无保护冠状动脉左主干病变的介入治疗及随访

目的探讨经皮冠状动脉介入术治疗无保护冠状动脉左主干狭窄的临床疗效和安全性。方法对46例无保护左主干狭窄超过50%以上的冠状动脉粥样硬化性心脏病患者行经皮冠状动脉介入术治疗,并对其进行随访。结果46例患者中,12例左主干开口狭窄,13例是左主干体部狭窄,21例左主干远段狭窄。46例患者中42例行支架置入术(其中药物支架11例),1例行切割球囊治疗,3例仅行经皮腔内冠状动脉成形术治疗,手术成功率100%。半年内4例发生术后再狭窄,其中2例为药物支架病例,2例为普通支架。术后平均随访(23.9±2.7)个月,1例6个月时,死于慢性肾衰竭,1例10个月时死于左心衰竭。结论介入治疗无保护冠状动脉左主干病变临床疗效可靠、安全性好。     

无保护左主干病变的冠状动脉介入治疗临床观察

左主干病变患者是冠心病中的高危人群，药物治疗预后很差，冠状动脉旁路移植术（CABG）是首选的治疗手段。近十余年，随着器械的改进，经验的积累和技术的提高，经皮冠状动脉介入治疗（PCI）已逐渐应用于无保护左主干病变的治疗。     

无保护左主干病变患者介入治疗的护理

目的总结87例冠状动脉造影发现为无保护左主干开口及体部狭窄患者的冠状动脉介入治疗前后的护理资料,探讨提高手术安全性和可行性及提高患者生活质量的护理方法。方法术前给予患者常规的用药护理、生活护理及加强心理护理;手术前后严密观察其生命体征,防止恶性心律失常的发生;出院时做好宣教,让患者及其家属认识到术后长期用药的重要性。结果87例无保护左主干病变患者进行冠状动脉内支架植入术,术后发生肾功能衰竭2例,穿刺口局部血肿3例（均为腹股沟穿刺口）。2例术后24h内发生恶性心律失常,经抢救恢复正常心律,8例术后1个月随访有胸闷、胸痛发生。术后所有患者均按医嘱按时、按量服用抗凝药物。结论有效的护理干预可以提高无保护左主干病变支架植入的成功率,减低术后并发症,有效提高患者生活质量。     

左冠状动脉主干病变的介入治疗

左冠状动脉主干病变为冠状动脉造影显示狭窄程度≥5 0 %的冠状动脉病变 ,约占冠状动脉造影病例的 5 %。左主干病变可分为开口处病变、干段病变和远段病变 ,后者常累及左前降支 (L AD)和 (或 )回旋支 (L CX)开口。左主干病变还可分为有保护与无保护左主干病变两种亚型 ,前者指以前经冠脉移植搭至左冠脉一支或多支的通畅血管桥或自身存在右向左的良好侧支循环。由于左主干血管供应整个左心系统 ,一旦血流被阻断 ,易发生室颤、心脏骤停、心源性休克。1　单纯球囊成形术 (PTCA)一般认为 ,左主干病变管腔大、病变短、少扭曲 ,是 PTCA的良好…     

无保护左主干病变介入治疗后冠状动脉造影随访结果分析

目的探讨左主干病变裸支架治疗后再狭窄的可能原因。方法回顾性分析自1997年到2004年间行无保护左主干病变介入治疗并进行冠状动脉造影随访的18例患者的病变情况及其远期疗效。结果(1)9例双支架置入患者中,药物支架V型支架术的6例患者中有4例发生了再狭窄,再狭窄均发生在前降支和回旋支血管开口处;裸支架T支架术的2例患者发生了再狭窄,其中1例弥漫性再狭窄,另外1例发生了回旋支开口的再狭窄。(2)9例置入单个支架的患者中,5例患者支架跨过了回旋支开口,即采取了Cross-over技术,复查时只有1例左主干支架发生了再狭窄;3例左主干体部支架的患者中1例发生了弥漫性再狭窄。(3)对两例V支架的患者进行了血管内超声检查,发现在开口处没有完全膨胀,亦没有完全贴壁。结论(1)左主干病变介入治疗(特别是双支架置入方法)的再狭窄率很高。(2)在左主干分叉病变治疗中,支架跨过回旋支患者的远期预后良好,即支架可以安全地跨过回旋支。     

