The evolution of medical and surgical therapy for coronary artery disease. A 15-year perspective

To elucidate the factors associated with improved survival following coronary artery bypass surgery, we studied 5809 patients receiving medical or surgical therapy for coronary artery disease. Three factors were associated with a significant surgical survival benefit: more severe coronary disease, a worse prognosis with medical therapy, and a more recent operative date. Patients with more extensive coronary obstruction had the greatest improvement in survival. Patients with a poor prognosis because of factors such as older age, severe angina, or left ventricular dysfunction had a reduction in risk that was proportionate to their overall risk on medical therapy. Survival with surgery progressively improved over the study period and by 1984 surgery was significantly better than medical therapy for most patient subgroups. Thus, contemporary coronary revascularization is associated with improved longevity in many patients with ischemic heart disease, especially in those with adverse prognostic indicators.     

冠状动脉旁路移植术治疗冠心病24例报告

目的:总结冠状动脉旁路移植术(CABG)治疗冠心病的临床经验.方法:收集24例行CABG的冠心病患者临床资料,对手术病例选择、手术方法、桥血管的选择及围手术期管理进行分析.结果:24例患者中14例为多支冠状动脉病变.所有患者采用胸部正中切口开胸,浅低温全身麻醉.其中13例行体外循环冠状动脉旁路移植术,11例非体外循环冠状动脉旁路移植术;共移植血管61支,人均2.5支;同期行心脏瓣膜置换5例,室壁瘤切除术1例.所有患者均恢复良好,无一例手术死亡.术后随访2个月～3年,患者心绞痛症状完全消失.结论:CABG是冠心病患者较为安全和有效的治疗方法.在基层医院开展此项技术,慎重选择病例、根据患者的病情特点及医疗条件决定手术方式、恰当选择移植血管及做好围手术期管理工作是保证手术成功的关键.     

Does coronary surgery prolong life in comparison with medical management?

This analysis attempts to utilize natural history controls to answer the question as to whether coronary surgery prolongs life in comparison to medical management. Selected natural history studies are compared and contrasted in an effort to obtain an average survival curve for patients with coronary artery disease comparable to those presently being operated. The Duke University Medical Center series of concurrent operated and non-operated patients is reviewed to demonstrate the difference of prognosis of patients with coronary artery disease and the complexities involved in answering the question. It is concluded that, on average, coronary surgery does not prolong life in comparison to medical management over the span of 2-5 years. There may be certain higher risk patients whose lives may be prolonged by aortocoronary bypass surgery but more patients and more prolonged follow-up are needed fully to answer the question.     

桥血管狭窄患者介入治疗影响预后的因素分析

目的：分析冠脉搭桥术后桥血管狭窄成功行介入治疗患者的基线资料特点,探讨原位血管及桥血管介入治疗、支架种类与桥血管狭窄行介入治疗患者预后的关系.方法：对入选的281例桥血管病变患者进行随访,统计基线资料,观察主要不良心血管事件（MACE）的情况,分为MACE组及无MACE组.对可疑影响MACE发生的危险因素行Logistic回归分析,得出影响该类人群预后的独立危险因素,采用Kaplan-Meier生存曲线Log-rank检验原位血管与桥血管介入治疗策略、药物涂层支架与裸支架对生存率的影响及区别.结果：在基线资料方面：年龄、性别、肥胖、高血压病史、吸烟史、高脂血症病史、冠心病家族史、既往心肌梗死病史、心功能情况及冠心病类型方面两组均无统计学差异（P＞0.05）,在血糖、胆固醇、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）水平中具有统计学差异（P值分别为0.003、0.02i、0.014及0.014）,糖尿病、HDL-C、支架直径及支架长度与桥血管介入治疗后发生MACE独立相关.原位血管组及桥血管组在发生MACE方面的差异具有统计学意义（P=0.008）,在原位血管及桥血管介入治疗后随访的MACE中,药物洗脱支架（DES）与金属裸支架（BMS）组在MACE发生率中具有统计学差异.结论：糖尿病与支架长度是影响桥血管狭窄介入治疗预后的危险因素;HDL-C及支架直径为预后的保护因素;原位血管与桥血管的介入治疗策略比较中,原位血管的预后优于桥血管.     

