冠状动脉左前降支开口部病变的血管内超声观察

目的 探讨冠状动脉左前降支(LAD)开口部病变的重塑类型。方法 对31例LAD开口部病变(甲组)和24例冠状动脉造影正常的LAD(乙组)进行血管内超声检查。分别于病变远端参照部位及开口部病变处测量血管面积、管腔面积及斑块面积。重塑指数定义为开口部病变处血管面积与病变远端参照部位血管面积的比值。结果 甲组的重塑指数明显小于乙组(0.79±0.19比0.97±0.11,P<0.001)。如定义重塑指数<0.92(乙组平均重塑指数的95％可信区间的下限值)为收缩性重塑,则甲组中81％(25/31)为收缩性重塑。在发生收缩性重塑的病变中,病变处管腔面积的减少54％是由病变处血管收缩所致。病变处管腔面积的减少与血管面积的减少的相关性比病变处管腔面积的减少与斑块面积的增加的相关性更强(r=0.75,P<0.001和r=0.62,P<0.01)。结论 LAD开口部病变以收缩性重塑更常见,收缩性重塑是决定LAD开口部病变狭窄程度的重要因素。     

Randomized comparison of debulking followed by stenting versus stenting alone for ostial left anterior descending artery stenosis: intravascular ultrasound guidance

Background

Although directional coronary atherectomy (DCA) before stenting has the advantage of combining substantial removal of atheromatous plaque and prevention of elastic recoil, there has been no randomized study to investigate its efficacy in ostial left anterior descending artery (LAD) lesions. This study was aimed to evaluate the effect of DCA followed by stenting on ostial LAD stenosis under the guidance of intravascular ultrasound (IVUS).

Methods

Eighty-six patients with ostial LAD stenoses were randomly assigned to DCA followed by stenting (group I) or stenting alone (group II). Aggressive DCA or optimal stenting was performed in both groups under the guidance of IVUS. The primary end point was angiographic restenosis at 6 months.

Results

Baseline clinical and angiographic characteristics were similar between the 2 groups. The postprocedural minimal lumen diameter was larger in group I than group II (4.0 ± 0.4 mm vs. 3.5 ± 0.5 mm, P < .001). However, the angiographic restenosis rates were not significantly different between the 2 groups (9/32 [28.1%] in group I vs. 11/30 [36.7%] in group II, P = .472). The postprocedural IVUS stent area was the only independent determinant of restenosis by multivariate analysis (odds ratio .61, 95% CI 0.41-0.92, P = .018).

Conclusions

DCA followed by stenting achieved greater lumen gain than stenting alone for ostial LAD stenosis. However, DCA did not improve angiographic restenosis.     

Early outcome of treatment of ostial de novo left anterior descending coronary artery lesions with drug-eluting stents

We investigated early and mid-term clinical and angiographic outcomes of patients who had de novo ostial left anterior descending coronary artery (LAD) lesions that were treated with drug-eluting stents (DESs) or bare metal stents (BMSs). We identified 43 consecutive patients who underwent percutaneous intervention for isolated de novo ostial LAD lesions with implantation of DESs and compared them with 43 patients who had similar lesions that were treated with BMSs. All stents were successfully implanted. There were no significant differences with respect to major in-hospital complications between the 2 groups. One patient in the BMS group died during hospitalization. Non-Q-wave myocardial infarction occurred in 2 patients (4.7%) in the DES and in 1 patient (2.3%) in the BMS group. At 9-month follow-up, 3 patients (7%) in the DES group and 11 (25.6%) in the BMS group underwent target lesion revascularization (p = 0.038); major adverse cardiac events were less frequent in the DES than in the BMS group (9.3% vs 32.6%, p = 0.015). Angiographic follow-up was available in 82% of patients in the DES group and 75% of those in the BMS group (p = 0.6) and showed lower binary restenotic rates (5.7% vs 31.3%, p = 0.01) and smaller late loss (0.30 +/- 0.81 vs 1.23 +/- 0.93 mm, p = 0.0001) in the DES group. In conclusion, DES implantation in de novo ostial LAD lesions appears safe and effective and is associated with a significant decrease in restenotic rates compared with historical experience with BMSs.     

药物洗脱支架与切割球囊预扩张后置入金属裸支架治疗前降支开口病变的近、远期临床疗效比较

目的 探讨药物洗脱支架(DES)治疗前降支开口病变的近、远期临床疗效,并与早期应用切割球囊预扩张后(CBA)置入金属裸支架(BMS)的近、远期临床疗效进行比较.方法 自2003年11月至2005年5月采用DES对51例连续前降支开口病变的患者进行介入治疗,选自2000年5月至2003年11月应用CBA+BMS治疗前降支开口病变的连续50例患者作为对照组,要求所有患者在介入治疗后6～8个月进行冠状动脉造影复查,DES组与CBA+BMS组患者分别完成了2年和4年的临床随访.结果 在DES组中1例于住院期间发生急性心肌梗死,住院期间主要不良心脏事件(MACE)发生率为1.96%(1/51),29例完成了6～8个月的冠状动脉造影复查,再狭窄发生率为10.3%(3/29).在2年临床随访中1例死亡,靶病变重建4例,MACE发生率为9.8%(5/51).在CBA+BMS组中住院期间无心脏事件,28例完成了6～8个月的冠状动脉造影复查,再狭窄发生率为17.9%(5/28).2年临床随访中1例死亡,行靶病变重建5例,MACE发生率为12%(6/50).结论 在2年的临床随访中,支架内再狭窄、MACE发生率两组比较差异均无统计学意义,研究结果 提示无论是采用DES还是CBA+BMS治疗前降支开口病变均有良好的近、远期疗效.     

