A case of RCA Calcified CTO post
上海交通大学英语水平考试样题及答案
上海交通大学英语水平考试样题学生姓名：________________ 年级：____________学号：_____________班级代号：_______________ 考试地点: 授课教师：Part I Listening （40％）Section 1 Long Conversations （10％）Directions: In this section, you will hear two long conversations. At the end of each conversation, you will hear five questions. Both the conversations and the questions will be spoken ONLY ONCE. After you hear a question, you must choose the best answer from the four choices.(注意：请把答案写在答题卷上,否则以零分处理)Conversation 11. A) It is exaggerated.B) It is self-important.C) It is a move toward the concepts she teaches.D) It doesn’t give a clear idea of what the department does.2. A) S he didn’t agree with him.B) It illustrates one of her basic ideas.C) The man was an expert on people management.D) It shows how some people do not understand people management.3. A) Worrying can cause needless stress.B) It is important to remember other things as well.C) They can stop you thinking about more basic things.D) We can’t solve them, so there’s no point in worrying.4. A) Completely.B) In no way at all.C) With respect to relationships.D) With respect to professional questions.5. A) By giving them a written warning.B) By sacking people who break the rules.C) By following organizational procedures.D) By understanding the employee’s personal circumstances.Conversation 26. A) Sarcastic.B) Humorous.C) Indifferent.D) Matter-of-fact.7. A) She was talking about suicide literally.B) She was talking about smoking literally.C) She wanted to be left alone by saying so.D) She was talking about both smoking and her life.8. A) None of them helped her positively.B) Her mother was too busy to be around her.C) Her father was the role model she followed.D) Her friends always cheered her up when she was feeling down.9. A) She feels less hopeless.B) She feels she has many dreams.C) She feels she is not part of this world any more.D) She feels that her life took the wrong way in the past, but now she wants tomake a change for the better.10. A) He is a psychiatrist.B) He is a school teacher.C) He is a policeman in disguise.D) He is a stranger she just ran into by chance.Section 2 Compound Dictation （10％）Directions:In this section, you will hear a passage twice. You have its script in the following, but with eleven blanks in it. You are required to fill in the first eight blanks with the exact words you have just heard. For the last three blanks, you can either use the exact words you have just heard or write down the main points in your own words. Remember, there will be a pause for the last three blanks in the second reading. (注意：请把答案写在答题卷上,否则以零分处理)The medical center at New York University is one of the clinical sites for the study.Thirty-nine-year-old Denise Harris is helping researchers gain a better understanding of the brain. She suffers from epilepsy, and doctors are monitoring her seizures in the hope of performing an operation to minimize them. Her head is 1) ____________. Wires protruding from the side are attached to electrodes implanted in her brain. Harris says doctors are monitoring her to see whether she is a good candidate for surgery."I've been on many medications throughout my life and after a while, they don'twork," said Denise Harris. "I still get seizures. So now, when they remove the part that the seizure is 2) ____________ from, it's supposed to stop."But while Harris is in the hospital, she is also helping scientists understand how the brain comprehends and uses language. For the study, researchers are monitoring the implanted 3) ____________ on a part of the frontal lobe called Broca's area, named after 19th century French physician Pierre Paul Broca. He was the first doctor to recognize the major role of that area in language.Through the implant process, called Intra-cranial Electrophysiology, or ICE, the researchers have found that Broca's area processes three different language functions in 4) ____________ –– within a quarter of a second. It is the first time the technique has been used to document how the brain processes grammar and produces words.Eric Halgren of the University of California, San Diego, School of Medicine, is one of the 5) ____________ investigators of the study."What we were able to find was that within a centimeter, around less than an inch, certainly, and probably half an inch, there were different regions - perhaps they 6) ____________ some –– but they were doing, at different times, different processes, all within this small area."The first function deals with recognizing a word, the second with understanding the word's context in a sentence, and the third lets us 7) ____________ the word by speaking.Harvard University brain expert Steven Pinker is another of the study's authors. Ned Sahin, a 8) ____________ fellow at Harvard and the University of California, San Diego, School of Medicine was the first author of the paper outlining the work, which was published in the journal Science.According to Sahin, 9)___________________________________________ _____________________________________________________________________ _____________."Nearly every introductory textbook as well as people practicing in the field in speech pathology, for instance, teach and believe that 10) ______________________ ____________________________________________________________________ _______________ ––Broca's area and Wernicke's area, where Broca's area is responsible for producing, for speaking, and Wernicke's for comprehending," said Sahin.This study shows that Broca's area is involved in both speaking and comprehension, illustrating that parts of the brain perform more than one task."Here's an example of one relatively small part of the brain that's doing three very different things at three different times, but all within the space of a quarter of a second."But Eric Halgren points out that despite our growing knowledge, much about the human brain remains unknown."How does this hunk of flesh, which is not much different from a muscle –– it's just a bowl of porridge –– how does it produce the mind? It's a total mystery".He says11) ______________________________________________________ ________________________________________.Section 3 Short-answer Questions （10％）Directions:In this section, you will hear a passage ONLY ONCE. In the following you have five questions. You are required to answer these questions with as few words as possible, in any case, no more than 25 words.(注意：请把答案写在答题卷上,否则以零分处理)1) What is the basic idea about intercultural competence?2) What is listed as one of the most important criteria for intercultural competence?3) What is considered as offensive in the Arab countries according to the woman?4) What mistake did the woman make when conducting business in Russia?5) What is the advice the woman gave in the end?Section 4: Listening and Translating （10％）Directions:In this section you are going to hear five short passages. You will hear them ONLY ONCE. In each of these passages some of the sentences are already printed. You are required to translate the missing parts into Chinese. After each of the passages there will be a pause lasting one and a half minutes. The pause is intended for you to do the translation.(注意：请把答案写在答题卷上,否则以零分处理)1) Our development agenda will also focus on women as drivers of economic growthand social stability. Women have long comprised the majority of the world’s unhealthy, unschooled, and underfed. They are also the bulk of the world’s poor.__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2) About 80 percent of Australians live in coastal areas. There are fears that somelow-lying communities may have to be abandoned in years to come because of flooding and erosion. And with higher sea levels, heavy rains and massive tides known as storm surges, which often accompany tropical storms, can do unexpected damage. _________________________________________________________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3) It is no coincidence that the relationship between our countries has accompanied aperiod of positive change. ___________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4) And yet the success of that engagement depends upon understanding -- onsustaining an open dialogue, and learning about one another and from one another. For just as that American table tennis player pointed out, we share much in common as human beings, but our countries are different in certain ways. _____________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 5) For a variety of reasons, production of the H1N1 vaccine has lagged behinddemand. The vaccine for the so-called swine flu is made in the same way as the seasonal flu vaccine - in chicken eggs. But the government's top infectious disease expert, Dr. Anthony Fauci, said the goal is to perfect new ways to make a vaccine."What we really want to do is get away from that and get it to be 21st century technology - molecular biology, recombinant DNA technology, where you have very good control over the process. It's rapid, it's consistent, and it proves to be something that we can rely on." _____________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Part II Integrated Reading (30%)Section 1 Banked Cloze (10%)Directions: In this section, there is a passage with ten blanks. You are required toselect one word for each blank from a list of choices given in a wordbank following the passage. Read the passage through carefully beforemaking your choices. You may not use any of the words in the bankmore than once. Give your answers to the questions on your ANSWERSHEET.Attention:You need to change the forms of the words in the word bank where necessary.(注意：请把答案写在答题卷上,否则以零分处理)A name might tell you something about a person's background. Names can be1) __________ of class and race. Data show African Americans are far more likely than other 2) __________ groups to give their children uncommon names. White people tend to 3) ________ more familiar names that were formerly popular with more affluent white people.The new study purports to show a link between name and outcome of life: The more 4) _________ your name, the more likely you are to land in juvenile hall. That's because we know that boys with uncommon names are more likely to come from a socio-economically 5) _________ background, which means that they also are more likely to get involved with crime. Even the researchers readily admit that it's not a name alone that 6）_______ a child's outcome, but rather the circumstance underlying the name.The researchers first assigned a popularity score to boys' names, based on how often they showed up in birth records in an undisclosed state from 1987 to 1991. Michael, the No. 1 boy's name, had a Popular Name Index score of 100; names such as Malcolm and Preston had index scores of 1. The researchers then assessed names of young men born during that time who landed in the juvenile justice system. They found that only half had a rating higher than 11. By 7) __________, in the general population, half of the names scored higher than 20. "A 10% increase in the popularity of a name is associated with a 3.7% 8) _________ in the number of juvenile delinquents who have that name."Still, the study theorizes that teenagers named Malcolm might also 9) ___________ because their peers treat them differently or they just don't like their names. And since the study's release last week, the name-crime 10) ___________ has been written or talked about in major media outlets.Section 2 True or False Judgement & Sentence Completion (10%)Directions:In this part, you will find 7 statements and 3 incomplete sentences followed by the reading passage.For questions 1-7, markY (for YES) if the statement agrees with the information given in the passage; N (for NO) if the statement contradicts the information given in the passage;For questions 8-10, complete the sentences with the information given in the passage. Attention: For questions 1-7, one more point will be deducted if you do n’t answer each one correctly.