合并阻塞性睡眠呼吸暂停综合征患者行非体外循环冠脉搭桥手术围术期处理分析

目的 探讨合并阻塞性睡眠呼吸暂停综合征(OSAS)患者行非体外循环冠脉搭桥手术(OPCABG)围术期处理对手术预后的影响.方法 选择欲行OPCABG的合并中、重度OSAS 的患者30例,分为处理组(12例)和对照组(18例).比较两组患者的术后并发症、预后及血清可溶性细胞间黏附分子-1(ICAM-1)、血管细胞黏附分子-1(VCAM-1)和内皮素-1(ET-1)水平手术前后的变化.结果 处理组患者的术后拔管时间、ICU停留时间、术后住院时间明显短于对照组,差异有统计学意义(P＜0.01);处理组患者的血清ICAM-1、VCAM-1、ET-1水平均低于对照组,差异有统计学意义(P＜0.001);术后两组患者的心房纤颤、主要不良心脏事件(MACE)及静脉桥病变的发生情况比较差异无统计学意义(P＞0.05);处理组患者术后血清ICAM-1、VCAM-1、ET-1水平低于术前(P＜0.05);而对照组患者上述各指标手术前后比较差异无统计学意义(P＞0.05).结论 合并OSAS患者行OPCABG,围术期处理可以改善内皮功能和手术预后;但不能降低术后房颤、MACE和静脉桥血管病变的发生率.     

升主动脉钙化冠心病合并心肌桥12例临床分析

目的：分析升主动脉钙化冠心病合并心肌桥的外科治疗效果。方法：对12例升主动脉钙化冠心病合并心肌桥患者施行冠状动脉旁路移植术和心肌切开术,12例患者均存在不同程度的升主动脉钙化,术中将血管桥近端吻合在降主动脉上,对于较浅的心肌桥在非体外循环下行心肌切开术,而对于走形于心肌深部的肌桥,采用体外循环下冠状动脉旁路移植术;血管段同时合并狭窄及肌桥时,在心肌桥远侧的部位进行冠状动脉旁路移植术。结果：所有患者均手术顺利,无严重并发症,术后随访未出现心脏不良反应。结论：升主动脉钙化冠心病合并心肌桥者选择适当的手术方式可取得令人满意的近期效果,其远期疗效还有待于进一步观察。     

Coronary angioplasty and surgery for coronary artery disease.

Heart disease remains the most common cause of morbidity and mortality in the United States. During the 1970s until the early 1980s, patients with angina pectoris refractory to medical therapy could only consider bypass surgery to relieve their symptoms. Beginning in the early 1980s, coronary balloon angioplasty became an alternative to bypass surgery in those with single vessel coronary artery disease and failure to medical therapy. In the mid-1980s, patients with multi-vessel coronary artery disease also were seen to benefit from balloon angioplasty. Now in the 1990s, balloon angioplasty's success is being compared to coronary bypass with prospective randomized trials. While balloon angioplasty has become relatively easy to perform due to advances in balloon, wire, and guiding catheter technology, many new interventional devices such as atherectomy and laser, are now available. The explosion in technology reflects our inability to prevent atherosclerotic disease and also reveals that while we can improve a patient's lifestyle and in some situations improve mortality rate, atherosclerotic disease remains a disease for which we have no cure.     

对375例冠心病介入治疗患者的证型分析

目的探讨冠心病（CHD）患者与中医证型的关系及冠心病介入治疗情况,为冠心病临床科研一体化技术平台服务。方法选择2012年5月-2013年5月于新疆医科大学附属中医医院心内科经冠脉造影检查诊断为冠心病并行PCI术375例出院患者。分为秽浊痰阻、心血瘀阻、痰阻心脉、气滞血瘀、气虚血瘀、气阴两虚、心肾阴虚7类中医证型。将病案资料中的相关信息填人表格,经核准后对数据进行全面分析。结果（1）375例冠心病行PCI术患者中,中医辨证标实证中秽浊痰阻证210例（56．00％）,所占比例最多,非秽浊痰阻者165例（44．00％）;非秽浊痰阻中以气虚血瘀、痰阻心脉、气阴两虚为主要证型;（2）冠心病患者中以汉族、维吾尔族、哈萨克族多见,显示证型以秽浊痰阻为主;（3）男性冠心病患者发病率高于女性（P〈0．001）;（4）冠心病各中医证型中秽浊痰阻为主要证型;（5）以高血压、吸烟及糖尿病为冠心病主要危险因素;（6）冠心病患者的冠脉病变以前降支为主,秽浊痰阻证型以多支病变为主;（7）冠心病患者PCI术前与术后中医证型均以秽浊痰阻为主要证型。（8）秽浊痰阻证的冠脉狭窄以重度狭窄为主,且以多支病变为主要证型,非秽浊痰阻型冠脉病变程度轻于秽浊痰阻证,PCI术前、术后均以秽浊痰阻型为主证。结论秽浊痰阻证是新疆医科大学附属中医医院冠心病患者行PCI术前术后的主要中医证型,中医证型与冠脉病变具有一定的相关性。     

Changes in working status of patients following coronary bypass surgery.

