The Treatment of Multiple Coronary Occlusions by Internal Mammary Artery Implantation and Omental Graft: Report on Two Human Cases

The importance of triple coronary artery disease was evident in 125 patients undergoing internal mammary artery implantation, when some patients died from right coronary artery occlusion. This occurred even when the internal mammary artery was patent and revascularizing the left ventricle.In 1961 the free omental graft operation was developed to revascularize both right and left ventricles. In animals this operation has proved most effective in preventing death after application of Ameroid constrictors to all three coronary arteries. Arteriolar or larger-sized vessels rapidly formed between the aorta and omentum and the pericardium and omentum and the heart and omentum.Two patients with triple coronary artery disease underwent internal mammary artery implantation and free omental graft early in December 1962. Postoperative convalescence was uneventful. They have returned home and appear to be improved. Wrapping the entire heart with the free omental graft has produced little reaction, suggesting that, as in the animal, the grafts are surviving.     

Revascularization of the Entire Heart by Internal Mammary Artery Implantation,Epicardiectomy and Free Omental Graft

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author''s experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were “bed-chair cripples” (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.     

Right Internal Mammary Artery Implantation into Right Ventricular Myocardium for Revascularization of the Entire Heart: Experimental Data and Preliminary Report

The left internal mammary artery implant combined with epicardiectomy and free omental graft provides three extra-coronary sources of blood. This operation tested in dogs with 92% main-stem occlusion of three coronary arteries protected 75% of the animals. Applied clinically in over 100 patients, the operation resulted in 90% improvement. To obtain complete myocardial revascularization, the right internal mammary artery has been used as a fourth source of extra-coronary blood. In 57 animals, the right internal mammary arteries were implanted into the anterior walls of the right ventricle; in 80% this vessel formed anastomoses with the right coronary tree, and in 65% with the right and left coronary arteriolar systems. Six patients are described who underwent right internal mammary artery implantation; five of these in addition had the combined operation of left internal mammary artery implant, epicardiectomy and free omental graft. All patients had completely blocked right coronary arteries; in addition, five had advanced disease of the left coronary arterial tree.     

Trickle Arteriography: Demonstration of Thrombi in the Origin of the Internal Carotid Artery

Thrombi developing within the origin of the internal carotid artery may be demonstrated by a slow trickle injection of highly concentrated contrast medium, which lingers in pools around the thrombus on the dependent wall of the vessel. With this technique thrombi have been detected which could not be visualized on conventional arteriography because they were obscured by the density of the vascular shadow produced by the forceful injection usually employed in carotid angiography. In addition, trickle arteriography is useful for assessing the position and extent of atheromatous plaques and the contrast stasis associated with them.     

冠状动脉内重叠支架置入术的临床研究进展

重叠支架置入术是临床上用来治疗冠状动脉弥漫性长病变的常用方法,以往曾采取重叠裸金属支架置入术,但其临床预后不佳,目前较为常用的重叠药物洗脱支架置入术被认为相对安全、有效,但仍存在许多潜在问题。本文介绍了适合使用重叠支架置入术进行治疗的冠状动脉病变的特点,回顾了重叠裸金属支架的临床应用情况,阐述了近年来药物洗脱支架的发展以及重叠药物洗脱支架置入术的优势,比较了四种负载不同药物的药物洗脱支架同种重叠置入后的临床疗效,观察了异种药物洗脱支架混合重叠置入后的临床特点和支架重叠段对临床预后的影响,分析了重叠支架置入术与几种其它治疗冠状动脉弥漫性长病变方法的应用区别,并对新一代药物支架的重叠应用进行了展望。     

Combined Internal Mammary Artery Implantation and Free Omental Graft Operation: A Highly Effective Revascularization Procedure: (A Study of 17 Cases)

One hundred and forty patients with coronary artery disease treated by internal mammary artery implantation were followed up from six months to 13 years. The mortality rate was 3%; improvement was obtained in 70%. Occlusive disease of all three major coronary arteries, however, requires more blood than can be supplied by the implant procedure, and the free omental graft operation was developed for the management of selected patients with this condition. Normally in animals triple coronary artery ameroid constriction results in 100% mortality. When the free omental graft operation, with or without internal mammary artery implantation, was performed, 80% of such animals survived. The free omental graft forms capillary anastomoses in three days and arteriolar vessels in eight days, which leave the base of the aorta, enter the omentum, thence to the myocardium. A combined internal mammary artery implantation and free omental graft operation was performed in 17 patients with triple coronary artery disease as shown by cine coronary arteriography. There was no operative mortality, and 12 of the patients are free of pain and have returned to work.     