(注意: 1-7题中每答错一题倒扣1分, 不答不得分,答对得1分; 请把答案写在答题卷上,否则以零分处理)Who are smarter, men or women? It's a topic of common –– and often comic ––contemplation, but it has also become a serious policy issue for colleges and students in the United States.After years of concentrated effort to raise the academic achievement of girls, who in previous decades had often received less attention in the classroom and been steered away from college-prep courses, the nation can brag that female students have progressed tremendously. Though still underrepresented in calculus and other advanced-level science and math courses in high school, women now outnumber men applying to and graduating from college –– so much so that it appears some colleges are giving male applicants an admissions boost. As a result, the U.S. Commission on Civil Rights is examining whether colleges are engaging in widespread discrimination against women in an effort to balance their male and female populations.Consider some of the numbers at leading schools: At Vassar College in New York State, a formerly all-women's college that is still 60% female, more than two-thirds of the applicants last year were women. The college accepted 35% of the men who applied, compared with 20% of the women. Locally, elite Pomona College accepted 21% of male applicants for this year's freshman class, but only 13% of female applicants. At Virginia's College of William & Mary, 7,652 women applied for this year's freshman class, compared with 4,457 male applicants. Yet the numbers of each who gained admittance were nearly the same. That's because the college accepted 45% of the men and only 27% of the women.A 2007 analysis by U.S. News & World Report, based on the data sent by colleges for the magazine's annual rankings, found that the admissions rate for women averaged 13 percentage points lower than that for men. But percentages don't tell thewhole story. It could be that the men were stronger candidates, or they might have applied in areas of engineering and science where women's numbers are still lower. But such justifications, even if true, are unlikely to fully explain these numbers. At schools such as the University of California, where admissions rely overwhelmingly on statistical measures of academic achievement such as grades and test scores, the disparities don't appear. Far more women than men applied to UCLA ––the UC's most selective campus ––last year. The university accepted about the same percentage of each, with a slight edge to the women. As a result, the freshman class has close to 800 more women than men.In recent years, several college leaders have admitted that their institutions give a boost to male applicants to maintain gender balance on campus. Most students of either sex, they point out, prefer such balance. If Vassar accepted equal percentages of each sex, women would outnumber men by more than 2 to 1.Jennifer Delahunty Britz, the dean of admissions at Kenyon College in Ohio, a formerly all-male school, brought the matter to broad public attention in 2006 with an Op-Ed article for the New York Times describing the dilemma of her admissions office. "What messages are we sending young women that they must . . . be even more accomplished than men to gain admission to the nation's top colleges?" New York Times has long favored allowing colleges to use race as an admissions factor in order to diversify student populations.She also wrote that exposure to people of different backgrounds and viewpoints better educates all students –– not just those given a leg up. We are not in favor of accepting underqualified or clearly inferior students for the sake of diversity. But most colleges are inundated with applications from students who more than meet their standards; the differences among many of them are slight. It makes sense for colleges to pick a balanced population from within this group. At the same time, admissions officers should avoid rigid notions of what constitutes enough men on campus. It's not harming UCLA, or destroying college social life, to admit somewhat more women than men.Even if the Civil Rights Commission finds pervasive gender discrimination inadmissions, there's little it could do about the situation. Such discrimination –– though not racial discrimination –– is legal for undergraduate admissions at private, nonprofit colleges, even those that receive federal funding. Commission documents on the inquiry suggest that colleges could find more "gender-neutral" ways of balancing their student numbers, perhaps by offering programs and extracurricular activities that attract men.Those might work for some schools but won't change the overall scenario. Not with college populations composed of 57% women nationwide. The issue we'd like the Commission on Civil Rights to investigate is: What's happening with the education of U.S. boys? Why are so few of them applying to and graduating from college?Theories and arguments abound. Some say that boys are more active and thus less able to sit still for long periods –– and as a result, more likely to be categorized as having attention deficit / hyperactivity disorder or needing special education. A 2008 study by researchers at Northwestern University found that when girls are involved in a language-related task –– such as reading –– they show more activity in areas of the brain involved in encoding language. Boys use more sensory information to do linguistic tasks. The study suggests boys might do better if they were taught language and arts in different ways. Race is a factor as well. The gender gap is starker among African American and Latino students.There may be no one reason –– or solution. But figuring out ways to help boys achieve in school is a better response to the gender gap than making it easier for them to get into college later.1. As a result of the effort to raise the academic achievement of the girls for years, the girls have exceeded boys tremendously in all courses in colleges except calculus and other advanced-level science and math courses.2. Female students are facing the low admission rate because some colleges areengaging in discrimination against women to achieve the balance of their male and female populations.3. Although the men were traditionally considered stronger candidates in areas of engineering and science, the admission rate for men in these areas is still lower than that for women.4. Women have outnumbered men in gaining admittance in UCLA’s freshman class this year because their admissions greatly rely on grades and test scores of their applicants.5. Some college leaders hold that most college students prefer their policy of maintaining gender balance by admitting equal percentages of each sex.6. The dilemma of the dean of admissions at Kenyon College is whether to use gender as an admissions factor in order to achieve gender balance or use race as an admissions factor in order to diversify student populations.7. According to Jennifer Delahunty Britz, it is reasonable for colleges to pick a balanced population from the candidates who more than meet their standards.8. Actually the Civil Rights Commission can do little to change the situation of discrimination in college admission because such discrimination is ____________________________________________________________________.9. The study shows that in doing linguistic tasks the boys use more sensory information, the girls show more _________________________________________.10. Despite various theories and arguments about why so few boys apply to and graduate from college, the better solution to the problem is to____________________________________________________________________. Section 3 Cloze (10%)Directions:In this section there are 20 blanks in the following passage. For each blank there are four choices marked A), B), C) and D) on the right side of the paper. You should choose the ONE that best fits into the passage. Give your answers to the questions on your ANSWER SHEET.(注意：请把答案写在答题卷上,否则以零分处理)Part III Writing (30%)Section A (10%)In this Section,, you have 15 minutes to write an essay on the following topic. You should write at least 100 words. （请务必写在答题卷上，否则以零分处理）Your cousin, Ming Zhang, is going to take the national entrance examination to college in June. However, he is under great pressure and simply can’t concentrate on his study. Please drop him a note of about 100 words, giving him some tips as to how to deal with this situation.Section B (20%)In this Section, you have 30 minutes to write an essay on the following topic. You should write at least 200 words. （请务必写在答题卷上，否则以零分处理）Many college students complain of their heavy course load. They think some courses offered are time-consuming and not very useful. What do you think of the complaints? S hould college students’ opinions be considered in curriculum development and policy-making? Please write an essay of about 200 words to express your opinion and explain why with specific reasons.上海交通大学英语水平考试答题卷学生姓名：_____________ 年级：____________学号：_____________班级代号：___ 考试地点: 授课教师：分数__________ Part I Listening (40%)1) ___________ 2) _____________ 3) ___________ 4)_____________5)____________6) _____________ 7) ____________ 8) _____________9) ____________________________________________________________________________________________________________________________________10)___________________________________________________________________________________________________________________________________11) ____________________________________________________________________________________________________________________________________ Section 3 Short-answer Questions （10％）1)_____________________________________________________________________________________________________________________________________2)____________________________________________________________________________________________________________________________________3)____________________________________________________________________________________________________________________________________4)____________________________________________________________________________________________________________________________________5)____________________________________________________________________________________________________________________________________Section 4 Listening and Translating （10％）1)______________________________________________________________________________________________________________________________________________________________________________________________________ 2)____________________________________________________________________________________________________________________________________ __________________________________________________________________ 3)____________________________________________________________________________________________________________________________________ __________________________________________________________________4)______________________________________________________________________________________________________________________________________________________________________________________________________ 5) _______________________________________________________________________________________________________________________________________________________________________________________________________ Part II Integrated Reading (30%) Section 1 Banked Cloze （10％） 1) _________ 2) ___________ 3) ___________ 4)_______ 5)__________ 6) __________ 7) ____________ 8) ___________ 9)_________ 10) _________ Section 2 True or False Judgement & Sentence Completion （10％） 1) _____ 2) _______ 3) _______ 4) ________ 5) _____ 6)_____ 7)_____ 8) _____________________________________________________________ 9) _____________________________________________________________ 10) ____________________________________________________________Part III Writing (30%) （请将作文写在答题卷背面)Section A （10%） Your cousin, Ming Zhang, is going to take the national entrance examination to college in June. However, he is under great pressure and simply can’t concentrate on his study. Please drop him a note of about 100 words, giving him some tips as to how to deal with this situation. Section B （10%） Many college students complain of their heavy course load. They think some courses offered aretime-consuming andnot very useful. What do you think of the complaints? Should college students’ opinions be considered in curriculum development and policy-making? Please write an essay of about 200 words to express your opinion and explain why with specific reasons.Key 答案：Section 1: 1-5 CBBDC 6-10 ADACASection 2:1)Bandaged 2）triggered 3）probes 4）succession 5）principal 6）overlap 7）articulate 8) postdoctoral 9）scientists have known for some time that conventional explanations for how parts of the brain work need to be revised10)there is a separation of tasks and a division of labor between two very different parts of the brain11)brain studies are shedding light on the pieces of the puzzle and might one day solve the mystery Section 3:1) I t’s basically the ability to c ommunicate successfully with people of other cultures. (2 points)2) Sensitivity to other cultures (1 point)3) Showing the bottom of your shoe or foot when crossing your legs (2 points)4) She did not remove her gloves when shaking hands with a business associate in Russia( without realising that this is considered impolite). (2 points)5) Never make false assumptions about other cultures, and never lack sensitivity. Be open tolearning about new cultures. And learn the local language. (3 points)Section 4:1) 全球经济的衰退对妇女和女孩所产生的影响尤其严重，这进而又波及到家庭、社区、乃至地区。