Coronary artery bypass surgery has gained a major role in the management of ischemic heart disease. Relief of symptoms is often the primary goal for these surgical procedures while other effects relating to rehabilitation of such patients have been neglected. To determine change in work status as a result of operation, job status and hours worked before and after surgery were analyzed in 350 patients who had coronary artery bypass grafting procedures. Overall, there was no improvement in return to work or hours worked after surgery. Hours worked before surgery, relief of symptoms, severity of disease, number of bypass grafts placed, and level of education all related substantially to a change in work capacity. It appears that if the potential for enhanced productivity is to be realized, rehabilitative measures must be intensified following coronary artery surgery.     

稳定型冠心病不同治疗方法的预后比较

目的比较稳定型冠心病单纯药物治疗、经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)3种治疗方法的远期预后。方法将317例稳定型冠心病患者按治疗方法不同分为单纯药物治疗组、PCI组和CABG组,每组再按冠状动脉病变情况分为单支病变和多支病变2个亚组。平均随访(48±8)个月,随访内容包括全因死亡、心肌梗死、血管重建、因急性冠脉综合征(ACS)再入院以及心绞痛缓解情况。结果无论单支病变或是多支病变,单纯药物治疗组心绞痛缓解率、全因死亡、心肌梗死、因ACS再入院与PCI组比较差异均无统计学意义(P>0.05);对于多支病变患者,CABG组心绞痛缓解率高于药物治疗组和PCI组(P<0.05或P<0.01),全因死亡、血管重建率显著低于药物治疗组和PCI组(P<0.01或P<0.05),PCI组血管重建率低于药物治疗组(P<0.05)。结论强化药物治疗是稳定型冠心病治疗的基础;早期PCI可能并不改善稳定型冠心病患者的远期预后;对于多支病变稳定型冠心病患者,CABG预后可能优于PCI。     

冠状动脉旁路移植术62例

目的 对冠状动脉旁路移植术（ＣＡＢＧ）进行临床研究,总结冠状动脉疾病术前 三、手术治疗、及术后处理的经验。方法 １９９８－１０／１９９９－０９行冠状旁路移植术６２例,其中包括３例风湿性心脏病患同时行二尖瓣替换术和２例夹层动脉瘤患同时行主动脉根部及主动脉瓣替换术。结果 随访１～１１ｍｏ,手术死亡４例。术后消化道大出血３例,其余患无严重并发症。结论 术前心功能严重受损的冠誊 知病患经药物调整后     

不阻断主动脉冠状动脉搭桥术疗效分析

目的报道 10例不阻断升主动脉的冠状动脉搭桥术的疗效。　方法体外循环低温室颤冠脉搭桥术2例 ;非体外循环冠脉搭桥术 8例。其中三支病变 8例 ;双支和单支病变各 1例。前降支 10例 ,回旋支 6例 ,后降支 2例 ,左主干开口 2例 ,右冠脉 7例。移植血管 :左乳内动脉 7支 ;大隐静脉 2 0支。　结果　术后 1例死于慢性左心衰 ,9例存活 ,心绞痛消失。结论不阻断升主动脉的冠脉搭桥术创伤轻 ,死亡率低 ,并发症少 ,费用低 ,尤其非体外循环冠脉搭桥术更具优越性     

Scientific Section: Coronary Artery Surgery, Task Force Appointed by the Conference of Deputy Ministers of Health: 2. Results, indications and recommendations

The large majority of reported studies of patients treated by aortocoronary bypass have not been randomized clinical trials, and hence must be interpreted with great caution.

Review of the seven randomized clinical trials in the literature leads to only one firm, positive conclusion: aortocoronary bypass results in a reduction in the morbidity of coronary artery disease, due to the alleviation of cardiac pain, for at least 3 years. In addition, there is some evidence that mortality for symptomatic patients with significant left main-stem coronary artery stenosis may be reduced by coronary artery bypass surgery. A significant effect on mortaliy form other forms of coronary artery disease has not yet been conclusively demonstrated but also has not been excluded. Most of the reports are preliminary and involve small numbers of patients followed for relatively short periods. The operation is still being improved. It is to be hoped that the randomized trials, involving large numbers of patients, now in progress will supply some of these answers.

