Effect of polymorphism and type II diabetes on aspirin resistance in patients with unstable coronary artery disease

Background  Aspirin is widely used in the secondary prevention of coronary artery diseases, including myocardial infarction, stroke, and vascular related deaths. However, the antiplatelet effect of aspirin appears to be variable and aspirin resistance (AR) is currently still controversial for Chinese patients. The aim of this study was to describe the prevalence of AR, and identify possible risk factors associated with a lack of response to aspirin treatments in patients with unstable coronary artery disease.

Methods  Platelet function tests with arachidonic acid (ARA) and urinary 11-dehydro-thromboxane B2 (11-DH-TXB2) concentrations were performed in 262 patients with unstable coronary artery disease who had not been taking aspirin before admission. ARA induced platelet aggregation and 11-DH-TXB2 were detected to evaluate the functional and biochemical responses to aspirin before and on days 1, 4, and 10 after aspirin administration. Six-month follow-up was completed in patients who developed AR to evaluate the effect of aspirin in a long-term treatment. GP1Bα (C1018T), Pl (A1/A2), P2Y1(A1622G), TBXA2R (T924C) were also detected to evaluate the influence of genetic variant on aspirin responsiveness.

Results  A total of 8.8% of patients were indentified as AR at the first day after aspirin treatment. The level of urine 11-DH-TXB2 in the AR group was higher compared to non-AR group (P <0.05). There was no relationship between ARA induced platelet aggregation and urinary 11-DH-TXB2 levels (r=0.038, P=0.412). The results of DNA sequencing showed that TBXA2R-924TT homozygotes had a significantly high rate of AR. Logistic regression demonstrated that diabetes was an independent risk factor of AR.

Conclusions  In the beginning period of administration, aspirin was not a sufficient factor that inhibits platelet aggregation. TBXA2R-924T allele was involved in AR. Diabetes was an independent risk factor of AR.

     

脉血康胶囊对PCI术后急性冠脉综合症患者长期预后的改善作用

Objective:To study the changes of adenosine diphosphate(ADP)-induced platelet aggregation rate,and evaluate the effects of Maixuekang Capsule(脉血康胶囊,MKC) on platelet aggregation rate and long-term prognosis of patients with acute coronary syndrome after percutaneous coronary intervention(PCI).Methods:A total of 236 patients with acute coronary syndrome,who received successful PCI,were randomly assigned to a trial group(116 cases) and a control group(120 cases) according to random numbers;treatment allocation occurred when the participants met the inclusion criteria and signed the informed consent forms.In the trial group,the patients were treated with MKC combined with routine medication,and in the control group the patients were treated with routine medication.The therapeutic course for the two groups was 12 months and the follow-up was 12 months.The levels of ADP-induced platelet aggregation rate and serum high-sensitive C-reactive protein(hs-CRP) were determined before PCI,12 h and 30 days after PCI.In the meantime,the incidence of cardio-/cerebrovascular events was recorded during the 12-month follow-up.Results:Compared with before PCI,the levels of ADP-induced platelet aggregation rate and serum hs-CRP were significantly higher at 12 h after PCI(P0.05).They were significantly reduced after 30-day-treatment of MKC,showing statistical differences when compared with those in the control group(P0.05).During the 12-month follow-up,the incidence of cardio-/cerebrovascular events was significantly lower in the trial group than in the control group(6.9%vs.12.5%,P0.01).Conclusions:ADP-induced platelet aggregation function was significantly elevated after PCI.MKC improved the prognosis of patients with acute coronary syndrome,possibly through inhibiting the platelet aggregation,fighting against inflammation,and protecting the vascular endothelial function.     

