复杂冠脉病变经皮冠状动脉介入治疗与冠状动脉旁路移植术的临床比较

目的 比较经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植术(CABG)治疗复杂冠状动脉病变的疗效。方法 对血管病变符合B2／C型病变的130例患者分别进行PCI或CABG治疗，进行近期和远期疗效分析。结果 从近期疗效看，在住院期间PCI组与CABG组总的心血管事件没有差异(3．8％vs7．7％；RR=0．480；P=0．341)。两组远期疗效相比其总的心血管事件没有差异(30．3％vs28．6％；RR=1．085；P=0．840)。随访结束时PCI组与CABG组总的心血管事件无差异(33．3％vS34．6％；RR=0．944；P=0．880)。结论 对于复杂冠状动脉病变的治疗由于PCI的优势，在部分病人、部分病变PCI有取代CABG的趋势。     

Comparison of drug eluting stent implantation with coronary artery bypass surgery in the treatment of patients with chronic total occlusion and multiple vessel disease

Background  In patients with chronic total occlusion (CTO) and multivessel coronary artery disease, the comparison of surgical and the percutaneous revascularization strategies has rarely been conducted. The aim of this study was to compare long term clinical outcomes of drug eluting stent (DES) implantation with coronary artery bypass surgery (CABG) in the patients with CTO and multivessel disease.

Methods  From a prospective registry of 6000 patients in our institution, we included patients with CTO and multivessel coronary artery disease who underwent either CABG (n=679) or DES (n=267) treatment. Their propensity risk score was used for adjusting baseline differences.

Results  At a median follow-up of three years, propensity score adjusted Cox regression analysis showed that the rate of major adverse cardiac cerebrovascular events (MACCE) was lower in CABG group (12.7% vs. 24.3%, hazard ratio (HR) 1.969, 95% CI 1.219–3.179, P=0.006) mainly due to lower rate of target vessel revascularization in CABG group than in DES group (3.1% vs. 17.2%, HR 16.14, 95% CI 5.739–45.391, P <0.001). The incidence of cardiac death or myocardial infarction (composite end point) was not significantly different between these two groups. On multivariate analysis, the significant predictors of MACCE were only the type of revascularization. Age, left ventricular ejection fraction (LVEF), and complete revascularization were identified as significant predictors of composite end points.

Conclusions  Our study shows that in patients with CTO and multivessel coronary disease, DES can offer comparable long term outcomes in cardiac death and myocardial infraction free survival in comparison with CABG. However, there is an increased rate of MACCE which results from more repeat revascularizations. Obtaining a complete revascularization is crucial for decreasing adverse cardiac events.

     

药物洗脱支架对首诊心内科患者转行冠状动脉搭桥治疗的影响

目的了解药物洗脱支架（DES）对首诊于心内科的冠心病患者转诊行冠状动脉搭桥术（CABG）的影响。方法入选2001年7月1日至2002年6月30日（BMS时代）以及2003年7月1日至2004年6月30日（DES时代）首诊于北京安贞医院心内科并接受经皮冠状动脉介入（PCI）或冠状动脉搭桥（CABG）的2598例患者,分析BMS时代与DES时代患者转行CABG术的临床及冠状动脉病变特征,评价DES对转诊CABG治疗的影响。结果DES时代1333例（80．1％）患者接受PCI治疗,331例（19．9％）患者转行CABG术,BMS时代721例（77．2％）患者接受PCI治疗,213例（22．8％）患者转行CABG术,转诊率下降约12．7％。与BMS时代相比,DES时代左主干病变（1．4％比3．2％,P=0．025）前降支近端（39．8％比44．2％,P=0．047）与弥漫长病变患者（11．2％比19．7％,P=0．021）接受PCI治疗的比例明显增加,但无论是否置入DES,左主干病变、慢性闭塞病变、前降支近段病变以及开口病变的患者仍是接受CABG治疗的最常见冠状动脉病变类型。DES时代接受PCI治疗的患者再次血管重建率明显低于BMS时代（12．7％比7．1％,P〈0．001）。多变量Logistic分析显示,病变血管支数、左主干病变、慢性闭塞病变以及前降支近端病变是选择CABG的主要预测因素。结论DES对冠心病患者血管重建方式及策略产生了一定的影响,在非DES时代需要转诊行CABG治疗的冠状动脉病变,在DES时代接受PCI治疗置入DES。     