An angiographic and intravascular ultrasound study of the left anterior descending coronary artery in takotsubo cardiomyopathy

The precise cause of takotsubo cardiomyopathy (TC) remains controversial. Plaque rupture with transient thrombotic occlusion of a transapical left anterior descending coronary artery (LAD) has been advanced as a potential mechanism. To explore this hypothesis, the investigators analyzed data from 11 patients prospectively enrolled in the Rhode Island Takotsubo Cardiomyopathy Registry who underwent coronary angiography and intravascular ultrasound evaluation of the LAD during their initial presentation. Despite the presence of nonobstructive coronary artery disease, no culprit lesion was identified in any patient. Similarly, the course of the LAD failed to account for the characteristic left ventricular apical ballooning seen in TC. In conclusion, an atherosclerotic coronary lesion in the LAD causing an aborted myocardial infarction may not be the primary underlying cause of TC, and nonobstructive coronary artery disease and TC may coexist without a direct causal association.     

Multiple overlapping drug-eluting stents to treat diffuse disease of the left anterior descending coronary artery

OBJECTIVES: We sought to determine the safety and efficacy of using multiple overlapping drug-eluting stents (DES) in patients with diffuse left anterior descending coronary artery (LAD) disease. BACKGROUND: Diffuse LAD disease represents a therapeutic challenge. Results after coronary artery bypass surgery are suboptimal, whereas the use of bare metal stents is limited by high rates of restenosis. The introduction of DES prompted treatment of long diffuse disease with multiple overlapping stents. METHODS: All consecutive patients with de novo diffuse LAD disease treated with more than 60-mm long DES from April 2002 to March 2004 were analyzed. RESULTS: The study population consisted of 66 patients. Thirty-nine patients were treated with sirolimus-eluting stents (SES), average length 84 +/- 22 mm, and 27 patients with paclitaxel-eluting stents (PES), average length 74 +/- 14 mm. The number of stents implanted per patient was 2.8 +/- 0.7, whereas the mean total stent length for the LAD treatment was 80 +/- 20 mm. Angiographic as well as procedural success was achieved in 95% of cases. Eleven (16.6%) patients had in-hospital non-Q-wave myocardial infarction (five SES and six PES), and one patient developed intraprocedural stent thrombosis. All patients had clinical follow-up, and 52 patients (79%) had an angiographic follow-up at six months. Hierarchical major adverse cardiac event rate was 15% (7.5% for SES and 7.5% for PES). No patients died, one patient had non-Q-wave myocardial infarction (non-index vessel), and 10 patients (15%) underwent target vessel revascularization. CONCLUSIONS: The implantation of multiple overlapping DES in patients with a diffusely diseased LAD is relatively safe and associated with good midterm clinical outcomes.     

国产与进口药物洗脱支架治疗前降支开口病变的临床疗效比较

目的:比较国产与进口药物洗脱支架治疗前降支开口病变的临床疗效。方法:回顾性分析95例前降支开口病变的患者置入国产支架(国产支架组,n=68)和进口支架(进口支架组,n=27),所有患者均行临床随访,部分患者进行了冠状动脉造影(CAG)复查。结果:国产支架组的急性心肌梗死患者多于进口支架组,但无统计学差异(46%vs.33%)。两组的介入成功率均为100%。国产支架组的冠脉钙化率、偏心斑块率和C型病变率均高于进口支架组(分别为20%vs.4%;14%vs.0%;28%vs.7%,均P0.05)。两组CAG随访的支架内和血管段再狭窄率无统计学差异;两组的主要不良事件发生率也无统计学差异。结论:国产药物洗脱支架治疗前降支开口病变是安全的,与进口药物洗脱支架具有相似的良好疗效。     

