Effectiveness of percutaneous coronary intervention in cardiac allograft vasculopathy

Twenty-five heart transplant recipients underwent 45 coronary interventions at a mean of 7.8 +/- 2.2 years from time of transplant. Periprocedural success was high, and there was a trend toward better outcomes in the group that underwent stent deployment compared with conventional balloon angioplasty.     

Statins and cardiac allograft vasculopathy after heart transplantation

Coronary artery disease in the transplanted heart, also known as cardiac allograft vasculopathy, is one of the major causes of mortality late after heart transplantation. There are multiple immune and nonimmune risk factors associated with this disease process, one of which is hyperlipidemia. Use of lipid-lowering agents, specifically 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) was initially reported to have outcomes benefit and possibly immunosuppressive effects in a single-center study of heart transplant recipients. Other subsequent studies have supported this beneficial effect. Hyperlipidemia is associated with immune activity, particularly with respect to oxidation-sensitive signaling pathways. By lowering lipids, statins can ameliorate this immune activity, but it has been a matter of contention as to whether statins have cholesterol-independent immune-modulating effects. In two recent papers, cholesterol-independent immune effects of statins have been reported, including repressed induction of major histocompatibility complex class II by interferon-gamma, and selective blocking of leukocyte function antigen 1, both of which reduce the activation of T lymphocytes. The clinical reports demonstrating outcomes benefits in heart transplant recipients and recent laboratory publications that report an immunomodulatory effect of statins provide a firm scientific rationale to support the routine use of statins in heart transplant patients.     

左旋精氨酸抑制大鼠心脏移植术后移植物血管病的研究

目的探讨左旋精氨酸(L—Arg)预防和治疗心脏移植术后移植物血管病的作用。方法建立大鼠异位心脏移植动物模型，观察给与L—Arg、一氧化氮合酶(NOS)抑制药物左旋精氨酸甲酯(L—NAME)后不同时间移植心脏冠状血管的改变。结果L—Arg组大鼠无移植物血管病(CAV)的形成和一氧化氮(NO)能大量合成，L—NAME组大鼠有CAV形成。结论NOS抑制药物L—NAME加重移植后移植物血管病病变，L—Arg可以预防和减轻移植后移植物血管病的病变，NO具有抑制新生内膜形成的作用。     

Iatrogenic left main coronary artery thrombosis during percutaneous coronary intervention

During diagnostic angiographic procedures or percutaneous coronary angioplasty-stenting of the other coronary arteries, the overall risk for a complication related to the left main coronary artery (LMCA) is low; however, if such complications occur, they tend to be life-threatening and contribute to a large part of the total catheter-related mortality. We encountered a case of iatrogenic significant subtotal left main coronary artery thrombotic stenosis in a patient who had undergone prior percutaneous transluminal coronary artery angioplasty-stenting of the left circumflex artery. In light of the literature, an extremely rare clinical presentation of iatrogenic left main coronary artery thrombosis is discussed.     

无保护左主干病变患者经皮介入治疗的即刻及远期疗效分析

目的探讨无保护左主干病变患者经皮冠状动脉介入治疗(PCI)的近、远期疗效。方法解放军总医院2001年12月~2006年8月接受PCI的77例左主干病变的病例资料,2006年8月对上述患者进行随访,包括造影及电话随访。结果即刻成功率100%,无严重术中并发症,住院期间无死亡。术后随访0.5~54(12.95±10.31)个月,其中1例术后6个月行冠状动脉CT检查,支架内无狭窄;20例患者进行了冠状动脉造影检查,1例术后30天出现支架内亚急性血栓;10例分别在1~12个月造影时显示支架内再狭窄,其中4例发生在左主干支架内,其余再狭窄均发生在分叉远端,并分别进行了处理。其余患者进行了电话随访,1例复发心绞痛,接受药物治疗。结论对经过选择的无保护左主干病变患者进行支架置入是可行和安全的,并有良好的近、远期疗效。     

Long-term outcomes after percutaneous coronary intervention of bifurcation narrowings

