先心病介入封堵治疗的新进展

先天性心脏病的发病率为8‰～12‰,传统外科手术是主要的治疗方法。随着微创介入手术的飞速发展,先心病介入封堵治疗日益成熟,现就目前几种常见先心病的介入封堵治疗的新进展做一综述。     

Acquired Coronary Artery Disease in Patients with Congenital Heart Disease: Issues in Diagnosis and Management

Objective: Acquired coronary artery disease, initially thought to rarely affect survivors of congenital heart disease, is increasingly recognized in this population, as these patients grow in age and numbers in the recent era. This study reports our experience with coronary artery disease in adults with congenital heart disease and discusses treatment issues and the existing literature. Methods: Retrospective review of all charts of adults with congenital heart disease and acquired coronary artery disease was performed. Patients’ clinical characteristics, diagnosis, risk factors, noninvasive and invasive imaging and management data were recorded. Results: Coronary artery disease was diagnosed at 35–70 of age in 17 patients out of a total of 1345 adult congenital heart disease patients followed. Congenital heart disease was moderate or complex in 5 patients (4 repaired Tetralogy of Fallot, 1 repaired ventricular septal defect) and simple unrepaired atrial septal defect diagnosed later in life before or after coronary artery disease identi- fication in 12 patients. Coronary artery disease symptoms were present in 12 patients (8 myocardial infarctions, 4 exercise intolerance), while all patients had 2–3 risk factors for coronary artery disease. Coronary angiography showed 1–3 vessel disease treated with percutaneous coronary intervention in 7 patients, coronary artery bypass graft in 2 patients and both in 2 patients. Patients received appropriate medical therapy and remained stable for 1–17 years, while 2 patients are awaiting surgical pulmonary valve replacement in the near future. Conclusion: Coronary artery disease can develop in adults with congenital heart disease later in life in the presence of traditional risk factors, and prevention, screening and treatment strategies should be applied in this population. Further studies are needed to fully elucidate the extent of this issue in this increasing and ageing population and to determine its optimal medical, interventional and surgical management.     

245例冠状动脉造影在冠心病诊断中的价值

为了探讨冠状动脉造影在冠心病诊断中的价值，将245例选择性冠状动脉造形分为心肌梗塞组（101例）、心绞痛组（76例）、不典型心绞痛组（45例）和非冠心病组（23例）进行分析观察，其中224例有满意的左室造影可供分析。结果发现164树冠状动脉造影显示阳性改变，其利心肌梗塞组阳性率96．1%，心绞痛组71．1％，不典型心绞痛组28.9％，非冠心病组无一例阳性．共查出病变冠状动脉血管290支，依次分布于前降支130支、左回旋支80支、右冠状动脉67支、左冠状动脉主干13支．224例在室造影阳性表现为节段运动异常或室壁瘤，心肌梗塞组阳性率86．5％、心绞痛组55．2％、不典型心绞痛组34．1％、非冠心病组5％．结果提示冠状动脉造影仍是显示冠状动脉病变的最直接、有效的方法．     

早发冠心病患者危险因素与冠状动脉病变的关系

目的探讨早发冠心病患者吸烟与冠状动脉病变的关系及其意义。方法选取经冠状动脉造影确诊的PCAD患者270例,其中男性158例、女性112例,采集患者吸烟史（吸烟年数、每日吸烟支数）、血脂水平（HDL—C、LDL—C、TG、TC）,记录患者冠状动脉造影结果。同时进行相关性分析。结果吸烟指数与冠状动脉慢血流之间存在正相关（r=0．156,P〈0．05）;HDL—C与吸烟指数及Gensini积分均呈负相关（r=-0．136、-0．156,均P〈0．01）;吸烟指数与Gensini积分之间无线性相关关系（r=0．084,P〉0．05）。结论早发冠心病患者吸烟与HDL—C水平下降和冠状动脉慢血流现象相关。     

Multiple Coronary Artery Aneurysms of the Right Coronary Artery in Neonate with Pulmonary Atresia with Intact Ventricular Septum

Pulmonary atresia with intact ventricular septum (PA/IVS) with right ventricular‐dependent coronaries is a rare congenital cardiac anomaly. It has been associated with wide range of considerable anomalies including sinusoids, fistulae, coronary stenosis, or complete atresia. Coronary artery aneurysms in a neonate with PA/IVS have not been described. We report a case of neonate with pulmonary atresia with intact ventricular septum with giant coronary artery aneurysms.     

