老年人或需同时行二尖瓣球囊扩张术者，导管经股动脉逆行放入左室不易到位，可采用房间隔穿刺法，本组６例均获成功。房室结改良患者采用下位法较后位法消蚀的平均放电次数、时间及操作时间均少（Ｐ值＜０．０５）。本组２例（０．４％）发生三度房室传导阻滞，置入永久性心脏起搏器。平均随访６．１±４．９个月，１４例（２．６％）复发，均再次消蚀成功。     

房室旁路射频消融后心脏复极改变

目的 :旨在评价房室旁路射频消融后心脏的复极改变情况及其特征。方法 :回顾性分析 132例房室旁路射频消融术后体表心电图 T波改变情况。结果 :80例隐匿性旁路在射频消融术后无 1例出现心脏复极改变 ,5 2例显性旁路中有 2 0例 （占 39% ）术后出现明显 T波变化 ,其中完全性旁路 （QRS≥ 0 .14s）占 19例 ,而不完全性旁路 （QRS<0 .14s）仅占 1例。室间隔部的旁路更易出现术后复极异常。结论 :显性房室旁路消融术后可以出现酷似心肌缺血的 T波改变     

S预激综合征对心室除极终末向量的影响

目的 对87例显性房室旁路及26例隐匿性房室旁路患者导管射频消融术前后体表心电图QRS波终末40ms的向量变化进行分析，探讨预激综合征对心室除极终末向量的影响。方法 选择经射频消融术证实的显性单房室旁路87例及隐匿性单房室旁路26例患者，经临床常规检查无器质性心脏病。将房室旁路分为间隔、左后游离壁、左前游离壁、右后游离壁及右前游离壁房室旁路。结果87例显性房室旁路中的72例患者导管射频消融术后终末向量发生改变，15例无变化，26例隐匿房室旁路中的2例患者导管射频消融术后终末向量发生改变，24倒无变化，显性房室旁路与隐匿房室旁路相比差异有显著性(P<0．05)，不同部位间的显性房室旁路相比差异无显著性(P>0．05)，显性房室旁路终末向量的变化特点具有导联的特异性，后间隔房室旁路主要表现Ⅱ、Ⅲ、aVF导联S波变浅或消失及V2～V4导联原有S波加深或新出现S波，中间隔房室旁路表现V2～V4导联原有S波加深或新出现S波，前间隔房室旁路表现Ⅰ、aVI，导联新出现S波及V4导联原有S渡加深，左后游离壁房室旁路表现Ⅰ、aVL导联新出现S波及V1～V4导联原有S波加深或新出现S波，左前游离壁房室旁路表现Ⅰ、Ⅱ．aVF导联波变浅或消失及V1～V4导联原有S波加深或新出现S波，右后游离壁房室旁路表现V2～V4导联原有S波加深或新出现S波，右前游离壁房室旁路表现口Ⅱ、Ⅲ、aVF导联S波加深及V4导联S波加探或新出现S波。结论任何部位显性房室旁路均可引起QRS波终末向量的改变，这种改变有导联的特异性。提示预激综合征不但影响QRS起始向量的改变，也可导致QRS终末向量的改变。     

射频消融位于冠状静脉窦憩室处的后间隔房室旁路

目的报道５例冠状静脉窦憩室处后间隔房室旁路的射频消融结果。方法对５例后间隔显性房室旁路患者进行电生理检查和射频消融术。术后冠状动脉造影,以观察冠状静脉窦形态。结果所有患者的冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁路。成功靶点图：心室激动较体表心电图Δ波提前（３１±３．７）ｍｓ,其中４例患者伴有旁路电位。结论冠状静脉窦憩室与后间隔旁路存在着解剖关系。术中冠状静脉窦造影检查有助于发现憩室和确定有效的消融部位。     

