Guidezilla~(TM)延长导管在冠状动脉慢性完全闭塞病变反向控制性前向与逆向内膜下寻径技术中的应用

目的探讨Guidezilla~(TM)延长导管在冠状动脉慢性完全闭塞病变(chronic total occlusion,CTO)行逆向经皮冠状动脉介入治疗时协助导丝通过闭塞病变与导丝体外化的可行性以及安全性。方法回顾性分析广东省人民医院119例CTO患者。其中,2015年1月至2015年10月入选80例未使用Guidezilla~(TM)延长导管的反向控制性前向与逆向内膜下寻径(controlled anterograde and retrograde sub-intimal tracking,CART)技术的患者(Non-Guidezilla组),2015年10月至2016年11月入选39例使用Guidezilla~(TM)延长导管的反向CART技术的患者(Guidezilla组)。结果本研究中反向CART技术总体成功率为84.0%(100/119)。Guidezilla组成功率(100%比76.2%,P0.05)高于Non-Guidezilla组,差异有统计学意义;两组患者平均J-CTO评分为2.67,Guidezilla组手术困难(35.9%比15.0%,P0.001)和非常困难(61.5%比32.5%,P0.001)的患者比例均高于Non-Guidezilla组,差异均有统计学意义;Guidezilla组二次手术率(25.6%比63.8%,P0.001)及开口/分叉病变比例(30.8%比62.5%,P=0.002)均低于Non-Guidezilla组,差异均有统计学意义;Guidezilla组闭塞近段刀割状(53.8%比32.5%,P=0.030)、闭塞段长度20 mm(89.7%比72.5%,P=0.035)及闭塞段弯曲45°(84.6%比63.8%,P=0.020)的比例均高于Non-Guidezilla组,差异均有统计学意义。结论对于长迂曲的复杂CTO患者,逆向导丝与微导管难以通过病变并进入正向指引时,Guidezilla~(TM)延长导管能提供安全有效的解决方案。     

逆向经皮冠状动脉介入治疗左前降支的慢性完全闭塞病变

患者男，42岁，反复胸部不适2年，加重数个月，行走500 m后胸部压榨感。既往吸烟史，每天2包以上。     

Usefulness of coronary epicardial collaterals for the retrograde approach treatment of coronary chronic total occlusions

Background The retrograde approach allows to significantly increase the success rate of coronary chronic total occlusion(CTO) percutaneous intervention(PCI). Epicardial collateral channels(CCs) remain an essential channel for retro-recanalization. But paucity of data in this area limits the use of epicardial CCs for retrograde canalization. The present study was to explore the feasibility and significance of coronary epicardial collaterals for the retrograde approach treatment of coronary CTO. Methods We retrospectively analyzed 347 CTO cases which the retrograde approach was attempted after reviewing the coronary angiograms of 1290 patients. And there were 89 retrograde approach PCI cases applying epicardial CCs. We collected the clinical and angiography data of those patents for analyzing the safety and usefulness of this technology. Results The study consisted of347 CTO PCI. Mean age was 60.8±10.4 and 60.3±10.2 years in epicardial CCs and septal CCs groups respectively. The total retrograde success rate was 79.8%. The success rate of retrograde approach applying epicardial CCs was not lower(82.0% vs. 79.1%, P=0.646) than that in cases applying septal CCs. There were 8 epicardial CCs injury cases(9.0%) and 3 cases resulted in cardiac tamponade and required emergency pericardiocentesis. Coils were used for all of them with success. No patients were dead in retrograde approach applying epicardial CCS.Conclusions Coronary epicardial collaterals can be used as an access for the retrograde approach in the percutaneous treatment of CTO, which is relative feasible, and has a high success rate. Epicardial CCs injury can be safety as long as it is treated timely.     