Echocardiographic Assessment of Conjoined Twins with Congenital Heart Disease in Shanghai

Background: The aim of this study is to improve the diagnosis of congenital heart disease in conjoined twins using echocardiography. Methods: Six sets of conjoined twins at Shanghai Children's Medical Center and Xin-Hua Hospital from 1980 to 2006 were assessed retrospectively. Cardiac anomalies of varying degrees of severity were first evaluated using 2D echocardiography. Tissue Doppler imaging (TDI) was then performed if fused ventricles were suspected. Peak systolic velocities, peak systolic strain rates, and peak systolic strains at the fused myocardium were quantitatively measured using strain rate imaging (SRI). If the M-mode echocardiographic image was poor or difficult to measure, the myocardial performance index (MPI) of the left ventricle was calculated. Results: Intracardiac anomalies were diagnosed correctly using echocardiography and confirmed by surgical findings. Cardiac functional assessment using MPI demonstrated heart failure in three out of the eight individuals. Subtle conjunction of the ventricles, however, were more difficult to visualize and two sets of conjoined twins with fused hearts could not be clearly demonstrated by echocardiography. In one case of suspected ventricular wall conjunction, TDI showed separate ventricular myocardia which was confirmed at surgery. Conclusions: Intracardiac anomalies and ventricular function can be readily demonstrated by echocardiography, but subtle conjunction of the ventricles may be more difficult to visualize. TDI may be required if there is uncertainty about the degree of cardiac fusion.     

Study of Coronary Artery Disease in Single Aortic Valvular Disease

Objectives To analyze the results of coronary angiographies (CAG) in patients with single aortic valvular heart disease; To study the relationship between aortic valve diseases and coronary artery disease (CAD). Methods 105 patients with single aortic valvular heart disease before surgery underwent angiography. The data of clinical characteristics and angiographies were analyzed. Results 51 patients had symptoms of angina pectoris among 105 patients with single aortic valvular heart disease. Seven of them were confirmed coronary artery disease by angiographies. Although the incidence of angina in aortic valve stenosis group was significantly higher than that in aortic valve regurgitation, the probability of combination of CAD in aortic valve stenosis group was similar to the later. However, the probability of combination of CAD in degenerative aortic valve group was significantly higher than the groups of rheumatic, congenitally bicuspid aortic valves, and other causes (p < 0.01 ). Conclusions Angina pe     

Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease

The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.     

Coronary Artery Disease Severity and Cardiovascular Biomarkers in Patients with Peripheral Artery Disease

Cardiovascular mortality in peripheral artery disease (PAD) patients is higher in critical limb ischemia (CLI) than in intermittent claudication (IC). We sought to evaluate differential characteristics of coronary artery disease (CAD) severity and prognostic biomarkers for cardiovascular events between CLI and IC patients. Coronary angiography was performed on 242 PAD patients (age 73 ± 8 years) with either CLI or IC. High-sensitivity troponin T (hs-TnT), eicosapentaenoic acid–arachidonic acid ratio (EPA/AA), and lipoprotein(a), as biomarkers for prognostic factors, were measured from blood samples. The study patients were divided into a CLI-group (n = 42) and IC-group (n = 200). The Gensini score as an indicator of coronary angiographic severity was higher in the CLI-group than in the IC-group (39.1 ± 31.2 vs. 8.5 ± 8.3, p < 0.0001). Hs-TnT and lipoprotein(a) values were higher in the CLI-group than in the IC-group (0.152 ± 0.186 ng/mL vs. 0.046 ± 0.091, p < 0.0001, 45.9 ± 23.3 mg/dL vs. 26.2 ± 27.7, p = 0.0002, respectively) and EPA/AA was lower in the CLI-group than in the IC-group (0.22 ± 0.11 vs. 0.38 ± 0.29, p = 0.0049, respectively). Greater CAD severity, higher hs-TnT, and lipoprotein(a), and lower EPA/AA were observed in the CLI-group, which may explain higher cardiovascular events in patients with CLI.     