左侧隐匿性房室旁路靶点局部慢电位的临床意义

目的 在射频消融左侧隐匿性房室旁路部分病例的靶点图中发现存在提前于常规心电图QRS波的局部低振幅慢电位,本文旨在探讨该电位在隐匿性旁路消融靶点中出现的可能原因、隐匿性旁路隐匿性前传的可能机制及临床意义。方法2000年1月～6月经二尖瓣瓣下成功射频消融的46例左侧隐匿性旁路,以 200mm/s描记速度分析射频消融术前、术后窦性心律和术前成功靶点的心室起搏与心动过速时心内电图,尤其注意分析窦性心律时成功靶点心内电图在射频消融术前与术后的区别与特点,以及心室起搏、心动过速时靶点电图与窦性心律时靶点电图的区别,并测量术前常规心电图QRS波最早起点至成功靶点V波起点之间的距离（QV间期）。结果46例患者中有16例（3.78％）术前存在提前于常规心电图QRS波的局部低振幅慢电位;QV间期为-5～-58ms,平均（-14.94±-13.40）ms。所有16例患者的这些局部低振幅慢电位在心室起搏和心动过速时不能显露,并在射频消融术后全部消失。结论 左侧隐匿性旁路部分病例的瓣下消融靶点存在提前于体表QRS波的低振幅慢电位,推测该电位可能为隐匿性房室旁路隐匿性前传所致;存在局部慢电位的靶点提示为有效的消融靶点。     

隐匿性房室旁路射频消融术后出现显性预激综合征二例

隐匿性房室旁路是指仅仅具有逆向传导功能的房室旁路,参与产生顺向型房室折返性心动过速,其电生理特点及消融治疗国内亦有报道[1].显性旁道因其前向传导在窦律下即可显示心室预激,但有部分间歇性房室旁路的前向传导表现为间歇性,当不显示前向传导时心电图完全正常[2,3].现报道2例隐匿性房室旁路治疗成功后再次出现显性预激综合征.     

BOOK REVIEWS

Book Reveiwed in this article:
Atrial-AV Nodal Electrophysiology: A View From the Millennium. Mazgalev and Tchou (eds).
Beating Heart Coronary Artery Surgery. Salerno, Ricci, Karamanoukian, D'Ancona, and Bergsland J (eds).
Cardiac Arrhythmias and Device Therapy: Results and Perspectives for the New Century. Ovsyshcher (ed).
Ventricular Fibrillation: A Pediatric Problem. (American Heart Association Monograph Series). Quan and Franklin (eds).
Practical Handbook of Advanced Interventional Cardiology. Nguyen (ed).     

Conservative valve surgery in endomyocardial fibrosis. Apropos of 8 cases among 46 surgically treated patients

The authors report their experience of conservative valvular surgery in endomyocardial fibrosis (EMF) (8 cases among 46 surgical cases). These patients were divided into 3 groups: Group I: bilateral EMF predominating on the left side with associated tricuspid involvement (n: 3). Group II: bilateral EMF predominating on the right side with moderate associated mitral involvement (n: 3). Group III: unilateral EMF with massive mitral insufficiency, (n: 2). At surgery, on the side of the conserved valve, the patients had a transvalvular endocardectomy (n: 3) and a valvuloplasty either tricuspid (n: 3) or mitral (n: 5). The results of the valvuloplasty were satisfactory. Two patients died in the post-operative period. Their death was unrelated with the conservative procedure. The authors study the literature concerning the cases of valvular conservative surgery in EMF (n: 4) and define the conditions under which this surgery can be done. They report 2 original cases of pure left sided limited EMF with massive mitral insufficiency successfully treated by a valvuloplasty.     

Presence of hepcidin-25 in biological fluids: Bile,ascitic and pleural fluids

AIM: To examine body fluids such as ascitic fluid (AF),saliva,bile and pleural effusions for the presence of hepcidin using a novel radioimmunoassay (RIA).METHODS: Serum samples were collected from 25 healthy volunteers (mean age: 36 ± 11.9 years,11 males,14 females).In addition bile was obtained from 12 patients undergoing endoscopic retrograde cholangiopancreatography (mean age: 66.9 ± 16.7 years,M:F = 5:7).Saliva was collected from 17 healthy volunteers (mean age: 35 ± 9.9 years,M:F = 8:9).Pleural and AF...     

Seroprevalence of herpes simplex virus type 2 antibodies in an STD clinic in Paris.

