心血管疾病与诊断

Background The practical utility of minimum contrast procedures in a real world setting is unclear. In this trial, the reality of this strategy was investigated. Methods Patients with an estimated glomerular filtration rate (eGFR) of <=45 ml/min/1.73m2 were included in this study with dates ranging from Jan 17th 2012 to Oct 8th 2013. Various methods to minimize the amount of contrast media were applied. An achievement rate of contrast volume/eGFR<2.0 was calculated and the characteristics of the patients and catheter procedures were investigated. Results A total of 88 patients were enrolled. There were 34 patients who underwent a diagnostic coronary angiogram (CAG group) and 54 patients who underwent an interventional procedure (PCI group). The PCI group tended to use a larger amount of contrast media compared to the CAG group (39 ± 49 ml vs 25 ± 14 ml, p=0.06). A ratio of contrast volume to eGFR of less than 2.0 was achieved in 100% of the CAG group but in only 82% of the PCI group. The patients with complex procedures (complex PCI) such as use of a rotablator and treatment of chronic total occlusion used significantly more contrast media than patients with other procedures (simple PCI). (87 ± 69 ml vs 23 ± 27 ml, p=0.006) Surprisingly, when simple PCI group was compared to the CAG group, there was no difference in the contrast volume used. (23 ± 27 vs 25 ± 14 ml, p=0.708) Conclusions Simple PCI can be done as safely as in CAG patients with chronic kidney dysfunction. Complex PCI should be done with careful assessment of the balance between risk and benefit.

Coronary artery anomalies are diagnosed coincidentally during conventional coronary angiography or autopsy, although coronary anomalies are the second common cause of the sudden cardiac death in young persons. They are usually benign and they rarely cause signs and symptoms. Some of them comprise arteriovenosus (AV) fistula arising from coronary arteries to the pulmonary artery. AV fistulae arising from a coronary artery to pulmonary artery are rarely encountered but two AV fistulae (CAF) arising from two separate coronary arteries are even rarer, only a few cases having been reported so far. Herein, we present a 53-year-old male patient who was on the waiting list for renal transplantation. He had exercise-induced dyspnea and angina pectoris. The electrocardiogram showed negative T waves in leads V5 and V6. A stress exercise (treadmill) test was performed, which revealed ST-T wave changes confined to leads V5 and V6. Coronary angiography detected two arteriovenous fistulae arising from circumflex (Cx) and right coronary arteries (RCA) to the pulmonary arteries. Right heart catheterization revealed a Qp/Qs ratio of 1:5 a PCWP of 13 mm-Hg, and a PVR of 0.2 Wood units. Coil embolization was carried out for the fistula from RCA to pulmonary artery in the first session, followed by normalization of right heart catheterization indices, leading to cancelling any intervention against the fistula in circumflex (Cx) artery.

Three dimensional printing (3D printing) is becoming a common useful technology in many areas in medicine. This technology allows better appreciation of complex anatomical and pathologic conditions. In vascular medicine and surgery 3d modeling may become of help in Endovascular Aortic Repair (EVAR) treatment planning, especially in cases of complex angulations and branching at the aneurysm neck. Accurate and rapid solid 3d models were prepared in house using common and freely available software programs, and an accurate 3D printer. These solid models allowed palpation and manual handling and visual inspection for a better appreciation of complex AAA necks. Color enhancement of these models added another dimension of comprehension, even for experienced surgeons and invasive radiologists. A full sized model may allow more accurate measurements of branch distances and angles in space when tortuosity is severe. Fenestrations and “Chimney” branches may be easily envisioned preoperatively. In addition, 3D hollow outer shells were constructed to obtain a workable AAA arterial wall-like model for rehearsal and preoperative stent graft deployment simulation. Various commercial stent grafts from several manufacturers were deployed under fluoroscopy to evaluate feasibility of the planned procedure. In simple AAA cases device deployment simulation was always successful, but in one AAA case with a severely angulated neck all devices failed. We conclude that 3D printing and modeling and outer shell fabrication for preoperative simulation are helpful in EVAR planning of complex AAA.

Background: Appropriate self-care in patients with chronic illnesses such as Heart Failure (HF) is associated with prevention or early detection of health problems, better overall health and quality of life, improved clinical outcomes and reduced healthcare costs. Unfortunately, self-care among patients with heart failure is commonly poor, and patients have considerable difficulties performing self-care. There are no studies that documented the selfcare behaviour of cardiac patients in the study area. The objective of this study was to assess predictors of adherence to self-care behaviour among patient with chronic heart failure attending JUSH chronic follow up Clinic.