经皮冠状动脉无保护左主干分叉病变支架术28例分析

目的评价经皮冠状动脉介入术（PCI）治疗无保护左主干分叉病变的近远期疗效。方法回顾性分析我院无保护左主干分叉病变择期行PCI的28例冠心病患者的临床资料,全部置入药物洗脱支架,置入单支架12例,双支架16例。术后每2周或1个月门诊复查1次,8～12个月行冠状动脉造影复查。结果 28例PCI均取得成功,16例置入双支架的患者均成功进行球囊对吻扩张。所有病例术后达TIMI3级血流,住院期间无严重不良心脏事件,术后随访20～30个月,6个月内有4例再次出现心绞痛症状,冠状动脉造影复查显示支架内再狭窄3例（10.71%）,随访期内死亡1例。结论经选择的无保护左主干分叉病变PCI即刻成功率高,有较好的近、远期疗效。     

冠状动脉左主干病变介入治疗

冠状动脉左主干病变的介入治疗具有挑战性。现从冠状动脉左主干的解剖特点、冠状动脉左主干病变的病因形成、左主干病变的诊断、左主干病变的治疗、左主干病变支架术的适应证和禁忌证、器械选择、治疗策略等进行了详细的阐述。对于存在冠脉旁路移植术禁忌证、拒绝外科治疗或经严格选择的左心功能正常的无保护左主干病变的病人,冠脉支架置入术是一种较理想的治疗方法。     

经桡动脉行无保护左主干病变介入治疗

目的:回顾性总结29例冠状动脉造影发现为无保护左主干开口及体部狭窄病例的冠脉介入治疗(PCI)资料,以探讨手术的安全性和可行性。方法:术前给予常规药物治疗,经桡动脉途径行PCI,观察桡动脉穿刺成功率、PCI即刻成功率、手术时间、支架扩张时间和扩张压力、住院期间严重并发症发生率、出院前心绞痛发作情况评估及术前心电图(ECG)特点分析。结果:29例患者桡动脉穿刺成功率和PCI即刻成功率均为100%,手术时间25～50(38±8)min,支架扩张时间3～7(5±1.3)s,支架扩张压力14～20(16.0±1.9)atm(1atm=101.325kPa),住院期间无严重并发症发生,前臂肿胀3例,术后心绞痛显著缓解。术前胸痛发作时ECG特点:典型"左主干"心电图17例,胸前导联ST-T改变者10例,间歇性左束支阻滞2例。结论:经桡动脉途径对无保护左主干开口和体部病变行PCI治疗,成功率高,安全有效。     

左主干病变的介入治疗

冠状动脉旁路术曾是无保护左主干病变的标准治疗,随着经皮冠状动脉介入治疗技术的进步,介入治疗已成为左主干病变的一种有效治疗手段。进一步规范患者的选择,科学选择治疗策略及相关器械有助于提高左主干病变经皮冠状动脉介入治疗的有效性及安全性。如何加强患者的定期随访、抗血小板治疗反应性的监测是亟待解决的问题。     

无保护左主干病变支架置入术的近、远期疗效

目的:探讨无保护左主干病变支架置入术的近、远期疗效。方法:选择25例无保护左主干病变患者,其中4例左室射血分数<40%,>70岁9例,>80岁2例,行冠状动脉内支架术,分析其临床、手术成功率及随访结果。结果:左主干支架术的成功率100%,无任何严重并发症,术后随访6~42(14.5±12.1)个月,临床心绞痛复发4例(16%),其中2例再次行经皮冠状动脉腔内成形术,2例药物治疗。结论:支架置入术治疗无保护左主干病变近期及远期疗效显著,是值得肯定的治疗方法,正确的选择患者和熟练的操作技巧是成功的关键。     