冠状动脉钙化成因及治疗新进展.doc
冠状动脉钙化成因及治疗新进展.冠状动脉钙化成因及治疗新进展作者：周玉杰[1]柴萌[1]单位：首都医科大学附属北京安贞医院[1]文章号：W109198XXXX年来证实血管钙化是一个与骨发育类似的主动的、可预防和可逆转的高度可调控的生物学过程。
许多因素都参与了血管钙化的发病过程。
冠状动脉钙化(Coronary artery calcification, CAC)可导致血管僵硬度增加，顺应性降低，心肌灌注受损[1]。
临床研究表明, CAC程度能够预测心肌梗死和突发冠脉事件死亡的危险[2,3]，无论在普通人群还是进行血运重建的冠心病患者，CAC的出现都提示预后不良。
目前其发病机制尚未完全阐明, 近年来证实血管钙化是一个与骨发育类似的主动的、可预防和可逆转的高度可调控的生物学过程。
许多因素都参与了血管钙化的发病过程。
CAC病理生理学及危险因素血管钙化是一个类似于生理性矿化的主动代谢过程，可发生于几乎全身的血管床，并同时累及血管的中膜和内膜。
血管中膜钙化多与年龄、糖尿病、终末期肾病相关，既往认为它对机体起保护作用，但近年来证实，中膜钙化导致动脉硬化，增加心血管不良事件。
血管内膜钙化则与动脉粥样硬化、炎症关系密切，炎症介质和高脂质含量在动脉粥样硬化损伤中诱导平滑肌细胞成骨化[4]。
CAC的程度与斑块负担密切相关[5]，微钙化如发生于覆盖动脉粥样硬化斑块的脂质核心的纤维帽，可引起微裂缝和斑块破裂[6]；钙化结节可破坏纤维帽结构,导致血栓形成[7]。
反复的斑块破裂、出血、愈合可导致阻塞性纤维钙化斑块形成,常常见于稳定心绞痛型和猝死型冠心病患者[7, 8]。
许多危险因素可影响CAC(表1)的发生、发展。
有研究甚至发现，CAC可能与常见的等位基因变异(如染色体9 p21)和磷酸代谢的罕见突变相关[9 – 11]。
一些微小核糖核酸可诱导平滑肌细胞向成骨样表型转变[12]，也与CAC的进展相关。
表1 CAC的危险因素危险因素内膜钙化中膜钙化年龄是是糖尿病是是高脂血症是否高血压是否男性是否吸烟是否肾脏疾病GFR否是高钙否是高磷是是PTH 否否透析时间否是GFR=肾小球滤过率，PTH=甲状旁腺激素慢性肾病患者心血管发病率和死亡率高很大程度上是由于存在CAC及动脉粥样硬化。
tpo-25听力解析
TPO-25听力解析Conversation 1(场景分类——询问课程)Listen to a conversation between a student and his academic advisor.Academic AdvisorHi Mark, what can I do for you?Student(1)I'm just filling out this approval for graduation form for the Dean's office and …I don't know,I hope I will be able to graduate next semester.Academic AdvisorWell, as long as you've met the departmental requirements and you submit the form on time, you Shouldn't have any problem. Make sure you include all the classes you will have taken for your degree in finance and the electives too.StudentYeah, but as I look over the form, I got confused because the way, uh, they've changed the requirements, so, now I'm not sure I'll qualify to graduate next semester. I know I would've before, under the old requirements.Academic Advisor(2)Well, when the business department changed the curriculum to include more courses in international business to dwell, because of the increasing globalization of business. (3)We made sure that students would finish to their second year, that is those who were in their third or fourth year wouldn't be affected. The new rules only apply to students in their first or second year.StudentOh, that's good to know. Uh, the department's hiring new faculty too, I heard, to teach some of the new courses? But, I want to…Academic AdvisorYes, one new faculty member has been hired. She'll be teaching International Banking as a matter of fact.StudentActually, that's what I wanted to ask about, International Banking. I took International Banking 1, but I never took International Banking 2. It used to be that the second semester of International Banking was an elective, but now it says it's a required class.Academic AdvisorYes, but that's one of the recent changes, so…StudentOh, oh, okay. Oh, and I am planning to take a management course next semester but I don't know if it's, if it will count toward my major.Academic AdvisorWhat's the course?StudentOrganizational behavior.Academic AdvisorYes, that'll count toward your major, that's a difficult class you know, but well worth it. So it looks like you'll have all the required classes you need, you should be just fine. (5)Uh, I assume you've taken a seminar?StudentYeah, I took the marketing seminar.Academic AdvisorOK, you're looking good. Just to be on the safe side, why don't you talk to someone in the Dean's office before you give them the form?StudentOK, so should I just explain to them that even though one of these classes got changed from an elective to a required class I don't have to take it?Academic Advisor(4)Yes, you've met the requirements for graduation, and if there's something I need to do, if, if I need to write a letter or whatever, just let me know.StudentOK, thanks. I'll let you know if I need that letter.词汇：submit v. 递交curriculum n. 课程elective n. 选修课required adj. 必修的seminar n. 研讨班eligibility n. 合格题目：1. What is the conversation mainly about?*The student's eligibility to graduate next semesterThe student's difficulties in registering for classesA difficult class the student must take next semester Possible elective choices in the student's degree program2. According to the woman, why was the program's curriculum changed?To attract more international students to the program*To reflect the growing importance of international businessTo take advantage of the expertise of new faculty membersTo give students a stronger background in management3. What does the woman imply about the new departmental requirements?*They will not affect the student's plans for graduationThey will not be officially approved by the department until next yearThey will be limited to students specializing in the international businessThey will be similar to recent changes made in other departments at the university4. Why does the woman mention writing a letter?To point out the best way for the student to contact the dean's officeTo confirm that a personal letter is a graduation requirement*To indicate that she is willing to provide the student with further assistanceTo emphasize that the student will need special permission to graduate5. Why does the woman say thisTo suggest that the student has not fulfilled all of his requirementsTo indicate one of the new graduation requirementsTo find out the student's opinion about a particular class*To be sure that the student has taken a required classLecture 1(学科分类——生物学)Narrow: Listen to a part of a lecture in a conservation biology classWhen consequence of global warming is extinction, there is compelling evidence that global warming will be a significant driver of many plant and animal extinctions in this century. (6)So we are considering various strategies to help some threaten species survive this unprecedented, this warming trend which, as you know, is caused mainly by green houses gases produced by the burning of fossil fuels.The most radical strategy being debated among conservation biologists is Assisted migration. Assisted migration means picking up members of the species or members of a group of interdependent species and physically moving or translocating them. Translocating threatened species to a cooler place to higher latitudes or higher elevations for example.Now migrations are natural survival strategy. (7)Over the past 2 million years, colder glacial periods have alternated with warmer inter-glacial periods. And so in response to this gradual climatic swings, some species have shifted their ranges hundreds of kilometers. So perhaps youare wondering why not let nature take its course now. Well we can't. The main problem is today's fragmented habitats.During previous inter-glacial periods, when glaciers were treated, they left behind open land in their wakes. Today human development has paved over much of the natural world. Ecosystems are fragmented. Housing developments, highways, and cities have placed or sliced through forests and prairies . There are few corders left for species to migrate through without help.So conservationists are trying to save as many species as possible. Now, assisted migration could become a viable part of our rescue strategy, but there are a number of uncertainties and risks. Without more research we can't predict if assisted migration will work for any given species. A translocated species could die out from like a food for example.At the other extreme, we might successfully translocate the species but within five or ten years, that species could proliferate and become an invasive species. Like a non-native plant that chokes out native plants by hogging the nutrients in the soil. (8)Translocated animals can become invasive, too. It happened in Australia. The cane toad was introduced back in 1935 to control an insect pest that was destroying Australia sugar cane plantations. But the cane toad itself became a pest and it destroyed much of the wild life on that continent.(9)Also, many species are interdependent, intimately connected to one another. Like animals that eat a certain plant and that plant relys on a certain fungus to help it get nutrients from soil. And on a certain insect for pollination, we probably have to translocate entire networks of species. And it's hard to know where to draw the line. And in addition to all that it's not even cleared that the assisted migration or any migration for that matter will help at least for some species. Earth was already at one of its warm inter-glacial periods when we started burning fossil fuels.And in the 21st century, global temperatures are expected to rise two to six degrees. That rate of heatings far greater than during the last glacial retreat some twelve thousand years ago. Whether to use the assisted migration? This debate is mostly within the biology community right now. (10)But the ultimate decision makers, in United States at least, will be the government agencies that manage natural resources. Assisted migration really needs this level of oversight and soon.Currently there is no public policy on using assisted migration to help species survive climate change. People aren't even required to see permits to move plants or invertebrate animals around as long as they are not classified as pests. In one case a group of conservationists has already take it upon itself to try on their own to save the endangered tree, the Florida torreya tree through assisted migration. There is only about a thousand individual Florida torreyas left and global warming is expected to significantly reduce or eliminate this tree's habitat. (11)So this conservation group wants to translocate seedlings, Florida torreyas seedlings, 500 kilometres north, in order to expand the species' range. The group believes that its effort is justified, but I and many other biologists will be watching very closely how this maverick group makes out because, like I said there could be unintended consequences.词汇：compelling adj. 引人注目的strategy n. 策略unprecedented adj. 空前的interdependent adj. 相互依赖的translocate v. 改变……的位置latitude n. 纬度elevation n. 海拔glacier n. 冰川alternate with 相间swing n. 摆动fragmented adj. 成碎片的wake n. 尾迹pave v. 安排prairie n. 大草原conservationist n. 自然资源保护者rescue v. 营救proliferate v. 激增invasive adj. 侵略性的choke v. 使窒息hog v. 贪婪索取continent n. 洲intimately adv. 亲密地fungus n. 细菌pollination n. 授粉ultimate adj. 最终的oversight v. 监督seedling n. 幼苗maverick adj. 行为不合常规的题目：6. What is the main purpose of the lecture?To explain the government's role in the regulating assisted migrationTo discuss ways in which plants and animals adapt to climate change*To discuss a controversial approach to conserving plant and animal speciesTo describe a recently discovered consequence of global warming7. According to the professor, what problem is assisted migration intended to overcome?*To diminishing amount of undeveloped land that species can migrate throughThe relative lack of nutrients available in cooler latitudes and higher elevationsThe increase in alternations between cool and warm periodsCompetition from other species in certain native habitats8. What point does the professor make when she discusses the cane toad?Translocated species sometimes die out from lack of food*Translocated species may spread too quickly in their new environmentSeveral techniques are available to achieve assisted migrationAnimal species are often easier to translocate than plant species are9. What does the professor imply when she mentions translocating networking of species?