Methods: This study was conducted at JUSH chronic follow up clinic, from February 3 to March 30, 2012, using cross sectional design employing both quantitative and qualitative methods and a total of 255 outpatients with congested heart failure were completed the questionnaire. The sample size was calculated using a formula to estimate a single population proportion and the data was collected by administering pretested structured questionnaire for quantitative study and in depth interview guide for qualitative study.

Result: Out of the total 264 clients, 255 were included in the final analysis and giving a response rate of 96.6 %. Majority of the study subjects 151(59.2%) had poor adherence to self-care behaviour. The result of multivariable analysis also showed that knowledge of CHF, depression, duration of CHF, co-morbidity (hypertension and DM) and medication (being digitalized) were independent predictors of poorer adherence to self-care behaviour. Knowledgeable study subjects had 9.395 times more likely adherent to self-care when compared to study subjects that were illiterate, [(Adjusted OR (95% CI of OR) =9.395(4.014, 21.991)] and CES-Depression scale also indicated significant association [(Adjusted OR (95% CI of OR) =2.142(1.168, 3.928)] with adherence to self-care behaviour.

Conclusions and recommendations: The results of this study provided insights into self-care behaviour in patients with CHF. First, patients with CHF did not fully engage in self-care behaviour. Second, important factors including; depression, duration of CHF, co-morbidity (hypertension and DM), medication (digitalize) and knowledge of CHF were identified as the top predictors of self-care behaviour. Therefore, nursing intervention programs regarding knowledge of HF is recommended for enhancing self-care and Self-care strategies should target especially patients with diabetes mellitus, depression and patient with less than one year duration of CHF.

Alcoholic cardiomyopathy represents one of the main clinical complications in chronic alcoholics. This pathology contrasts the seemingly beneficial effect of small doses of alcohol on the cardiovascular system. Studies carried out in liver cells exposed acutely or chronically to varying doses of EtOH indicate that intrahepatic alcohol metabolism results in a major loss of cellular Mg2+. To investigate whether EtOH administration also induced Mg2+ extrusion in cardiac cells, H9C2 cells were exposed to varying doses of EtOH for short- or ling-term periods of time. The results indicate that H9C2 cells exposed to EtOH doses higher than 0.1% (v/v, or 15 mM) extruded Mg2+ into the extracellular medium on a time- and dose-dependent manner. Consistent with the involvement of cyP4502E1 in metabolizing EtOH, administration of chloro-methiazole (CMZ) as an inhibitor of the cytochrome prevented EtOHinduced Mg2+ loss to a large extent. EtOH-induced Mg2+ extrusion was also prevented by the administration of di-thiotreitol (DTT) and n-acetyl-cysteine (NAC), two agents that prevent the negative effects of ROS formation and free radicals generation associated with EtOH metabolism by cyP4502E1. Taken together, our data indicate that Mg2+ extrusion also occur in cardiac cells exposed to EtOH as a result of alcohol metabolism by cyP4502E1 and associated free radical formation. Interestingly, Mg2+ extrusion only occurs at doses of EtOH higher than 0.1% administered for an extended period of time. The significance of Mg2+ extrusion for the onset of alcoholic cardiomyopathy remains to be elucidated.

Tricuspid incompetence after blunt chest trauma is uncommon and is most often associated with traffic accidents. The signs of traumatic tricuspid insufficiency can be appear early or delayed, depending upon the severity of injury. We present the case of a young male who had severe tricuspid regurgitation due a blunt chest trauma in an automobile collision and underwent successful repair.

