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心脏再同步治疗联合经皮冠状动脉介入术对缺血性心肌病的疗效

心脏再同步治疗联合经皮冠状动脉介入术对缺血性心肌病的疗效

引用

中华医学会心电生理和起搏分会第十次全国学术年会

作者：麦憬霆陈样新邱琼王景峰中山大学孙逸仙纪念医院心血管内科广东省心律失常与心电生理重点实验室

目的心脏再同步治疗(CRT),作为心力衰竭重要的器械治疗方法,虽然能一定程度改善缺血性心肌病(ICM)的预后,但疗效普遍差于扩张性心肌病(DCM),这可能与ICM患者心肌缺血持续存在,缺血心肌仍难以获得较好的同步效果有关。经皮冠状动脉介入术... 详细信息

目的心脏再同步治疗(CRT),作为心力衰竭重要的器械治疗方法,虽然能一定程度改善缺血性心肌病(ICM)的预后,但疗效普遍差于扩张性心肌病(DCM),这可能与ICM患者心肌缺血持续存在,缺血心肌仍难以获得较好的同步效果有关。经皮冠状动脉介入术(PCI)在急性心梗和高危险分层的不稳定性心绞痛中能降低死亡率,但在慢性稳定性心绞痛不能改善预后。对于ICM,慢性稳定性冠心病合并严重的心力衰竭,这一特定类型的病人,有少量的临床研究发现PCI能提高心功能,改善心室重构。我们假设,有CRT置入指证的ICM患者,联合PCI治疗可能进一步获益,可能达到近似或者超过CRT治疗DCM的获益。目前相关研究国内外没有报道。方法回顾2005-2012年置入CRT/CRT-D病人资料,病例纳入标准:(1)EF(35%,QRS)120ms,最佳药物治疗基础上NYHA分级Ⅲ-Ⅳ级(2)CRT术前均行CAG检查,明确诊断为ICM或者DCM。(3)随访不少于6个月。排除标准:(1)接受PCI治疗时为急性心梗和高危险分层的不稳定性心绞痛的病人。(2)联合治疗的病人CRT与PCI手术相隔超过2个月。(3)合并其他严重疾病或其他原因引起的心力衰竭。分为ICM单纯CRT组(IC组),ICM联合CRT+PCI组(ICP组),DCM(DC)组。符合纳入排除标准的ICP病人全部入组,IC、DC组分别与ICP组通过年龄、性别、随访时间进行2:1配对。分析对比各组手术前后NYHA分级,彩超EF值,左心室收缩末容积(LVESV)变化,并将变化差值进行组间比较。结果入组ICP组14人,配对IC组、DC组各28人。随访时间6-79个月,各组间年龄、性别无统计学差异。3组NYHA分级,EF值,LVESV术前与术后自身对比均有统计学差异(P<0.05)。EF改善值DC组(8.3±4.2%)高于IC组(5.6%±3.4%,P=0.02),ICP组与DC(7.4±3.7%)差异无统计学意义(P=0.50)。LVESV缩小值DC组(27.1±1 1.3%)大于IC组(17.4±12.7ml,P=0.02),ICP组(24.0±11.8%)与DC组差异无统计学意义(P=0.43)。三组间NYHA改善无统计学差异差异(0.54±0.78,0.78±0.70,0.75±0.79,P=0.587)。结论本回顾性研究的结果提示:(1)CRT对于EF《35%,QRS》120ms,NYHA分级Ⅲ-Ⅳ级的ICM和DCM患者的治疗,均能明显改善心功能及心室重构,单纯CRT对ICM的疗效差于DCM,这与之前的临床研究结果相符。(2)另外我们发现,对于符合CRT置入指证的稳定性心绞痛ICM患者,在接受CRT治疗的同时,联合PCI血运重建的治疗,能进一步提高病人远期心功能和缩小LVESV,疗效与DCM相当。我们的研究提示,虽然过往研究认为PCI不能改善慢性稳定性心绞痛病人的预后,但是对于ICM合并严重心力衰竭置入CRT的这一部分特定人群,应该考虑联合PCI治疗改善局部心肌缺血,能进一步获益。