Association of the Platelet Membrane Glycoprotein Ⅰ a C807T Gene Polymorphism with Aspirin Resistance

To explore the correlation between the C807T polymorphism of platelet membrane gly- coprotein Ⅰa (GPⅠa) gene and aspirin resistance in Chinese people, 200 patients with high-risk of atherosclerosis took aspirin (100 mg/d) for 7 days. Platelet aggregation function was detected using adenosine diphosphate (ADP) and arachidonic acid (AA) before and after the administration of aspi- rin. Then the subjects were divided into three groups according to the results of platelet aggregation function: an aspirin resistant (AR) group, an aspirin semi-responder (ASR) group and an aspi- rin-sensitive (AS) group. Platelet GPⅠa gene 807CT polymorphism was examined by means of po- lymerase chain reaction-sequence specific primers (PCR-SSP). The results showed that T allelic fre- quency in AR group and ASR group were higher that of AS group (P<0.005), and the prevalence of genotypes (TT TC) of these two groups was significantly higher than that in AS group (P<0.05). Platelet GPⅠa T allele was significantly associated with aspirin resistance as revealed by multiple logistic regression (OR=3.76, 95% CI: 2.87–9.58). The results suggest that inherited platelet GPⅠa variations may have an important impact on aspirin resistance and the presence of GPⅠa T allele may be a marker of genetic susceptibility to aspirin resistance.     

Comparision of high sensitivity C-reactive protein and matrix metalloproteinase 9 in patients with unstable angina between with and without significant coronary artery plaques

Background Inflammation within vulnerable coronary plaques may cause unstable angina by promoting rupture and erosion. C-reactive protein (CRP) is the most reliable and accessible test method for clinical use for identifying coronary artery disease event. Matrix metalloproteinase 9 (MMP-9) is highly over-expressed in the vulnerable regions of a plaque.Our aim was to evaluate the plasma levels of MMP-9 and hsCRP in subjects with both unstable angina and coronary plaques, as well as in those with unstable angina without coronary plaques.Methods Patients with newly diagnosed unstable angina pectoris from clinical presentation and ECG, who were undergoing coronary angiography from April 2007 to April 2009, were included in this study. A total of 170 subjects were enrolled in the study. Before angiography, the baseline clinical data (mainly including conventional risk factors) was collected.These patients were divided into two groups, a non-plaque group (G1) which included 55 patients with no significant stenosis or less than 20% stenosis in at least one of the major coronary artery branches, and a plaque group (G2) which included 115 patients with at least one of the major coronary artery branches unstable angina pectoris with at least 50% stenosis of one major coronary artery. The patients presenting with calcified nodules of a major coronary artery were excluded from this study.We examined the serum levels of MMP-9 for all cases by multi-effect enzyme-linked immunosorbent assay.Results There was a significant difference in the serum levels of MMP-9 between the two groups (P＜0.001). The percentage of patients with hypertension, diabetes and current smokers were significantly different between the two groups (P=0.034, P=0.031, and P=0.044 respectively). The univariate Logistic regression analyses of risk factors showed that smoking was the main risk factor for angina in the non-plaque group with the OR being 1.95 (95% Cl 1.02-3.75).Hypertension, diabetes mellitus were negatively related with the occurrence of angina in the non-plaque group with the ORs being 0.50, and 0.36, respectively (95% Cl 0.26-0.96 and 0.14-0.94). The MMP-9 level was negatively related to the occurrence of angina in the non-plaque group with an OR of 0.59 (95% Cl 0.47-0.81).Conclusions There is a significantly difference in MMP-9 levels between the plaque and non-plaque groups. Current smoking has a significant influence on unstable angina patients without documented plaques. The serum MMP-9 level may be a significant biomarker which can help differentiate patients with unstable angina with plaques from those with unstable angina but without plaques.     