Long-term outcome of patients of over 85 years old with acute coronary syndrome undergoing percutaneous coronary stenting: a comparison of bare metal stent and drug eluting stent

Background Patients aged over 85 years have been under-represented in percutaneous coronary intervention （PCI） trials despite an increase in referrals for PCI. The long-term safety and efficacy of percutaneous coronary stenting in patients aged over 85 years with acute coronary syndrome （ACS） remain unclear. Moreover it is unknown whether there are differences between bare metal stent （BMS） and drug eluting stent iDES） in this special population.
Methods A total of 80 patients with ACS aged over 85 years undergoing stenting （BMS group n=21 vs DES group n=59） were retrospectively studied. In-hospital, one year and overall clinical follow-up （12-36 months） of major adverse cardiac events （MACEs） including cardiac deaths, myocardial infarction, target lesion revascutarization （TLR） and target vessel revascularization （TVR） as well as stroke and other major bleeding were compared between the two groups.
Results In the entire cohort, the procedure success rate was 93.8% with TIMI-3 coronary flow post-PCI in 93.8% of the vessels and the procedure related complication was 17.5%. The incidence of in-hospital MACEs in BMS group was higher （14.3% vs 6.8%, P=0.30）. The 1-year incidence of MACEs in DES group was 7.0% while there was no MACE in the BMS group. Clinical follow-up for 12-36 months showed that the overall survival free from MACE was 82.9% and the incidence of MACE in the BMS group was lower （5.3% vs 21.1%, P=0.20）. Multivariate regression analysis showed that the creatinine level （OR：. 1.013; 95%CI： 1.006-1.020; P=0.004） and hypertension （OR; 3.201; 95%CI： 1.000-10.663; P=0.04） are two major factors affecting the long-term MACE.
Conclusions Percutaneous coronary stenting in patients aged over 85 years is safe and provides good short and tona-term efficacy. Patients with renal dvsfunction and hvoertension may have a relatively hiah incidence of MACE.     

2型糖尿病合并冠心病多支血管病变血运重建方式选择

目的：比较2型糖尿病（type 2 diabetes mellitus,T2DM）合并冠心病多支血管病变患者接受经皮冠状动脉介入治疗（ percutaneous coronary intervention ,PCI）或冠状动脉旁路移植术（ coronary artery by-pass graft,CABG）3年后的预后情况,探讨该类患者如何选择再血管化治疗方式。方法选择2009年5月1日至2010年5月31日于天津市胸科医院连续进行的冠状动脉造影（ coronary angiography ,CAG）确诊T2DM伴多支血管病变并成功行PCI或CABG治疗且病例及随访资料完整者,进行为期3年的随访,收集患者一般情况、临床指标、实验室检查指标等信息,分析死亡、心肌梗死、再次血运重建、再发心绞痛、心力衰竭、卒中等主要不良心脑血管事件（ major adverse cardio cerebral events ,MACCE）。结果3年期随访显示,PCI组MACCE发生率显著高于CABG组（31.58％ vs 17.68％,P＜0.01）,PCI组心源性死亡（4.82％vs 1.10％,P＜0.05）、心肌梗死（4.39％ vs 1.10％,P＜0.05）及再发心绞痛（17.27％ vs 10.50％, P＜0.05）发生率较高。结论与PCI相比,CABG仍然是目前T2DM合并多支血管病变患者血运重建治疗的更好方法。     

