行经皮冠状动脉介入术老年人的冠状动脉病变特点

目的调查老年人行经皮冠状动脉介入术的冠心病患者冠状动脉病变特点。方法对比老年与中青年冠心病患者的临床特点、冠状动脉造影所见病变特点及经皮冠状动脉介入术疗效。结果老年组冠状动脉病变支数为(1.8±0.8)支;中青年组平均为(1.4±0.7)支。差异有统计学意义(P=0.024)。老年组单支病变18例,双支病变14例,3支病变10例;中青年组单支病变33例,双支病变9例,3支病变5例。老年组有心肌梗死史6例(14%),中青年组有心肌梗死史18例(38%),差异有统计学意义(P<0.02)。术后6个月电话随访生存率为99.2%。问卷随访(21±9)个月,其中出现心血管不良事件4例,老年组1例,中青年组3例;6例经皮冠状动脉介入术不满意者,术后症状未改善,其中老年组2例,中青年组4例(P>0.05)。结论老年冠心病患者冠状动脉病变程度较重,多支血管病变多见。应选择合适病例进行经皮冠状动脉介入术治疗。     

二维超声检测冠脉介入术后存活心肌的探讨

目的：评估二维超声(2—DE)检测经皮冠脉介入治疗术(PCI)术后二周存活心肌的价值。方法：18例冠心病患者均行PCI。术前一周内．行常规2—DE检查．并于术岳二周及三月复查2～DE。以术后三月2—DE检查结果为评价存活心肌标准。得出PC术前、术后二周．三月射血分数(EF)、室壁运动计分指数(wMSI)数值及存活心肌节段数．并进一步明确三者之间的相互关系。结果：PCI术后EF变化值(△EF)与再通血管相关存活心肌节段数呈中度以上正相关(r=0．63)．△EF、与△WMSI呈中度以上负相关(r=-0．67)。PCI二周2—DE检测存活心肌方面有较高的敏感性(91．1％)、特异性(80％)、准确性(89．9％)。结论：PCI后二周2—DE识别存活心肌有较高的灵敏性。     

Influence of coronary artery disease and percutaneous coronary intervention on mid‐term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

BackgroundA high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.HypothesisWe hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.MethodsWe divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.ResultsThe CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.ConclusionsCAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.     

冠状动脉旁路移植术后行PCI患者特点分析

目的:探讨冠状动脉旁路移植术后行经皮介入治疗(PCI)患者的临床及造影特点,为冠脉旁路移植术后患者治疗策略的选择提供参考. 方法:分析150例搭桥术后行PCI患者的临床及造影特点. 结果:患者平均年龄(62.3±9.3)岁,左室射血分数(59.1±6.6)％.150例患者均为冠状动脉多支血管病变,共处理罪犯病变197处,其中自身血管153处,动脉桥血管2处,静脉桥血管42处.所有患者均行PCI治疗,无再流发生率为12.7％,其中16例为桥血管病变,3例自身冠状动脉病变,桥血管介入治疗较自身血管介入治疗后其心肌标志物升高明显,无术中死亡病例. 结论:PCI是冠状动脉搭桥术后心肌缺血患者的有效治疗手段,心功能和血管病变造影特点是成功治疗的关键.     

钙化积分与冠状动脉多支病变介入术后预后的相关性

目的 研究冠状动脉钙化积分（CCS）与冠状动脉多支血管病变患者经皮冠状动脉介入治疗（PCI）后近、远期预后的关系.方法 入选145例冠状动脉多支血管病变的冠心病患者,在PCI治疗前均接受了多排螺旋CT （MDCT）检查并计算CCS.根据CCS水平将患者分为三组：CCS≤100、CCS=101～400和CCS＞400组.记录患者PCI操作相关并发症,随访记录患者PCI术后主要不良心血管事件（MACE）情况.结果 CCS＞400组患者Syntax积分[（23.5＆#177;8.8）比（17.9＆#177;8.5）,P＜0.001]、三支血管病变的比率（75.4％比56.3％,P=0.015）和PCI操作相关并发症发生率（21.5％比5.0％,P=0.005）均显著高于CCS≤400组患者.所有患者随访360～2542 d（中位数952 d）,Kaplan-Meier生存分析显示CCS≤100、CCS=101～400和CCS＞400组患者累积无事件生存率差异无统计学意义（84.6％比78.0％比64.6％,P=0.141）.但女性患者中累积无事件生存率差异有统计学意义（100.0％比75.0％比50.0％,Log rank 6.836,P=0.033）.结论 在冠状动脉多支血管病变患者中CCS与PCI预后有关,CCS＞400提示较高的PCI并发症发生率.女性患者CCS越高PCI预后越差.     