Smoking and hyperlipidemia are important risk factors for coronary artery spasm

Objective To investigate the role of coronary artery spasm in the etiology of chest pain lacking significant coronary stenosis and to identify the clinical risk factors related to coronary artery spasm.Methods Two hundred and seventy five patients with chest pain, but without significant coronary artery stenosis underwent the intracoronary acetylcholine test. Coronary artery spasm was diagnosed while coronary artery stenosis increased to 90% and was accompanied by the usual chest pain with or without ischemic changes on electrocardiogram. Logistic regression was employed to investigate the relationships between coronary artery spasm and sex, age, hypertension, diabetes mellitus, smoking,hyperlipidemia and results of electrocardiographic treadmill stress test. Left ventricular ejection fraction and end diastolic pressure were compared between spasm group and non-spasm group.Results Coronary artery spasm was detected in 103 out of 271 patients, a rate of 38%. Logistic regression analysis showed that smoking and hyperlipidemia increased the relative risk of coronary artery spasm 4.2 times and 2.3 times, respectively. There was a significantly negative relationship between diabetes mellitus and coronary artery spasm. Furthermore, there was no coronary artery spasm detected in left ventricular ejection fraction and end diastolic pressure.Conclusions Coronary artery spasm was one of the important etiological factors for patients with chest pain but no coronary artery stenosis. Smoking and hyperlipidemia were the main clinical risk factors for coronarv arterv spasm.     

Cigarette smoking inhibits the anti-platelet activity of aspirin in patients with coronary heart disease

Objective  Tobacco smoking results in increased platelet aggregability, which suggests that low-dose aspirin used in common clinical practice may not effectively inhibit platelet activity in smokers with coronary heart disease (CHD). This review was performed to assess the effect of aspirin on platelet aggregation in patients with CHD.

Data sources  We performed an electronic literature search of MEDLINE (starting from the beginning to March 15, 2009) using the term “smoking” or “tobacco” paired with the following: “platelet”, “aspirin” or “coronary heart disease”.

Study selection  We looked for review articles regarding the effect of tobacco smoking on platelet activity and on the anti-platelet efficacy of aspirin in healthy people and patients with CHD. The search was limited in “core clinical journal”. In total, 1321 relevant articles were retrieved, and 36 articles were ultimately cited.

Results  Tobacco smoking results in increased platelet aggregability, which can be inhibited by low-dose aspirin in the healthy population. However, in patients with CHD, the increased platelet aggregability can not be effectively inhibited by the same low-dose of aspirin. A recent study indicated that clopidogrel or an increased dose of aspirin can effectively inhibit the increased platelet aggregability induced by tobacco smoking in patients with CHD.

Conclusions  It is important for patients with CHD to quit smoking. For the current smoker, it may be necessary to take larger doses of aspirin than normal or take an adenosine diphosphate receptor inhibitor along with aspirin to effectively inhibit the increased platelet activity.

     

Predictive value of antiplatelet resistance on early stent thrombosis in patients with acute coronary syndrome

Background  Despite outstanding antiplatelet properties of aspirin and clopidogrel, some patients taking these drugs continue to suffer complications. Antiplatelet resistance appears to be a new prognostic factor in acute coronary syndrome patients for clinical events associated with stent thrombosis (ST). However, there is no optimal method to identify it and assess its correlation to clinical outcomes. This study sought to evaluate the predictive value of antiplatelet resistance assessed by whole blood impedance aggregometry for the risk of early ST in patients with acute coronary syndrome who underwent coronary stenting.

Methods  Platelet responses to aspirin and clopidogrel in 86 patients with acute coronary syndrome were measured by whole blood impedance aggregometry. Spontaneous platelet aggregation was defined as antiplatelet resistance identified by the increased electrical impedance. The clinical endpoint was early stent thrombosis during 30-day follow-up after coronary stenting.

Results  The prevalence of aspirin resistance, clopidogrel resistance and dual resistance of combined clopidogrel and aspirin resistance were 19.8%, 12.8% and 5.8% respectively. Diabetes, female and higher platelet counts were more frequently detected in clopidogrel-resistant and dual-resistant patients. During 30-day follow-up, the patients with clopidogrel resistance and dual resistance had higher incidence of early stent thrombosis (18.2% vs. 1.3%, 40.0% vs. 1.2%, P <0.05). Binary Logistic Regression analysis indicated that dual resistance remained an independent predicator for early stent thrombosis (odds ratio 34.064, 95% CI 1.919–604.656, P=0.016).