稳定型冠心病合并高同型半胱氨酸血症人群冠脉病变特点分析

目的 研究稳定型冠心病合并高同型半胱氨酸血症(Hcy)人群冠脉病变特点。方法 106例稳定型冠心病依据血浆Hcy水平分为高Hcy组、正常Hcy组。两组性别、年龄、血压、血脂等临床基础情况具可比性,将冠脉造影图像采用直径法分析血管狭窄程度,以血管支数法和Gensis评分评价冠脉病变程度。结果 与正常Hcy组相比,高Hcy组在冠脉病变血管支数和Gensis评分方面均存在差异,表现为高Hcy组冠脉三支血管病变比例增高(34.48% vs 8.33%)、Gensis评分增高(37.82±8.29 vs 30.06±4.94), P< 0.05,差异具有统计学意义。且Hcy水平与冠脉病变血管支数、Gensis评分存在正相关关系(P< 0.05)。结论 在稳定型冠心病患者,高血浆Hcy可进一步影响冠脉病变的范围和严重程度。     

吸烟与男性早发冠心病的临床病因学的相关性研究

目的探讨吸烟与男性早发冠心病（PCAD）的关系。方法纳入270例经冠状动脉造影确诊为PCAD患者,其中男性组158例和女性组112例,对两组常见心血管危险因素（吸烟史、高血压、糖尿病、早发冠心病家族史、血脂异常等）进行分析。结果PCAD患者男性组和女性组平均年龄比较差异有统计学意义（P〈0．01）,男性组吸烟比例显著高于女性组,差异有统计学意义（P〈0．01）。两组间高血压、糖尿病、PCAD家族史无差异,但男性HDL-C（mg／d1）显著低于女性,差异有统计学意义（P〈0．01）。男性PCAD与吸烟呈正相关（OR=153．82,P〈0．01）,与HDL-C呈负相关（OR=0．95,P〈0．01）。结论男性PCAD的发病年龄早于女性,且与男性的吸烟和低HDL-C密切相关。     

女性冠心病危险因素分析

近年来,男性冠心病患者的病死率已呈下降趋势,而女性冠心病的病死率却仍在上升,因此针对女性冠心病的危险因素对其进行预防和控制十分紧迫。现综述女性冠心病的主要易患因素,尤其是与男性迥异之处。其中不可逆的危险因素包括:年龄、家族史、身高、出生体重;可逆的危险因素包括:高血压、糖尿病、吸烟、血脂异常、肥胖和体力活动减少、雌激素减少与激素替代治疗、铁过多、生育孩子的数目等。高敏C反应蛋白等可能是女性冠心病的风险标记物。     

Cardiac Catheterization and Selective Angiography in Infants with a New Flow-Directed Catheter

Preliminary experience with a new flow-directed pediatric anglography catheter in 35 infants indicates that catheterization of all cardiac chambers and both great vessels can be accomplished without risk of perforation or major arrhythmia. Antegrade access to the aorta from the left ventricle via the foramen ovale reduced the need for retrograde arterial catheterization. The maneuverability of this balloon-tipped catheter coupled with the ability to perform safely selective anglography at any site entered establishes a unique advantage over standard cardiac catheters now in use. The success with this catheter in performing right and left heart studies and the safety in its use promise to significantly reduce the risk of mechanical and angiographic accidents during the intracardiac investigation of critically ill Infants with congenital heart disease.     

Percutaneous Transfemoral Coronary Arteriography Without Systemic Anticoagulation—A Review of 648 Consecutive Procedures

Experience with 648 consecutive percutaneous transfemoral coronary arteriograms and left ventriculograms performed in a teaching laboratory without the use of systemic anticoagulation during the procedure was reviewed. Only 1 death was felt to be related to a procedure, and this occurred 3 weeks after a myocardial infarction. There were 10 myocardial infarctions or emboli, 8 cerebral vascular accidents, and 7 femoral artery complications. Only 1 patient experienced a residual neurologic change following a procedure-related cerebral vascular accident, and this was a mild visual field defect. Clotting of the catheter without sequelae but necessitating procedural changes occurred in 10 instances. The transient nature of the neurologic deficits and the low mortality suggest that the emboli which occurred in these patients were small, possibly platelet-fibrin accumulations. It is postulated that with the use of careful technic larger emboli capable of producing myocardial infarction with shock or disabling cerebral vascular accidents can be prevented, even in a training situation. However, smaller embolic phenomena probably cannot be completely avoided by the use of careful technic, and it is for prevention of small emboli that systemic anticoagulation with heparin may be of value.     