关键词：心脏再同步治疗不稳定性心绞痛危险分层 PCI 急性心梗 CRT 经皮冠状动脉介入术缺血性心肌病

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黛力新联合美托洛尔治疗功能性室性期前收缩的临床疗效观察

黛力新联合美托洛尔治疗功能性室性期前收缩的临床疗效观察

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中华医学会心电生理和起搏分会第十次全国学术年会

作者：刘惠良齐晓勇王秀萍李英肖谷剑党懿河北省人民医院心脏中心

目的功能性室性期前收缩是临床上常见的心律失常,常用的抗心律失常药物对于伴有心悸、胸闷等明显躯体不适症状患者往往不能获得满意疗效。近年来研究表明抑郁、焦虑等精神因素可引起体内自主神经功能紊乱、交感神经活性增强,是功能性室... 详细信息

目的功能性室性期前收缩是临床上常见的心律失常,常用的抗心律失常药物对于伴有心悸、胸闷等明显躯体不适症状患者往往不能获得满意疗效。近年来研究表明抑郁、焦虑等精神因素可引起体内自主神经功能紊乱、交感神经活性增强,是功能性室性期前收缩的主要诱因。本研究观察应用黛力新联合美托洛尔治疗功能性室性期前收缩的临床疗效。方法选择2011年2月至2012年3月期间入住我院心内科患者为研究对象,患者入院后根据病史、体格检查及心脏超声等检查除外器质性心脏病且经Holter检查明确心律失常以室性期前收缩为主。87例患者随机分为试验组和对照组。治疗方案:试验组给予黛力新10mg早午各一次,美托洛尔6.25mgTid,据心率及血压情况可增加剂量;对照组服用盐酸美西律150mg Q6-8h。治疗2周后复查Holter。观察两组患者治疗前后室性期前收缩和症状（对心悸、失眠、胸闷、头昏/头痛、乏力等症状进行评分）的改善情况,并记录不良反应。疗效评定标准:（1）显效:临床症状消失或基本消失,无期前收缩或<10次/h或较原来减少90%以上;（2）有效:临床症状明显改善,期前收缩次数减少50%～90%;（3）无效:临床症状改善不明显,室性期前收缩次数减少<50%或增多。统计学方法SPSS13.0软件包进行统计学处理,计量资料采用均数±标准差及t检验,计数资料采用X检验,以P<0.05为差异有统计学意义。结果 87例患者纳入本研究,试验组45例,其中男15例,女30例,平均年龄（39.4±16.2）岁,期前收缩次数（12852±9656）次/24h;对照组42例,其中男13例,女29例,平均年龄（40.1±15.9）岁,期前收缩次数（12569±10 121）次/24 h。两组在性别构成、年龄、室性期前收缩数量方面差异无统计学意义（P>0.05）。在室性期前收缩的改善方面,试验组显效22例,有效17例,无效6例,总有效率为86.67%;对照组显效17例,有效15例,无效9例,总有效率为78.05%,两组比较差异无明显统计学意义（χ=1.106,P=0.396）。在心悸、失眠、胸闷、头昏/头痛、乏力等症状的改善方面,试验组显效35例,有效8例,无效2例,总有效率为95.56%;对照组显效23例,有效10例,无效8例,总有效率为76.74%,两组比较差异有统计学意义（χ=4.740,P=0.043）。结论功能性室性期前收缩女性发生率明显多于男性,以青壮年及更年期女性多见,多数有劳累、精神紧张、焦虑、饮酒等诱因,β受体阻滞剂联合黛力新治疗效果优于单用美西律治疗效果,且临床症状改善更为明显,安全性更高,对于有明显临床症状而需要治疗的功能性室性期前收缩提供了新的治疗途径。

关键词：功能性室性期前收缩黛力新美托洛尔临床疗效观察

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Clinical significance of the fragmented QRS in the acute myocardial infarction with percutaneous coronary intervention treatment

Clinical significance of the fragmented QRS in the acute myo...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Yanjun liu? Tao Cong,Yunlong Xia,Yanzong Yang First Affiliated Hospital of Dalian Medical University,Dalian 116011,China

