Percutaneous revascularization strategies in saphenous vein graft lesions: long-term results

AimsAlthough half of saphenous vein grafts (SVGs) present obstructive atherosclerotic disease 10 years after implantation, controversy remains concerning the ideal treatment. Our aim was to compare percutaneous revascularization (PCI) options in SVG lesions, according to intervention strategy and type of stent.MethodsA retrospective single-center analysis selected 618 consecutive patients with previous bypass surgery who underwent PCI between 2003 and 2008. Clinical and angiographic parameters were analyzed according to intervention strategy – PCI in SVG vs. native vessel vs. combined approach – and type of stent implanted – drug-eluting (DES) vs. bare-metal (BMS) vs. both. A Cox regressive analysis of event-free survival was performed with regard to the primary outcomes of death, myocardial infarction (MI) and target vessel failure (TVF).ResultsDuring a mean follow-up of 796±548 days the rates of death, MI and TVF were 10.9%, 10.5% and 29.5%, respectively. With regard to intervention strategy (74.4% of PCI performed in native vessels, 17.2% in SVGs and 8.4% combined), no significant differences were seen between groups (death p=0.22, MI p=0.20, TVF p=0.80). The type of stents implanted (DES 83.2%, BMS 10.2%, both 3.2%) also did not influence long-term prognosis (death p=0.09, MI p=0.11, TVF p=0.64). The implantation of DES had a favorable impact on survival (p<0.001) in the subgroup of patients treated in native vessels but not in SVG.ConclusionsAmong patients with SVG lesions, long-term mortality, MI and TVF were not affected by intervention options, except for the favorable impact on survival of DES in patients treated in native vessels.     

80岁以上急性心肌梗死患者的急诊冠状动脉介入治疗

目的　评价高龄 (≥ 80岁 )急性心肌梗死 (AMI)患者急诊冠状动脉介入治疗 (PCI)的安全性和近、中期疗效。方法　 1999年 9月至 2 0 0 3年 10月收治的行急诊PCI(<12h)的AMI患者中≥80岁的 2 1例 (高龄组 )和 <6 0岁的 37例 (年轻组 ) ,分析两组基础资料特征、即刻手术成功率和随访期间主要不良心血管事件 (复发性心绞痛、心肌梗死及猝死 )发生率的差异。结果　高龄组心力衰竭及多支病变比例高于年轻组 (分别为 71%vs 16 %和 81%vs35 % ,P均 <0 0 5 ) ,高龄组入院至梗死相关动脉开通时间长于年轻组 [(6 3 6± 17 0 )minvs (5 5 3± 13 0 )min ,P <0 0 5 ]。两组患者急诊PCI成功率均为 10 0 %。住院期间死亡高龄组 2例 ,年轻组 0例。随访 4个月至 4年 ,高龄组发生心绞痛 3例、心肌梗死 2例、猝死 0例 (共占 2 4 % ) ;年轻组发生心绞痛 3例、心肌梗死 0例、猝死 0例 (总计 8% ,P <0 0 5 )。结论　高龄AMI患者急诊PCI成功率高 ,入院至梗死相关动脉开通时间延长 ,围手术期死亡和近、中期主要不良心血管事件发生率较高。     

Percutaneous coronary intervention versus coronary artery bypass grafting as primary revascularization in patients with acute coronary syndrome

New European Society of Cardiology/American College of Cardiology guidelines classify patients with acute coronary syndrome and increased cardiac troponins as non-ST-segment elevation myocardial infarction (NSTEMI) who would have been classified as unstable angina pectoris (UAP) using the older World Health Organization (WHO) definition. The optimal revascularization strategy in these patients is poorly defined. This prospective cohort study included 1,024 consecutive patients with acute coronary syndrome classified as UAP, NSTEMI according to the WHO definition (WHO NSTEMI), and NSTEMI additionally identified by the novel European Society of Cardiology/American College of Cardiology definition (additional NSTEMI). All patients underwent coronary angiography within 24 hours and were treated with immediate percutaneous coronary intervention (PCI) or early coronary artery bypass grafting (CABG). The primary end point was all-cause mortality during follow-up of 36 months. Patients with additional NSTEMI showed excessive cumulative 3-year mortality if undergoing CABG (hazard ratio 5.9, 95% confidence interval 2.7 to 13.1, p <0.001). In patients with UAP or WHO NSTEMI, mortality was similar in the CABG and PCI groups. In conclusion, in the absence of randomized trials specifically including patients with additional NSTEMI, the excessive mortality observed with CABG in this cohort study suggested that PCI may be the preferable revascularization strategy in this subgroup.     