PCI对冠心病合并糖尿病行冠状动脉旁路移植的影响

目的 评价术前PCI对冠心病合并2型糖尿病患者行冠状动脉旁路移植术的影响.方法 回顾性分析2003年1月至2013年1月,上海交通大学医学院附属仁济医院心血管外科1848例冠状动脉旁路移植术患者,合并糖尿病352例.患者分为2组,术前PCI组106例,术前无PCI组246例.结果 围术期死亡率6.2%,PCI组死亡率16.04%,非PCI组死亡率2.03%.运用x2、t试验,logistic多因素回归分析表明,术前PCI史是影响围术期心功能、术后死亡、术后并发症发生的重要因素.结论 术前PCI是冠心病合并2型糖尿病行冠状动脉旁路移植围术期死亡、术后心血管不良事件发生的危险因素.     

孤立性左冠状动脉主干狭窄的诊治分析

目的分析孤立性左冠状动脉主干(左主干)狭窄的临床特点、造影所见和治疗方法.方法根据冠状动脉造影病变特点将129例左主干狭窄患者分为两组:孤立性左主干狭窄组7例;左主干合并一支或以上主要冠状动脉支狭窄组122例,对比分析两组间临床特点、造影所见和治疗方法.结果孤立性左冠状动脉主干狭窄的检出率为0.16%.6例表现为不稳定型心绞痛,1例为急性前壁心肌梗死.左主干狭窄部位:开口部4例,中部2例,叉口部1例.4例行外科手术,3例行冠状动脉支架术.与复合病变组相比较,孤立性左主干狭窄组女性的比例较高(57.1%vs20.5%,P<0.05),平均年龄较小[(52.3±5.1)岁vs(64.2±7.8)岁,P<0.001];开口部狭窄多见(57.1%vs17.2%,P<0.05).结论孤立性左冠状动脉主干狭窄以女性多见,以开口部狭窄多见,可选择外科和介入治疗.     

高龄女性冠心病患者冠状动脉造影特点及介入治疗的疗效

目的:探讨高龄女性冠心病患者的冠状动脉造影介入治疗特点及近远期的疗效。方法:在2004年1月~2006年3月行冠状动脉介入治疗的患者中,入选183例女性患者,根据年龄分为高龄女性组(年龄≥75岁,48例)和非高龄女性组(年龄<75岁,135例),同时入选同期77例高龄男性组患者作为对照。回顾性分析这些患者的临床及冠状动脉病变特点、即刻手术成功率和近远期主要心脏不良事件。结果:与非高龄女性组相比,高龄女性组表现为更多的危险因素及基础疾病丛集(P<0.05),多见冠状动脉多支病变及复杂病变(P<0.01),住院期间及远期随访严重心脏不良事件发生率高。与高龄男性组相比,高龄女性也表现为更多的危险因素及基础疾病丛集(P<0.05),尽管冠状动脉病变分布及严重程度相似(P>0.05),但住院期间及远期随访严重心脏不良事件发生率高(P<0.05)。高龄女性与高龄男性患者的总病死率差异无统计学意义,在校正了基线特征后,女性患者的危险降低(OR=0.82,95%CI0.675~0.989,P<0.05)。结论:高龄女性冠心病患者常伴有多种危险因素及基础疾病,冠状动脉病变严重复杂,近远期主要心脏不良事件发生率高,总病死率与高龄男性患者差异无统计学意义。     

冠心病合并外周动脉硬化病变的联合介入治疗

目的探讨冠心病合并外周动脉粥样硬化病变的患者行冠状动脉介入治疗(percutaneous coronary intervention,PCI)和外周动脉介入治疗(percutaneous peripheral intervention,PPI)联合应用的策略、近期疗效和安全性。方法2000年1月～2007年1月接受联合介入治疗的冠心病合并外周动脉粥样硬化病变的住院患者141例,根据患者临床和病变严重程度及耐受程度同次或分次完成PCI和PPI。术前、术后常规用抗血小板药、控制糖尿病药、抗高血压药并常规长期服用他汀类药。结果141例患者中多支冠状动脉病变90例(占63.8%);共对225支靶冠状动脉的264处靶病变行PCI,冠状动脉靶病变狭窄88%±11%,共植入冠状动脉支架289枚,每例1～4枚。PCI即刻成功率100%,术后心绞痛完全缓解率98.6%(139/141,仅2例术后有轻微心绞痛)。合并2～3处外周动脉粥样硬化靶病变45例(占31.9%),外周动脉靶病变狭窄85%±10%。PPI共治疗靶血管189支,共植入189枚外周动脉支架,每例1～2枚。54例与PCI同台完成PPI(占38.3%),PPI即刻成功率为100%,外周动脉病变患者术前存在的相关缺血临床表现完全缓解。介入手术相关并发症发生率为2.8%(4/141,PCI术中冠状动脉螺旋撕裂1例、股动脉穿刺局部较大血肿1例、假性动脉瘤1例、肾周围血肿1例,均处理成功);术后一过性肾功能改变3例,经治疗恢复正常。无死亡、急性心肌梗死、肾功能不全等发生。结论冠心病合并外周动脉粥样硬化病变患者其病变以多支、多处居多,提示其全身性动脉粥样硬化病变的严重性和不良的预后,单行PCI或PPI不能明显改善其生活质量;联合行PCI和PPI安全可行,近期疗效好,并发症发生率低;PCI和PPI可同次或分次完成,但首次介入治疗应完成主要罪犯冠状动脉的PCI,以保证患者安全并提高对PPI治疗的耐受性。     