Objective: The genome-wide association studies have pointed out lots of disease-associated variants in coronary artery disease (CAD). However, whether the polymorphisms of rs2516839 of upstream transcription factor (USF1) and -173G/C (rs755622) of macrophage migration inhibitory factor (MIF) are associated with CAD has remained undetermined. This study was to explore the associations between these two polymorphisms and the risk of CAD and dyslipidemia. Methods: A case-control study was carried out in 654 angiographic confirmed CAD patients and 455 none-CAD control subjects. The polymorphisms were detected by TaqMan SNP Genotyping Assays. Results: We did not observe significant association between the polymorphism of rs2516839 of USF1 with CAD risk, neither -173G/C (rs755622) of MIF. In the subgroup analysis of myocardial infarction and hypertension, the associations for theses two polymorphisms were negative also. However, the GG genotype carriers of rs2516839 of USF1 showed significantly lower levels of cholesterol, low-density lipoprotein cholesterol and apolipoprotein B. Conclusions: Our findings showed that the rs2516839 of USF1 and -173G/C (rs755622) of MIF do not contribute to CAD risk. Nevertheless, the rs2516839 of USF1 might have a protection for the dyslipidemia disorders.

Objective: The aim of this study was to assess the incremental benefit of denervation of vagal responses for the prevention of recurrence of atrial fibrillation (AF) in patients undergoing a mini-maze procedure. Patients and methods: Between September 2007 and May 2009, 209 patients (aged 53 ± 10 years, 63 male) undergoing cardiac surgery underwent concomitant radiofrequency ablation for persistent AF. Intraoperative highfrequency stimulation showed a positive vagal response in 103 patients and a negative vagal response in 106 patients. The average history of AF was 36 ± 43 months. Preoperatively, 144 patients (68.9%) were in New York Heart Association functional class III or IV. Results: There were no in-hospital deaths, and no significant differences in mortality or complications between the two groups during the postoperative or follow-up periods. Immediately after surgery, 132 patients (63.2%) were in sinus rhythm, with a similar proportion of sinus rhythm in the groups with positive and negative vagal responses (56.3% vs. 62.3%, p=0.38). At the latest follow-up (mean 18.9 ± 9 months), 60.8% of patients had freedom from AF, with a higher proportion of freedom from AF in patients with positive vagal responses than those with negative vagal responses (68.2% vs. 53.3%, p=0.0004). Cox univariate and multivariate analyses identified positive vagal response as a predictor of late recurrence of AF (Wald=9.71; 95% CI, 0.081–0.563; p=0.002). Logistic regression analysis showed that positive vagal response was inversely related to left atrial dimension (Wald=4.45; 95% CI, 0.965–0.999; p=0.035). The proportion of patients with left atrial dimension >70 mm was larger in the group with negative vagal responses than the group with positive vagal responses (48.1% vs. 30.1%, p=0.008). Active ganglionated plexi were found in 49.2% of patients (102/209) with a mean number of 3.6 ± 2.2 sites (range 1–11) per patient. The majority of active sites (78.6%) were located at the pulmonary vein (PV) antrum rather than the PV ostia, including 81.9% of right-sided sites and 70.5% of left-sided sites. Conclusion: The results of this study indicate that parasympathetic attenuation by PV denervation achieved an incremental benefit in patients undergoing PV isolation for AF. In patients with persistent AF, positive vagal response was related to small left atrial diameter, and predicted outcome after ablation.

Background: Nonalcoholic fatty liver disease (NAFLD) has reached epidemic proportions in the last decade, and it is related to high cardiovascular mortality. This disorder encompasses a spectrum of increasingly severe clinicopathological conditions, i.e. nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH) with or without fibrosis/cirrhosis. Mortality associated with NAFLD is significantly higher in patients with the more advanced stages of this condition and is chiefly due to concomitant cardiovascular disease. The association between NAFLD severity and carotid artery intima-media thickness (CIMT) is controversial.

Objective: To investigate the association between CIMT and the clinical forms of NAFLD.

Methods: The study included 34 adult patients with NAFL, 20 with NASH, and 26 asymptomatic controls without the MS and/or NAFLD. The clinical and metabolic characteristics as well as CIMT values, measured using a fully automated ultrasound system, were compared between the NAFL and NASH groups. CIMT of the NAFLD patients were also compared to those of the control group.

Results: The proportion of patients with athermanous plaque was significantly higher in the NAFLD group in comparison to the controls. Internal carotid artery CIMT and the combined measurement in the right side (common carotid artery, carotid bifurcation and internal carotid) were higher in the NAFL group when compared to the NASH patients. No other significant differences were found between CIMT values of the NAFL and NASH groups. After adjustment for clinical, demographic, and laboratorial variables, age was the main determinant of CIMT.

Conclusions: No clinically significant association was observed between CIMT of the patients with NAFL and NASH. Age was the main determinant of CIMT.