Percutaneous coronary angioplasty in patients over 75 years old: immediate and mid-term results

Ninety-five patients 75 years or older (range 75-90, mean 79) underwent PTCA from 1987 to 1991. Forty-two patients were 80 years or older. Forty-four had prior MI, 5% had prior coronary bypass surgery (CBS), 13% had a prior history of recent cardiac failure, and 81% (77/95) presented with unstable angina, refractory to intravenous treatment in 31 cases. The mean left ventricular ejection fraction was 62% (range 34%-80%). Thirty-nine percent had single vessel disease, 41% had two vessel disease, and 20% had three vessel disease. Coronary calcifications were present in 28%. A single vessel was dilated in 81 patients, two vessels in 14 patients; complete revascularization was achieved in 41%. The clinical angiographic primary success rate was 79% (75/95). There were five procedural deaths, five MI, five CBS and, ten hematomas. Follow-up data were obtained in 100% cases, with a mean follow-up duration of 12 months (ranging from 1-36). There were four deaths, one MI, and two CBS. Twenty percent (15/74) of patients had a second PTCA with a 73% success rate. Finally, 70% of the initial population was asymptomatic after first or second PTCA at mid-term follow-up. We conclude that PTCA is safe and effective in elderly patients, with 70% clinical success rate at mid-term follow-up in spite of frequent incomplete revascularization limited to the culprit lesion.     

Percutaneous coronary revascularization improves the prognosis of patients with cardiogenic shock in acute coronary syndrome: a chronological study

BACKGROUND: Cardiogenic shock complicating acute coronary syndrome (ACS) implies grim prognosis with conventional management. Previous studies of coronary intervention yielded controversial results and were rarely analyzed chronologically. This study was to determine the impact of percutaneous coronary revascularization on outcome by studying two time periods 5 years apart in which the revascularization was more frequent and techniques more refined in the later period. METHODS AND MATERIALS: All patients admitted to the intensive or coronary care unit for ACS in two 1.5-year study periods (Period I: Jan 1994-Jun 1995, Period II: Oct 1999-Apr 2000) were retrospectively screened. Patients who met strict criteria of cardiogenic shock within 24 h of ACS were enrolled. The demographics, management and in-hospital/3-month outcomes were analyzed. RESULTS: Thirty-seven patients (33M/4F, aged 65+/-8 years) were enrolled in Period I and 32 patients (25M/7F, aged 68+/-13 years) in Period II. The incidence of cardiogenic shock was 11.8 and 9.3%, respectively. The demographics were similar except patients in Period II were older. Significantly more coronary angiography and interventions were done in the later period. The in-hospital (68 vs. 44%, P=0.047) and 3-month mortalities (70 vs. 44%, P=0.03) were significantly reduced in Period II. The in-hospital survivors in two study periods differed only in use of coronary angiography (94 vs. 50%, P=0.005) and interventions (83 vs. 33%, P=0.005) but not others. CONCLUSIONS: Percutaneous coronary revascularization does improve the clinical outcome of cardiogenic shock when analyzed chronologically. This treatment is warranted in every such patient in the interventional era.     