Iatrogenic left main coronary artery stenosis following aortic valve replacement

A case of severe iatrogenic fibrous left main coronary arterystenosis following aortic valve replacement (Hall-Kaster prosthesis)is documented clinically, angiographically and histologically.Reported histological data of this rare complication of valvereplacement are reviewed. The onset of ischaemic symptoms inthe first six months after valve replacement is highly suggestiveof iatrogenic coronary artery stenosis, and urgent coronaryangiography is recommended.     

Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement

Background

In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR.

Methods

Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other.

Results

The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis > 70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 bpm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis.

Conclusion

In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class < III and low coronary Agatston score.     

The adequacy of myocardial revascularization in patients with multivessel coronary artery disease

In patients with multi-vessel coronary artery disease (MVCAD) myocardial revascularization may be accomplished either on all diseased lesions – complete myocardial revascularization – or on selectively targeted coronary segments by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Complete revascularization has a potential long-term prognostic benefit, but is more complex and may increase in-hospital events when compared with incomplete revascularization.     

Impact of coronary artery disease on outcomes after transcatheter aortic valve implantation

Background: Coronary artery disease (CAD) negatively impacts prognosis of patients undergoing surgical aortic valve replacement and revascularization is generally recommended at the time of surgery. Implications of CAD and preprocedural revascularization in the setting of transcatheter aortic valve implantation (TAVI) are not known. Method: Patients who underwent successful TAVI from January 2005 to December 2007 were retrospectively divided into five groups according to the extent of CAD assessed with the Duke Myocardial Jeopardy Score: no CAD, CAD with DMJS 0, 2, 4, and ≥6. Study endpoints included 30‐day and 1‐year survival, evolution of symptoms, left ventricular ejection fraction (LVEF), and mitral regurgitation (MR) and need of revascularization during follow‐up. Results: One hundred and thirty‐six patients were included, among which 104 (76.5%) had coexisting CAD. Thirty‐day mortality in the five study groups was respectively 6.3, 14.6, 7.1, 5.6, and 17.7% with no statistically significant difference between groups (P = 0.56). Overall survival rate at one year was 77.9% (95% CL: 70.9, 84.9) with no difference between groups (P = 0.63). Symptoms, LVEF, and MR all significantly improved in the first month after TAVI, but the extent of improvement did not differ between groups (P > 0.08). Revascularization after TAVI was uncommon. Conclusion: The presence of CAD or nonrevascularized myocardium was not associated with an increased risk of adverse events in this initial cohort. On the basis of these early results, complete revascularization may not constitute a prerequisite of TAVI. This conclusion will require re‐assessment as experience accrues in patients with extensive CAD. © 2010 Wiley‐Liss, Inc.     

SYNTAX积分对经皮冠状动脉介入治疗的临床疗效与预测作用研究

目的:研究SYNTAX积分、临床SYNTAX积分及Global Risk Classification(GRC)对左主干/3支病变的冠心病患者,经皮冠状动脉介入治疗术后临床的预测作用,并评价三种积分系统的预测价值。方法:回顾性分析自2007年1月31日至2008年12月31日,北京安贞医院心内科经皮冠状动脉介入治疗术(percutaneous coronary intervention,PCI)置入Cypher select药物洗脱支架的左主干/3支病变的冠心病患者共190例。根据冠状动脉造影结果计算三种积分系统,并根据3分位数值分别分为低分、中分及高分组。通过门诊或电话随访PCI术后患者的主要不良心脑血管事件(major adverse cardiac and cerebrovascular events,MACCE),包括死亡、非致命性心肌梗死、再次血运重建、脑血管事件发生率。分别评价三种积分系统对患者术后临床预后的预测作用,评价三者的预测能力。结果:190例患者中,失访10例,失访率5.3%,随访中位数为29.4个月,29例观察到MACCE,MACCE发生率18.5%。SYNTAX积分低分(≤20.5)、中分(21.0~31.0)及高分组(≥31.5)的主要MACCE发生率分别为9.1%、16.2%及30.9%。临床SYNTAX评分低分(≤19.5)、中分(19.6~29.1)及高分组(≥29.2)的主要MACCE率分别为14.9%、9.8%及30.6%。GRC低、中、高分组的MACCE发生率分别为17.8%、14.2%及46.1%,单因素及多因素分析结果均显示三种积分系统是MACCE的独立预测因子。ROC曲线分析结果 SYNTAX积分AUC=0.667(95%CI=0.564~0.770,P=0.004),临床SYNTAX积分AUC=0.636(95%CI=0.519~0.753,P=0.020),GRC预测PCI术后MACCE的能力(AUROC=0.617,95%CI=0.512~0.736,P=0.046),三者都显示对MACCE有预测价值。结论:三种积分系统对冠状动脉左主干/3支病变患者行PCI治疗后的MACCE均有预测作用,可作为MACCE的独立预测因子。     