心电图对冠状动脉多支病变的预测作用

冠状动脉多支病变的患者心肌缺血范围广,心功能差,易出现心脏突发事件,预后不良。发掘冠脉多支病变与心电图之间的规律性关系,对于预测冠状动脉多支病变,积极干预,改善患者预后有重要作用。     

稳心颗粒治疗冠心病室性期前收缩的临床研究

目的研究稳心颗粒治疗冠心病室性期前收缩的临床疗效。方法将70例病人随机分为稳心颗粒组(治疗组)36例和心律平组(对照组)34例,两组均以4周为1个疗程,观察两组治疗前后综合临床疗效、心电图疗效、伴随症状改善情况、心功能改善情况及不良反应。结果治疗组总有效率为88.89%,明显优于对照组的61.76%(P<0.05),两组治疗后临床症状积分、心功能均较治疗前明显改善(P<0.05或P<0.01),且治疗组优于对照组(P<0.05或P<0.01)。结论稳心颗粒能改善冠心病室性期前收缩病人的症状及心功能,疗效显著,且不良反应发生率低。     

53例早发冠心病心血瘀阻证甲襞微循环的检测分析

目的探讨早发冠心病心血瘀阻证甲襞微循环变化的特点,为临床辨证提供依据。方法早发冠心病心血瘀阻证组53例,健康对照组66例,采用北京福凯公司生产的XTW—J微循环彩色显微分析仪,按田牛教授加权积分法计分设计,测定甲襞微循环指标。结果早发冠心病心血瘀阻证甲襞微循环与正常对照组比较,早发冠心病心血瘀阻证病人输出支管径与袢顶管径较大（P〈0.05）,而流速显著减慢（P〈0.01）;血管粗细不均、管袢畸形、红细胞聚集、渗出、出血、血色、乳头下静脉丛的积分显著高于对照组（P〈0.05或P〈0.01）。结论早发冠心病心血瘀阻证甲襞微循环的形态指标、流态指标、袢周指标都有一定程度改变,甲襞微循环检测为早发冠心病辨证提供了客观定量的指标。     

早发性冠心病患者脂蛋白(a)水平变化

观察较早发生的冠心病(CHD)患者的血清脂蛋白(a)[Lp(a)]水平变化.方法:用ELISA法测定经冠脉造影证实的185例CHD患者及31例对照(NS)Lp(a)水平.结果:(1)血清Lp(a)水平在185例CHD患者明显高于31例NS组(216.96±215.39比119.68±71.07mg/L,P<0.02).(2)CHD组中,血清Lp(a)水平,在80例<55岁比105例≥55岁者明显升高(252.86±253.77比189.61±177.24mg/P<0.05).结论:血清Lp(a)水平升高可能在较早发生的冠心病患者中更为明显.     

QT间期及其离散度与冠状动脉病变的关系

探讨心电图QT间期、QT离散度 (QTd)与冠状动脉病变及其程度和范围的关系。分析 138例行选择性冠状动脉造影病例的临床及心电图资料 ,观察不同程度和范围的冠状动脉病变对QT指标的影响。结果 :无冠状动脉狭窄病人的QTd为 42 .0± 18.2 4ms,单支病变组及多支病变组的QTd分别为 48.42± 17.11,5 9.15± 2 2 .75ms ,P均 <0 .0 5 ;轻度狭窄组及重度狭窄组的QTd分别为 48.6 7± 2 0 .45 ,5 8.12± 2 1.6 1ms ,P均 <0 .0 5。结论 :QTd延长有助于心肌缺血的诊断 ,并可能反映冠状动脉病变的范围及程度