Aortocoronary bypass surgery is the treatment of choice for patients with stable cardiac pain that is disabling despite adequate treatment, or when adequate treatment is impractial; for patients with unstable cardiac pain, uncontrolled despite adequate treatment; and for symptomatic patients with critical stenosis of the left main-stem coronary artery.

     

冠脉旁路移植手术移植血管的选择

在冠脉旁路移植手术移植血管的选择中，内乳动脉因为其移植10年后仍有高达95％的通畅率而成为首选，而且病人的生存率较高，心血管系统并发症的发生率较低。桡动脉因其1年高于95％的通畅率近年渐被广泛使用，胃网膜右动脉在移植3－4年后的通畅率大于90％，腹壁下动脉1年后的通畅率能达到80％。其他可被选择的旁路血管包括人造血管可在特殊情况下有条件地使用。在选择旁路血管时，需要综合考虑病人的年龄、临床状况和手术类型等多方面的情况。     

50例冠状动脉搭桥术的临床研究

目的：观察冠状动脉搭桥术的临床疗效。方法：选择经内科治疗仍反复心绞痛发作或不适于PTCA等治疗的冠心病人50例,均在体外循环,心脏停跳下行冠状动脉搭桥术,选用的血管桥包括大隐静脉,乳内动脉和桡动脉,共搭145根桥,平均每例2．9支桥,5例同时行室壁瘤切除或成形术。结果：治愈48例,死亡2例,48例长期随访,效果良好,结论：对有冠脉搭桥指征的病人行搭桥手术,疗效安全可靠, 远期效果好。     

《2020年欧洲非阻塞性冠状动脉缺血疾病专家共识》解读——提高分级诊疗能力，加强全-专联合管理

非阻塞性冠状动脉缺血疾病（INOCA）是指具有可疑缺血相关症状，但经冠状动脉造影检查没有发现阻塞性冠状动脉狭窄（狭窄程度≥50%）的疾病。该疾病患者人群广泛而治疗不足。近日，欧洲经皮心血管介入学会（EAPCI）与欧洲心脏病学会（ESC）冠状动脉病理生理学和微循环工作组联合发布了《欧洲非阻塞性冠状动脉缺血疾病专家共识》。本文结合欧洲专家共识对INOCA的亚型、患病率、危险因素、病理生理学机制、临床特征、预后意义、无创及侵入性诊断方法、患者管理和药物治疗等内容进行解读，以期提高临床医生对这类患者的认识，使其重视对疾病亚型的分类，采取个体化的治疗策略，改善患者症状及预后，降低医疗消耗。     

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

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

冠状动脉旁路移植术治疗年龄≤40岁冠心病患者术后中期疗效分析

 目的 探讨年龄≤40岁冠心病患者的临床特点、外科治疗经验及冠状动脉旁路移植术后的中期疗效。方法 2009年1月至2015年12月复旦大学附属中山医院单中心诊断为冠心病且年龄≤40岁于心脏外科行手术治疗的患者共12例,其中男性10例,女性2例,平均年龄(37.9±2.5)岁(32~40)岁。该组病例临床特点包括,有高血压病史5例,糖尿病史3例,高脂血症病史4例,有吸烟史8例,术前心梗病史7例,3支主干中不少于1支全闭6例,2例反复行PCI术,分别植入支架5枚和3枚。回顾性分析患者的临床资料、外科手术治疗情况及随访结果。结果 围手术期及随访期间均无死亡。采用双侧乳内动脉联合桡动脉全动脉化冠状动脉旁路术6例,双侧乳内动脉联合大隐静脉冠状动脉旁路术2例,左侧乳内动脉联合大隐静脉冠状动脉旁路术4例。非体外下冠状动脉旁路术9例,体外循环辅助下冠状动脉旁路术3例。平均随访时间(47.8±24.3)个月,随访过程中1例术后5年静脉桥出现再狭窄,于心内科行经皮冠状动脉介入术,其余11例随访心功能恢复至Ⅰ~Ⅱ级。结论 年轻冠心病患者(年龄≤40岁)因心功能代偿良好一般发病较隐匿,临床诊断时冠脉病变较严重。冠状动脉旁路术预后良好,手术中远期疗效满意。     

Acute myocardial infarction and Friedreich's ataxia

While cardiac disease is noted in 90% of patients with Friedreich's ataxia (FRDA), the finding of coronary artery disease is unusual. To the best of our knowledge only two cases of acute myocardial infarction (AMI) has been reported in patients with FRDA. Large vessel CAD has not been reported previously in patients with FRDA. We report a young patient with AMI and obstruction of large epicardial arteries.