不同血运重建方式治疗复杂冠状动脉病变合并左心功能不全的围术期疗效比较

目的对比研究冠状动脉旁路移植术（CABG）和经皮冠状动脉介入术（PCI）治疗复杂冠状动脉病变合并左心功能不全 （LVD）的围术期疗效。方法回顾性分析2003年1月~2013年12月在我院接受CABG和PCI治疗的复杂冠脉病变合并左心功 能不全（左室射血分数LVEF≤50%）患者的临床资料,其中CABG 患者386 例,PCI 患者580 例,采用1∶1 配对方法,以 EuroSCORE危险因素及术前超声心动图指标为配对标准,两组各纳入患者135例,比较两组患者近期结果及术前术后左室形态 及功能变化。结果两组患者基线资料比较,PCI组慢性肺病及3个月内心梗发生率显著高于CABG组（8.1% vs 0.7%,P=0.003; 64.4% vs 31.9%,P=0.000）,而左主干病变比例显著低于CABG组（12.6% vs 23.7%,P=0.018）,其它方面两组之间无统计学差 异。血运重建结果比较：CABG组处理的靶血管数目明显多于PCI组（2.90±0.81 vs 1.67±0.73,P=0.000）,完全再血管化程度明 显高于PCI 组（94.8% vs 51.8%,P=0.000）。术后术前超声结果比较：CABG组与PCI 组LVEF差值无显著差异（P=0.171）,而 CABG组LVEDD差值明显高于PCI组（P=0.000）。围术期不良事件方面,两组住院死亡率及其它严重并发症无统计学差异。 结论对于复杂冠脉病变合并LVD患者,CABG与PCI均为安全可行的血运重建方式。与PCI相比,CABG完全再血管化程度 更高,术后早期左心功能改善更为明显。     

尼可地尔对冠脉多支病变血运重建不完全患者疗效观察

目的观察尼可地尔对冠脉多支病变血运重建不完全患者的疗效。方法选择冠脉多支病变血运重建不完全的58例冠心病患者,随机分为观察组（n=28）和对照组（n=30）,对豫组患者PCI术后常规行冠心病二级预防治疗,观察组在此基础上加用尼可地尔。对比二组患者6min步行实验（6MWD）、超声心动图、观察患者心绞痛缓解、心功能改善情况及发生主要心血管不良事件情况。结果二组患者在治疗期间及随访期间均未发生死亡、心肌梗死、脑卒中事件,而尼可地尔组患者心绞痛发作持续时间及次数明显减少、6min步行距离提高、心功能有明显改善,与对照组相比差异有统计学意义。结论在常规治疗的基础上加用尼可地尔对冠脉多支病变血运重建不完全患者可显著提高运动耐量水平,同时改善心脏功能。     

非顺应球囊后扩张对置入药物洗脱支架预后的影响

目的评估使用非顺应性球囊后扩张对经置入药物洗脱支架冠状动脉粥样硬化性心脏病(以下简称冠心病)患者的疗效。方法回顾性分析2011年1月至2011年5月共356例行药物洗脱支架植入且使用非顺应性球囊后扩张的患者,采用倾向性评分抽取同期356例行药物洗脱支架植入术而未后扩张的患者与之1∶1匹配。结果 2组在年龄、性别、临床表现、主要危险因素及冠状动脉病变特征方面比较,差异无统计学意义(P>0.05),具有可比性。平均随访时间18个月,后扩张组主要不良心血管事件(major adverse cardiac events,MACE)明显低于未后扩张组(10.1%vs 15.7%,P=0.020),主要是靶血管重建(6.2%vs10.7%,P=0.010)、支架内血栓(1.1%vs 3.7%,P=0.030)发生率比较,差异有统计学意义(P<0.05),而心肌梗死(3.9%vs4.6%,P=0.700)、死亡(1.1%vs 1.7%,P=0.760)比较,差异没有统计学意义。结论冠心病患者置入药物洗脱支架后使用非顺应性球囊后扩张安全,可改善患者的临床预后。     

Outcomes after primary coronary intervention with drug-eluting stent implantation in diabetic patients with acute ST elevation myocardial infarction