Conclusions  Antiplatelet resistance assessed by whole blood impedance aggregometry is paralleled to clinical events, and dual antiplatelet resistance is an independent predicator for early stent thrombosis in patients with acute coronary syndrome. As a physiological assessment of platelet reactivity, whole blood impedance aggregometry is a convenient and accurate option for measuring antiplatelet resistance and hence predicting early stent thrombosis.

     

Emergency off-pump coronary artery surgery

Background Off-pump coronary artery bypass grafting is fast-becoming a procedure of choice for elective revascularization in high-risk patients with multi-vessel coronary artery disease. However, the role of off-pump coronary artery bypass grafting for patients with acute coronary syndromes requiring emergency revascularization still requires validation. We present our experience to show the feasibility of off-pump coronary artery surgery as an emergency revascularization technique. Methods From April 2001 to September 2003, emergency (operation within 24 hours after hospitalization) coronary artery bypass grafting without cardiopulmonary bypass (CPB) was performed in 66 patients with a mean age of (66.9±5.4) years (range 49-72 years). They presented acute coronary syndromes with 38 patients on platelet glycoprotein Ⅱb/Ⅲa receptor antagonists. All patients underwent off-pump coronary artery bypass surgery via sternotomy with the intention of complete coronary revascularization.Results An average of 2.9 grafts per patient were performed and the posterior descending artery and marginal branches of the circumflex artery were grafted in 83.3% of the patients. There were 4 events of intraoperative cardiac instability, precipitated by occlusion of right coronary artery or positioning of a cardiomegaly heart, leading to immediate conversion to CPB. The mortality rate was 3% (2/66). Two patients suffered postoperative stroke while three needed hemofiltration for acute renal failure. Post surgery elective coronary angiography (n=46) showed no significant stenosis.Conclusion Emergency off-pump coronary artery surgery with complete revascularization is feasible in patients with acute coronary syndrome with low morbidity and mortality and excellent early results.     

Optimal low dosage of acetylsalicylic acid (ASA) for the prevention and treatment of ischemic cerebrovascular disease in geriatric patients.

A series of 108 geriatric patients with ischemic cerebrovascular disease were treated with low dose aspirin (acetylsalicylic acid, ASA). Daily doses of 100 mg, 50 mg and 25 mg were administered to three groups of 36 patients. Changes in platelet aggregation responses were dynamically observed in 64 (22 normal subjects, 42 patients). Monitoring of 22 normal subjects revealed inhibition of platelet aggregation at a dose of 300 mg or 100 mg which could last as long as 7 days. This suggests that 100 mg or less could be clinically effective. Satisfactory inhibitory effects on platelet aggregation were observed in all three groups, with 14 patients in each group given daily doses of 100 mg, 50 mg and 25 mg during four weeks' observation. The most effective inhibition was obtained in the 50 mg group. Therefore, the authors recommend 50 mg/d as the optimal dosage for low dose aspirin therapy in geriatric patients.

     

Embolic events in 93 elderly Chinese patients with atrial fibrillation

Objectives To evaluate the prevalence of embolic events and relevant factors in elderly Chinese patients with atrial fibrillation(AF), and to provide evidence on ways to prevent embolic events.Methods Autopsy data from ninety-three continous elderly Chinese patients with AF were analysed. The incidence of embolic events and its relationship to underlying disease, pathologic changes in the heart, and other clinical characteristics were examined.Results Embolism were observed in 27 of 93 cases, with an incidence of 29.03%. The incidence of embolic events was higher in elderly patients with rheumatic heart disease than those with coronary artery disease, hypertensive myocardiopathy and heart diseases. Patients with chronic AF,with a course of AF≥3 years, and those with heart failure or diabetes had a higher incidence of embolic events than those without these complications. There was significant difference in incidence between paroxysmal and chronic AF. Patients with left atrial or ventricular enlargement, mural thrombosis in cardiac chambers, valvular calcification and valvular vegetation also had a higher incidence of embolic events. Oral dipyridamole (75-150 mg/d) or aspirin (50-150 mg/d) showed no definite effects in preventing embolism in some patients.Conclusions There was a high incidence of embolic events in elderly Chinese patients with AF. Anticoagulation therapy should be provided to the elderly patients with AF, especially to the patients with risk factors for embolism.     