The optimal approach to percutaneous coronary intervention (PCI) of bifurcation lesions remains unclear, reflecting lack of long-term follow-up and heterogeneity of lesions encountered. We evaluated the long-term outcome of patients undergoing bifurcation PCI followed in the prospective bifurcation registry at the University Health Network, Toronto, Ontario, Canada. Of 526 patients undergoing bifurcation PCI between November 2003 and March 2005, most (n = 406) were treated by main vessel stenting only (n = 266) or crush/culotte stenting (n = 140). After median follow-up of 26.5 months, major adverse cardiac events (MACEs) and Canadian Cardiovascular Society class > or =2 angina occurred in 28.5% and 22.3% of patients in these groups, respectively (p = 0.190), whereas MACE rates were 20.8% for main vessel stenting and 18.7% for crush/culotte stenting (p = 0.670). A low bifurcation angle was associated with better outcomes in the crush/culotte group but had no effect on outcome of patients treated with main vessel stenting only. Use of crush/culotte techniques independently predicted freedom from MACEs or Canadian Cardiovascular Society class > or =2 angina compared with main vessel stenting only (odds ratio 0.55, 95% confidence interval 0.32 to 0.94, p = 0.029). In conclusion, the use of crush/culotte stenting is safe, with efficacy and MACE rates being similar to main vessel stenting alone. Our observations regarding the effect of lesion characteristics such as bifurcation angle and extent of side branch disease on outcome underscore the need for randomized trials that are inclusive of patients with complex side branch disease.     

65岁以上老年患者冠状动脉介入治疗单中心随访研究

目的 观察年龄＞65岁老年患者经皮冠状动脉介入(PCI)的远期疗效.方法 将2003年1月至2005年1月在上海交通大学医学院附属瑞金医院心脏科行PCI治疗并完成随访的1012例患者根据年龄分为＞65岁组(583例)和≤65岁组(429例),记录各组患者的一般资料、临床特征和冠状动脉造影及PCI情况.术后每3个月通过随访记录患者所有原因病死、中风和主要心脏不良事件.比较＞65岁组患者药物洗脱支架和普通金属支架的临床疗效.结果 与年龄≤65岁组比较,年龄＞65岁组患者女性较多、体重较轻、吸烟史少,但高血压病及慢性肾功能不全多见,而且冠状动脉病变程度严重、PCI同期行肾动脉支架术患者增多、完全血运重建率和药物洗脱支架置入比例较低.平均随访17个月,年龄＞65岁组与年龄≤65岁组比较,主要心脏不良事件(12.52%对8.62%,P＜0.05)、所有原因病死率(5.83%对1.17%,P＜0.01)和所有不良事件(15.27%对9.09%,P＜0.01)发生率均增高.年龄＞65岁组患者中,药物洗脱支架组较普通金属支架组主要心脏不良事件发生率显著减少(10.14%对16.51%,P＜0.05),但心源性病死率(3.01%对4.59%,P＞0.05)和所有原因病死率(5.48%对6.42%,P＞0.05)差异无显著性意义.结论 年龄＞65岁老年患者冠状动脉支架术后远期心脏事件和所有原因病死率显著增加;药物洗脱支架可明显降低主要心脏不良事件发生率,但不能减少心源性和非心源性死亡.     

冠状动脉旁路移植术和药物支架植入术远期疗效的比较

目的比较冠心病患者非药物治疗手段冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）术后的桥血管和支架的再通率。方法CABG术后和药物支架植入术后再次出现心绞痛症状的冠心病患者各40例,其年龄、性别、心肌梗死、高血压、高脂血症、心功能不全、脑卒中、药物治疗病史具有可比性。通过冠状动脉造影术比较两组患者的桥血管和药物支架的效率和寿命的远期效果。结果与行CABG患者的桥血管比较,行PCI患者的药物支架远期狭窄或者闭塞率降低34．3％。与行CABG患者的左乳内动脉（LIMA）桥血管比较,行PCI患者的左前降支的药物支架远期狭窄或者闭塞率降低14．8％。与行CABG患者的左回旋支和右冠状动脉静脉桥血管比较,行PCI患者的左回旋支以及右冠状动脉的药物支架远期狭窄或者闭塞率降低49．8％。结论冠状动脉药物支架植入术的远期通畅率较CABG明显增高,冠状动脉药物支架植入术的药物支架的效率和寿命要优于CABG的桥血管。     