Our objective was to evaluate the seroprevalence of herpes simplex virus (HSV)-2 and HSV-1 in a population of men and women attending the STD clinic of H?pital St-Louis (Paris, France). Four hundred and eighty-seven patients (264 men and 223 women) were tested for HSV-2 and HSV-1 antibodies by specific enzyme immunoassay (EIA) (Smithkline-Beecham Biologicals). Univariate and multivariate analyses were carried out for correlations with clinical, socio-epidemiological and behavioural data. HSV-2 seroprevalence was 55% (44.7% in men, 67.3% in women). HSV-1 seroprevalence was 93% (94.7% in men, 91% in women). The predictive factors of HSV-2 seropositivity being female (OR: 3.37), age (OR: 1.04), country of origin (Central Africa OR: 3.52, North Africa OR: 1.36), history of genital herpes (OR: 10.97), hepatitis B virus (HBV) markers (OR: 1.92) and hepatitis C virus (HCV) markers (OR: 3.96). The only protective factor was HSV-1 seropositivity (OR: 0.25). The predictive factors of HSV-1 seropositivity were only the country of origin (Central Africa OR: 2.95, North Africa OR: 1.83) and the absence of genital herpes (OR: 11.01). Only 23 (8.6%) HSV-2 seropositive patients had a history of genital herpes. This study underlines the very high HSV-2 seroprevalence of patients with STDs, only a few of whom have a history of genital herpes. Detection and counselling is urgently needed for these patients.     

An index based on the age and free thyroxine rate predicts the likelihood of Graves' disease in hyperthyroidism]

PURPOSE: Graves' disease patients are generally younger and have more severe symptoms than other thyrotoxic patients. We established an index based on the normalized free thyroxine rate and age, capable of predicting Graves' disease in thyrotoxic patients. METHODS: The predictive index was established from a discriminant analysis from a retrospective population of 114 thyrotoxic patients and its predictivity was confirmed by cross-validation on the same population. RESULTS: The index IGD = 41.38 - age + 37.05 x in (normalized free T4) classifies accurately 80.7% of the patients (CI 95%: 72.2-87.5). Sensitivity is 78.5% (CI 95%: 66.5-87.7). Specificity is 83.7% (CI 95%: 70.3-92.7). Predictive positive value is 86.4% (CI 95%: 75.0-94.0). Negative predictive value is 74.5% (CI 95%: 61.0-85.3). Likelihood ratio of Graves' disease in case of prediction by the index is 4.81 (CI 95%: 2.66-9.32). Likelihood ratio of Graves' disease in case of non-prediction by the index is 0.26 (IC 95%: 0.16-0.40). CONCLUSION: A simple index based on the normalized free thyroxine rate and age provides an early diagnosis orientation toward Graves' disease in thyrotoxic patients who are waiting for complementary investigations.     

p27(Kip1) is an independent predictor of recurrence after surgical resection in patients with small hepatocellular carcinoma

BACKGROUND/AIMS: Alterations in p27(Kip1) (p27) and cyclin E (cycE) expression are found in tumors and are related to poor prognosis. This study assesses the role of these cell cycle regulators in the development of recurrence after surgical resection in 46 cirrhotic patients (age: 61.3+/-7 years, 30 males, 44 Child-Pugh's A, 30 HCV-positive) with small hepatocellular carcinoma (HCC, size: 3.1+/-1.5cm, 40 solitary at pathological examination). METHODS: p27 and cycE expression in tumoral and non-tumoral liver were analyzed by Western blot (WB). p27 was also assessed by immunohistochemistry (IHC). RESULTS: Tumor p27 underexpression (50% decreased vs. non-tumoral liver) occurred in 12 cases. Throughout follow-up, 26 patients developed recurrence, which was significantly higher in patients with p27 underexpression than in those without (3-year recurrence: 80 vs. 44%, respectively, P=0.026). IHC showed concordant inverse findings: 13 tumors showed high p27 staining that was related to lower recurrence rate (P=0.019). Multivariate analysis identified p27 measured by WB as an improved predictor of recurrence (OR: 3.09, 95% CI: 1.26-7.08, P=0.016). By contrast, cycE, increased in 66% of the tumors, had no impact on recurrence but was associated to poor differentiation (P=0.015) and microvascular invasion (P=0.016). CONCLUSIONS: p27 underexpression is frequent in relatively early stages of HCC and constitutes an independent predictor of recurrence after surgical resection.     