选择性左冠状动脉主干病变的介入治疗

目的冠状动脉旁路移植术(CABG)是多支血管病变血运重建的最佳方法,是无保护性左冠状动脉主干(LMCA)病变的标准治疗.本研究探讨无保护性LMCA病变介入治疗的疗效和可行性.方法总结分析1996年10月～2000年8月间20例住院的冠心病左主干病变患者接受直接支架术治疗.入选患者例行左室造影(LVEF>45%),冠状动脉血管成形术及其疗效评判采用常规标准,合并右冠脉严重弥漫狭窄病变或前降支(LAD)与回旋支(LCX)同时严重狭窄者不行该术.结果 20例中男17例、女3例,年龄42～71(平均64±12)岁,临床呈心绞痛Ⅱ-Ⅲ级,其中合并高血压9例、糖尿病(2型)1例.冠脉造影显示,左冠脉主干病变呈单纯狭窄者8例,其中近中段狭窄(50%～80%)者6例、开口狭窄(50%～60%)者2例,左主干夹层分离者2例,动脉瘤者1例,合并LAD或LCX病变(狭均>70%)者9例(狭窄50%～70%).全部患者左主干病变均进行直接支架术,其中6例伴LAD或LCX病变者先行PTCA或支架术后再进行左主干病变的支架置入术.置入左主干内的支架均为管状宽径短支架,16例为4.0 mm×9 mm(直径×长度)支架,3例为3.5 mm×9 mm支架,1例冠状动脉瘤者应用4.5 mm×9mm支架.左主干支架术成功率为100%,无残余狭窄或残余狭窄<10%,无任何并发症如支架血栓形成、急性心肌梗死、紧急CABG及死亡等.9例合并LAD(6例)或LCX(3例)狭窄者,先行LAD或LCX的PTCA术,其中3例PTCA术后残余狭窄<20%,5例残余狭窄30%～40%者中2例置入3.0×16mm支架、1例3.5×20mm支架、1例3.0×14 mm支架,1例LCX开口后狭窄(75%)者因PTCA后发生夹层放置3.5×12 mm支架,造影示夹层消失,无残余狭窄.冠状动脉瘤行带膜支架术者造影示瘤体消失,左主干管壁平整.随访1～4年,14例心绞痛发作消失、6例心绞痛复发但显著减轻(心绞痛Ⅰ级),后者有4例于术后半年～1年内复查冠脉造影提示早期再狭窄,其中2例单纯LMCA再狭窄者再次行冠脉血管成形术、2例LMCA合并LAD再狭窄者行CABG手术,无急性心肌梗塞或死亡等严重心脏事件发生,患者均能维持正常生活.结论本研究结果表明,选择性无保护性左冠状动脉主干病变支架术在临床上切实可行、疗效显著,可以是继CABG的另一治疗选择.     

One-year clinical outcomes of protected and unprotected left main coronary artery stenting.

AIMS: To evaluate outcomes for left main coronary artery (LMCA) stenting and compare results between protected (left coronary grafted) and unprotected LMCA stenting in the current bare-metal stent era. METHODS: We reviewed outcomes among 142 consecutive patients who underwent protected or unprotected LMCA stenting since 1997. All-cause mortality, myocardial infarction (MI), target-lesion revascularization (TLR), and the combined major adverse clinical event (MACE) rates at one year were computed. RESULTS: Ninety-nine patients (70%) underwent protected and 43 patients (30%) underwent unprotected LMCA stenting. In the unprotected group, 86% were considered poor surgical candidates. Survival at one year was 88% for all patients, TLR 20%, and MACE 32%. At one year, survival was reduced in the unprotected group (72% vs. 95%, P<0.001) and MACE was increased in the unprotected patients (49% vs. 25%, P=0.005). CONCLUSIONS: In the current era, stenting for both protected and unprotected LMCA disease is still associated with high long-term mortality and MACE rates. Stenting for unprotected LMCA disease in a high-risk population should only be considered in the absence of other revascularization options. Further studies are needed to evaluate the role of stenting for unprotected LMCA disease.     

Elective stenting of unprotected left main coronary disease

For the 12-mo period of 1995, we encountered seven consecutive patients with symptomatic unprotected left main coronary stenosis requiring revascularization. There were five males and two females, age ranging 48–76 years. One patient was referred to coronary bypass surgery. Of the remaining six patients, three refused surgery and the other three, including one with previous bypass surgery and two with previous interventional procedures, preferred percutaneous revascularization. All six had successful elective stenting of their left main coronary stenoses with the new short Palmaz-Schatz stents, P084 and PS104. There were no complications and all remained totally asymptomatic at 3–14 months followup. We conclude that with proper patient selection and the availability of appropriate stents, elective stenting of unprotected left main coronary stenosis is safe with good immediate and medium term results. © 1996 Wiley-Liss, Inc.     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.     