Surgical treatment of coronary artery fistulae associated with other cardiovascular anomalies.

OBJECTIVE To evaluate retrospectively our surgical experience, techniques and long-term results in 11 patients with coronary artery fistulae associated with other cardiovascular anomalies.

METHODS From January 1980 to April 1995, 11 patients with coronary artery fistulae associated with other cardiovascular anomalies were found among 20,000 open-heart procedures and treated surgically. Besides closure of the fistulae, coronary artery bypass grafting was performed in 5 patients with atherosclerotic coronary artery disease, and aneurysm angioplasty was done in 4 patients with coronary artery aneurysm. Ventricular septal defect and patent ductus arteriosus were closed in one patient and mitral valve replacement was performed in another patient.

RESULTS There were no surgical deaths, but one late death due to acute myocardial infarction occurred 6 months after surgery. The mean follow-up time was 75.7 months and all patients' functional status improved by an average 1.4 judged by the New York Heart Association functional classification.

CONCLUSIONS Coronary artery fistula associated with other cardiovascular anomalies will aggravate symptoms and cause deterioration of heart function. Therefore, evaluation and surgical intervention should be done as soon as possible to restore coronary blood flow and correct concomitant cardiovascular anomalies. The surgical results are excellent with a low operative risk and good long-term results.

     

Surgical outcome and clinical follow-up in patients with symptomatic myocardial bridging

Background Myocardial bridging with systolic compression of the left anterior descending coronary artery (LAD) may be associated with myocardial ischaemia. The clinical outcome in patients with surgical treatment for symptomatic myocardial bridging remains undetermined. This study assessed the middle- and long-term results of surgical treatment for symptomatic myocardial bridging. Methods From 1997 to 2006, 37 463 patients received selective coronary angiography in the Fuwai Cardiovascular Hospital, Beijing, China. Of these, 484 patients had angiographic diagnosis of myocardial bridging. Of the 484 patients, 35 underwent surgery for treatment of myocardial bridging with significant systolic arterial compression. Among the surgical treatment patients, 24 presented with other cardiac disorders, and the remaining 11 symptomatic patients with isolated myocardial bridging were included in the follow-up study. Results The angiographic prevalence of myocardial bridging was 1.3% in this study. The coronary angiographies of the 11 patients revealed myocardial bridging in the middle segment of LAD causing systolic compression ≥75% (ranging from 75% to 90%). The mean age of patients was 48.4 years. Surgical myotomy was performed in 3 patients and coronary artery bypass grafting (CABG) in 8 patients. Eight patients were operated on with an off-pump approach and 3 with a cardiopulmonary bypass technique after median sternotomy. Conversion to on-pump CABG surgery was necessary in 1 patient because of perforation of the right ventricle. The left internal mammary artery was used in all patients with CABG. The acute clinical success rate was 100% with respect to the absence of myocardial infarction, death or other major in-hospital complications. All of the patients were followed up clinically. The median follow-up was 35.3 months (range: 6 to 120 months). Nine patients were free from symptoms and one of them continued taking beta blockers. The remaining 2 patients with myotomy had atypical chest pain. One received coronary angiography again and no stenosis was found two years after operation; while exercise testing was performed in the other patient and revealed no evidence of myocardial ischaemia. None of the patients sustained a myocardial infarction or other major adverse cardiac events (death or vessel revascularization) during follow-up.Conclusions Myocardial bridging is a relatively common angiographic finding. Surgical myotomy or CABG should be limited to patients who are refractory to oral medication. Surgical relief of myocardial ischaemia due to systolic compression of intramyocardial coronary arteries can be accomplished with low operative risk and excellent middle- and long-term results.     