*There are aspects of interdependency that are unknownSome species evolve in ways that help them survive in new habitatsIt is difficult to know how far to move a network of species from its native habitatMany assisted-migration plans should involve the translocation of just one species10. What does the professor imply about the government's role in regulating assisted migration in the United States?The government should continue to encourage assisted migrationThe government has created policies that have proved unhelpfulThe government should follow the example set by other countries*The government needs to increase its involvement in the issue11. What is the professor's attitude toward the effort to save the Florida torreya?She is glad that some conservationists are willing to take a chance on assisted migration*She is concerned because it may have unintended consequencesShe is surprised because other species are more endangered than Florida torreya isShe expects the effort will have to be repeated several times before it succeedsLecture 2(学科分类——艺术)Narrow: Listen to part of a lecture in a music history classProfessor: So, I just finish reviewing your papers on the influence of nationalism of composers' music. And initially, I was surprised that none of you chose to write about Bella Bartok. That isn't until I remembered that we haven't had a chance to discuss him in the class yet. He was a wonderful and ground-breaking composer. Bella Bartok was a Hungarian whose life stretched from the late 19th century to the middle of 20th century. But he was not a fan of the romantic style of music that was popular in his homeland during his youth.Female student: Wait, Hungary wasn't a country in 1900, was it?Professor: You're right, I should have been clear. Bartok was born in Austria Hungary, a nation that broke apart when he was 40 years old. Actually the town where he was born is presently part of Romania. The political history of that region is complex. Suffice to say Bartok is generally known has a Hungarian composer.So, during Bartok's youth, the music played in the concert halls of the Austria Hungary was dominated by romantic pieces by mostly German composers. We discussed the romantic style last week. These pieces were long and lyrical. They were meant to have a sort of grandeur about them.(13)And in the early 1900, composers worked in the romantic style were most popular in Austria Hungary. But Bartok, he was part of the musical community that was trying to change this. And it let him to, well, the first thing ... was to led him travel, he looked to the countryside for the music of the farmers and the people who lived in the small towns. And their music, well, you can say he discovered the music that was popular in those areas.Male student : What do you mean?Professor: Well, all the music we've been talking about the past few weeks, it really was all in the cities. That's where the composers and the orchestras were. Out in remote areas of the countryside in rural locations, music was more traditional. The same song was enjoyed by previous generations. Bartok went out, he traveled through a significant portion of eastern Europe actually.(14)He roamed the countryside and listened to the music heard in the small towns and all sorts of celebrations.He attended weddings, dances and religious ceremony where he heard a very different sort of music from the romantic stuff being played in the concert halls in the cities. The music he heard is what we considered folk music.Male student : And any of those same songs played in the concert halls?Professor: No.(15) At first, he went around to document the folk music. He really wanted to make sure that folk songs were written down before they disappeared. In fact, Bartok did start out a trip thinking himself as a composer. He was an ethnomusicologist, and he studied the traditional music of the region. But it turns out that what were later had but notable influence on the European music on the whole, was the way Bartok used the elements he heard in folk songs in his own compositions. He adopted a number of elements from what he heard, like unusual rhythms and he liked to use Gelli Sandor as his home mark, which you probably got from listening to Croatian folk music. (17)Gelli Sandor is, well, I've got a recording of Bartok here. Let's wait until the music is fresh in our minds. Suzi, do you have something you want to ask first?Female student: Yeah. Before, you mentioned nationalism, and ...Professor: Ah, right! Yes. (16)When Bartok kept new pieces performed, their folk music routes made them instantly popular. It happened to be a time of strong nationalism in Austria, Hungary. So his composition came just at the right time. It became very successful there. Particularly, when Bartok's ballet The Wooden Prince opened, it was a great excitement for music that included musical elements from local folk songs, music that reflected the region's musical traditions.However, as popular as Bartok was in his homeland, he did not get much international recognition during his lifetime.词汇：nationalism n. 民族主义ground-breaking adj. 开拓性的suffice to say 可以说dominate v. 支配lyrical adj. 抒情的grandeur n. 宏伟orchestra n. 管弦乐队rural adj. 农村的roam v. 漫步celebration n. 庆典ethnomusicologist n. 人种音乐学家rhythm n. 节奏题目：12 What is the lecture mainly about?The influence of the Romantic style of music on eastern European composersThe relationship between nationalism and popular music in the early 1900sThe popularity of folk music in Austria-Hungary during the early 1900s*The influence of folk music on the compositions of one Hungarian composer13. What does the professor imply about romantic music in Austria-Hungary in the early 1900s?It was not as popular there as it was in other European countries*It motivated Bartok to listen to other types of musicIt was listened to in the countryside more than it was in the citiesIts popularity was due to the work of Bartok and other ethnomusicologists14. Why does the professor mention local celebrations in the countryside?To show how folk music influenced composers throughout Eastern EuropeTo give an example of when performances of Bartok music took place*To give an example of occasions when Bartok had an opportunity to hear folk musicTo talk about why romantic music was popular in the countryside15. What was Bartok original goal when he started to travel through eastern Europe?To promote his ballet, the wooden prince*To document the local popular musicTo discover which musical elements were popular in all countriesTo find unusual musical elements he could use in his own compositions16. According to the professor, why was Bartok music popular in Austria-Hungary?Bartok music was considered more sophisticated than other concert-hall music*Bartok compositions incorporated music from the local culturePeople were familiar with the Romantic elements Bartok included in his musicBartok took advantage of the popularity of ballet there and wrote many new ballets17. What does the professor mean when he says this:He wants to change the topic of discussionHe wants to acknowledge that the students may not be familiar with Bartok's musicHe believes the students should already be familiar with the term 'glissando'*He will use an example of glissando to help define the termConversation 2(场景分类——老师办公室)Listen to a conversation between a student and his biology professor.Student(2)Well, you know, I'm reading the papers about whales, and the path they travel as they swim through the ocean, their migration patterns.ProfessorYes, I remember.Student(1)Well, I was thinking about it, and I realized I don't understand how they hold their breaths under water. It's a little crazy for me to be writing a paper about migration patterns without actually knowing how they stay underwater for so long.ProfessorDid you do any research to find out how they do it?StudentYeah, I did. I searched on the Internet, and there was a lot of information about whales, their habitats, the way they communicate, you know, their songs. But if there was anything about whales and how they hold their breaths, I missed it. I've got a bunch of books. Actually, I've got so much information, it's a little overwhelming.ProfessorI'm surprised that there is nothing about it in any of those books.StudentWell, to be honest, I've only skimmed them so far. I'm still working on finding sources.Professor(3)OK, I know I encourage everyone in class to look at a substantial number of sources, but I don't want you to get overwhelmed. (4)Looking at a number of sources gives you a good knowledge base, but students only have a limited amount of time to work on each paper. I don't expect you to read a dozen of books on whales for this assignment. Focus on just a few.StudentOK, thanks.ProfessorYou know, since you're already here, I can give you a quick summary of how whales hold their breaths underwater. It's just a matter of certain adaptations in their anatomies, specifically in their circulatory system.StudentSo, the blood flow was what makes the difference?ProfessorYes, and in a couple of ways. First, blood makes up a larger share of whale's weight than any other mammals.StudentSo they can store more oxygen because they have more blood?ProfessorYes, but that's only part of it. They also have a greater capacity than land animals to store oxygen in their blood.StudentSo how does having more oxygen in their blood help them stay underwater longer?ProfessorIt's the way the whale's blood carries oxygen to the rest of its body. Whales carefully conserve their oxygen when underwater in a couple of ways. (5)When a whale dives, its metabolic weight drops, causing its heart beat to slow down. And the blood flows to its muscles and some of its none-vital organs, like its kidneys, is also cut off. Whales muscles and none-vital organs are able to function without oxygen for an extended period of time.StudentI see, well, now I can concentrate on my topic.词汇：migration n. 迁移overwhelming adj. 压倒性的substantial adj. 大量的anatomy n. 身体结构circulatory system 循环系统metabolic adj. 新陈代谢的kidney n. 肾脏题目：1. Why does the man go to see the professor?To find out how to distinguish between different types of whale songsTo request permission to change the topic of his paperTo discuss the difference between using the internet and using books to find sources*To get help locating some information for his paper2. What is the topic of the man's paper?How whales hold their breath*Whale migration patternsCharacteristic of whale habitatsThe differences between the circulatory system of whales and that of other mammals3. What is the professor's attitude toward the man's question about how whales hold their breath? *She thinks he does not need to spend a lot of time looking for the answerShe is surprised because she has already addressed this question in classShe dismissed it as unimportantShe is pleased that he has a plan to obtain the answer himself4. Why does the professor mention the limited time students have to complete their papers?To suggest that looking at research on the internet is a good way to save timeTo point out that the library has reduced the amount of time it is open each day*To indicate her expectations for the amount of research to be done for the paperTo emphasize the important of starting to write the paper a couple of weeks before it is due5. According to the professor, how does a whale conserve oxygen while underwater?Click on 2 answers*Its heart rate decreasesIts lung capacity temporarily increasesIt slows the pace of its swimming*Blood flow to certain organs is decreasedLecture 3(学科分类——历史)Narrow: Listen to part of lecture in history class, the professor has been discussing Egyptian hieroglyphs.Egyptian hieroglyphs are the ancient Egyptian writings, found in ancient Egyptian on walls, monuments, and on the inside and outside of the temples. (6)Hieroglyphic writing ended abruptly about 1600 years ago, and it mystified the most brilliant minds in the study of the Egyptian artifacts and archeology for many many centuries. Finally, the possibility of deciphering hieroglyphs came about with the discovery in 1799 of the Rosetta stone.The Rosetta stone is arguably the most famous archeology artifact ever discovered. It contains the same exact text written in three different alphabets: Greek, demotic and hieroglyphic. But we didn't even know at first, that the three texts on the Rosetta stone contain the same information. And two of the three alphabets are ancient Egyptian scripts that stop being used, the hieroglyphic and the demotic. The demotic script found on the Rosetta stone, um …(7)Well, demotic was not as elaborate as the hieroglyphic writing. It was used for Mondey matters or like administrative documents. (8)These ancient Egyptian scripts were replaced by Coptic script, but eventually the Arabic language replaced the Coptic, and this cut off the linguistic link between ancient and modern Egypt. Now the Rosetta stone was remarkable, because as I said, honored with the same text in three different alphabets: Greek, demotic and hieroglyphs. The soon was centrally the dictionary that the scholars needed to interpret the meaning of hieroglyphs, and it took a uniquely equipped researcher to finally decipher and understand what was written on the stone.