Outcomes of Middle Cardiac Vein Arterialization via Internal Mammary/Thoracic Artery Anastomosis

Objective

Cardiac vein arterialization is seldom applied for treating right coronary artery disease. This study aimed to improve outcomes of cardiac vein arterialization in a porcine model using intramammary artery anastomosis.

Methods

A chronic, stenotic coronary artery model was established in 12 of 14 Chinese experimental miniature pigs of either sex, which were randomly divided into equal control (n = 6) and experimental (n = 6) groups. In experimental animals, blood flow was reconstructed in the right coronary artery using intramammary artery. Arterialization involved dissection of right internal mammary artery from bifurcation to apex of thorax followed by end-to-side anastomosis of internal mammary artery and middle cardiac vein plus posterior descending branch of right coronary artery. Intraoperative heart rate was maintained at 110 beats/min. Graft flow assessment and echocardiography were performed when blood pressure and heart rate normalized.

Results

The experimental group had significantly higher mean endocardial and epicardial blood flow postoperatively than control group (mean endocardial blood flow: 0.37 vs. 0.14 ml/(g*min), p<0.001; mean epicardial blood flow: 0.29 vs. 0.22, p = 0.014). Transmural blood flow was also higher in experimental group than in control group (0.33 vs. 0.19, p<0.001); ejection fraction increased from 0.46% at baseline to 0.51% (p = 0.0038) at 6 hours postoperatively, and mean blood flow of internal mammary artery was 44.50, perfusion index 0.73 at postoperative 6 months, 43.33 and 0.80 at 3 months.

Conclusion

Successful cardiac vein arterialization via intramammary artery in a porcine model suggests that this may be a viable method for reconstructing blood flow in chronic, severe coronary artery disease.     

ACTH- and Cortisol-Associated Neutrophil Modulation in Coronary Artery Disease Patients Undergoing Stent Implantation

Background

Psychosocial stress and activation of neutrophil granulocytes are increasingly recognized as major risk factors of coronary artery disease (CAD), but the possible relationship of these two factors in CAD patients is largely unexplored. Activation of neutrophils was reported to be associated with stenting; however, the issue of neutrophil state in connection with percutaneous coronary intervention (PCI) is incompletely understood from the aspect of stress and its hypothalamic-pituitary-adrenal axis (HPA) background. Thus, we aimed to study cortisol- and ACTH-associated changes in granulocyte activation in patients undergoing PCI.

Methodology/Principal Findings

Blood samples of 21 stable angina pectoris (SAP) and 20 acute coronary syndrome (ACS) patients were collected directly before (pre-PCI), after (post-PCI) and on the following day of PCI (1d-PCI). Granulocyte surface L-selectin, CD15 and (neutrophil-specific) lactoferrin were analysed by flow cytometry. Plasma cortisol, ACTH, and lactoferrin, IL-6 were also assayed. In both groups, pre- and post-PCI ratios of lactoferrin-bearing neutrophils were relatively high, these percentages decreased substantially next day; similarly, 1d-PCI plasma lactoferrin was about half of the post-PCI value (all p≤0.0001). Post-PCI ACTH was reduced markedly next day, especially in ACS group (SAP: p<0.01, ACS: p≤0.0001). In ACS, elevated pre-PCI cortisol decreased considerably a day after stenting (p<0.01); in pre-PCI samples, cortisol correlated with plasma lactoferrin (r∼0.5, p<0.05). In 1d-PCI samples of both groups, ACTH showed negative associations with the ratio of lactoferrin-bearing neutrophils (SAP: r = −0.601, p<0.005; ACS: r = −0.541, p<0.05) and with plasma lactoferrin (SAP: r = −0.435, p<0.05; ACS: r = −0.609, p<0.005).

Conclusions/Significance

Pre- and post-PCI states were associated with increased percentage of activated/degranulated neutrophils indicated by elevated lactoferrin parameters, the 1d-PCI declines of which were associated with plasma ACTH in both groups. The correlation of plasma cortisol with plasma lactoferrin in the extremely stressed ACS before stenting, however, suggests an association of cortisol with neutrophil activation.     