Objective Myocardial infarction(MI) patients' infarction myocardial will form part of the scar tissue,and the myocardial scar will directly influence the Ventricular depolarization,and then lead to conduction abnormalities,so fragmented QRS(fQRS) developed on the electro cardio gram(ECG),which on electrocardiography was defined by the presence of single or multiple notches in the R or S wave various RSR'patterns,without a typical bundle branch *** that the fQRS appeared on the ECG of MI patients can forecast the myocardial scar and the mortality,so we explore the clinical significance of acute myocardial infarction(AMI) by percutaneous coronary intervention (PCI) treatment,the fQRS changes on the body surface electrocardiogram of prcoperative and postoperative PCI. Methods 137 cases of patients with diagnosis of AMI(mean age,60.5±12.5 years,109 males,28 females),including 125 cases of ST-segment elevation myocardial infarction(STEMI),and 12 cases of non ST-segment elevation myocardial infarction(NSTEMI),who accept PCI therapy(31 cases accept emergency PCI,61 cases accept optional PCI,and 45 cases refuse to PCI).When they are hospitalized, preoperative and postoperative PCI,after 1 week of PCI,after 2weeks of PCI and after 6 months of PCI, accept conventional ECG examination respectively,so that we can observe the evolution of the *** the same time,we evaluated the patients' level cardiac function and left ventricular ejection fraction (LVEF) by heart *** patients with post-operative PCI were followed up for 6 months. Results In 137 patients,accepted preoperative PCI ECG examination,we developed 14 cases (45.16%) whose ECG appeared the fQRS on the infarction corresponding leads in emergency PCI group, in others groups the number respectively is 35 cases(57.38%)、21 cases(46.67%).The patients who accepted emergency PCI group after two weeks the fQRS incidence on ECG more lower than refused to PCI group(P=0.002);The patients who accepte

关键词： QRS Clinical significance of the fragmented QRS in the acute myocardial infarction with percutaneous coronary intervention treatment ECG PCI

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The use of intracardiac echocardiography and method to guide noncoronary cardiac interventions

The use of intracardiac echocardiography and method to guide...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Tao Guo1,Guicheng Liang2 1.The First Affiliated Hospital in Kunming Medical College 2.The Second Peoples Hospital of Guilin

Objective we sought to assess the utilization and strategy of intracardiac echocardiography(ICE) during noncoronary Cardiac Interventions,to evaluate the feasibility and accuracy guided with and without the help of ICE. Methods A consecutive series of 46 patients were selected from the cardiology department of the first affiliated hospital in Kunming Medical College,who underwent transcatheter closure of interatrial communications,ablations of supraventricular tachycardia and implantations of pacemakers through jugular with ICE(groupl:23patients,12men,llwomen,45.78±21.54 years) and without ICE(group2: 23patients,12men,11 women,49.22±24.79years).We measured the fluoroscopy time and the total procedure time,compared the difficulty of the procedure,locations of the ablation catheters and the complications between the two groups,assessed the feasibility,safety of using ICE for the guidance of noncoronary cardiac interventions.A level of statistical significance was set to P<0.05. Results①All the 23 patients with the ICE guidance in group land the another 23 without ICE were completed the whole procedure,and none sever complements or damage of cardiac structure was observed,②During the procedure for closure of ASD,the diameter measured with ICE and TEE were correlated with each *** predict diameter of ASD with ICE was trended to be larger(by 2～4mm) than the measurement.③During the ablation procedure,ICE could provide imaging e of the movement and position of the sheaths and catheters,guide the transseptal puncture,monitor the damage to adjacent structure,improve the whole procedure.④During the implant procedure,ICE could provide the visualization images of the movement of the cathodes,embedment of screw-in electrodes.⑤The total fluoroscopy time in patients guided with ICE were shorter than those guided with TEE:(13.87±5.63) min versus(25.09±10.32) min. Conclusion①The closure of ASD guided with ICE was superior to those with *** suggest to chose the diameter of t

关键词： The use of intracardiac echocardiography and method to guide noncoronary cardiac interventions

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Quantitative proteomic analysis of respiratory chain related proteins in left and right atrial appendages from patients with mitral valve disease at sinus rhythm and atrial fibrillation by iTRAQ-coupled 2-D LC-MS/MS

Quantitative proteomic analysis of respiratory chain related...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Tao Tu,QimingLiu,Shenghua Zhou,Zhenjiang Liu,XupingLi,Zhongle Bai The Second Xiangya Hospital 410011