Evaluation of bone mineral density in hyperthyroid patients before and after medical therapy

Osteoporosis is a common complication of hyperthyroidism, but it is not often evaluated. The aim of this study is to examine bone mineral density (BMD) (dual energy X-ray absorptiometry: DEXA) in lumbar spine (L1-L4), femoral neck (FN) and Ward's triangle (TW) in 45 hyperthyroid patients (group A: n 25 active hyperthyroidism, group B: n 20 controlled hyperthyroidism on medical therapy, after a mean of 7 months of euthyroidism), compared to control group (group C: n 22). These 3 groups are adjusted by age, sex, menopausal status and BMI. In hyperthyroid patients (group A), as compared to the control group, we noticed a significant reduction of BMD (z score) in different sites, more markedly in the lumbar spine (p L1-L4: 0,005; p FN: 0,011; p TW: 0,019). In group A, no differences were found between BMD values after adjustment for Z score whatever the menopausal status (p L: 0.12; p FN: 0.33; p TW: 0.09) and degree ofhyperthyroidism (p L: 0.48; p FN: 0.41; p TW: 0.21). The degree of BMD in group B patients was different from that of patients in group A (p L: 0.37; p FN: 0.28; p TW: 0.31). and was significantly lower than in those of group C except for the TW (p L: 0.009; p CF: 0.038; p TW: 0.068). We conclude that it is important to consider that after reaching euthyroidism hyperthyroidism patients present a bone risk.     

Effects of chronic hyperglycaemia on incident stroke in Hong Kong Chinese patients with type 2 diabetes

BACKGROUND: It remains unclear whether hyperglycaemia as measured by HbA(1c) is a significant risk factor for stroke in patients with type 2 diabetes mellitus (T2DM). METHODS: A case-control study nested in a prospective cohort with 1 : 3 controls matched on age, gender, systolic blood pressure and low-density lipoprotein cholesterol (LDL-C) was conducted. The case group included 105 patients who developed incident stroke during 2.88 years (SD: 1.59) of follow-up of 4150 T2DM patients and 299 matched patients without incident stroke, used as the control group. Stratified Cox proportional hazard regression was used to obtain hazard ratio (HR). RESULTS: Median age was 71 years (IQR: 9.0 for the case and 10.0 for the control). HbA(1c) was significantly higher in the cases than in the controls (median 8.0% [IQR: 2.0] versus 7.2% [2.1], p < 0.0001). After controlling for smoker status, haematocrit, drug treatments and other covariates, 1% increase in HbA(1c) was associated with 1.49 (95% CI: 1.18-1.88, p = 0.0008) folds risk of occurrence of incident stroke. Patients with a history of coronary heart disease (CHD) were also at increased risk of stroke (HR: 8.25, 95% CI: 2.22-30.73, p = 0.0016). Smoker status and haematocrit were marginally significant predictors of incident stroke. Every adjusted month using lipid-lowering drugs was significantly associated with reduced risk of incident stroke (HR: 0.95, 95% CI: 0.90-0.99, p = 0.0199). Similar analysis using ACEI or ARB as a drug group was marginally significant (p = 0.0555). CONCLUSION: Chronic hyperglycaemia is a risk factor of stroke in Chinese patients with T2DM.     

Hemodialysis with 2.5 mEq/L of calcium in relative hypoparathyroidism: long-term effects on bone mass