Predictors of long-term outcomes in patients after elective stent implantation for unprotected left main coronary artery disease

The purpose of this study was to investigate the predictor of long-term outcomes in patients after stent implantation for unprotected left main coronary artery (LMCA) disease. Coronary stenting has recently been advocated as an alternative procedure for LMCA disease. Information on the predictors of long-term outcomes in patients after stent implantation for unprotected LMCA disease is not clear. Seventy six patients (51 men and 25 women, age 68 ± 10 years) with medically refractory angina received coronary stenting for unprotected LMCA disease. During a follow-up period of 40 ± 26 months, 7 patients (9%) died because of cardiovascular disease in 5 (7%) and noncardiovascular disease in 2 (3%). In the other 69 patients, 19 patients (25%) needed repeated percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG). In a univariate analysis, only female sex was related to the repeated PCI and/or CABG (P = 0.04). A history of cerebral vascular attack (CVA) (P = 0.005), anemia (P = 0.03) and lower left ventricular ejection fraction (LVEF) (P = 0.008) were related to the cardiovascular mortality. A history of myocardial infarction (P = 0.03), a history of CVA (P = 0.02), anemia (P = 0.02), and lower LVEF (P = 0.002) were related to the total mortality. In a multivariate analysis, female sex (P = 0.007; odds ratio 5.29, 95% confidence interval [CI] 1.57–17.80) and young age (P = 0.025; odds ratio 3.92, 95% CI 1.19–12.98) could predict the repeated PCI and/or CABG. Only a history of CVA could predict the cardiovascular mortality (P = 0.027; odds ratio 34.18, 95% CI 1.49–783) and only lower LVEF could predict the total mortality (P = 0.027; odds ratio 13.26, 95% CI 1.34–131). Female sex and young age could predict the repeated PCI and/or CABG in patients after stent implantation for unprotected LMCA disease. Furthermore, a history of CVA could predict the cardiovascular mortality and lower LVEF could predict the total mortality.     

二代支架时代数据中糖尿病对无保护左主干患者不同血运重建术预后的影响

目的:在二代支架时代,糖尿病对不同血运重建策略治疗无保护左主干冠状动脉疾病患者的影响尚未可知。方法:回顾性入选823例无保护左主干冠状动脉疾病的患者,其中接受二代药物洗脱支架(DES)置入治疗的患者331例(糖尿病患者,n=99;非糖尿病患者,n=232),接受冠状动脉旁路移植术(CABG)患者492例(糖尿病患者,n=127;非糖尿病患者,n=365)。我们根据不同的血运重建策略比较了糖尿病对临床结果的影响。结果:在接受血运重建的无保护左主干病变患者中,糖尿病患者占27.5%(226/823)。经过平均25.3个月的随访后发现,在接受DES治疗的人群中,糖尿病患者与非糖尿病患者的全因死亡率、心源性死亡率、血运重建发生率、卒中和主要不良心脑血管事件的发生率没有显著差异。然而,在全因死亡/心肌梗死/卒中联合终点(糖尿病组21.5%vs.非糖尿病7.2%,P=0.001)及心肌梗死发生率(糖尿病组15.4%vs.非糖尿病组1.6%,P<0.001)中,糖尿病患者明显高于非糖尿病患者。在接受CABG治疗的群体中,糖尿病组和非糖尿病组所有临床终点发生率相似。结论:在二代药物洗脱支架治疗无保护左主干病变的患者中,合并糖尿病的患者较非糖尿病组预后较差,在接受CABG的患者中,糖尿病和非糖尿病组预后相似。     

无保护左主干病变支架置入术预后及影响因素的分析--中国无保护左主干病变支架置入术注册(CHANCE)研究

目的评价无保护左主干(LMCA)病变支架置入术后的即刻及长期预后,并探讨影响预后的因素.方法本研究为多中心注册研究,对国内23家医院在1997年5月至2003年3月间完成的连续择期无保护LMCA病变裸金属支架置入术的患者进行注册登记,全部患者均填写固定表格.结果共224例患者进行了注册,年龄22～88岁,平均(60.1±12.0)岁.有既往心肌梗死史患者53例(23.7%),合并糖尿病45例(20.1%).孤立性无保护LMCA126例(56.2%),LMCA合并其他血管病变98例(43.8%).平均左室射血分数(63.9±12.3)%. 223例(99.6%)LMCA病变支架置入术成功,91例(92.9%)非LMCA病变支架置入术成功.住院期间死亡1例(0.45%),非Q波心肌梗死(MI)1例(0.4%).平均随访(15.6±12.3)个月,死亡12例(5.4%),其中心原性死亡10例(4.5%),非心原性死亡2例(0.9%),急性MI 4例(1.8%), LMCA 靶病变血管重建术26例(11.7%),累积主要心脏不良事件(MACE)36例(16.1%).左室射血分数<40%、女性和LMCA合并多支血管病变增加死亡危险,多支病变非完全血管重建增加MACE发生率;多因素回归分析显示左室射血分数<40%和女性为预测死亡和MACE的独立危险因素.102例(45.7%)患者进行了造影复查,LMCA 再狭窄32例(31.4%).术中有回旋支开口部受累者再狭窄率增加.结论经过选择的无保护LMCA病变支架置入术是可行和安全的,并可取得较好近、远期疗效.目前,无保护LMCA支架置入术应选择孤立性LMCA病变或合并多支病变但能达到完全性血管重建、左室射血分数≥40%的患者或不能行冠状动脉旁路移植术的患者.     