左心室辅助装置在高危冠状动脉介入治疗中的应用

经皮冠状动脉介入治疗（percutaneous coronaryintervention, PCI）技术越来越成熟。已在越来越多的高危患者中应用。同时,对于无保护的左主干患者、多支病变患者、最后存留血管患者、左心室功能受损者以及持续性缺血症状发作的患者。介入心血管医生通常应用各种经皮辅助装置来降低术中的风险。     

The effect and safety of chronic total occlusion etrograded recanalization by epicardial collateral channel

Background Data on retrograde recanalization of epicardial collateral channels in patients with chronic total occlusion(CTO) undergoing percutaneous coronary intervention(PCI) are limited. Fearing about the complications of perforation, few CTO patients have chosen retrograde recanalization of epicardial collateral channels. Methods A retrospective analysis was conducted in this study. We followed up eligible patients who underwent continuous CTO via epicardial CCS from August 2011 to October 2018 in our center, and analyzed the detailed clinical baseline and angiographic data, surgical success rate and hospital complications to determine the efficacy and safety. The Cox model was used to compare major adverse cardiac events(MACE) and related co-variables between CTO patients with epicardial CCS perforation and non-perforated PCI patients. Results The study enrolled 191 patients with epicardial CCs PCI of CTO and the long term follow-up time was 24.03±19.18 months.Successful CCs PCI of CTO was achieved in 161(84.8 %) patients. Procedural collateral perforation occurred in23(12.0%) patients. MACEs occurred in 18 patients(9.4%) at 1-year follow-up. Kaplan-Meier curves showed no significant difference in MACEs between perforating recanalization of CCs PCI of CTO and non-perforating PCI of CTO.( adjusted hazard ratios(HR): 0.467; 95% confidence intervals(CI): 0.13 to 1.69, P=0.245). The multivariate Cox regression analysis identified the Werner score=0/1(HR: 5.80; 95% CI: 1.89 to 17.8; P=0.002) as significant independent predictors of perforation of CCs PCI of CTO. Conclusions The major complication of the procedure is collateral perforation. Recanalization of CTOs through epicardial collateral channel is safe and effective. It may be a available choice for recanalization of complex CTO.[S Chin J Cardiol 2019;20(1):37-43]     

N-terminal pro-B-type natriuretic peptide levels after hospital discharge in patients with acute myocardial infarction for predicting long term outcome

Background N-terminal-pro-brain natriuretic peptide(NT-pro-BNP)is associated with worse outcome in patients with acute myocardial infarction(AMI). However,the role of short-term follow-up of NT-pro-BNP level remains unclear. Methods Three hundred and sixty-two patients diagnosed with AMI were retrospectively enrolled in this study from March 2014 to March 2017 in our center. Blood samples were obtained at initial admission and again within 1 month after hospital discharge. The univariate and multivariate cox regression analyses including significant covariables were performed on NT-pro-BNP level at admission,discharge,or change from admission to discharge to predict adverse cardiovascular events(MACE)as study endpoints. Results There were 211 cases in NT-pro-BNP decrease group,while 151 cases in NT-pro-BNP increase group. The median follow-up was 365 days(interquartile range[IQR],322-861 days). After adjusting the covariables in the multiple logistic regression analysis,follow-up NT-pro-BNP level was still a significant independent predictor for MACE(OR,1.395;95% CI,1.102-1.869,P=0.005). However,the initial NT-pro-BNP level or change of NT-pro-BNP level had no significant predictive value for MACE. Conclusions A short-term follow-up NT-pro-BNP level after hospital discharge is a powerful prognostic biomarker for MACE in patients with AMI.[S Chin J Cardiol 2019;20(3):168-173]     

冠状动脉内旋磨术在慢性完全闭塞病变介入治疗中的应用

冠状动脉慢性完全闭塞病变（chronic total occlusion,CTO）是指闭塞时间≥3个月的血管病变,约占冠状动脉造影检出病变的13％～18％[1-2],尽管近年来在CTO的病理生理基础研究、治疗专用器械和经皮冠状动脉介入治疗（PCI）手术技巧等方面取得了很大的进展,但是CTO介入治疗的成功率仍然只有70％～80％[3-4].其中,80％的手术失败是因为导丝不能通过闭塞病变,约15％～20％的患者因球囊不能通过或支架不能很好扩张而失败.目前,关于球囊不能通过的闭塞病变介入手术方法,国内外相关文献报道较少.本文对在广东省人民医院心内科二病区13例球囊不能通过的CTO患者行冠状动脉腔内旋磨术进行了总结报道.