Objective To analyze the expression profiles of the respiratory chain related proteins in atrial appendages from atrial fibrillation patients and provide a better understanding of the mechanisms in AF energetic metabolism. Methods We used iTRAQ-coupled 2-D LC-MS/MS technique to screen the expression profiles of the respiratory chain related proteins in left and right atrial appendages from patients with mitral valve disease at sinus rhythm(SR) and ***,one of the differentially expressed candidate cytochrome c oxidase subunit 5B was validated by Western blot and repeated iTRAQ detection to confirm the reliability of iTRAQ-coupled 2-D LC-MS/MS technique. Results A total of 792 unique proteins were quantified,and 49 distinct proteins of them are related to biological *** the 49 distinct proteins related to biological oxidation,22 proteins were down-regulated in SR-LAA when compare to the SR-RAA and 25 proteins were down-regulated in AF-LAA when compare to the *** RAA from AF patients a significant down-regulation of 22 distinct proteins was observed as compared with their corresponding RAA from SR patients.23 different proteins were down-regulated in LAA from AF patients when compared with their corresponding LAA from SR *** of the down-regulated biological oxidation associated proteins in each comparison were components of the respiratory chain in ***,the results of Western blot and the repeated iTRAQ detection were generally consistent with the variations from the first LC-MS/MS analysis. Conclusion Amount of down-regulated respiratory chain related proteins were observed in LAA and RAA from AF patients which suggest impaired energy production in atrium of AF patients.

关键词： iTRAQ Quantitative proteomic analysis of respiratory chain related proteins in left and right atrial appendages from patients with mitral valve disease at sinus rhythm and atrial fibrillation by iTRAQ-coupled 2-D LC-MS/MS

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Effect of renal sympathetic denervation on atrial substrate remodeling and the inducibility of atrial fibrillation

Effect of renal sympathetic denervation on atrial substrate ...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Qingyan Zhao,Zixuan Dai,Shengbo Yu,XuleWang,Jinping Xiao,Congxin Huang Renmin Hospital of Wuhan University 430060

Objective Whether renal sympathetic denervation has effect on atrial substrate remodeling and inducilibity of AF is unknown. Methods Thirteen dogs were randomly divided into control group(7 dogs) and renal artery ablation(RAA) group(6 dogs).In control group,rapid atrial pacing was performed for 7 hours and atrial effective refractory period(AERP) was measured at every hour in the status of ***, pacing was stopped and AF was induced by atrial burst *** RAA group,each renal artery was ablated via femoral artery and dogs were allowed to recover for 6 *** that,the procedure of pacing and electrophysiological measurement was nearly same as in the control *** of autonomic nerve,Cox43 and ANP in pulmonary veins and atrial tissues were measured and levels of TGF- β,Ang II and aldosterone in blood were studied. Results There was a persistent decrease in AERP in both the two groups during atrial *** cessation of pacing,induced number of times and duration of AF was higher in control group than that in RAA *** plasma AngⅡand aldosterone concentration increased significantly after rapid pacing 7 hours in control group(AngⅡ:119.8±31.1 pg/ml vs 185.3±103.5 pg/ml,P<0.01;Aldosterone: 288.2±43.1 pg/ml vs 369.6±109.8 pg/ml,P=0.01).However,compare with before RAA,the plasma AngⅡand aldosterone concentration decreased significantly after rapid pacing in RAA group(AngⅡ: 159.8±28.2 pg/ml vs 93.1±24.6 pg/ml;Aldosterone:272.2±37.4 pg/ml vs 131.3±53.8 pg/ml,P<0.01). Densities of Cox43 and levels of ANP in RAA group were lower than that in control *** was no significant difference in the densities of autonomic nerve and TGF-P between the two groups. Conclusions Renal sympathetic denervation results in atrial substrate remodeling and markedly decrease the inducilibity of AF by inhibiting activity of RAAS.