同期不停跳冠脉旁路移植术与颈动脉内膜剥脱术治疗冠心病合并颈动脉狭窄的初步结果

Background Coronary and carotid artery diseases frequently coexist and patients with concomitant significant disease of coronary and carotid arteries remain at high risk of perioperative stroke and myocardial infarction after coronary bypass surgery. The aim of this study was to investigate the effect of combined carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting on patients with carotid and coronary artery disease. Methods Consecutive patients with carotid and coronary artery disease underwent one-staged unilateral CEA and off-pump coronary artery bypass grafting between January 2002 and December 2007 in our heart institute. Perioperative complications including neurological events or major adverse cardiac events were assessed and follow-up was carried out. Results A total of 51 cases of isolated off-pump coronary artery bypass grafting and unilateral CEA including 34 right and17 left was performed. Mean blocked time of carotid artery in CEA was 25.5 ± 7 mins. Mean number of distal grafts per patient was 3.30 ± 0.45. Mean ventilation time,ICU stay and postoperative hospital stay were 11.3±5.4 hours,2.1 ± 0.9 days and 12.5 ± 6.1days respectively. None of the patients had stroke or myocardial infarct and there was one perioperative death due to acute cardiac failure, with operative mortality of 1.96%. Follow-up was complete in 47 patients (92.16%). After mean follow-up of 39.5 ±12.5 months (6～73 months) , none of patient manifested with stroke , new angina or new-born cardiac infarct and there was also no late death. Conclusions Concomitant off-pump coronary artery bypass grafting and CEA is a safe and effective procedure in selective patients with significant carotid and coronary artery disease.     

Direct intracoronary delivery of tirofiban during primary percutaneous coronary intervention for ST-elevation myocardial infarction

ST-segment elevation myocardial infarction (STEMI)is usually caused by acute occlusion of an infarct-related coronary artery (IRA),resulting from rupture or erosion of an atherosclerotic plaque and subsequent platelet aggregation and thrombosis.1-3Prompt reperfusion is the key aspect of the optimal management,4-7 and timely expert primary percutaneous coronary intervention (PCI) becomes the best reperfusion strategy with respect to improvement in survival and reduction of combined clinical endpoints in the treatment of STEMI.8-11 Given the high thrombotic risk of patients with STEMI,pretreatment with a high clopidogrel loading dose before primary PCI was advised to reduce distal thrombotic embolization and angiographic no-reflow and improve clinical outcomes.12,13 The use of adjunctive intravenous glycoprotein (GP) Ⅱb/Ⅲa inhibitors following oral dual-antiplatelet therapy enhances thrombus disaggregation by inhibiting fibrinogen binding to the active receptor complex and subsequently disrupting platelet cross-linking,14 and improves IRA patency and myocardial perfusion,14 and has been recommended as class Ⅱa (at the time of primary PCI) or Ⅱb (before primary angiography and PCI)indication in the recent practice guidelines for the management of patients with STEMI.9,10 Tirofiban (a small-molecule platelet GP Ⅱb/Ⅲa inhibitor) seems even more attractive,because of its consistent and rapidly reversible platelet inhibition at increased dose and efficient penetration into the platelet-fibrin thrombus.15 In a broad population of largely unselected patients undergoing primary PCI for STEMI,tirofiban was associated with a noninferior complete resolution of ST-segment elevation (an indirect measure of myocardial reperfusion after PCI14,16) compared with abciximab,17 and was well tolerated and effective in reducing ischemic acute coronary syndrome complications in patients with mild-to-moderate renal insufficiency.18 Previous studies have shown that an upstream low dose of tirofiban favorably ameliorates IRA patency and reperfusion of the infarct area compared with down-stream use,19 and routine initiation of high-bolus dose of tirofiban could further improve clinical outcome after primary PCI.20 These observations highlight that further platelet aggregation inhibition besides high-dose clopidogrel is mandated in patients with STEMI undergoing primary PCI.     