(11)Thomas Yang, an English scholar, was the first to seriously attempt to decide for the symbols on the Rosetta stone. He suspected rightly, that the hieroglyphs were phonetic symbols, that they represented sounds rather than pictures. Until then, all scholars assumed that the hieroglyphs were pictographs, that they symbolize objects or concepts. Thomas Yang focused his attention on one set of hieroglyphs that he thought would probably spell out a single word, the name of a king or queen. He guessed that the symbols represented the name of the earlier Egyptian ruler Ptolemy, since Ptolemy was also written in Greek on the stone and was indeed a Greek name. (9)And Yang, did actually prove that these hieroglyphs represented sounds rather than whole words.Strangely though, he gave into the dominant thesis of the day that hieroglyphs were pictographs.He actually dismissed his own finding, as an anomaly, because the Ptolemy dynasty was Greek, not Egyptian. In other words, he figured it was an exception to the rule. It was phonetic because it was Greek not Egyptian. How else could an Egyptian to pick a Greek name other than spell it out? And that brings us to the hero of our story, Jean-François Champollion.(10)Champollion built on Yang's work, showing that different hieroglyphs spell the name of the kings or queens like Alexander or Cleopatra. But his critics noticed that this was still not traditional Egyptian names, he hadn't done anything more than Yang has been able to do. So he couldn't disprove the dominant theory. Then, in 1822, Champollion was shown a set of hieroglyphs that contain traditional Egyptian names.The first two of the symbols were unknown, but Champollion knew that the repeated hieroglyphs to the far right symbolized an 's' sound. He then drew on his linguistic knowledge to arrive at the solution to the problem. You see, unlike the any of other scholars who have tried to crack the code, Champollion happened to be fluent in Coptic. (11)He wondered, and this was the real breakthrough, if the Coptic was the language that symbolized by the hieroglyphs on Rosetta stone, and if so, then perhaps that first this shape symbol might represent the sound. And the Coptic word for sound is 'ra' . See where this was it headed, so if the symbol were Coptic, the first symbol would be 'ra'. And then, an unknown symbol followed by a double 's' sound, was this Champollion Yang wondered the name "Ramses". He was eventually able to confirm that it was. So, he had figured it out. Hieroglyphs were mainly phonetic, they represent sounds not pictures, and the underlined language was Coptic. A lot of work remained, but Champollion had cracked the code.词汇：hieroglyph n. 象形文字mystify v. 使迷惑artifact n. 人工制品decipher v. 解译arguably adv. 可论证地alphabet n. 字母系统elaborate adj. 详尽的Coptic n. 埃及古语phonetic adj. 音形一致的pictograph n. 象形文字anomaly n. 反常事物题目：6. What's the lecture mainly about?The history of language in ancient EgyptThe process that was used to create hieroglyphic writingThe competition between two scholars to solve an archaeological puzzle *The circumstances that led to the solution of an archaeological puzzle7. What was demotic script used for in ancient Egypt?Decorations on temples and monuments*Administrative documentsIllustration for storiesRepresentations of objects。
Image Guided Therapy Coronary Vascular Excimer las
Image Guided TherapyCoronary VascularExcimer laser atherectomy for a long, diffusely diseased, moderately calcified right coronary artery Operator and facilityAntonis Pratsos, MDBryn Mawr Hospital,Main Line Health SystemBryn Mawr, PennsylvaniaCase history• 75-year-old male• Dyslipidemia, insulin dependentdiabetes, hypertension with ahistory of CAD positivestress test.Angiography• Subtotal occlusion• RCA: Long diffuse disease,moderately calicifed• LAD: Patent with minorluminal irregularities• Circumflex: 50% stenosis in themid portion“The 0.9 mm X80 helped modify the calcium and improved vessel compliance allowing for easy delivery of balloons and stent.”– Antonis Pratsos, MD Results and conclusion • TIMI 3 Flow • As demonstrated in this case, laser ablation was performed to treat a moderately calcified long lesion in the RCA • 0.014 x 135 cm Quick-Cross was used to facilitate the wire crossing the calcified lesion • The 0.9 mm X80 ELCA was used to treat the underlying calcium resulting in easy delivery of balloons & full apposition of the stent Dr. Pratsos has been compensated by Philips for his/her services in preparing this material for Philips’ further use and distribution. The opinions and clinical experiences presented herein are for informational purposes only. Individual results may vary depending on a variety of patient-specificattributes and related factors. Results from this case study are not predictive of future results.Images courtesy of Dr. Pratsos Intervention • RCA was engaged with a 6F FR4 guide • 0.014˝ Asahi guidewire was inserted into the RCA along with a .014 x 135 Quick-Cross support catheter to help cross the lesion • 0.9 mm X80 ELCA catheter was used at 50 fluence/40Hz • PTCA was then performed with a 2.5 mm Maverick at 14 ATMs • Xience 3.0 x 28 stent was placed in the RCA deployed at 18 ATMS • PTCA post stent deployment was performed with a 2.50 x 12 mm Quantum Maverick Devices Guide 6F FR4 guide catheter (Boston Scientific)Wire(s)0.014˝ Grandslam Wire (Asahi)Support catheter 0.014˝ x 135 cm Quick-Cross (Philips)Atherectomy 0.9 mm X80 ELCA (Philips)Balloon 2.5 x 20 mm Maverick (Boston Scientific)2.5 x 12 mm Quantum Maverick (Boston Scientific)Stent 3.0 x 2.8 mm Xience (Abbott Vascular)Anticoagulation Angiomax (The Medicines Company)Featured Philips products ELCA coronary laser atherectomy catheter Quick-Cross support catheter©2019 Koninklijke Philips N.V. All rights reserved. Some or all products manufactured by Spectranetics, a Philips company. Approved for external distribution. D008980-03 052019Philips3721 Valley Centre Drive, Suite 500 San Diego, CA 92130 USA/IGTdevicesELCA important safety informationIndications:The laser catheters are intended for use either as a stand-alone modality or in conjunction with percutaneous transluminal coronary balloon angioplasty (PTCA) in patients who are acceptable candidates for coronary artery bypass graft (CABG) surgery. The following indications for use, contraindications and warnings have been established through multicenter clinical trials. The Philips CVX-300 Excimer laser system and the multi-fiber laser catheter models are safe and effective for the following indications: occluded saphenous vein bypass grafts, ostial lesions, long lesions (greater than 20mm in length), moderately calcified stenosis, total occlusions traversable by a guidewire, lesions which previously failed balloon angioplasty, restenosis in 316L stainless steel stents, prior to the administration of intravascular brachytherapy. These lesions must be traversable by a guidewire and composed of atherosclerotic plaque and/or calcified material. The lesions should be well defined by angiography.Contraindications:Lesion is in an unprotected left main artery. Lesion is beyond acute bends or is in a location within the coronary anatomy where the catheter cannot traverse. Guidewire cannot be passed through the lesion. Lesion is located within a bifurcation. Patient is not an acceptable candidate for bypass graft surgery.Potential adverse events: Use of the Philips CVX-300 Excimer laser system may contribute to the following complications: dissection of the arterial wall, perforation, acute reclosure, embolization, aneurysm formation, spasm, coronary artery bypass graft surgery, thrombus, myocardial infarction, arrhythmia, filling defects, death. No long term adverse effects of ELCA are known at this time.Risks:The primary endpoint defined in the laser angioplasty of restenosis stents (LARS) randomized trial was the absence of major adverse cardiac events (MACE) at6 months: Death; myocardial infarction; coronary artery bypass surgery. Procedural complications include: any dissection, acute thrombus, haziness, no reflow, arrhythmia, acute vessel closure, occlusion of side branch, occlusion non-target, coronary spasm, coronary embolism, coronary perforation, laser/stent damage, balloon/stent damage, and other serious complications.Caution:Federal law restricts this device to sale by or on the order of a physician.。
2021-2022学年四川省成都市崇庆中学实验学校高二英语月考试卷含解析
2021-2022学年四川省成都市崇庆中学实验学校高二英语月考试卷含解析一、选择题1. With everything______, the manager left for England to attend an important business meeting.A. arrangingB. to be arrangedC. to arrangeD. arranged参考答案：D2. The student _____ in the games on the phone didn’t notice his teacher behind him.A. absorbingB. be absorbedC. to absorbD. absorbed参考答案：D【详解】考查非谓语动词。
句意：那个全神贯注地用电话玩游戏的学生没有注意到他后面的老师。
be absorbed in表示“全神贯注于”，此处去掉be做后置定语，故D项正确。
3. Paul’s mother had him because she couldn’t look after him herself.A. adaptedB. adjustedC. adoptedD. addicted参考答案：C4. The criminal, as well as some ______ persons, ______ questioned by the police yesterday.A. ; wasB. relevant; wasC. released; wereD. confused; were参考答案：B5. Mr. Green stood up in defense of the 16-year old boy，_________ that he was not the one ____________.A. said; blamedB. saying; to blameC. to say; to be blamedD. saying; blaming参考答案：B6. _____ your advice, I would have had no trouble with my papers.A. Had I followedB. If I followedC. If I have followedD. Once I followed参考答案：A7. ---- Hi, Li Ping, why are you so happy?----______________ I saw Yu Dan in the Quanzhou Hotel today.A. Guess what!B. I suppose so.C. Me too.D. How awful!参考答案：A8. —Smoking should be banned in public.—. ____It is harmful to both the smokers and non-smokers.A. I’d love toB. It’s my pleasureC. I’m with you on thatD. It’s up to you参考答案：C考察情景对话。
冠状动脉钙化病变治疗的新进展:环形轨道旋磨系统临床应用的结果评价
冠状动脉钙化病变治疗的新进展：环形轨道旋磨系统临床应用的结果评价尹达;周旭晨【期刊名称】《中国介入心脏病学杂志》【年(卷),期】2018(026)002【总页数】3页(P112-114)【关键词】冠状动脉钙化病变;旋磨;环形轨道旋磨系统【作者】尹达;周旭晨【作者单位】116000 辽宁大连,大连医科大学附属第一医院心内科;116000 辽宁大连,大连医科大学附属第一医院心内科【正文语种】中文【中图分类】R543.3严重冠状动脉钙化病变约占经皮冠状动脉介入治疗（PCI）的6%～20%［1-2］。
冠状动脉钙化不仅是主要不良心血管事件（major adverse cardiac events ，MACE）发生的高危因素，也常导致支架置入后发生膨胀不良、贴壁不良等其他并发症。
冠状动脉钙化程度随着年龄的增长显著增加［3］，随着中国老龄化社会的到来，冠状动脉钙化病变在PCI治疗中的比例将不断增加，故而开发新的高效安全的治疗手段是现实而又迫切的课题。
目前冠状动脉钙化病变处理策略主要有两个方面：（1）球囊扩张技术，包括单纯球囊扩张、高压球囊扩张、双导丝技术（buddy wire）、切割球囊扩张、棘突球囊、巧克力球囊、小球囊爆裂技术及药物球囊扩张等；（2）斑块去除（debulking）及斑块重塑（modifying）技术，包括定向冠状动脉旋切术、冠状动脉旋磨术（rotational atherectomy，ROTA）及准分子激光治疗。
球囊扩张技术多用于轻至中度的薄层钙化，斑块去除及重塑技术则用于处理较厚的同心性钙化及斑块负荷较重的偏心性钙化。
近年来随着应用于外周血管疾病的环形轨道旋磨系统（orbital atherectomy system ，环形OAS）进行了改进并应用至冠状动脉，冠状动脉钙化的治疗又出现了一种新的选择。
环形OAS是一种新型重塑斑块的器械，既能减少总的斑块负荷，改变动脉的顺应性，又能减少血管壁的损伤［4］。
冠状动脉钙化性病变旋磨治疗策略的研究进展