关键词： Effect of renal sympathetic denervation on atrial substrate remodeling and the inducibility of atrial fibrillation

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Carto-Merge can improve the ablation accuracy for pulmonary vein isolation

Carto-Merge can improve the ablation accuracy for pulmonary ...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Songwen Chen,Gang Chen,Ying Zhuge,Feng Zhang,Shaowen Liu Department of Cardiology,Shanghai First People's Hospital,School of Medicine,Shanghai Jiao Tong University 200000

Objective To quantify the superiority of performing AF ablation guided by Carto-Merge. Methods Forty-eight consecutive AF patients,with four discrete pulmonary veins(PVs),were *** the four separate PVs and the two ipsilateral PVs of each patient,three types of p lanes were defined respectively at the PV *** fluoroscopy planes(FPs) were labeled in t he Carto under the guidance of contrast PVs *** procedure,the ablation planes(A Ps) were defined with the ablation *** image planes(IPs) were labeled in the CT image. Results The angle between the APs and the IPs was significantly smaller than that between the FPs and the IPs with regard to the left inferior PV planes(15.80±7.64°vs.20.69±13.91°,p =0.040) and the left superior PV planes(15.17±7.20°vs.23.21±12.97°,p=0.001).Moreover,com pared to that between the FPs and the IPs,less difference of angle and distance between the AP s and the IPs was demonstrated in the left PV planes(1.36±1.27mmvs.2.89±2.49mm,p<0.001;1 3.91±6.20°vs.30.52±20.97°,p<0.001),the right inferior PV planes(2.58±1.69mmvs.3.51±2.46m m,p<0.05;13.58±8.01°vs.17.94±8.89°,p=0.014),the right superior PV planes(2.10±1.80mmvs. 3.47±2.97mm,p=0.009;11.20±6.75°vs.33.38±15.86°,p<0.001) and the right PV planes(2.33±1.7 lmmvs.4.13±3.47mm,p=0.002;13.27±6.14°vs.26.40±18.89°,p<0.001). Conclusions Navigation by Carto-Merge,less difference of angle and distance between the ablation lesions and the actual PV ostia can be achieved,compared with the guidance of contrast PV angiography.

关键词： Carto-Merge can improve the ablation accuracy for pulmonary vein isolation

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The association between the recurrence rate and different type of endpoint of slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia

The association between the recurrence rate and different ty...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Zhen Yang,Shaobin Jia,Yong Sha,Xuezhong Wang,Weina Guo,Jingjing Wang Heart Center,the General Hospital of Ningxia Medical University 750000

Objective To investigate the recurrence rate of slow pathway ablation in patients with atrioventric ular nodal reentrant tachycardia(AVNRT) in our hospital in the last 3 years,and the association betwee n the recurrence rate and different type of endpoint. Methods We analysed and investigated the 325 patients with AVNRT during the last 3 years of from 2009 to 2011 who received the slow pathway ablation procedure in our *** gross recurre nce rate was calculated,and then,according to the different end point under which the patients were grou ped into four subgroups:complete slow pathway ablation,with a residual jump without echo,with one ec ho and with the combination of a residual jump and echo,the recurrence rate for each group were respecti vely obtained also. Results The mean age was 45+19 years,and male 94(29%),female231(71%).One hundred and se venty-six(54%) patients got complete slow pathway ablation without both residual jump and echo,48(1 5%) getting an endpoint with a residual jump only,51(16%) an endpoint with one echo,50(15%)gettin g an endpoint with a combination of one residual jump and one ***,fourteen patients(4. 5%) had recurrence of *** recurrences rate were 4.0%(7/176) in patients with complete slow pa thway ablation,4.2%(2/48) in patients with a residual jump only,4.0%(2/51) in patients with one echo an d 6.0%(3/50) in patients with the combination of a residual jump and *** was no significant diffe rence in the recurrence rate among these four subgroups. Conclusions As complete slow pathway ablation,the endpoint with a residual jump only,with on e echo and with a combination of one residual jump and one echo are all dependable endpoint for slow pa thway ablation procedure for patients with AVNRT.