Background Drug-eluting stent (DES) has been used widely for the treatment of patients with acute coronary syndrome with or without diabetes mellitus during percutaneous coronary intervention (PCI), but its long-term safety and efficacy in diabetic patients with acute ST elevation myocardial infarction (STEMI) remain uncertain. This study aimed to investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute STEMI, compared with non-diabetic counterparts. Methods From December 2004 to March 2006, 56 consecutive diabetic patients (diabetic group) and 170 non-diabetic patients (non-diabetic group) with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac event (MACE) including cardiac death, non-fatal recurrent myocardial infarction (re-MI) and target vessel revascularization (TVR) during hospitalization and one-year clinical follow-up were compared between the two groups. Results Patients in diabetic group were more hyperlipidemic (69.6% and 51.8%, P=0.03) and had longer time delay from symptom onset to admission ((364±219) minutes and (309±223) minutes, P=0.02) than those in non-diabetic group. The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two groups, but multi-vessel disease was more common in diabetic than in non-diabetic group (82.1% and 51.2%, P&lt;0.001). Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion grade (TMPG) ≥2 was lower in diabetic group (75.0% vs 88.8% in non-diabetic groups, P=0.02). The MACE rate was similar during hospitalization between the two groups (5.4% vs 3.5%, P=0.72), but it was significantly higher in diabetic group (16.1%) during one-year follow-up, as compared with non-diabetic group (6.5%, P=0.03). The cumulative one-year MACE-free survival rate was significantly lower in diabetic than in non-diabetic group (78.6% vs 90.0%, P=0.02). Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively (P=0.19). All of these patients experienced non-fatal myocardial infarction.Conclusions Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of diabetic cohort suffering STEMI.     

严重左心室扩张患者行经皮冠状动脉介入治疗和冠状动脉旁路移植术的对比研究

目的 对比严重左心室扩张(LVD)患者行经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)的近期和远期临床结果.方法 选择2003年7月至2005年9月在我院接受PCI或CABG治疗的严重LVD患者251例,分析不同血运重建方式对住院和随访期间不良心脑血管事件(MACCE)的影响.结果 严重LVD患者接受PCI治疗101例,CABG治疗150例,其中PCI组的住院MACCE发生率低于CABG组[3.0％ (3/101)比10.7％ (16/150),P=0.024],住院病死率分别为2.0％、8.7％(P=0.028).PCI组和CABG组分别随访(516±182)d和(515±231)d(P=0.967),分别有99例(98.0％)和136例(90.7％)完成随访.两组随访MACCE发生率PCI组、CABG组分别为18.2％ (18/99)、9.6％ (13/136)差异无统计学意义(P=0.054),PCI组再次血运重建率(14.1％、14/99)比CABG组高(0.7％、1/136,P＜0.01),两组随访死亡[4例(4.0％)比12例(8.8％),P=0.151]、心肌梗死[2例(2.0％)比1例(0.7％),P=0.781]和脑卒中[2例(2.0％)比0例(0.0％),P =0.176]的发生率相当.结论 严重LVD患者接受PCI安全可行,其住院病死率较低,远期预后与CABG相当,但再次血运重建率较高.     

Effects of different therapies on coronary artery disease

Objective To analyse the effects of different therapies on coronary artery disease (CAD).Methods A total of 1055 patients who suffered from CAD diagnoised by coronary angiograpy were divided into three groups, namely pure drug therapy, percutanious coronary intervention (PCI) and coronary artery bypass graft (CABG) groups. Follow up was carried out from March to May in 2001, and the major adverse cardiac events (MACEs) including death, no-lethal myocardial infarction (Ml) and revascularization were observed. In long-term observation, angina reoccured, and their improvement was evaluated. The short-term period was defined as the duration of 30 days after discharge, and the long term period was defined as the duration from 30 days after discharge.Results In the long-term period, the recurrences of angina both in PCI group and CABG group were lower than pure drug group (PO. 018, 0. 002 respectively). No differences about long-term endpoint events were observed among these three groups ( P > 0. 05). Forty-t     

冠状动脉粥样硬化性心脏病病人冠状动脉旁路移置术的治疗效果

①目的 探讨冠状动脉粥样硬化性心脏病(CAD)病人行冠状动脉旁路移置术的治疗效果。②方法 148例CAD病人，体外循环下行旁路移置术(CABG)62例，非体外循环下行旁路移置术(OPCAB)86例。③结果 围手术期死亡3例，8例病人使用主动脉内球囊反搏(IABP)，145例病人术后康复出院。④结论 冠状动脉旁路移置术是治疗CAD的一种安全有效的方法，在掌握手术适应证及技术条件允许情况下应尽量行非体外循环旁路移置术和全动脉化旁路移置术。     

Coronary stenting versus bypass surgery in heart failure patients with preserved ejection fraction

Background  The optimal revascularization strategy in patients with heart failure with preserved ejection fraction (HFPEF) remains unclear. The aim of the present study was to compare the effects of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with HFPEF.