Percutaneous transluminal coronary angioplasty in the elderly: early and long-term results

The immediate and long-term efficacy of coronary angioplasty in the elderly was determined by studying 752 patients greater than or equal to 65 years old and comparing patients greater than or equal to 75 years old with those 65 to 74 years old. The oldest patients were more highly symptomatic, were more likely to be in heart failure, had more multivessel disease and were more likely to undergo multivessel dilation. The immediate success rate of angioplasty was higher in the oldest patients (92.8% versus 82%) (p = 0.0003). The hospital mortality rate was also higher (6.2% versus 1.6%) (p less than 0.001). Long-term overall survival was high. However, long-term event-free survival was lowest in the oldest patients, and recurrent severe angina was particularly common. Thus, in very elderly patients, coronary angioplasty is usually successful, but extra caution is warranted; also, long-term relief from angina is less common than in younger patients.     

Percutaneous transluminal coronary angioplasty in patients aged 70 years and older: immediate and long-term results.

We analyzed all coronary angioplasty procedures performed in patients aged greater than 70 yr since 1987. There were a total of 92 patients with a mean age of 74 +/- 4 yr (range 70-82). The clinical diagnosis was unstable angina in 79%. Single-vessel disease was present in 41%, double-vessel in 29% and triple-vessel in 30% of patients. A left ventricular ejection fraction of less than 40% was present in 18 patients. Angioplasty was attempted on one vessel in 52 patients (56%), on two vessels in 29 patients (32%) and in three vessels in 10 patients (11%). Angiographic success was achieved in 96% of stenoses and in 53% of chronic total occlusions attempted. Complete revascularization was achieved in 56% of patients. Complications included three patients (3.2%) who underwent emergency coronary artery bypass grafting, 1 patient (1.1%) who sustained a myocardial infarction and 5 patients (5.4%) who died. During hospitalization, which averaged 3 +/- 2 days, 1 patients sustained reversible renal failure and 5 patients required blood transfusion for a large groin hematoma. Clinical success at discharge was 83%. At a mean follow-up of 13 months (range 3-45 months), symptomatic improvement was observed in 59 of the 76 patients who had achieved clinical success, with 42 of these patients (55%) being asymptomatic. The following clinical events occurred: myocardial infarction in 1 patient, new percutaneous transluminal coronary angioplasty in 9 and 3 patients died of cardiac reasons.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transluminal coronary angioplasty in patients more than 75 years old: early and long-term results.

Over 4 yr, 102 consecutive patients more than 75 yr old (56 men, 46 women; mean age 78 +/- 3 years, range: 76-89 years) underwent 120 percutaneous transluminal coronary angioplasty procedures. At baseline, 86% had severe anginal symptoms (Canadian class III or IV), 43% had a history of prior myocardial infarction; 61% had multivessel coronary artery disease, and mean left ventricular ejection fraction was 60 +/- 11%. Calcifications were observed on 66% of the dilated arteries. A total of 158 vessels (1.3 vessel per procedure) were attempted: 1 vessel in 89 procedures (74%), 2 vessels in 24 (20%) and 3 vessels in 7 (6%). The primary success rate was 80% per lesion (126/158) and 77% per procedure (92/120). Complications included 3 deaths (3%), 9 Q-wave infarctions (7.5%) and there was no emergency coronary bypass surgery. The primary success rate was significantly related to the absence of coronary calcifications on the dilated segment (88% versus 75%, p < 0.05) and to the initial patency of the dilated artery (subtotal stenosis: 83% versus total occlusion: 53%, p < 0.05). Follow-up data were obtained in the 79 consecutive patients with a duration of follow-up exceeding 8 months. The mean duration of follow-up was 23 +/- 13 months (range 8 to 61 months). No patient was lost to follow-up; 11 patients died (cardiac causes: 7), 2 had a non-fatal infarction, 7 had aortocoronary bypass surgery and 18 had repeat percutaneous transluminal coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