冠状动脉前降支近段临界靶病变的血管内超声影像学特点研究

目的 研究前降支近段临界靶病变的血管内影像特点,为治疗该类病变提供依据。方法 收集2010年6月至2011年10月沈阳军区总医院诊治的10例冠心病患者,造影显示前降支存在临界病变,直径狭窄程度30%～50%,其中男性7例,10例患者均有不同程度的心前区不适感,同时伴有糖尿病者2例,高血压者3例,高胆固醇血症者1例,有吸烟史者2例,既往有心肌梗死病史者2例。对症状典型的患者,行血管内超声检查,明确斑块分布情况后行介入治疗,对症状不典型的患者,先行运动负荷试验,阳性者血管内超声检查后行介入治疗。结果 10例经介入治疗患者临床症状均消失,最小血管管腔面积为(4.85±1.49)mm2,其中大于4 mm2共7例,占70%;斑块面积负荷为(69.99±7.07)%,其中小于70%共4例,占40%。结论 在前降支近段,以最小管腔面积4 mm2或斑块面积负荷70%作为判断是否应行介入治疗的界值是不可靠的,血管内超声检查结果结合患者临床情况有助于准确选择治疗策略。     

Coronary artery bypass graft surgery versus drug-eluting stents for patients with isolated proximal left anterior descending disease

Background Few recent studies have compared the outcomes of coronary artery bypass graft(CABG) surgery with percutaneous coronary interventions(PCIs) in patients with isolated(single vessel) proximal left anterior descending(PLAD) coronary artery disease in the era of drug-eluting stents(DES).Objectives The goal of this study was to compare outcomes in patients with PLAD who underwent CABG and PCI with DES.Methods New York's Percutaneous Coronary Interventions Reporting System was used to identify and track all patients who underwent CABG surgery and received DES for isolated PLAD disease between January 1, 2008 and December 31, 2010, and who were followed-up through December 31, 2011. A total of 5,340 of 6,064(88%) patients received DES. Patients were matched to vital statistics data to obtain mortality after discharge and matched to New York's administrative data to obtain readmissions for myocardial infarction(MI) and stroke. To minimize selection bias, patients were propensity matched into 715 CABG and / or DES pairs, and3 outcome measures were compared across the pairs.Results Kaplan-Meier estimates for CABG and DES did not significantly differ for mortality or mortality, MI, and /or stroke, but repeat revascularization rates were lower for CABG(7.09% vs. 12.98%; P = 0.0007). After further adjustment with Cox proportional hazards models, there were still no significant differences in 3-year mortality rates(CABG and / or DES adjusted hazard ratio(AHR): 1.14; 95% confidence interval [CI]: 0.70 to 1.85) or mortality, MI, and / or stroke rates(AHR: 1.15; 95% CI: 0.76 to 1.73), and the repeat revascularization rate remained significantly lower for CABG patients(AHR: 0.54; 95% CI: 0.36 to 0.81).Conclusions Despite the higher rating in current guidelines of CABG(Class Ⅱa vs. Class Ⅱb) for patients with isolated PLAD disease, there were no differences in mortality or mortality, MI, and / or stroke, although CABG patients had significantly lower repeat revascularization rates.(From: Journal of the American College of Cardiology Volume 64, Issue 25, 30 December 2014, Pages 2717-2726)     

血管内超声指导下对冠状动脉严重钙化病变行旋磨介入治疗疗效评估

目的评估血管内超声（IVUS）指导下冠状动脉旋磨术联合药物洗脱支架（DES）治疗严重钙化病变的疗效。方法 13例冠状动脉严重钙化患者在IVUS指导下行冠状动脉旋磨及支架置入术,评估手术即刻成功率、术后管腔最小直径、最小直径狭窄率、管腔有效面积变化及随访结果。结果 13例中,单支病变1例（7.7%）,双支病变3例（23.1%）,三支病变6例（46.2%）,左主干＋三支病变1例（7.7%）,左主干病变2例（15.4%）。术前、术后肌钙蛋白T、肌酸激酶同工酶与肌酸酐比较,差异无统计学意义。靶血管管腔最小直径由术前（2.0±0.3）mm增大至术后的（3.6±0.8）mm,直径狭窄率由术前的（74.5±6.8）%减少至术后的（20.3±12.5）%,管腔有效面积由术前的（4.0±1.4）mm2增大至术后的（10.7±5.5）mm2,差异均有统计学意义。即刻手术成功率100%,术后随访期间无心绞痛再发、心肌梗死及靶血管再次血运重建。结论 IVUS指导下冠状动脉旋磨术联合DES可安全用于冠状动脉严重钙化病变患者,提高了介入手术的成功率。     

Comparison of high-frequency two-dimensional transthoracic echocardiography versus intravascular ultrasound for evaluation of the left anterior descending coronary artery

The purpose of this study was to evaluate the feasibility of high-frequency transthoracic echocardiography for measuring the wall thickness and luminal area of the left anterior descending coronary artery (LAD). Fifteen patients underwent simultaneous high-frequency transthoracic echocardiography and intravascular ultrasound (IVUS) examinations. There were good agreements for wall thickness (0.38 +/- 0.05 vs 0.38 +/- 0.06 mm, p = 0.0004) and luminal area (3.24 +/- 1.05 vs 3.32 +/- 1.34 mm2, p <0.0001) between high-frequency transthoracic echocardiography and IVUS measurements. High-frequency transthoracic echocardiography was reliable in the measurement of the wall thickness and luminal area of the LAD.