DOI :10.15972/ki.43-1509/r.2020.03.022㊃小专论㊃收稿日期:2020-02-19;修回日期:2020-03-26∗通信作者,E-mail:ningbin1972@.冠状动脉钙化性病变旋磨治疗策略的研究进展Research advances in the treatment of coronary artery calcified lesionsby rotational atherectomy吕明智,宁㊀彬∗LV Mingzhi,NING Bin ∗(安徽医科大学阜阳临床学院,安徽阜阳236001)摘㊀要:㊀冠状动脉钙化常存在于各种复杂的冠状动脉病变中,使经皮冠状动脉介入治疗(PCI )的操作难度增加,是心脏介入治疗所面临的一技术难点㊂对于冠状动脉钙化病变(CAC )的治疗可选择不同冠脉旋磨术(RA )治疗策略,以获得更好的手术获益㊂本文综述了不同手术方案的结局㊁标签外适应证治疗进展㊁相关辅助检查等,为探索旋磨治疗策略提供新的思路㊂关键词:㊀旋磨术;㊀钙化病变;㊀经皮冠状动脉介入治疗Key words :㊀rotational atherectomy ;㊀coronary artrey calcium ;㊀percutaneous coronary intervention 中图分类号:R543.3文献标识码:A㊀㊀冠状动脉钙化病变(coronary artrey calcium,CAC)是经皮冠状动脉介入治疗(Percutaneous coronary intervention,PCI)中难以攻克的技术难题㊂由于钙化环限制导致管腔不规则狭窄㊁顺应性变差,介入器械难以通过或病变无法得到充分扩张,一般球囊扩张后支架植入术即刻成功率低,并发症发生率高㊂自1987年旋磨术首次被用来治疗血管内动脉粥样硬化性病变,随着这项新技术的不断发展,在用于治疗严重的冠状动脉钙化性病变取得了显著的成效㊂术中使得支架更充分地传送及扩张,提高了冠脉严重钙化病变的手术成功率,有效降低术后并发症[1]㊂目前,冠状动脉旋磨术(Rotational atherectomy,RA)主要用来治疗如严重钙化狭窄及开口病变,也可用于多次置入支架后,支架内再狭窄支架消融术[2]㊂本文主要从近年来RA 对于冠状动脉钙化病变的治疗策略做一综述㊂1㊀RA 术中操作策略RA 始于20世纪90年代,它是通过物理方法去除坚硬的钙化斑块来治疗管腔阻塞的几种工具之一㊂最初被作为球囊扩张血管成形术的替代方法,可获得即刻手术成功㊂曾经,RA 参与了多达10%的PCI 治疗㊂现国外RA 的使用率已逐渐降低,一些大容量中心的RA 使用率已下降至3%~5%,有的地区则不到1%[3]㊂在我国,RA 在现代心脏导管治疗CAC 病变中仍具有着重要地位㊂目前临床上使用的旋磨仪组件包括:磨头㊁推进器及操纵控制台等部分㊂有金刚石涂层的旋磨头在旋磨导丝的带动下高速旋转,消蚀钙化性斑块及突出于冠腔内的 毛刺 ㊂高速旋转的磨头能够选择性消融无弹性的钙化性斑块,保持正常血管组织的完整性㊂在血管内冠状动脉成像技术的帮助下,研究提示术后支架内再狭窄的发生受到旋磨头平台期转速的影响㊂国外对行旋磨治疗患者进行随访观察表明[4],平台期选择低转速(150000~160000r /min)可以减少再狭窄的发生率,同时术中可显著减瘤,提高了患者长期存活率㊂旋磨时较为理想的转速为140000~150000r /min,使得绝大部分钙化斑块被粉碎至5~10μm 大小的微颗粒,这些颗粒可通过微循环至全身血液循环,在肝脏㊁脾脏中被吞噬细胞所吞噬,不会引起微循环堵塞㊂STRATAS 试验[5]表明当旋磨时转速下降超过5000r /min,产生血管热损伤,心肌标志物升高,有可能引起靶血管支架内再狭窄的发生㊂较低转速能降低旋磨时温度升高,血小板凝聚也相对下降,出现无复流概率降低[6]㊂但术中低平台期转速易导致磨头嵌顿的情况出现㊂使用积极的旋磨头策略,即旋磨头/动脉比>All Rights Reserved.0.7,在靶血管血运重建后的随访中,再狭窄相比于常规旋磨策略(最大旋磨头/动脉比<0.7)呈增长趋势[5]㊂小旋磨头相比,使用直径较大的旋磨头可能引起术中出现严重的血管并发症㊂但较大直径旋磨头其因纵轴大,更加贴合血管壁,有助于增加手术成功率㊂基于对STRATAS试验的结果,一般旋磨头/动脉比为0.6,即使用直径为1.25~1.75mm的旋磨头便可达到管腔扩大㊁血运重建的手术目的,且发生相关血管并发症减少㊂2㊀不同手术策略的研究2.1㊀单纯旋磨术联合药物洗脱支架㊀㊀我国有学者研究表明[7],RA治疗手术即刻成功率高,围术期并发症罕见,少有因旋磨导致死亡㊁冠脉穿孔㊁无复流㊁ACS的发生㊂旋磨术后植入药物支架(Drug eluting stent,DES)较金属裸支架相比,靶血管血运重建率㊁支架内再狭窄率㊁晚期管腔丢失率及死亡率均显著降低[8],提示DES-RA的组合在PCI治疗中呈现有利作用㊂对于长度>25mm的弥漫性病变,RA使用的最大磨头直径㊁手术成功率较局限性病变无差异,但弥漫性钙化旋磨次数及植入支架数的增加,使无复流㊁夹层㊁穿孔等并发症发生率增高[9]㊂Mario等[10]研究表明,RA联合第二代DES治疗长度ȡ25mm的CAC病变不会影响短期和长期结果㊂对此类病变,应采用多次㊁短时间的旋磨方式,术后监测患者心电图㊁心肌酶等指标,及时发现㊁处理围手术期不良事件的发生㊂2.2㊀RA与传统球囊预扩张术的比较国内学者对比了RA联合PCI治疗与单独PCI 治疗,当联合PCI治疗时并发症发生率低,随着样本量的增多,不良事件的发生显著降低㊂根据旋磨前是否行球囊扩张,分为直接旋磨和预扩张后旋磨㊂直接旋磨需使用更多的球囊以及更大的扩张压力,但器械传送成功率高于预扩张后旋磨,且术中并发症㊁边支受压㊁支架膨胀不良较低㊂行直接旋磨随访期间主要心脑血管不良事件(major adverse cardi-ovascular and cerebrovascular events,MACCE)发生率低,Cox生存因素分析提示预扩旋磨为MACCE的独立危险因素[6]㊂直接球囊扩张通常需较高压力,使冠脉夹层㊁穿孔等并发症发生概率增加,支架内血栓㊁再狭窄风险增加,直接旋磨有利于减少旋磨前无效的球囊扩张,减少并发症及不良事件的发生㊂根据冠状动脉造影及光学频域成像(optical fre-quency domain imaging,OFDI)提示病变存在深钙化板性质的钙化结节㊂可选择RA先期修整管腔后进行药物涂层球囊(drug-coated balloon,DCB)扩张术的无支架PCI㊂术后复查CAG无慢血流等不良事件的发生,随访期间有较良好的手术获益㊂但RA 联合DES相比于RA联合DCB对于钙化性病变的治疗仍具有较低的MACE发生率[11]㊂2.3㊀RA联合切割球囊治疗重度钙化性病变冠状动脉钙化病变因坚硬钙化环限制,普通非顺应性球囊常难以有效扩张,球囊破裂㊁冠状动脉撕裂㊁穿孔㊁无复流等手术风险增加㊂旋磨后使用切割球囊预扩张较使用普通球囊相比可获得更好的即刻管腔㊂植入支架后常因支架膨胀不良,影响手术成功率,并发症发生率增大㊂而切割球囊作为高度钙化性病变的预处理,联合RA可以达到良好的管腔获得㊂国外一项随机对照试验中[12],使用切割球囊较普通球囊对病变进行预处理,围手术期并发症的发生率相似,但在1年的随访中,前者对靶血管再狭窄的血运重建率较低,不良事件发生率低(5.7%vs.22.2%)㊂2.4㊀直接旋磨与补救旋磨的治疗研究处理重度CAC病变时,可选择常规球囊扩张,当球囊不能扩张,为提高手术成功率,而转为旋磨术,称为补救旋磨㊂研究表明[13],直接旋磨与补救性旋磨相比,手术成功率㊁并发症㊁死亡率㊁住院及随访期间MACCE均无差异㊂直径为2.0mmˑ15.0 mm半顺应性球囊和(或)直径2.5mmˑ15.0mm非顺应性球囊是否可通过或扩张病变,可作为转向补救性旋磨的选择标准,如治疗时选择此规格球囊无法通过㊁扩张病变,则需旋磨术进一步优化病变管腔㊂同时避免了旋磨过度应用,不会增加术中并发症㊂而是否发生围术期并发症是不良事件的独立危险因素㊂此外,应积极应用IVUS和OCT等腔内影像学对病变进行评估,及时采取计划旋磨治疗,即直接旋磨,可提高手术成功率㊂3㊀标签外适应证行旋磨术的治疗研究3.1㊀高危病变及非标签内适应证文献报道,RA标签内适应证手术成功率为95.6%~100%[14]㊂根据冠状动脉旋磨操作说明列出的非标签内适应证:(1)静脉桥血管;(2)大量血栓病变;(3)无保护左主干病变;(4)急性心肌梗死罪犯病变;(5)大夹层病变;(6)严重左心功能不全(左心射血分数<30%);(7)严重三支病变;(8)长All Rights Reserved.病变(ȡ25mm);(9)成角病变(ȡ45ʎ)㊂若患者存在上述非标签内适应证,选择旋磨治疗时,慢血流/无复流是其最常见的并发症,其它严重并发症及不良事件罕见,非标签内使用旋磨术并未增加慢血流/无复流的发生率㊂当存在患者年龄ȡ70岁㊁弥漫性病变Tandem病变㊁累及左主干以及左心室射血分数30%~50%时,为高危病变㊂对于存在高危病变的患者,研究围术期并发症及MACCE发生率提示,手术即刻成功率较非高危病变无显著差异,提示RA治疗高危钙化病变安全㊁有效,且术中并发症及术后MACCE发生率低㊂Mori等[15]比较标签外组和标签内组之间的中期临床,结果显示晚期管腔丢失㊁不良事件的发生率均无统计学差异㊂以上多项研究结果显示,高危病变及非标签内适应证并非导致RA术后不良事件及并发症的增加,CAC病变若存在非标签内适应证仍可行RA治疗㊂3.2㊀特殊病类型支架植入后支架内新生内膜钙化是动脉粥样硬化的一种形式㊂可导致钙化性支架内再狭窄(in-stent restenosis,ISR)㊂一项单中心研究[2],对ISR 病变行RA治疗可获得冠腔的显著改善,但对于严重钙化性ISR的临床结局还是不佳㊂钙化病变累及左主干时,术中发生并发症风险高㊂Fuku Y等[16]对于复杂的左主冠状动脉(left main coronary artery, LMCA)分叉病变,进行长达5年随访,RA组相对于非RA组的全因死亡和靶血管血运重建的额外风险无显著差异,RA联合DES植入是治疗复杂LMCA 分叉病变患者的安全可行的策略㊂RA往往不能应用于慢性闭塞性病变(Chronic total occlusion,CTO)的治疗,通常因工作导丝无法交换微导管,复查造影对闭塞后病变狭窄程度难以评估使得手术难以进行㊂Brinkmann C等[17]学者,术中沿指引导管植入旋磨导丝并使其跨过闭塞病变,随后植入旋磨导管进行手术,与非CTO使用RA 相比对CTO病变行RA治疗手术成功率和并发症并无差异,同样安全有效㊂ST段抬高型心肌梗死(ST-elevation Myocardial Infarction,STEMI)因闭塞处血栓负荷重,并非为旋磨治疗的适应证,旋磨过程中产生的微粒激活凝血机制,有进一步增加无复流的发生风险㊂来自于阿拉伯的一项研究[18]表明,旋磨术治疗急性STEMI 伴严重钙化病变可作为一项突破性的解决方案㊂严重左心功能不全(左心射血分数<30%)的患者更普遍出现无复流现象㊂RA仍可以有效地用于严重左心功能不全患者,但患者出现低血压的风险增加,术中及时实施血流动力学支持可降低低血压对医院内不良事件和死亡率的发生㊂4㊀腔内影像学检查与QCA评估CAC 病变的研究㊀㊀目前有条件的介入中心旋磨治疗策略的选择主要参考血管内超声成像(Intravascular ultrasound, IVUS),其利用单元转换器或传感器发出信号和接收信号,经过编码系统处理后形成血管内图像㊂IVUS能够评价斑块的形态㊁判断何种性质的病变导致管腔狭窄,当回声高于邻近外膜组织且伴有后方伴声影时提示为钙化性斑块㊂IVUS指导旋磨治疗CAC病变具有减少支架内血栓形成及靶血管血运重建率,对辅助钙化病变的治疗IVUS的应用较冠状动脉造影(Coronary angiography,CAG)更有价值㊂IVUS的应用已30年,光学相干断层成像(Optical coherence tomography,OCT)应用近15年㊂腔内影像学指导PCI治疗可为患者带来更好的临床获益㊂在我国实际临床中,上述两项技术的应用在我国并未普及,IVUS及OCT使用率不足5%,远低欧美国家㊂我国IVUS或OCT在实际临床应用的局限现状,受到其高费用㊁医保负荷加重㊁延长了手术时间㊂应用腔内影像学检查可能增加器械嵌顿㊁血管痉挛等并发症,造成手术失败㊂实际临床工作中, RA多是在CAG基础上进行㊂目前CAG对于CAC病变程度的分级较为粗糙,敏感性欠佳㊂量化冠状动脉造影(Quantitative coronary angiography,QCA)在对冠状动脉病变程度分析,指导治疗策略中起到了重要的指导作用㊂利用冠状动脉造影系统自带软件,测量CAC病变的长度与位置㊁钙化病变狭窄率,管腔狭窄面积,钙化层厚度等信息,评估病变性质具有快捷性㊁简便性㊁可重复性及一致性强等特点㊂QCA在指导CAC病变行RA治疗决策有着重要的意义[19]㊂5㊀小结与展望随着RA技术的逐步发展进步,在促进钙化复杂病变的治疗中很好地展现出其实用性㊂并且旋磨术的安全性随着积累的经验和技术的成熟而得到改善,包括通过增加使用更小的旋磨头和指引导管㊁更少的导管交换和低平台期低转速等,可进一步减少术中并发症的发生㊂本文认为RA仍然是在治疗涉及中度至严重钙化病变的复杂冠状动脉疾All Rights Reserved.病中获得最佳血管造影结果的不可或缺的工具㊂RA对于CAC病变的治疗并非孤军奋战, IVUS㊁OCT或QCA技术有助于识别斑块形态,有预测获益的特征,对不同旋磨时机的选择提供了指导意见㊂RA与其它治疗方式相结合,取得了较好的手术获益,如与切割球囊或药物涂层球囊联合治疗CAC病变㊂较传统球囊扩张相比,增加了治疗方案的选择性㊂此外RA不仅限于慢性稳定性病变的治疗,对于CTO病变㊁急性血栓性病变㊁左主干病变的治疗,仍具有其优势性,随着国内介入技术的不断提升,RA可治疗领域将会更加广泛㊂然而RA有其局限性,部分RA不成功的病例,应用准分子激光冠状动脉内消蚀术(excimer laser coronary angioplasty,ELCA)或联合RA成为一种选择[20]㊂ELCA利用紫外线脉冲光波的能量细胞内聚集,使水分蒸发,裂解组织,最终使纤维斑块解体㊂ELCA对复杂病变的处理安全有效,能够提高介入治疗手术的成功率㊂对于CAC病变如果旋磨效果差,可考虑行ELCA治疗或预处理,辅助RA的治疗,两者相结合治疗CAC病变的疗效仍有待于进一步研究㊂参考文献:[1]㊀SI DY,LIU GH,TONG YL,et al.Rotational atherectomy ablationfor an unexpandable stent under the guide of IVUS:a case report [J].Medicine(Baltimore),2018,97(7):e9978.[2]㊀UEMURA Y,TAKEMOTO K,KOYASU M,et al.Clinical outcomesof rotational atherectomy in severely calcified in-stent restenosis:a single-center,retrospective study[J].Nagoya J Med Sci,2019,81(2):313-23.[3]㊀MOTA P,SANTOS R,PEREIRA H,et al.Facts on rotationalatherectomy for coronary artery disease:multicentric registry(ab-str)[J].Euro PCR,2013,21(5):256-9.[4]㊀GAUL G,VIERTL N,AUSTIN,PC,et al.Low-speed rotationalatherectomy with substantial debulking and long-term survival:a retrospective observational study of889consecutive patients[J].Kardiol Pol,2019,77(4):451-7.[5]㊀WHITLOW P,BASS T,KIPPERMAN R,et al.Results of the studyto determine rotablator and transluminalangio-plasty strategy (STRATAS)[J].Am J Cardiol,2001,87:699-705.[6]㊀孔婷,白静,王禹,等.直接球囊旋磨和球囊预扩旋磨治疗冠状动脉钙化病变的对比研究[J].中国循环杂志,2016,31(4): 327-31.[7]㊀赵兵兵,李滔,田刚,等.冠状动脉旋磨术联合药物洗脱支架置入术治疗冠状动脉严重钙化病变的治疗研究[J].中国介入心脏病学杂志,2017,25(3):58-162.[8]㊀HIROSHI T,KATSUMI M,TOMOTAKA D,et parison ofclinical and angiographic outcomes after bare metal stents and drug-eluting stents following rotational atherectomy[J].Int Heart, 2016,57(2):150-7.[9]㊀李琪,刘健,卢明瑜,等.斑块旋磨术联合药物洗脱支架置入术治疗冠状动脉弥漫性钙化性病变的近期效果分析[J].中国介入心脏病学杂志,2016,24(12):667-71.[10]㊀MARIO T,UMBERTO B,FABRIZIO D,et al.Rotational atherec-tomy in very long lesions:results for the ROTATE registry[J].Catheter Cardiovasc Interv,2016,88(6):e164-72.[11]㊀DONG H,HACHINOHE D,NIE Z,et al.Reappraisal value of amodified rotational atherectomy technique in contemporary coronaryangioplasty era[J].J Interv Cardiol,2020:9190702.[12]㊀LI QY,HE,Y,CHEN L,et al.Intensive plaque modification withrotational atherectomy and cutting balloon before drug-elutingstent implantation for patients with severely calcified coronary le-sions:a pilot clinical study[J].BMC Cardiovasc Disord,2016,16:112.[13]㊀吴义林,骆峰,施鸿毓,等.直接旋磨及补救旋膜治疗重度钙化性冠状动脉病变的对比研究[J].中国介入心脏病学杂志,2017,25(5):249-54.[14]㊀JIANG J,SUN Y,XIANG MX,et plex coronary lesionsand rotational atherecotomy:one hospital s experience[J].J Zhe-jiang Univ Sci B,2012,13(18):645-54.[15]㊀MORI T,SAKAKURA K,WADA parison of mid-termclinical outcomes between on-label and off-label use of rotationalatherectomy[J].Heart Vessels,2017,32(5):514-9.[16]㊀FUKU Y,KADOTAK,TOYOFUKU M,et al.Long-term outcomesof drug-eluting stent implantation after rotational atherectomy forleft main coronary artery bifurcation lesions[J].Am J Cardiol,2019,123(11):1796-805.[17]㊀BRINKMANN C,EITAN A,SCHWENCKE C,et al.Rotationalatherectomy in CTO lesions:too risky?Outcome of rotationalatherectomy in CTO lesions compared to non-CTO lesions[J].EuroIntervention,2018,14(11):e1192-8.[18]㊀SHAHIN M,CANDREVA A,SIEGRIST PT,et al.Rotationalatherectomy in acute STEMI with heavily calcified culprit lesion isa rule breaking solution[J].Curr Cardiol Rev,2018,14(3):213-6.[19]㊀王天保,关汝明,夏霏.QCA法评估冠状动脉钙化病变需行冠状动脉旋磨术的预测因素研究[J].大连医科大学学报,2019,41(4):311-4.[20]㊀ASHIKAGA T,YOSHIKAWA S,ISOBE M.The effectiveness ofexcimer laser coronary atherectomy with contrast medium for un-derexpanded stent:the findings of optical frequency 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GuidezillaTM_延长导管在复杂冠状动脉介入治疗中的应用
㊃论著㊃通信作者:赵秀峰,E m a i l :z h a o x i u f e n g_123@y a h o o .c o m G u i d e z i l l aT M延长导管在复杂冠状动脉介入治疗中的应用袁思敏,赵秀峰,信栓力,常 超,刘丽军,韩丽英(邯郸市第一医院心内一科,河北邯郸056000) 摘 要:目的 对应用G u i d e z i l l a T M延长导管在复杂经皮冠状动脉介入治疗(P C I)中的有效性及安全性进行评估,并总结应用G u i d e z i l l a T M临床经验㊂方法 2017年1月至2018年12月邯郸市第一医院P C I 手术中应用因球囊或支架难以通过,补救性应用G u i d e z i l l a T M 辅助球囊或支架通过病变进行P C I 手术患者53例㊂收集术中穿刺入路㊁病变性质㊁靶血管开口变异㊁钙化迂曲㊁特殊操作及G u i d e z i l l a T M 延长导管深插冠状动脉长度等数据,观察应用该器械的安全性和有效性㊂结果 应用G u i d e z i l l a T M辅助球囊和支架进行手术患者53例,其中成功植入支架49例(92.5%)㊂经右桡动脉途径45例㊁经右股动脉进行手术8例,靶血管开口异常4例,靶血管开口存在病变22例,慢性完全闭塞病变19例,钙化病变19例,迂曲病变9例,钙化迂曲病变24例,辅助旋磨磨头达到病变1例,G u i d e z i l l aT M深插冠状动脉深度(19.38ʃ12.66)mm ㊂术中术后无严重并发症,无死亡病例㊂结论 在复杂P C I 治疗中,补救性应用G u i d e z i l l aT M辅助介入治疗安全有效,手术成功率高,安全有效,并发症少㊂关键词:血管成形术,气囊,冠状动脉;G u i d e z i l l aT M延长导管;复杂病变中图分类号:R 654.3 文献标志码:A 文章编号:1004-583X (2019)08-0720-04d o i :10.3969/j.i s s n .1004-583X.2019.08.010C a s e s e r i e s e x p e r i e n c e o fG u i d e z i l l a T Me x t e n s i o n c a t h e t e rf o r p e r c u t a n e o u s i n t e r v e n t i o n a l t h e r a p y o f c o m pl e x l e s i o n s Y u a nS i m i n ,Z h a oX i u f e n g ,X i nS h u a n l i ,C h a n g C h a o ,L i uL i j u n ,H a nL i y i n gF i r s tD e p a r t m e n t o f C a r d i o l o g y ,H a n d a nF i r s tH o s pi t a l ,H a n d a n 056000,C h i n a C o r r e s p o n d i n g a u t h o r :Z h a oX i u f e n g ,E m a i l :z h a o x i u f e n g _123@ya h o o .c o m A B S T R A C T :Ob je c t i v e T o s u mm a r i z e r e p o r t s o n e x p e r i e n c e u s i n g t h eG u i d e z i l l a T Me x t e n s i o n c a t h e t e rf o r c o m p l e x c o r o n a r y l e s i o n s a t t h ed o c u m e n t e d i n s t i t u t i o na n de v a l u a t i o no f i t ss a f e t y a n de f f i c a c y .M e t h o d s W e r e t r o s p e c t i v e l yc o l l e c t e d53c a s e s f r o mt h eC a rd i o l o g y De p a r t m e n t o fH a n d a nF i r s tH o s p i t a lf r o mJ a n u a r y of 2017t oD e c e m b e r o f 2018w h oh a d r e c e i v e d p e r c u t a n e o u s c o r o n a r y i n t e r v e n t i o n (P C I ).G u i d e z i l l a T Me x t e n s i o n c a t h e t e rw a s u s e dd u r i n g PC I S i n c e t h eb a l l o o no rs t e n tc a n n o t p a s sl e i s i o n .T h ec l i n i c a l ,a n g i o g r a ph i ca n d p r o c e d u r a ld a t ao fa l l53p r o c e d u r e s w e r e c o l l e c t e d .t h e s a f e t y a n d e f f i c a c y o f t h i s n o v e l e q u i p m e n tw a s e v a l u a t e d .I n a d d i t i o n ,r e c o r d e t h e s u c c e s s f u l r a t e a n d t h e i n c i d e n c e o f c o m p l i c a t i o n s .t h e a d v e r s e c a r d i o v a s c u l a r e v e n t sw e r e a l s o r e c o r d e dd u r i n g f o l l o w -u p .R e s u l t s 53p a t i e n t s w e r er e c e i v e d w i t h G u i d e z i l l a T Me x t e n s i o n -a s s i s t e db a l l o o na n ds t e n t t oac h i e v ec o r o n a r y a r t e r y l e s i o n s f o rP C I .T h e m e a nde p t ho fi n t u b a t i o n w a s19.38ʃ12.66mm.S t e n ti m pl a n t a t i o n w a ss u c c e s s f u l i