80岁以上冠心病患者的冠状动脉病变分析

目的 研究80岁以上冠心病患者冠状动脉造影的影像学特点.方法 收集150例诊断为冠心病行行冠状动脉造影的80岁以上患者的临床资料和冠状动脉造影结果,分析患者的合并疾病,冠状动脉病变部位、支数和狭窄程度,危险因素,危险因素与冠状动脉病变程度的关系.结果 高血压是最主要的合并症(72.7%),冠状动脉以多支病变为主(66.9%),病变血管平均3.08支/人.冠状动脉重度以上狭窄58.1%.糖尿病、陈旧性心肌梗死病史、脑梗塞在不同病变支数分组中差异显著(P＜0. 05).单支病变、多支病变、左主干病变、前降支病变、右冠状动脉病变的比例与危险因素的数量有关(P＜0. 05).结论 糖尿病、陈旧性心肌梗死病史、脑梗塞是80岁以上冠心病患者冠状动脉病变严重程度的危险因素.     

急性冠脉综合征患者经皮冠状动脉介入术后5年以上再次血运重建造影前预测

目的 建立急性冠脉综合征（ACS）患者经皮冠状动脉介入（PCI）术后5年以上再次血运重建的造影前预测模型。 方法 对连续纳入的296例PCI术后5年以上ACS患者进行回顾性研究,多因素分析找出再次血运重建的独立危险因素,针对相应回归系数进行赋分。 结果 胸痛、肌钙蛋白I>0.03 ng/ml、首次PCI年龄≤60岁、首次PCI时冠脉初始狭窄程度≥90%和既往冠脉多支病变是ACS患者首次PCI术后5年以上需要再次血运重建的独立危险因素。赋分:胸痛计5分,肌钙蛋白I>0.03 ng/ml计1分,首次PCI年龄≤60岁计1分,首次PCI时冠脉初始狭窄程度≥90%计2分,既往冠脉多支病变计1分。以预测评分为检验变量、再次血运重建为状态变量绘制受试者工作特征（ROC）曲线,其曲线下面积（AUC）值为0.822。 结论 本预测评分可以用于造影前评估ACS患者PCI术后5年以上再次血运重建的个体化风险。     

Triple vessel coronary angioplasty: acute outcome and long-term results

Triple vessel coronary angioplasty, defined as angioplasty of one or more lesions in each of the three major coronary arteries (left anterior descending, left circumflex, right coronary artery) was performed in 50 (11%) of 469 patients who had angioplasty of multiple vessels. There were 32 men and 18 women with a mean age of 56 years. All 50 patients had severe three vessel coronary disease and represent approximately 5% of patients with three vessel disease who had revascularization in this institution; 8 (16%) had previous coronary bypass surgery, and 23 (46%) had previous myocardial infarction. Unstable angina was present in 33 patients (66%) and 96% had Canadian Heart Association class III or IV angina; mean left ventricular ejection fraction was 57 +/- 11%. Angioplasty was performed in 176 vessels (3.5 vessels per patient, range 3 to 6) and in 250 lesions (5 lesions per patient, range 3 to 9); angiographic success was achieved in 240 lesions (96%) and 166 vessels (94%). Success in all vessels attempted was achieved in 40 (80%) of the 50 patients. Clinical success (angiographic success associated with clinical improvement) was obtained in all 50 patients in whom triple vessel angioplasty was performed; none of them required urgent bypass surgery and 5 patients (10%) had a non-Q wave myocardial infarction. In four other patients triple vessel angioplasty was planned but not performed because of failure to dilate the primary vessel; urgent bypass surgery was required in one of these, who developed a Q wave infarction. Thus, overall clinical success in 54 patients was 93%; the incidence rate of myocardial infarction was 11%, and that of urgent surgery 1.8%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous coronary revascularization in elderly patients: impact on functional status and quality of life

BACKGROUND: Percutaneous coronary intervention (PCI) is frequently performed in elderly patients, but little is known about its impact on overall health and quality of life. OBJECTIVE: To examine changes in health-related quality of life among elderly patients after PCI. Design: Observational study. SETTING: 75 U.S. hospitals. PATIENTS: Participants in two clinical trials of PCI. MEASUREMENTS: Health-related quality of life was assessed by using the Medical Outcomes Study Short Form (SF-36) survey and the Seattle Angina Questionnaire at baseline, 6 months, and 1 year. RESULTS: Serial data on health-related quality of life were available for 295 elderly (> or =70 years) and 1150 nonelderly (<70 years) patients. At 6 months, physical health had improved in 51% of elderly patients and mental health had improved in 29%. Cardiovascular-specific health status had improved in 58% to 75% of elderly patients. Improvement did not significantly differ between elderly and non-elderly patients at 6 months or 1 year. CONCLUSIONS: Elderly patients selected for participation in a trial of PCI had substantial improvements in health-related quality of life after PCI that were similar to those in younger patients.     