关键词： AVNRT The association between the recurrence rate and different type of endpoint of slow pathway ablation in patients with atrioventricular nodal reentrant tachycardia

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Reversal of cardiomyopathy in patients with congestive heart failure secondary to tachycardia

Reversal of cardiomyopathy in patients with congestive heart...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Donghua Zhao,Zhongbo Xiao,Feifei Zhang,Xinhui Peng,Hao Yang, Surong Meng,Jian Peng 南方医科大学附属南方医院心血管内科

Objective Tachycardia-induced cardiomyopathy(TCM) is a reversible cause of heart failure. Little is known of the characteristics of tachycardia associated with the development of left vent ricular(LV) dysfunction and the reversal of cardiomyopathy after cure of *** study is aim to examine the reversal of cardiomyopathy in patients underwent ablation with congestive heart failure secondary to tachycardia. Methods A total of 625 patients underwent radiofrequency ablation for tachycardiarrhymias between January 2009 and July *** analysis was performed to identify patien ts with depressed LV function,defined as a left ventricular ejection fraction NT-proBNP assessme nt was performed before ablation in patients considered to have TCM(n=17).Repeated echocardi ography study and NT-proBNP assessment were measured after a mean follow-up of 3 months.L evels of NT-proBNP before and after ablation were *** of cardiomyopathy was al so assessed. Results The incidence of TCM was 2.7%(12 males;age,35.8±17.1 years).Successful ablation was performed in 16 of 17 patients(94.1%).There was a significant improvement in left ventricular ejection fraction(36.7%±7.5%vs.59.4%±9.7%,P<0.001).The mean LVEDD before treatment was (59.5±8.3)mm(range 43 to 70mm),compared with a mean LVEDD(51.9±7.4 )(range 40 to 67mm, P=0.009) after 3 months *** levels of NT-proBNP decreased after ablation procedure,from 4092.6±3916.6 pg/ml to 478.9±881.9 pg/ml(P<0.001).After successful ablation,ventricular function normalized in 15 of 17(88.2%) of patients at a mean of 3 months. Conclusions Restoration of LV function and reversal of LV remodeling can be achieved wi th successful elimination of tachycardia in the majority of ***-proBNP levels are elevate d in subjects with TCM and decreases sharply after ablation.

关键词： LVEDD Reversal of cardiomyopathy in patients with congestive heart failure secondary to tachycardia

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Intramyocardial injection of induced pluripotent stem cells improves left ventricular function and perfusion:a preclinical study in a porcine model of acute myocardial infarction

Intramyocardial injection of induced pluripotent stem cells ...

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中华医学会心电生理和起搏分会第十次全国学术年会

作者： Xiaorong Li,Fengxiang Zhang,Guixian Song,Weijuan Gu,Minglong Chen,Bing Yang,Yingchuan Yan,Linzhong Zhang,Zidun Wang,Daowu Wang,Kejiang Cao The Department of Cardiology,the First Affiliated Hospital of Nanjing Medical University 210029

Objective Induced pluripotent stem(iPS) cells have potential to differentiate to different cardiovascular cells and repair the injured *** potential therapeutic benefits of iPS cells based treatment have been established in small-animal models of myocardial infarction,but it has not been assessed in large animals. Methods Undifferentiated iPS cells or PBS were injected into the ischemic myocardium induced by 90 minutes occlusion of left anterior descending artery in a porcine *** cardiac function, myocardial perfusion,cell differentiation and tumorigenesis were investigated. Results One week after iPS delivery,global left ventricular ejection fraction(LVEF) decreased significantly in both iPS group and PBS group compared with Sham group(P<0.05,respectively).Six weeks after iPS delivery,LVEF of iPS group improved significantly compared with the PBS group(56.68% vs.50.93%,P=0.04) but still lower than Sham ***,the iPS transplantation improved regional perfusion compared with the PBS injection(19.67%vs.13.67%,P=0.02).The infarct area was significantly smaller in iPS group than PBS group(12.04%vs.15.98%P=0.01).iPS cells engrafted into myocardium can differentiated into vessel cells,which result in increased formation of new vessels in infarcted *** tumors were detected in all pigs for any of the major organs after the morphologic and histopathology examination after iPS transplantation. Conclusions This study shows that direct intramyocardial injection of iPS cell can decreases infarct size,improves left ventricular function and perfusion for an immunosuppressed porcine AMI *** cells may have the potential to be used in the treatments of ischemic heart diseases.

关键词： Intramyocardial injection of induced pluripotent stem cells improves left ventricular function and perfusion:a preclinical study in a porcine model of acute myocardial infarction

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