n49o u to f53p r o c e d u r e s (92.5%).45c a s e sv i ar a d i a l a r t e r y ,8c a s e sv i aa r t e r i a f e m o r a l i s ,4c a s e so f t a r g e t a b n o r m a l o p e n i n gs ,22c a s e so f t a r g e t v e s s e l n a r r o wo p e n i n g s ,19c a s e so f c h r o n i c ,t o t a l l y o c c l u d e d (C T O )9c a s e s c i r c u i t yp a t h o l o g i c a l c h a n ge s ,19c a s e sof c a l c i f i e d l e s i o n s ,9c a s e s o f t o r t u o s i t y l e s i o n s a n d 24c a s e o f t o r t u o s i t y an d c a l c i f i e d l e s i o n s .1c a s e s o f r o t a t i o n a l a t h e r e c t o m y .N o n eo ft h e p a t i e n t se x p e r i e n c e dc o r o n a r y d i s s e c t i o n ,t h r o m b o g e n e s i sa i re m b o l i s m ,o ro t h e r m a j o r c o m p l i c a t i o n s d u r i n g t h e p r o c e d u r e .C o n c l u s i o n T h eu s eo fG u i d e z i l l a T Mg u i d ee x t e n s i o nc a t h e t e r t os u p po r t e x t e n s i o n c a t h e t e ra s s i s t e db a l l o o na n ds t e n t t or e a c ht h e l e s i o ns i t eo f c o m p l e xc o r o n a r y le s i o n i ss af ea n de f f e c t i v ea n dh a sa h igh e r s u c c e s s r a t e a n d l e s s c o m pl i c a t i o n s .K E Y W O R D S :a n g i o p l a s t y ,b a l l o o n ,c o r o n a r y ;G u i d e z i l l a T Me x t e n s i o n c a t h e t e r ;c o m p l e x c o r o n a r yl e s i o n 心脏介入操作技术和设备快速发展,心脏介入器械不断改进,提升对球囊及支架的推进性㊁追踪性和输送性㊂在伴有严重迂曲和(或)钙化的冠状动脉病变中,经皮冠状动脉介入治疗(P C I)仍面临许多挑战㊂2013年G u i d e z i l l aT M获得美国食品药品监督管理局(F A D )批准㊂G u i d e z i l l a T M由不锈钢海波管与单腔导引管以圆领结构连接,全长145c m ,单腔导引导管两端有射线标记带便于冠状动脉内定位㊂G u i d e z i l l aT M为单腔快速交换导管,适用于辅助输送器械及改善导引导管同轴性[1]㊂目前,关于国内外临床使用G u i d e z i l l a T M治疗冠状动脉复杂病变的报道较少,其安全性及有效性有待临床验证㊂因此,本㊃027㊃‘临床荟萃“ 2019年8月20日第34卷第8期 C l i n i c a l F o c u s ,A u gu s t 20,2019,V o l 34,N o .8Copyright ©博看网. All Rights Reserved.研究旨在回顾性单中心真实世界研究G u i d e z i l l a T M 在冠状动脉介入治疗中的安全性及有效性,总结相关临床经验㊂1资料与方法1.1病例选择2017年1月至2018年12月邯郸市第一医院行P C I术患者53例,均应用6F导引导管,因微导管㊁球囊或支架难以通过,补救应用G u i d e z i l l a T M辅助球囊或支架通过病变完成手术㊂平均年龄(61ʃ9)岁,其中男44例(83%),既往高血压病史40例(75.5%),糖尿病病史18例(34.0%),吸烟史26例(49.1%),首次P C I34例(64.2%),其中1例(1.9%)使用主动脉内球囊反搏泵(I A B P)㊂术前诊断为急性冠状动脉综合征50例(94.3%),包括不稳定性心绞痛27例(50.9%)㊁非S T段抬高型心肌梗死(N S T E M I)8例(15.1%)及S T段抬高型心肌梗死(S T E M I)15例(28.3%)㊂1.2手术方法选择应用S e l d i n g e r技术经桡动脉或者股动脉穿刺入路,操作过程:①应用无菌肝素盐水冲洗G u i d e z i l l a T M;②P C I术中导引导管及导丝到位,打开Y型止血阀,沿导丝推进G u i d e z i l l a T M;③关闭Y型止血阀,全程X线透视下,将G u i d e z i l l a T M沿导丝通过导引导管远端,推送至冠状动脉内,通过头端标记带,难以到达靶血管病变时,采用球囊锚定技术辅助推送G u i d e z i l l a T M;④P C I术后,撤出G u i d e z i l l a T M,造影确认手术成功,撤出整套系统;⑤采用e F i l m W o r k s t a t i o n软件4.1.0版测量G u i d e z i l l a T M深入冠状动脉深度(mm)㊂手术成功标准:成功植入药物洗脱支架后,靶血管管腔残余狭窄<20%,远端前向血流T I M I3级,无明显冠状动脉夹层分离㊁穿孔等并发症㊂1.3数据采集收集患者的临床资料:临床病史(包括年龄㊁性别㊁既往史等);临床诊断㊁穿刺路径;冠状动脉造影结果(靶血管开口异常㊁开口病变㊁靶血管的病变类型㊁病变性质);经皮冠状动脉介入治疗手术(指引导管㊁导丝及支架数目㊁G u i d e z i l l a T M深插冠状动脉的深度及结果)㊂患者住院期间及出院后30天进行随访,观察不良心血管事件(包括复发心绞痛㊁急性心肌梗死㊁严重心律失常㊁心力衰竭㊁心源性死亡)发生情况㊂1.4相关标准美国心脏协会/美国心脏病学会(A H A/A C C)经皮冠状动脉腔内血管成形术指南中,根据操作成功率和并发症发生率,提出冠状动脉病变A㊁B㊁C分类[2]㊂病变迂曲指心脏舒张期血管至少有3个沿主干方向ȡ45ʎ弯曲方向的病变,或至少有1个ȡ90ʎ定义为冠状动脉血管迂曲[3]㊂造影前在X线透视下观察血管走形,根据亮度和大小确定钙化严重程度[4]㊂2结果2.1穿刺路径本研究的穿刺路径主要为右桡动脉45例(84.9%),右股动脉8例(15.1%),其中1例为右桡动脉入路作为正向支架植入系统,而左桡动脉入路反向造影及寻径的慢性闭塞病变(C T O)手术将其归为右桡动脉途径,8例为保留右桡动脉造影导管作为反向造影及寻径,而右股动脉作为正向入路的C T O手术将其归为股动脉㊂靶血管前降支(L A D)20例(37.7%);回旋支(L C X)12例(22.6%);右冠状动脉(R C A)21例(39.6%)㊂靶血管存在开口异常4例,其中3例为左㊁右冠状动脉共同开口于升主动脉壁,1例为右冠状动脉与主动脉的长轴近同轴㊂按A H A/A C C分类B型20例(37.7%);C型33例(62.3%),其中C T O病变19例(35.8%)㊂靶血管开口存在狭窄22例(41.5%),靶血管病变存在钙化19例(35.8%),迂曲9例(17.0%),钙化迂曲24例(45.3%),1例为右冠状动脉开口异常导引导管不易到位㊂通过球囊锚定辅助G u i d e z i l l a T M通过8例(15.1%),通过G u i d e z i l l a T M 进行特殊操作:伙伴导丝12例(22.6%),多重预扩23例(43.4%),切割球囊19例(35.8%),旋磨1例(1.9%)㊂见表1㊂2.2手术结果53例患者术中使用G u i d e z i l l a T M从冠状动脉开口至远端射线标记带之间的长度为5~ 72mm,平均(19.38ʃ12.66)mm㊂补救性应用G u i d e z i l l a T M植入支架成功率92.5%(49/53)㊂其中选择经股动脉穿刺入路进行8例,手术100%成功,而选择经桡动脉穿刺入路进行45例,手术成功率91.1%(41/45)㊂其中靶血管开口异常4例,应用G u i d e z i l l a T M100%成功植入支架㊂靶血管开口存在病变22例中95.5%(n=21)手术成功,靶血管开口正常31例中90.3%(n=28)手术成功,并未出现P C I相关并发症㊂B型病变成功率100%(n=20), C型病变成功率为87.9%(n=29)㊂4例失败病例的靶血管病变为C型病变,均存在严重的钙化迂曲, 1例右冠状动脉及3例回旋支病存在严重钙化迂曲,术者考虑植入支架存在血管内夹层㊁穿孔等风险,仅应用顺应性球囊做冠状动脉腔内血管成形术㊂见表1㊂㊃127㊃‘临床荟萃“2019年8月20日第34卷第8期 C l i n i c a l F o c u s,A u g u s t20,2019,V o l34,N o.8Copyright©博看网. All Rights Reserved.表153例P C I患者靶血管病变特征[例(%)]术中特征例数失败成功穿刺路径右桡动脉454(8.9)41(91.1)右股动脉808(100.0)靶向管位置前降支20020(100.0)回旋支123(25.0)9(75.0)右冠脉211(4.8)20(95.2)靶向管开口异常正常494(8.2)45(91.8)异常404(100.0)靶向管开口存在病变是221(4.5)21(95.5)否313(9.7)28(90.3)病变类型B20020(100.0) C334(12.1)29(87.9)C T O191(5.3)18(94.7)病变性质钙化19019(100.0)迂曲909(100.0)钙化迂曲244(16.7)20(83.3)特殊操作伙伴导丝12球囊锚定3多重预扩23切割球囊19旋磨12.3随访患者住院期间及出院后30天进行随访,无不良心血管事件(包括复发心绞痛㊁急性心肌梗死㊁严重心律失常㊁心力衰竭㊁心源性死亡)发生情况㊂3讨论G u i d e z i l l a T M延长导管为辅助输送冠状动脉介入器械,改善导引导管的同轴性㊂P C I中,深插冠状动脉管腔提供额外的导引支持㊂G u i d e z i l l a T M不良事件包括:血管穿孔及夹层,穿刺部位并发症,慢血流和(或)闭塞,内膜中断,动脉痉挛,栓子等㊂除了上述不良事件外,G u i d e z i l l a T M延长导管还可能出现压力抑制㊁导丝缠绕[5]㊁支架脱载[6-7]等问题㊂P C I术中靶血管存在钙化㊁迂曲㊁慢性闭塞等复杂病变,53例补救性应用G u i d e z i l l a T M的病例中,输送介入器械仍然困难,本研究统计G u i d e z i l l a T M延长导管系统进行特殊操作技术:伙伴导丝㊁球囊锚定㊁多重预扩及切割球囊增加支撑力和同轴性后, 92.5%患者成功植入支架㊂4例病例由于病变部位位于靶血管远端,结构复杂,钙化迂曲,血管顺应性差,在G u i d e z i l l a T M增加支撑力和改善同轴性的情况下,使用 伙伴导丝 ㊁ 多重预扩 等特殊操作,随着手术时间延长患者不耐受手术及不同程度的压力抑制,术者考虑支架植入术风险与患者受益不对等情况下放弃植入支架㊂本研究中5例患者术中出现慢血流,给与硝普钠等冠状动脉注射,慢血流得到改善㊂无死亡及其他严重并发症等不良事件㊂本研究冠状动脉开口存在狭窄病变22例,仅1例手术失败,其中8例使用球囊锚定技术辅助G u i d e z i l l a T M延长导管的无创头端顺利通过开口狭窄,并深插冠状动脉,未出现严重冠状动脉内膜撕裂㊁夹层及穿孔并发症,表明G u i d e z i l l a T M可以安全跨过开口病变深插入冠状动脉㊂1例通过G u i d e z i l l a T M送1.25mm旋磨磨头至钙化严重的病变部位,考虑到延长导管直径较小,撤出G u i d e z i l l a T M送1.5mm旋磨磨头,极大的缩短手术时间㊂药物球囊及生物可吸收支架以 没有残留 作为新型的P C I治疗变革㊂G u i d e z i l l a T M可以为药物球囊和生物可吸收支架同轴校准建立通道㊂Y e w等[8]报道使用G u i d e z i l l a T M推送药物球囊成功治疗C T O 病变㊂Y e w等[9]报道冠状动脉存在迂曲情况下G u i d e z i l l a T M可以解决生物可吸收支架输送的难题㊂G u i d e z i l l a T M在P C I术中推送直径体积较大的器械为术者提供新的途径㊂近年来考虑到患者舒适性及降低出血等并发症发生,桡动脉入路成为P C I手术首选入路,但是由于支撑点解剖位置的原因,支撑力及同轴性较股动脉差㊂经桡动脉应用G u i d e z i l l a T M延长6F导引导管系统相当于临床仅应用8F指引导管的支撑力[10]提升P C I成功率㊂但在桡动脉入路应用G u i d e z i l l a T M输送介入器械存在困难时,股动脉应用G u i d e z i l l a T M可以带术者 另辟蹊径 ㊂靶血管开口发育异常4例应用G u i d e z i l l a T M 100%成功植入支架,由于收集病例偏少,未能收集到更全面的冠状动脉开口异常应用G u i d e z i l l a T M的手术病例㊂但是就收集到的手术病例分析, G u i d e z i l l a T M对开口异常的冠状动脉造影及输送介入器械提供同轴性,可减少冠状动脉开口急性闭塞等严重并发症的发生㊂波士顿科学公司不建议G u i d e z i l l a T M深插冠状动脉超过15mm,并未达成专家共识㊂但是在本研究中G u i d e z i l l a T M从冠状动脉开口至远端射线标记带之间平均深度为(19.38ʃ12.66)mm,最大值72 mm㊂最小值5mm㊂C h e n等[6]报道G u i d e z i l l a T M平均深度为(27.90ʃ12.23)mm,最小值为5.35mm,最大值为57mm㊂P C I术中延长导管深度受到实际病变位置㊁血管腔直径及自身结构的影响㊂在㊃227㊃‘临床荟萃“2019年8月20日第34卷第8期 C l i n i c a l F o c u s,A u g u s t20,2019,V o l34,N o.8Copyright©博看网. All Rights Reserved.G u i d e z i l l a T M圆领结构以远为25c m延长导管,圆领结构存在很多争议,H a s h i m o t o等[5]报道G u i d e z i l l a T M在经过主动脉弓及导引导管弯曲处自发旋转可能会导致导丝的缠绕;W a g g o n e r等[7]报道关于应用G u i d e z i l l a T M支架脱载处理的临床经验㊂该报道指出导引导管近端圆领结构与海波管衔接处可能引起支架脱载㊁支架损伤㊁导丝缠绕及血管夹层等㊂长支架送入延长导管管腔内,然后一起沿导引导管送入冠状动脉病变处㊂推送器械及支架时,应尽量避免G u i d e z i l l a T M与导丝缠绕㊂向远段输送导引导管时动作轻柔避免引起撕裂血管内膜, 冒烟 时,缓慢推注造影剂,避免发生血管夹层等并发症㊂术中操作G u i d e z i l l a T M应时刻注意压力线的变化,必要时重新调整导引导管及延长导管的位置,保证冠状动脉内血压稳定㊂本研究仅为关于G u i d e z i l l a T M的回顾性研究,收集样本局限,缺乏对其进行亚组分析㊂另外,本研究尚未对其他类型延长导管如H e a r t r a i l T M(泰尔茂,日本)㊁G u i d e L i n e r T M(明尼苏达州,美国)的临床效果进行分组对照研究㊂目前收集到的关于补救性应用G u i d e z i l l a T M的病例有限,但是本研究显示G u i d e z i l l a T M延长导管用于复杂经皮冠状动脉治疗手术中,特别是对严重钙化迂曲,开口变异的靶血管可提供有效的支撑力及同轴性,使用G u i d e z i l l a T M安全性好,成功率高㊂对于经皮冠状动脉支架植入手术患者,如术中球囊或支架难以通过,补救应用G u i d e z i l l a T M可辅助球囊或支架通过病变完成复杂病变手术,安全有效㊂参考文献:[1]谢洋,赵继义.导引延长导管的临床应用[J].中国介入心脏病学杂志,2018,26(6):50-56.[2] R y a nT J,B a u m a n W B,K e n n e d y J W,e ta l.G u i d e l i n e sf o rp e r c u t a n e o u s t r a n s l u m i n a lc o r o n a r y a n g i o p l a s t y.A r e p o r to ft h e A m e r i c a n C o l l e g e o f C a r d i o l o g y/A m e r i c a n H e a r tA s s o c i a t i o n T a s k F o r c e o n A s s e s s m e n t o f D i a g n o s t i c a n dT h e r a p e u t i c C a r d i o v a s c u l a r P r o c e d u r e s(S u b c o mm i t t e e o nP e r c u t a n e o u sT r a n s l u m[J].C i r c u l a t i o n,1988,78(2):486-502.[3] Z a a c k sS M,A l l e n J E,C a l v i n J E,e t a l.V a l u e o f t h e a m e r i c a nc o l l e g e o f c a rd i o l o g y/a me r i c a n h e a r t a s s o c i a t i o n s t e n o s i sm o r p h o l o g y c l a s s i f i c a t i o n f o r c o r o n a r y i n t e r v e n t i o n s i n t h e l a t e 1990s[J].A mJC a r d i o l,1998,82(1):43-49.[4]王伟民,霍勇,葛均波.冠状动脉钙化病变诊治中国专家共识[J].中国介入心脏病学杂志,2014,22(2):69-73. [5] H a s h i m o t oS,T a k a h a s h iA,Y a m a d aT,e ta l.S p o n t a n e o u sr o t a t i o no f t h em o n o r a i l-t y p e g u i d e e x t e n s i o ns u p p o r t c a t h e t e rd u r i n g a d v a n ce m e n t of a c u r v e dg u i d i n g c a th e t e r:t h e p o t e n ti a lh a z a r do f t w i s t i n g w i t h t h e c o r o n a r yg u i d e w i r e[J].C a r d i o v a s cI n t e r vT h e r,2018,33(4):379-383.[6] C h e nC Y,H u a n g Y Y,T a n g L,e ta l.G u i d e z i l l ae x t e n s i o nc a t h e t e rf o r p e r c u t a n e o u si n t e r v e n t i o n a lt h e r a p y o fc o m p l e xl e s i o n s v i aat r a n s r a d i a la p p r o a c h:c a s es e r i e sf r o m as i n g l e-c e n t e r e x p e r i e n c e[J].C a rd i o l J,2018,25(2):171-178.[7] W a g g o n e rT,D e s a iH,S a n g h v iK.Au n i q u ec o m p l i c a t i o no ft h eG u i d e Z i l l a g u i d e e x t e n s i o n s u p p o r t c a t h e t e r a n d t h e r i s ko f s t e n t s t r i p p i n g i n i n t e r v e n t i o n a l&e n d o v a s c u l a r i n t e r v e n t i o n s[J].I n d i a nH e a r t J,2015,67(4):381-384.[8] Y e w K L,K a n g Z.G u i d e z i l l a g u i d e e x t e n s i o n c a t h e t e rf a c i l i t a t e d t h e d e l i v e r y o f l o ng a n db u l k y I n.P a c tF a l c o nd r u g-c o a t e db a l l o o nf o rt h et r e a t m e n to fc h r o n i ct o t a lo c c l u s i o nl e s i o n[J].I n t JC a r d i o l,2015,201:220-221.[9] Y e w K L,L e o n g K.G u i d e z i l l a g u i d e e x t e n s i o n c a t h e t e re n h a n c e s t h ed e l i v e r y o fb i o r e s o r b a b l ev a s c u l a rs c af f o l d i na na n o m a l o u s c o r o n a r y a r t e r y[J].I n t JC a r d i o l,2016,223:239-241.[10] M a J,H o u L,Q i a nJ,e ta l.T h es a f e t y a n df e a s i b i l i t y o fg u i d e z i l l ac a t h e t e ri nc o m p l e xc o r o n a r y i n t e r v e n t i o n sa n da no b s e r v a t i o n a l s t u d y[J].M e d i c i n e(B a l t i m o r e),2017,96(40): e8172.收稿日期:2019-05-23编辑:王秋红㊃327㊃‘临床荟萃“2019年8月20日第34卷第8期 C l i n i c a l F o c u s,A u g u s t20,2019,V o l34,N o.8Copyright©博看网. 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优化严重冠状动脉钙化病变的介入治疗策略
优化严重冠状动脉钙化病变的介入治疗策略沈卫峰;张瑞岩【期刊名称】《中国介入心脏病学杂志》【年(卷),期】2017(025)012【总页数】3页(P661-663)【关键词】冠状动脉钙化病变;介入治疗【作者】沈卫峰;张瑞岩【作者单位】200025 上海,上海交通大学医学院附属瑞金医院心内科;200025 上海,上海交通大学医学院附属瑞金医院心内科【正文语种】中文【中图分类】R541.4过去的30多年中，我国的经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）迅猛发展。
2016年，全国PCI病例数超过66万，经桡动脉入径广泛使用，各种介入操作和相关影像学技术蓬勃开展［1］。
然而，随着我国人口逐渐老龄化，高危和复杂冠状动脉病变（例如左主干、分叉、慢性完全闭塞病变等）越来越多见。
严重冠状动脉钙化病变的介入治疗仍具挑战性［2-4］。
且PCI患者常存在较多的内科合并症，故而血运重建的决策需多学科的通力协作，以提高整体临床疗效［5-6］。
在本期《中国介入心脏病学杂志》中，温尚煜教授及其团队总结了2000年1月至2016年10月大庆油田总医院连续248例严重冠状动脉钙化病变患者旋磨术并发症的防治以及关键操作技术［7］。
尽管这些经验来自单中心，却仍值得国内同行们借鉴。
显然，PCI术前冠状动脉病变钙化程度的严格评估、术中介入治疗策略的正确选择以及围术期并发症的及时防治，是优化严重冠状动脉钙化病变介入治疗的关键。
1 如何评估与介入操作相关的冠状动脉钙化病变的严重性在X线透视下清晰可见的冠状动脉钙化，大多为老年退行性冠状动脉Monckeberg钙化（中层钙化）。
但是，真正引起介入操作和支架置入困难的主要是严重冠状动脉内膜钙化（斑块钙化），尤其是当钙化累及范围＞270°或整个血管圆周时，冠状动脉造影对此很难识别。
虽然无创性冠状动脉CT造影（CTA）对检出冠状动脉钙化较为敏感，但对内膜钙化的判断尚存在严重不足［8］。
严重钙化病变的pci治疗_王海昌
Xijing Hospita2l8
钙化病变介入治疗的难点（I）
单纯依靠冠脉造影评价钙化程度欠准确 植入支架后的再狭窄率高 旋磨术适于内膜弥漫钙化病变，利于支架充分
植入，长期疗效更好，“无复流现象”增加
斑块切除术（DCA、TEC、ELCA）对钙化病变帮
OCT
IVUS
OCT
IVUS
Xijing Hospital9
Non-invasive Quantification for Calcified Lesions by CT Scan
Xijing Hospita1l0
Xijing Hospita1l1
Xijing Hospita1l2
“中－重度钙化（B型）病变是导致冠状动 脉球囊成形术（PTCA）手术失败和血管急 性闭塞的主要危险因素”
29% of men and 15% of women who had no cardiovascular symptoms and exhibited no other common risk factors, had extensive coronary artery calcification. [European Heart Journal 25: 48–55, 2004]
盖率好。能够使支架更合理扩张、血栓率低、再狭窄 率低
旋磨头
依据血管直径，从小到大更换，最大旋磨头应 选择直径小于血管直径的75％。
Xijing Hospita3l8
钙化病变的操作要点（I）
预扩张：非常重要！ 支架往往不能直接通过病变；支架直接植入常会 导致支架不能充分扩张
球囊扩张 选择比血管直径小0.5mm以上的半顺应性、耐高压 球囊，扩张压在8atm以上，逐渐增加压力，直至 球囊切迹消失
湖南科技大学高级英语第二册试题及答案