Low PTH secretion is known to be associated with Adynamic Bone Disease (ABD). Positive balance calcium by CaCO3 or dialysate calcium (DCa) might play a role in the parathyroid gland suppression and a decrease in DCa to 2.5 mEq-l or lower has been proposed. The long-term effect of this procedure on bone mineral density (BMD) has not been established. The aim was to evaluate the effect of lowering dialysate calcium on bone mass in patients with relative hypoparathyroidism. We studied 20 patients with intact PTH below 120 pg/ml, using 3 mEq/l DCa and CaCO3 as sole phosphate binder. Sex: 10M/10F. Age: 57 +/- 13 yrs. Months on dialysis: 40 +/- 29. None of them had previous renal transplantation, parathyroidectomy nor aluminic toxicity. BMD of the lumbar spine was assessed by Quantitative Computed Tomography (QCT). They were randomized in two groups (GI and GII), with similar age, sex, and time on dialysis. There were no difference in BMD, levels of intact PTH, serum calcium, phosphate and AP (Alkaline Phosphatase) GI (n = 11; 5M/6F) was transferred to 2.5 mEq/l DCa and GII (n = 9; 5M/4F) continued using 3 mEq/l. BMD was measured one year later. Calcium, phosphate and AP were measured monthly and PTH every three months. After one year of hemodialysis with 2.5 mEq/l of calcium dialysate, BMD showed a significant reduction. BMD mg/cc Baseline (B): 146.09 +/- 54; Final (F): 125.42 +/- 54 (p < 0.01). Z-score B: 0.13 +/- 1.89; F: -0.68 +/- 1.89 (p < 0.05). GII did no show change. The mean change: GI: -15 +/- 13%, GII: 1.28 +/- 17% (p < 0.05); Z-Score GI: -0.81 +/- 0.92, GII: 0.27 +/- 0.67 (p < 0.01). A separate analysis of BMD in both sexes (GI) revealed a tendency for females to lose more bone mineral than males: F: = 17.12 +/- 7.1%. M: -12.23 +/- 18.6% (ns). GI: PTH and AP increased: PTH B: 38.75 +/- 41; F: 99 +/- 69 (p < 0.01); AP: B: 118.4 +/- 47; F: 152 +/- 38 (p < 0.01). GII: PTH B: 53.8 +/- 28; F: 79 +/- 5 (ns). AP: B: 125.1 +/- 36; F: 138 +/- 38 (ns). The rate of BMD loss inversely correlated with the increase of PTH (r = -0.61, p < 0.01). Serum calcium and phosphate did not change. In GI CaCO3 doses were: B: 332 +/- 261; F: 537 +/- 260 (as grams of element calcium, every three months, p < 0.01). By multiple lineal regression only delta PTH and DCa were predictors of greater BMD loss. In conclusion, the use of 2.5 mEq/l dialysate calcium resulted in: 1) Loss of trabecular vertebral bone mass. 2) Increase in PTH secretion and biochemical markers of bone formation. 3) A greater CaCO3 dose.     

Prognostic importance of cognitive impairment in chronic heart failure patients: Does specialist management make a difference?

BACKGROUND: Cognitive impairment is common among chronic heart failure (CHF) patients. AIMS: To determine the prognostic significance of cognitive impairment in patients participating in a randomized study of a CHF management program (CHF-MP). METHODS: CHF patients were randomized to a CHF-MP (n=100) or usual care (n=100). Baseline cognition was assessed using the Mini Mental Status Examination (MMSE). Five-year all-cause mortality, and combined death-or-readmission, were compared on the basis of the presence (MMSE 19-26) or absence (MMSE >26) of cognitive impairment. RESULTS: 27 patients (13.5%) had cognitive impairment and, on an adjusted basis, were more likely to die (96.3% versus 68.2%. RR 2.19, 95% CI 1.41 to 3.39: P<0.001) and/or experience an unplanned hospitalization (100% versus 94%. RR 1.44, 95% CI 1.06 to 1.95: P=0.019). Cognitively impaired patients had a similar (non-significant) adjusted risk of death-or-readmission in both the CHF-MP (RR 1.40, 95% CI 0.63 to 3.11: P=0.403) and in usual care (RR 1.38, 95% CI 0.75 to 2.53: P=0.305). In the usual care cohort, cognitive impairment was associated with a greater (non-significant), adjusted risk of death (RR 1.61, 95% CI 1.10 to 4.92: P=0.122). In the CHF-MP, adjusted risk of death was significantly higher for cognitively impaired patients (RR 2.33, 95% CI 1.10 to 4.92: P=0.027). CONCLUSION: These data suggest that "mild" cognitive impairment is of prognostic importance in CHF: even when a CHF-MP has been applied.