女性冠心病患者冠状动脉介入治疗长期预后

目的:了解女性冠心病患者在接受冠状动脉介入治疗(PCI)后的长期临床疗效.方法:584例经PCI治疗的患者,被分为女性组(122例)和男性组(462例),收集其一般临床资料及PCI治疗情况,并进行长期(3～49个月)临床随访,详细记录患者临床主要不良事件的发生情况.结果:男性患者的全因性死亡率(0:3.03%,P＞0.05)及心因性死亡率(0:2.98%,P＞0.05)有增高趋势,女性患者因心脏病再住院率(15.57%:9.96%,P＜0.05)显著增加,但2组患者其他临床主要不良事件差异无统计学意义.经过校正不匹配因素的偏相关分析显示,男性与心因性死亡(r=0.0874,P＜0.05)及全因性死亡(r=0.0970,P＜0.05)呈正相关.结论:女性患者PCI治疗的长期临床预后良好.     

急性冠状动脉综合征的急诊介入治疗

目的评价急诊冠状动脉内介入治疗急性冠状动脉综合征的疗效和安全性。方法急性冠状动脉综合征患者87例,男72例,女15例。年龄37～82岁。其中ST段抬高心肌梗死62例,非ST段抬高心肌梗死和不稳定型心绞痛25例,行急诊冠状动脉内介入治疗,分析其临床表现,冠状动脉病变特点,处理以及并发症和预后。结果87例患者共成功置入支架169枚,其中直接支架术53次,经皮冠状动脉腔内成形术加支架术116次。单纯冠状动脉腔内成形术22次。有16例患者行血管内超声指导冠状动脉内介入。手术成功率96．5％,住院期间死亡1例。随访5～22月,生存率98.8％,无事件生存率86．0％。院外猝死1例,心肌梗死1例,心绞痛再发10例。结论急诊冠状动脉内介入治疗急性冠状动脉综合征安全有效,有助于改善预后。     

经桡动脉冠状动脉介入诊疗232例临床分析

目的 探讨经桡动脉冠脉介入诊疗的可行性及安全性.方法 选择符合冠脉造影指征且Allen's试验阳性患者232例,首选以右桡动脉途径行冠脉造影,对符合介入指征者158例行介入治疗.结果 造影成功221例,成功率95.3%,失败11例,其中7例为穿刺不成功(桡动脉痉挛),另外4例因动脉狭窄或迂曲(桡动脉迂曲1例、肱动脉狭窄...     

成人主动脉瓣疾病冠状动脉造影分析

目的 调查成人主动脉瓣疾病合并冠状动脉硬化性心脏病的情况。方法 成人主动脉瓣疾病需行手术治疗病人211例,根据病情均在术前行冠状动脉造影,分析临床资料及造影结果。结果 211例成人主动脉瓣疾病病人有58例合并冠心病。其中,钙化退行性主动脉瓣组病人合并冠心病显著高于风湿性、先天性及感染性主动脉瓣组。结论 退行性主动脉瓣病常合并冠心病,成人主动脉瓣疾病有心绞痛症状行手术治疗术前应常规行冠状动脉脉造影检查,无心绞痛症状的病人行此检查的年龄应适当放宽。     

主动脉瓣钙化与冠心病的相关性研究

目的 探讨珠海地区汉族人群主动脉瓣钙化（AVC）与冠心病的相关性.方法 回顾性研究心内科住院患者1140例.所有患者均同期行超声心动图和冠状动脉造影检查,分析AVC与冠心病的相关性.结果 冠心病组中检出AVC的比率明显高于非冠心病组（32.3％比13.8％,P＜0.01）.冠心病组AVC患者冠脉受累严重程度高于无AVC患者.多因素分析显示,AVC、年龄、性别、高脂血症和糖尿病为全组冠心病的独立预测因子（P＜0.05）.结论 AVC与冠心病之间存在显著的相关性,对预测冠心病有一定参考价值.