非侵入性起搏器负荷超声心动图对永久起搏器植入术后合并冠脉病变的临床诊断意义

目的：探讨非侵入起搏器负荷超声心动图对永久起搏器植入术后合并冠脉病变的临床诊断意义。方法：采用前瞻性研究,实验对象为24名因房室传导阻滞或慢性心房纤颤而植入永久起搏器的患者（男12人,女12人,平均年龄70.2±6.1岁）,所有患者均因不典型心绞痛入院和完全起搏依赖,心电图改变无法判断是否存在心肌缺血。通过体外程控进行非侵入性起搏器负荷超声心动图检测室壁运动幅度如左室射血分数评估心功能,检测后行冠脉造影术评估冠脉狭窄情况,及实验前后测定B型脑钠肽的变化。结果：24例患者中,有13例通过起搏器负荷超声心动图应激实验测得LVEF随起搏心率增加而降低,这其中又有11例患者通过冠状动脉造影证实其冠脉存在不同程度的狭窄,诊断的准确性84.62%;11例冠脉造影结果阳性的患者实验后30分钟测得的BNP水平较实验前明显升高。结论：非侵入性起搏器负荷超声心动图应激实验作为一种简单、快速、安全及具有诊断意义的方法,可用来评价植入起搏器术后完全起搏依赖,心电图继发性ST-T改变难以判断的心肌缺血,为进一步检查及治疗提供可靠临床数据。     

药物洗脱支架植入术与冠状动脉旁路移植术治疗冠心病多支病变伴糖尿病患者的临床效果分析

目的:比较药物洗脱支架(DES)植入术及冠状动脉旁路移植术(CABG)治疗冠心病多支病变伴糖尿病患者的近期及远期临床疗效。方法:回顾性分析2014年1月~2016年10月在哈尔滨医科大学附属第一医院经冠状动脉造影证实为多支血管病变并伴有糖尿病的患者186例,根据血运重建方式的不同分为DES组及CABG组,随访50.5±14.3个月,观察两组患者住院期间及随访期主要不良心脑血管事件(包括非致死心肌梗死、脑卒中、再次血运重建、全因死亡)的发生情况。结果:在所有入选患者中,DES组有更多双支病变(P0.05),CABG组三支病变较多(P0.05),两组在完全血运重建方面无显著性差异(P0.05)。住院期间,CABG组死亡2例(2.3%),DES组死亡1例(1.0%),死亡率比较无统计学意义(P0.05)。两组均未出现非致死性心肌梗死、脑卒中、再次血运重建。出院后对186例入选患者随访,其中失访11例(DES组5例,CABG组6例)。随访期间CABG组发生非致死性心肌梗死1例(1.3%)、脑卒中6例(7.5%)、全因死亡10例(12.5%),DES组发生非致死性心肌梗死5例(5.3%)、脑卒中3例(3.2%)、全因死亡9例(9.5%),两组间比较差异无统计学意义(P0.05);而CABG组再次血运重建2例(2.5%),DES组15例(15.8%),两组比较差异具有统计学意义(P0.01)。结论:行DES置入术或CABG术治疗冠心病多支病变伴糖尿病患者,住院期间主要心脑血管不良事件发生率、远期非致死性心肌梗死、脑卒中、全因死亡发生情况均无显著性差异,但DES组再次血运重建率明显升高,可能与糖尿病患者较高的再狭窄率有关。     

基于功能一致性预测冠心病致病基因

目的:为了解疾病致病机理和改进临床治疗,基于功能一致性挖掘潜在的疾病致病基因.方法:本文基于功能一致性基因的共定位特性,结合蛋白质互作网络拓扑结构,获取疾病候选基因集,并通过GO及KEGG功能富集分析方法进一步筛选,预测出新的致病基因.结果:挖掘得到的59个冠心病致病基因通过文献证实绝大部分基因与疾病的发生发展存在着联系.结论:本方法具有可行性,研究者能够在此基础上很好地进行疾病致病机理的研究.     