Percutaneous transluminal coronary recanalization: Procedure,results, and acute complications

Percutaneous transluminal coronary recanalization, a new therapeutic procedure used in acute myocardial infarction, offers significant reduction in mortality, as well as more effective limitation of the zone of infarction than has been possible with other pharmacologic treatment employed in the past. The risk of coronary angiography during acute myocardial infarction was surprisingly low, as was the risk of hemorrhagic complications following the intracoronary administration of relatively low doses of thrombolytic substances such as streptokinase. Mechanical recanalization was possible in about one fifth of patients and successful in approximately half of all such attempts, but complications occurred in a small percentage of attempts at this step. Coronary artery spasm was excluded as a possible cause of occlusion in almost all cases. Selective intracoronary infusion of streptokinase produced the highest degree of myocardial reperfusion, and best results were achieved when therapy was initiated shortly after thrombotic occlusion occurred. Residual stenosis of more than 75% luminal diameter narrowing was present in approximately three fourths of cases after complete thrombolysis, and the majority of patients remained appropriate candidates for coronary bypass surgery or for percutaneous transluminal coronary angioplasty (Grüntzig procedure). Although complete analysis of the efficacy of selective recanalization was difficult because it was not possible to establish a suitable control group for purposes of comparison, the mortality of less than 1% in the present group of 232 patients within the first 6 hours following myocardial reperfusion provides an encouraging result.     

稳妥开展急性心肌梗塞的经皮冠状动脉腔内成形术

稳妥开展急性心肌梗塞的经皮冠状动脉腔内成形术高润霖８０年代以来，急性心肌梗塞（ＡＭＩ）的治疗进入了再灌注治疗的年代，其中静脉溶栓治疗应用最为广泛。现已证明，溶栓治疗使冠状动脉再通，可明显改善ＡＭＩ近期及长期预后。据国家“八五”攻关课题研究组的报道，应...     

Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with acute coronary syndromes

Ischemic heart disease is the most common cause of death in patients with chronic kidney disease (CKD). Patients with CKD who develop an acute coronary syndrome (ACS) have a poor prognosis, with >70% mortality at 2 years. Despite this heavy burden of disease, the optimal management of ACS in this patient population is unknown. Our goal was to compare the effect of coronary revascularization or medical therapy alone on the long-term survival of patients with CKD presenting with ACS. From 1990 to 1998, data were prospectively collected on 4,758 patients admitted to a coronary care unit with the diagnosis of ACS. Of these, 3,104 had preserved renal function, and 1,654 had significant renal dysfunction, as defined by the National Kidney Foundation in the Kidney Disease Outcomes Quality Initiative classification of kidney function as an estimated glomerular filtration rate of <60 ml/min/1.73 m(2). Long-term survival was assessed and outcomes were compared according to whether patients were treated with medical therapy alone or if they underwent a percutaneous or surgical revascularization procedure. Follow-up information was available in 99% of the patients up to 8 years after the index hospitalization. Of the 1,654 patients with significant renal dysfunction, 64 underwent coronary artery bypass surgery, 232 underwent percutaneous coronary revascularization, 280 underwent a diagnostic cardiac catheterization and were subsequently treated medically, whereas 1,078 were treated with medical therapy alone. Percutaneous coronary revascularization was associated with superior long-term survival. In conclusion, patients with severe CKD and ACS had improved long-term survival when treated with percutaneous coronary revascularization.