无保护左主干病变经皮冠状动脉介入治疗的近期和远期疗效

目的　探讨无保护左主干病变 (UPLMT)经皮冠状动脉介入治疗 (PCI)的近、远期疗效。方法　自 1992年 12月至 2 0 0 2年 12月期间 ,对 174例UPLMT行PCI,其中定向斑块旋切术 (DCA) 12 1例 ,支架术 5 3例。其中 85例被列为不能耐受冠状动脉旁路移植术 (CABG)或外科手术高危。术后半年内每月至少门诊复查一次 ,以后定期随诊、电话随访。术后 3、6、12月行冠状动脉造影复查。结果　PCI术均获血管造影成功。住院期间主要不良心脏事件 (MACE) 16例 (9 2 % ) ,15 8例 (90 8% )获操作成功。术后半年随访发现死亡 17例 (9 8% ) ;其中心源性死亡 8例 (4 6 % ) ,均发生于不能耐受CABG或外科手术高危组。半年内有 15 2例患者接受冠状动脉造影复查 ,其中有 36例 (2 3 7% )行血管重建。Kaplan Meier生存分析显示 :PCI术后 1年、3年生存率 (免于死亡 )分别为 89 7%、84 5 % ,术后 1年、3年免于心脏事件的生存率分别为 6 3 8%、5 7 5 %。结论　对UPLMT ,尤其是开口部、体部病变 ,PCI的近期疗效可以接受 ,但术后主要心脏事件 (如血管重建、心肌梗死、死亡等 )有待进一步减少。     

PCI和CABG治疗单纯左主干病变效果进展

随着基础医学、医疗设备、高新技术的进展和循证医学的广泛开展,血运重建技术已经取得了快速的进展。左主干病变可通过内科和外科手段实现心肌血运重建,缓解症状,改善预后和延长寿命。目前血运重建措施有经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)。但是对于更适当的治疗措施尚无定论。故本文就PCI和CABG在左主干病变患者的治疗效果做一综述。     

Long-term cost-benefit ratio of cardiac rehabilitation after percutaneous coronary intervention

OBJECTIVE: Cardiac rehabilitation (CR) has been shown to reduce short-term mortality and morbidity after percutaneous coronary intervention (PCI). Nonetheless, the long-term effects of CR after PCI and its cost-benefit ratio are not well studied. This study analyses the effect of multidisciplinary, hospital-based, ambulatory CR on long-term health-related costs after PCI. METHODS AND RESULTS: 213 patients were studied after PCI: 133 patients referred to cardiac rehabilitation were compared with 80 patients who were referred for PCI from another hospital, where no rehabilitation was available. The hospital files of these patients were studied and the patient and/or his/her general practitioner were contacted by telephone after a follow-up of approximately 4.5 years. All cardiovascular events (recurrent angina, coronary revascularization, acute myocardial infarction, and death) were noted and their cost to the community was calculated. Compared to no CR, CR resulted in a significant reduction of hospitalizations for angina (75% vs. 45%), and coronary revascularizations (17% vs. 7%). There was a significant increase in the incidence of myocardial infarction (2.5% vs. 7.5%). The intervention group experienced a total of 0.93 events/patient, as compared to 1.52 events/patient in the control group. The total health care cost (including the cost of CR) at 4.5 years of follow-up was lower in the rehabilitation group compared to the control group (4,862 Euro/patient vs. 5,498 Euro/patient). CONCLUSION: Cardiac rehabilitation after PCI not only significantly reduces the number of cardiac events, but, despite the additional cost due to CR, results in cost savings from the Belgian health care payer's perspective.     

Long-term follow-up after orthotopic heart transplantation

While infection and acute rejection continue to be the most frequent cause of early postoperative mortality, chronic rejection including both coronary vasculopathy and unspecific myocardial allograft failure and side effects of immunosuppressive therapy determine late survival and quality of life. Some data are presented of a systematic program for long-term follow-up of cardiac transplant recipients with particular emphasis on coronary vasculopathy and modern concepts in rejection detection and control. Infections remain a notable source of morbidity and mortality. The importance of continued efforts to prevent infection even in the Cyclosporin era has to be emphasized. Tricuspid insufficiency is influenced by the mismatch of recipient and donor heart size. Intraoperative adaptation of the recipient pericardium to the size of the donor heart reduces the magnitude. Unspecific graft failure has been observed to occur at an incidence of 8% three years after transplantation. Three types of rejection can be distinguished after heart replacement, the hyperacute rejection as a rare complication precipitated by preformed recipient antibodies to donor antigens, the acute rejection as a major risk factor for survival in the postoperative first year, and, finally, the chronic rejection which is an important factor for long-term survival and quality of life. Considering the detection and classification of the acute rejection, a semiquantification is advantageous because of its therapeutic relevance. The chronic rejection is characterized by vascular abnormalities, interstitial changes, and myocardial alterations. Of these, the vascular component is the most important clinically. The incidence of this coronary vasculopathy, taking all forms visible angiographically, is about 30-40% of surviving patients three years after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)