以CT图像为基础的冠状动脉狭窄处血流动力学研究

目的:冠状动脉粥样硬化好发于具有特殊几何构型的血管部位,提示血流动力学参数在粥样硬化形成方面起到重要作用.以往研究多局限于理想的血管模型,本文旨在探索以CT图像为基础构建个体化冠状动脉血流动力学模型的技术方法,对人体左冠状动脉前降支粥样硬化病变狭窄处进行计算流体动力学(computational fluid dynamics,CFD)数值模拟,探讨冠状动脉粥样硬化病变形成和发展的血流动力学机制.方法:用MIMICS软件读取CTA数据,以CT图像为基础进行冠状动脉三维几何建模,假设动脉血流为层流、不可压缩、牛顿流体,入口血液流速随时间周期性变化,应用有限体积法FLUENT软件进行血流数值模拟,分析与动脉粥样硬化形成、发展相关的血流动力学参数.结果:获得个体化左冠状动脉前降支狭窄处血管模型及血流动力学参数,数值模拟结果包括冠状动脉的血液流场、壁面压力(wall pressure WP)及壁面切应力(wall shear stress WSS)分布,可见狭窄段血管血液流速加快,WP降低、WSS增高,且在狭窄邻近区域出现低WSS区、较高的WP及血液湍流区域.结论:以CT图像为基础的CFD技术是在体评价人狭窄冠状动脉内血流动力学状况与冠状动脉粥样硬化病变之间关系的有效方法,能够更为真实的建立人体血管几何模型,为分析血流动力学参数与冠状动脉粥样硬化形成与发展的关系提供研究手段.     

Identification of Risk Pathways and Functional Modules for Coronary Artery Disease Based on Genome-wide SNP Data

Coronary artery disease(CAD) is a complex human disease, involving multiple genes and their nonlinear interactions, which often act in a modular fashion. Genome-wide single nucleotide polymorphism(SNP) profiling provides an effective technique to unravel these underlying genetic interplays or their functional involvements for CAD. This study aimed to identify the susceptible pathways and modules for CAD based on SNP omics. First, the Wellcome Trust Case Control Consortium(WTCCC) SNP datasets of CAD and control samples were used to assess the jointeffect of multiple genetic variants at the pathway level, using logistic kernel machine regression model. Then, an expanded genetic network was constructed by integrating statistical gene–gene interactions involved in these susceptible pathways with their protein–protein interaction(PPI)knowledge. Finally, risk functional modules were identified by decomposition of the network. Of 276 KEGG pathways analyzed, 6 pathways were found to have a significant effect on CAD. Other than glycerolipid metabolism, glycosaminoglycan biosynthesis, and cardiac muscle contraction pathways, three pathways related to other diseases were also revealed, including Alzheimer's disease, non-alcoholic fatty liver disease, and Huntington's disease. A genetic epistatic network of 95 genes was further constructed using the abovementioned integrative approach. Of 10 functional modules derived from the network, 6 have been annotated to phospholipase C activity and cell adhesion molecule binding, which also have known functional involvement in Alzheimer's disease.These findings indicate an overlap of the underlying molecular mechanisms between CAD and Alzheimer's disease, thus providing new insights into the molecular basis for CAD and its molecular relationships with other diseases.     

Implantation of the Right and Left Internal Mammary Arteries with Epicardiectomy and Free Omental Graft: A Preliminary Experimental Report

In animal experiments the right internal mammary artery was implanted into the outflow tract of the right ventricle during performance of left mammary artery implantation with epicardiectomy and free omental graft. The effect of double mammary artery implantation operation was tested by triple coronary artery ameroid constriction in 24 animals. In 20 animals studied both implanted arteries remained open and had commenced to bud and branch at the time of examination. The double implant operation is still an experimental procedure.     

Selection of Patients for Coronary Artery Bypass Operations

Bypass operations have proved to be an effective treatment for advanced coronary artery disease. Randomized clinical trials have now shown that compared with medical treatment, bypass operations enhance survival in patients who have three-vessel disease or left main coronary stenosis. The goals of both medical and surgical treatment should be to improve a patient''s quality of life, extend survival and reduce medical care costs. Preliminary data suggest that bypass operations may be less costly than medical treatment in patients with severe angina that requires repeated or prolonged stays in hospital.     

3D Coronary Artery Reconstruction by 2D Motion Compensation Based on Mutual Information

Background

3D reconstruction of the coronary arteries can provide more information in the interventional surgery. Motion compensation is one kind of the 3D reconstruction method.

冠状动脉支架植入术后高凝状态的研究进展

支架内血栓形成是冠状动脉支架植入术后的重要并发症之一,尽管发生率较低,但严重者可危及生命。冠心病支架植入术后高凝状态源自患者的自身因素及支架植入所导致的一系列病理生理反应,包括斑块破裂、血管内皮损伤、组织因子大量表达、微粒生成增多等,进一步可激活血细胞和凝血系统,重者可导致局部血栓形成。及时检测及防治支架术后的高凝状态对降低支架内血栓的发生率有积极作用。本文主要对冠状动脉支架植入术后高凝状态的研究进展进行了综述。