无保护左主干病变合并急性冠状动脉综合征介入与手术治疗对比研究

目的:探讨急性冠状动脉综合征(ACS)合并无保护左主干病变患者经桡动脉介入治疗(TRI)与冠状动脉旁路移植术(CABG)二者的疗效。方法:连续入选2008年3月至2010年12月,于北京安贞医院行经桡动脉介入治疗(n=236)或冠状动脉旁路移植术(n=354)的无保护左主干病变合并ACS患者。对于患者的临床基线特征及冠状动脉病变特征纳入倾向性评分模型进行匹配,得到154对患者。结果:平均随访时间27个月。经过倾向性评分模型进行校正,两组患者的基线资料及病变特征无显著差异。结果显示TRI与CABG两组全因病死率(4.5%vs.6.5%;P=0.454)及心肌梗死发生率(5.2%vs.7.8%;P=0.355)并差异无统计学意义。CABG组患者脑卒中发生率显著增加(零vs.2.6%;P=0.044),而TRI组靶血管重建率(TVR)显著增加(13.0%vs.5.2%;P=0.017)。两组患者复合终点(死亡/心肌梗死/靶血管重建),差异无统计学意义(7.1%vs.12.3%;P=0.124)。结论:对于ACS合并无保护左主干病变患者TRI与CABG的临床复合终点事件风险相似,然而尽管应用药物洗脱支架CABG组患者靶血管重建率仍显著低于介入治疗组。     

不稳定型心绞痛无保护左主干病变支架术后随访研究

目的　探讨冠状动脉内支架治疗无保护左主干病变 (LMD)的安全性及有效性。方法　2 7例LMD经球囊预扩张后置入支架。术后 6和 12个月行冠状动脉造影随访。结果　左主干开口病变 12例、体部 4例、末端 6例 (累及分叉开口 6例、单纯末端 1例 ) ,自开口到体部均狭窄者 5例 (含自开口处就完全闭塞 1例 )。术后 12个月时 ,左心室射血分数从 4 9 8%增加到 5 6 3% (P <0 0 5 )。球囊扩张时 2 0例 ( 6 2 % )出现显著心率减慢和血压下降。共置入 2 8枚支架 ,其中左主干内 2 7枚 ,主干内支架直径 ( 3 90± 0 4 7)mm、长度 ( 12 5 4± 3 95 )mm。全部患者均完成 12个月的临床随访 ,19例 ( 70 % )患者接受 6个月时冠状动脉造影 ,3例支架内再狭窄 ( 15 % ) ,其中 2例接受冠状动脉旁路术 ,1例行血管内放射治疗 ;术后 12个月时 15例 ( 5 5 % )行冠状动脉造影随访 ,1例再狭窄行冠状动脉旁路术 ,因此术后 12个月内累积再狭窄率为 2 1%。 4例再狭窄患者中 ,3例为末端病变 ( 75 % ) ,1例为开口病变( 2 5 % )。结论　冠状动脉内支架治疗LMD疗效可靠 ,冠状动脉造影随访可及时发现再狭窄。左主干末端病变再狭窄率显著。     

51例左冠状动脉主干病变的临床分析

分析 51例左冠脉主干病变 (狭窄≥ 50 % )的冠心病患者。其中单纯左主干病变 8例 ,左主干合并其它冠脉病变 4 3例。并与非左主干病变的冠心病患者 2 1 0例进行比较。结果表明 :左主干病变组临床上多表现为不稳定性心绞痛 ,易发心梗 ,猝死率较高。但冠心病的易患因素及左室射血分数 ,在两组中差异无显著性。单纯左主干病变与非左主干病变者类似 ,但心绞痛发作时其心肌缺血更为严重。冠脉搭桥术可改善左主干病变患者的症状和预后。