湖南科技大学高级英语第二册试题及答案(试卷1)I. Vocabulary (30%)Section 1: From the list of words at the top, select the correct word or phrase foreach blank space. Use each word or phrase only once (15%).lashed scudded desolate derelictundoing makings booming contemptuousa catalytic agent sprees swiveled smolderedlucrative macabre adjunct1. Hurricane Camille _________ northwestward across the Gulf of Mexico.2. Gray clouds________ in from the Gulf on the rising wind.3. Most of Morocco is so _________ that no wild animal bigger than a hare can lieon it.4. The burying-ground is merely a huge waste of hummocky earth, likea _________building lot.5. The Americans are unwilling to witness or permit the slow________ of thesehuman rights to which this nation has been committed. 6. Although she was not very smart now, she already had the _________7. The _________ of American industry no longer left any room forthe code of theVictorian age.8. Journalism was a mere ________ to commercialism.9. The war acted as ____________ in this breaking down of theVictorian socialstructure.10. Like most escapist _________, this one lasted until the moneyran out. 11. Not hostile, not _________ , not sullen, not even inquisitive. 12. Back and forth, his head ________, desire waxing, resolution waning. 13. Maybe somewhere in the extinct crater of her mind, a few embers still__________.14. Here was the very heart of industrial America, the center of its most _________and characteristic activity.15. It reduced the whole aspiration of man to a ________and depressing joke.Section 2: From the list of words at the top, select the correct synonym for theunderlined words or phrases in each sentence (15%)hit distress fell apart noticeablecrazy gap aimlessly toughenedcall forth ambitious perceptive industriousput an end to moral attitudes criticism1. Hurricane Camille was certain to pummel Gulfport, Miss., where the Koshakslived.2. The group heard gunlike reports as other upstairs windows disintegrated.3. But the blues did occasionally afflict all the adults.4. Instantly, from the dark holes all round, there was a frenzied rush of Jews.5. Still, a white skin is always fairly conspicuous.6. The conversation moved desultorily here and there.7. What al this tells us is of a deep rift in the culture of England after the NormanConquest.8. For man holds in his mortal hands the power to abolish all forms of humanpoverty and all forms of human life.9. This new generation has been tempered by war, disciplined by a hard and bitterpeace.10. Flaming diatribes poured from their pens denouncing the materialism.11. Let both sides seek to invoke the wonders of science instead of its terrors.12. He was an enterprising fellow.13. He called himself a perspicacious man.14. I award this championship only after laborious research and incessant prayer.15. Thus in a changing world youth was faced with the challenge of bring our moresup to date.II. Paraphrase the following sentences. (20%)1. We‘re elevated 23 feet.2. The place has been here since 1915, and no hurricane has ever bothered it.3. No one has any idea where it will go as it meanders or leaps and sparkles or justglows.4. And yet the same revolutionary belief for which our forebears fought is still atissue around the globe.5. And it is an activity only of humans.6. Boy and man, I had been through the region often before.7. The slightest mention of the decade brings nostalgic recollections to themiddle-aged8. The place has been here since 1915, and no hurricane has ever bothered it. 9. All colonial empires are in reality founded upon that fact.10. United, there is little we cannot do in a host of cooperative ventures.III. Translate the following sentences (using the expressions given in the brackets. (20%)1. A moment later, the hurricane lifted the entire roof off the house and skimmed it40 feet through the air.2. In a tropical landscape one‘s eyes takes in everything except the human beings.3. If a free society cannot help the many who are poor, it cannot save the few whoare rich.4. Fads, I submit, are the very negation of reason.5. Here were human habitations so abominable that they would have disgraced a raceof rally cats.6. 暴风雨使旅客们处于孤立无援的处境。
外贸英语口语电子书
一．对外贸易和对外贸易关系（一）They mainly trade with Japanese firms.他们主要和日本商行进行贸易。
For the past five years, we have done a lot of trade with your company.在过去的五年中，我们与贵国进行了大量的贸易。
Our trade is conducted on the basis of equality.我们是在平等的基础上进行贸易。
There has been a slowdown in the wool trade with you.和你们的羊毛贸易已有所减少。
Our foreign trade is continuously expanding.我们的对外贸易不断发展。
Trade in leather has gone up (down) 3%.皮革贸易上升（下降）了百分之三。
Trade in general is improving.贸易情况正在好转。
Our company mainly trades in arts and crafts.我们公司主要经营手工艺品。
They are well-known in trade circles.他们在贸易界很有名望。
We trade with people in all countries on the basis of equality and mutual benefit.我们在平等互利的基础上和各国人民进行贸易。
To respect the local custom of the buying country is one important aspect of Chinas foreign policy.尊重买方国家的风俗习惯是我国贸易政策的一个重要方面。
Our purpose is to explore the possibilities of developing trade with you.我们的目的是和你们探讨一下发展贸易的可能性。
2022考研英语阅读司法的学问
2022考研英语阅读司法的学问The science of justice司法的学问I think it s time we broke for lunch该吃午餐了Court rulings depend partly on when the judge lasthad a snack法庭判决结果肯定程度上取决于法官上一次吃点心的时间AROUND the world, courthouses are adorned witha statue of a blindfolded woman holding a set ofscales and a sword: 世界各地的法院都装饰有一尊女子的雕像，这个女人被蒙住双眼，手持一架天平和一把剑。
Justice personified.她是正义的化身。
Her sword stands for the power of the court, her scales for the competing claims of thepetitioners.剑代表着法庭的权力，而天平代表着上诉人的竞争性权利主见。
The blindfold represents the principle that justice should be blind.眼罩代表着司法的盲目性原则。
The law should be applied without fear or favour, with only cold reason and the facts of thecase determining what happens to the accused.也就是说应用法律应当毫无畏惧和偏袒之心，只有冷静的推理和案件事实才能打算如何处理被告。
Lawyers, though, have long suspectedthat such lofty ideals are not always achieved in practice, even in well run judicial systemsfree from political meddling.然而，律师们始终以来都怀疑在实践中这种崇高的抱负是否总能实现，就连在那些不受政治干涉、运转良好的司法体系里都是如此。
冠状动脉斑块旋磨联合药物洗脱支架术对不同年龄段老年钙化治疗效果的对比分析
Feb. 2021Vol. 42 No. 12021年 2月 第 42 卷$ 第 1 期首都医科大学学报Journal of Capital Medical Universito[doi ： 10. 3969/j. U sp . 1006-7795. 2021. 01. 017]・ 临床研究 ・冠状动脉斑块旋磨联合药物洗脱支架术对不同年龄段老年钙化 治疗效果的对比分析胡 宾周玉杰！贾德安秦政许晓啥杨士伟周志明(首都医科大学附属北京安贞医院心内科北京市心肺血管疾病研究所冠心病精准治疗北京市重点实验室首都医科大学冠心病 临床诊疗与研究中心，北京100029)$摘要】目的探讨冠状动脉粥样硬化性心脏病(以下简称冠心病)严重钙化患者的年龄对冠状动脉旋磨联合药物洗脱支架治 疗效果及其安全性的影响。
方法 选取2016年1月至2017年12月连续在首都医科大学附属北京安贞医院接受冠状动脉内旋 磨和药物洗脱支架植入治疗的198例冠心病患者为研究对象，分为#65岁组116例和<65岁组82例，比较两组旋磨治疗的基线特征、并发症、1年主要不良心血管事件，包括因心肌梗死、再次血运重建及死亡。
结果 #65岁组和<65岁组围术期合并症的发生率分别为18. 9%'13. 3%,差异无统计学意义(P =0.202)。
两组患者1年主要不良心血管事件比较，差异无统计学意义 (P =0. 320) $结论 冠状动脉内旋磨和药物洗脱支架治疗老年冠心病严重钙化的效果及安全性，不受患者的年龄影响。
$关键词】旋磨术;药物洗脱支架;冠状动脉粥样硬化性心脏病$中图分类号】R541. 14Observation on effect of rotational atherectomy follower by drrg-eluting stents nmplantatnonnnpatnentsage #65 yearswnthseverecalcnfne!coronary lesnonsHu Bin ，Zhou Yujie **，Jia Dean ，Qin Zheng ，Xu Xiaohan ，Yang ShiweRZhou Zhimin 基金项目：国家重点研发计划(2017YFC0908800)，北京市医院管理局“登峰”计划专项经费资助(DFL20150601)，北京市医院管理局“使命”计划 专项经费资助(SML20180601)，北京市卫生健康委员会科技创新中心建设项目(PXM2019_026272_000006，PXM2019_026272_000005 )。
指引导管的选择和操作技术
1958 — The diagnostic coronary angiogram – the key to selective imaging of the heart is discovered by Mason Sones.
JL 3.5
开口向上或水平
冠脉起源异常导管选择
左冠口起源于右冠窦，选JR4或Amplatz 右冠起源于左冠窦，选Amplatz或JL 升主动脉造影或CTA有帮助
LCA起源右冠窦
三维导管在不同轴向上进行各种弯曲、形状的设计如3DRC(Mdetronic)导管。
Sherpa NX Active 3DRCA
AL
AR
第二弯曲小 限制器械通过 支撑力弱 仅用于“牧羊钩”样RCA
进出导管时需注意： 1、当Amplatz导管的“L”或“R”段位于冠状动脉开口水平线上方时，可直接撤出或深插导管。
2、当“L”或“R”段位于冠状动脉开口水平线下方时，切忌直接后撤导管，应推送导管，以底部为支撑点，使导管尖端后退，离开冠脉开口，再旋转导管。
输送各种介入器械 支持作用 注射造影剂及各种相关治疗、抢救药物 血流动力学监测
导引导管功能
导引导管选择要求
创伤小 同轴性好 支撑力好 足够管腔直径
柔软的可视头端（安全区） 柔软的同轴段（柔软区或传送区） 中等硬度的抗折段（支撑区） 牢固的扭控段（扭控区或推送区）
Medtronic EBU
Boston left specialty curves
LAD 通常选Q curve 4
通常选Voda 3.5
支撑力更好
XBRCA
ART
2020-2021学年高一英语同步课堂帮帮帮(牛津译林版(2020)必修第一册)
Unit 1 Back to school 1.1 Welcome to the unit &Reading重点词汇1. __________ n. 潜力；可能性adj. 潜在的；可能的2. __________ adj. 中学的；级别高的；高水平的；老年的n. 级别（或地位）较高者3. __________ vt. & n. 挑战；质疑4. __________ adj. 积极乐观的；良好的；正面的5. __________ n. 机会，时机6. __________ vt. 获得，得到7. __________ n. 努力，费力的事；试图8. __________ n. 进步，进展；前进，行进vt. & vi. 发展；进步9. __________ adj. 令人大为惊奇的，令人惊叹的10. __________ n. 信心，信任；把握11. __________ n. 资源；资料；谋略12. __________ n. 设备，设施；场所13. __________ adj. 相同的，相等的；平等的；相当的；能胜任的n. 同等的人（物）vt. 与…相等；比的上14. __________ n. 态度，看法15. __________ vt. 同等重视；（使）保持平衡；权衡重要性n. 均衡，平衡；平衡能力16. __________ vt. & vi. 改进；改善17. __________ n. 个人adj. 单独的，个别的18. __________ n. 品质，性格；特点；人物，角色；文字19. __________ adj. 有责任，负责；可靠的20. __________ adj. 为11或13岁以下儿童设立的；地位（或级别）低的；青少年的n. 职位较低者；青少年运动员21. __________ adj. 自主的，有主见的；自立的重点词组1.______________________ 存在，在于2. ______________________ 能够处理3. ______________________ 起作用，有影响4. ______________________ 充分利用，尽情享受5. ______________________ 利用6. ______________________ 最后但同样重要7. ______________________ 盼望，期待重点句型1. can’t wait to do sth2. find+宾语+宾补3. 表语前置倒装【重点词汇】1.potential2.senior3.challenge4.positive5.opportunity6.acquire7.effort8.advance9. amazing 10.confidence 11.resource 12.facility 13.equal 14.attitude 15. Balance 16. improve 17. individual 18. character 19. responsible 20. junior 21. independence【重点词组】1.lie in2.rise to3.make a difference4.make the most of5. take advantage of6. last but not least.7. look forward to之词汇篇1. potential potentials(复数) potentially adv.潜在地potent adj. 有效的；强有力的原文：Realizing your potential 挖掘你的潜能？(教材P2)◆adj.潜在的;可能的n.可能性;潜在性;潜力;潜质potential customers 潜在的客户a potential source of conflict 潜在的冲突根源the potential for change 变革的可能性have the potential to do sth. 有做某事的可能【跟踪典例】完成句子①First we need to identify actual and _________________.首先，我们需要弄清实际的问题和潜在的问题。
分析辩题的辩论技巧是什么
分析辩题的辩论技巧是什么英文回答：Dialectical Argumentation Techniques。
When developing a dialectical argument, it is important to employ a variety of techniques to effectively present your case. Here are some key strategies to consider:Establishing a Clear Thesis Statement: Begin by formulating a concise and specific thesis statement that articulates your main argument. This will serve as the foundation for the entire debate.Identifying Opposing Viewpoints: Acknowledge and address the opposing viewpoints to your thesis. This demonstrates that you have considered alternative perspectives and strengthens your credibility.Using Evidence and Reasoning: Support your argumentswith evidence from credible sources and sound reasoning. Provide examples, statistics, and expert opinions tobolster your claims.Anticipating Counterarguments: Identify potential counterarguments that may arise and prepare responses to effectively address them. This shows that you have anticipated objections and are prepared to defend your position.Conceding Points: Demonstrate fairness and objectivity by acknowledging and conceding points where necessary. This builds trust with the audience and strengthens your overall argument.Maintaining a Neutral Tone: Avoid biased language and inflammatory statements. Present your case in a balanced and respectful manner to avoid alienating the audience.Using Transitional Phrases: Smoothly transition between different points of your argument usingtransitional phrases such as "however," "in addition," or"on the other hand."Summarizing and Concluding: Sum up your main arguments and reiterate your thesis statement in the conclusion. Restate your key points and leave a lasting impression on the audience.中文回答：辩论技巧。
QCA法评估冠状动脉钙化病变需行冠状动脉旋磨术的预测因素研究
QCA法评估冠状动脉钙化病变需行冠状动脉旋磨术的预测因素研究王天保;关汝明;夏霏【摘要】目的通过量化冠状动脉造影(quantitative coronary angiography,QCA)评估钙化病变,探究冠状动脉钙化病变需行冠状动脉旋磨预处理的相关因素.方法回顾性收集2017年1月至2018年8月于辽宁省人民医院行冠状动脉造影提示存在2～4级钙化病变且行介入治疗患者103例,根据治疗方式不同分为常规治疗组及被动旋磨组.通过QCA方法(西门子影像分析系统)比较两组冠状动脉钙化病变的相关影像学指标的差异.结果旋磨组与常规治疗组病变在狭窄直径,狭窄程度,钙化厚度,内膜钙化等方面比较存在统计学差异,P均＜0.05.Logistic回归模型分析提示狭窄程度及内膜钙化是冠状动脉钙化病变需行旋磨术干预的危险因素,P值分别为0.001及0.027,OR值分别为1.11(95％ CI 1.04-1.18)及0.25(95％ CI 0.07-0.85).对狭窄程度指标进行ROC曲线分析提示曲线下区域面积0.76(95％ CI 0.66-0.81).结论QCA在冠状动脉钙化病变是否行旋磨术中具有预测和指导价值.冠状动脉钙化病变的狭窄程度与内膜钙化是该病变需行冠状动脉旋磨术预处理的相关因素.【期刊名称】《大连医科大学学报》【年(卷),期】2019(041)004【总页数】4页(P311-314)【关键词】量化冠状动脉造影;冠状动脉钙化;冠状动脉旋磨术【作者】王天保;关汝明;夏霏【作者单位】大连医科大学研究生院,辽宁大连116044;辽宁省人民医院心内科,辽宁沈阳110016;辽宁省人民医院心内科,辽宁沈阳110016【正文语种】中文【中图分类】R541.4冠状动脉钙化病变是冠状动脉粥样硬化性心脏病中的高阻力病变，也是冠状动脉介入治疗(percutaneous coronary intervention， PCI)中器械通过失败、支架膨胀不良及冠状动脉破裂等事件发生的高危险因素，并与PCI近期及远期预后明确相关[1-2]。