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis （AS）,even in patients without significant coronary artery disease （CAD）.However,the incidence of angina pectoris and related CAD in such patients is controversial.There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement （AVR） in patients with severe AS.The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population.Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995.Clinical and echocardiographic follow-up data were recorded into the database annually.Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70％ and left main coronary arteries having an estimated narrowing of ≥50％ on coronary angiography.We excluded patients with multiple valve disease,significant aortic regurgitation,or prior CAD or valve surgery.Results Totally 574 patients with severe AS （mean age,（65.9±9.6） years） were enrolled in this study.Significant CAD was found in 61 patients （10.6％）.Factors associated with increased likelihood of CAD were age,hypertension,diabetes mellitus,chronic renal failure,carotid disease,and aorta calcification.In Logistic regression analysis,the independent predictor of the presence of CAD was age （P=0.011）.The incidence of CAD increased significantly at 69.2 years of age.Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD.Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS.Therefore,coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age with     

Surgical treatment of anomalous origin of coronary artery from the pulmonary artery

Background Anomalous origin of coronary artery from the pulmonary artery is a rare congenital cardiac malformation with a mortality rate of up to 90% within the first year of life without surgical intervention. Direct implantation of the anomalous coronary artery （ACA） into the aorta is successful in early life, but it may have increased surgical difficulty and risk with age. This retrospective study summarized our operative experience in direct implantation for treatment of this coronary anomaly in pediatric and adult patients.
Methods From August 2000 to January 2003, 4 consecutive patients aged from 9 months to 41 years underwent dual coronary repair. Among them, two children and one infant with anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA） and one adult was anomalous origin of right coronary artery from the pulmonary artery （ARCAPA）. Coronary arteries were directly implanted into the ascending aorta in 4 patients. In a boy with ALCAPA associated with moderate mitral insufficiency （MI）, whose ACA arose remotely from the ascending aorta, we created a tube-shaped graft using part of the pulmonary arterial wall in continuity with the origin of the left coronary artery （LCA）. Concomitant moderate MI was repaired in 2 patients, including this boy, after a dual-coronary repair.
Results All patients survived. There were no hospital or late deaths and no major complications as well. Echocardiography revealed that the left ventricular （LV） function including LV end-diastolic dimension （EDD） and ejection fraction （EF） was markedly improved at hospital discharge. At 3-6 years follow-up after surgery all patients were asymptomatic and currently in NYHA class 1.
Conclusions The best results are achieved with direct implantation of the ACA into the ascending aorta and simultaneous mitral valve repair if needed. Direct implantation is feasible in pediatric and adult patients with ALCAPA or ARCAPA including the coronary artery in a location remote from th     

Early local intracoronary platelet activation after drug-eluting stent placement

Background Early local platelet activation after coronary intervention identifies patients at increased risk of acute stent thrombosis （AST）. However, early changes in platelet activation in coronary circulation following drug-eluting stent （DES） implantation have never been reported. Methods In a prospective study of 26 consecutive elective stable angina patients, platelet activation was analyzed by measuring soluble glycoprotein V （sGPV） and P-selectin （CD62P） before and after implantation of either DES or bare metal stent （BMS）. All patients were pretreated with clopidogrel （300 mg loading dose） and aspirin （75 mg orally） the day before the procedure. Blood samples were drawn from the coronary ostium and 10 - 20 mm distal to the lesion site. Results Consistent with the lower baseline clinical risk, the levels of CD62P and sGPV were within normal reference range, both in the coronary ostium and distal to the lesion before percutaneous coronary intervention （PCI） procedure. The levels of CD62P and sGPV did not change significantly （CD62P： （31.1 ± 9.86） ng/ml vs （29.5 ± 9.02） ng/ml, P=0.319 and sGPV： （52.4 ± 13.5） ng/ml vs （51.8 ± 11.7） ng/ml, P=0.674, respectively） after stent implantation when compared with baseline. Changes in these platelet activation markers did not differ between stent types. Conclusions Intracoronary local platelet activation does not occur in stable angina patients before and immediately followina DES implantation when dual anti-Dlatelet is administered.     

FACTORS RELATED TO THE LEFT VENTRICULAR ANEURYSM FORMATION AFTER ANTERIOR MYOCARDIAL INFARCTION

To examine the factors related to left ventricular (LV) aneurysm formation after transmural anterior myocardial infarction (MI), 22 patients with a first attack of anterior MI who underwent left ventriculography and coronary angiography within 6 months of infarction were divided into two groups on the basis of presence (10 patients, Group Ⅰ) or absence (12 patients, Group Ⅱ) of a LV aneurysm. Group Ⅰpatients were shown to have larger infarct and poorer LV function. Single vessel disease and total occlusion of the left anterior descending (LAD) artery were more common and collateral blood supply in the presence of an occluded LAD was significantly less adequate in Group Ⅰcompared with Group Ⅱ. Age, sex and risk factors for coronary artery disease were found to have no correlation with aneurysm formation. It is indicated in this study that total occlusion of the LAD in association with inherent poor collateral blood supply is an important determinant of aneurysm formation after anterior MI.     

Preliminary results of combined carotid endarterectomy and off-pump coronary artery bypass grafting in patients with coexistent carotid and coronary artery diseases

Background Coexistent carotid and coronary artery diseases are common and patients with them remain at a high risk for perioperative stroke or myocardial infarction after coronary bypass surgery. The aim of this study was to investigate the effect of combined carotid endarterectomy （CEA） and off-pump coronary artery bypass grafting （CABG） in patients with coexistent carotid and coronary artery diseases. Methods Between January 2002 and December 2007, consecutive patients with coexistent carotid and coronary artery diseases underwent one-stage unilateral CEA and off-pump CABG in Heart Institute of Nanjing First Hospital Affiliated to Nanjing Medical University. Perioperative complications were assessed and follow-up was carried out. Results A total of 51 cases of isolated off-pump CABG and unilateral CEA, including 34 right and 17 left, were performed. The mean blocked time of carotid artery in CEA was （25.5_±7.0） minutes. The mean number of distal grafts per patient was 3.30±0.45. The mean ventilation time, intensive care unit stay, and postoperative hospital stay was （11.3±5.4） hours, （2.1±0.9） days, and （12.5±6.1） days respectively. None of the patients had stroke or myocardial infarct. There was one perioperative death due to acute cardiac failure, resulting in an operative mortality of 1.96%. Follow-up was completed for 47 patients （92.16%） with a mean follow-up of （39.5±12.5） months. None of the patients manifested stroke, new angina or newly developed cardiac infarct. No late death occurred. Conclusion Combined CEA and off-pump CABG is a safe and effective procedure in selected patients with coexistent carotid and coronary artery diseases.     

Small-diameter prosthetic H-graft portacaval shunts in the treatment of portal hypertension

Background Portasystemic shunts, especially total shunts, are effective tools for reducing portal pressure and controlling variceal bleeding but lead to high risk of encephalopathy and accelerating liver failure. The purpose of this study is to evaluate the clinical effects of small-diameter expanded polytetrafluoroethylene (ePTFE ) H-graft portacaval shunts in the treatment of portal hypertension.Methods Thirty-one patients with portal hypertension were treated with ePTFE small-diameter H-graft portacaval shunts from December 1995 to April 2002. Twenty-one had externally ringed grafts and 10 had non-ringed grafts; 20 had 10 mm diameter grafts and 11 had 8 mm grafts. The left gastric artery and coronary vein were ligated in 22 patients. Additionally, 6 patients underwent pericardial devascularization, and splenectomies were performed on 30 patients.Results An average decrease of free portal pressure (FPP) from (32. 13 ±4. 86) cmH2O before shunting to (12. 55 ±5. 57) cmH2O after shunting was observed.