Methods  From July 2003 through September 2005, a total of 920 patients with coronary artery disease (CAD) and HFPEF (ejection fraction ≥50%) underwent PCI (n=350) or CABG (n=570). We compared the groups with respect to the primary outcome of mortality, and the secondary outcomes of main adverse cardiac and cerebral vascular events (MACCE), including death, myocardial infarction, stroke and repeat revascularization, at a median follow-up of 543 days.

Results  In-hospital mortality was significantly lower in the PCI group than in the CABG group (0.3% vs. 2.5%, adjusted P=0.016). During follow-up, there was no significant difference in the two groups with regard to mortality rates (2.3% vs. 3.5%, adjusted P=0.423). Patients receiving PCI had higher MACCE rates as compared with patients receiving CABG (13.4% vs. 4.0%, adjusted P <0.001), mainly due to higher rate of repeat revascularization (adjusted P <0.001). Independent predictors of mortality were age, New York Heart Association (NYHA) class and chronic total occlusion.

Conclusion  Among patients with CAD and HFPEF, PCI was shown to be as good as CABG with respect to the mortality rate, although there was a higher rate of repeat revascularization in patients undergoing PCI.

     

无保护左主干病变不同治疗策略远期临床效果

目的观察无保护左主干(ULM)冠状动脉病变不同治疗策略远期临床效果。方法比较211例冠状动脉内药物洗脱支架置入术(DES)(DES组)和176例冠状动脉搭桥术(CABG)(CABG组)治疗ULM病变后远期主要心脑血管事件(MACCE)发生率。结果 DES组远期再次血运重建率明显高于CABG组,心源性病死率明显低于CABG组(P<0.05)。采用倾向性得分法分析,血运重建方式与远期MACCE、总病死、心源性病死、心肌梗死和脑卒中发生率未见明显相关(P>0.05);DES与远期再次血运重建率明显相关,风险比为3.050,95%可信区间(1.289,7.217),P<0.05。结论与DES比较,CABG治疗的ULM病变患者临床状态更复杂,冠状动脉病变更严重。DES是接受血运重建的ULM病变患者远期再次血运重建的独立预测因子。     

冠状动脉旁路移植术治疗冠心病25例

目的 :回顾冠状动脉旁路移植术 ( CABG)治疗冠心病的早期效果和经验。方法 :2 5例冠心病病人92 %为多支冠状动脉病变。 1 0例左室射血分数 ( EF)≤ 45 % ,其中 4例 <30 %。所有患者均有心绞痛症状 ,CCS ～ 级。 1 0例在非体外循环、心脏不停跳下手术 ,余为低温体外循环 ( CPB)下手术。 1 4例采用左乳内动脉与左前降支搭桥 ,余均为大隐静脉桥 ,人均搭桥 3.0 8支。同期行激光心肌血管重建术 ( TMLR) 3例。结果 :2 5例 CABG临床效果良好 ,无手术死亡。术后 96%的患者心绞痛症状完全消失。结论 :CABG是一种治疗冠心病安全和有效的方法 ,近期临床效果满意。     

冠状动脉旁路移植术应用于介入治疗后血管再狭窄患者

目的：总结分析76例介入治疗后患者行冠状动脉旁路移植术(coronary artery bypass grafting，CABG)的经验体会。方法：1999年8月至2002年4月共完成介入治疗后的CABG手术76例，占同期CABG手术的14.0％。单纯经皮腔内冠状动脉成形术(percutaneous transluminal coronary angioplasty，PTCA)39例，合并支架置人术37例，合并斑块旋切术2例，二次介入治疗史5例。介入治疗相关血管再狭窄46例，新产生的其他冠脉病变6例，介入治疗不成功者4例，介入治疗后残留严重血管病变11例，介入治疗急性并发症9例。介入治疗组心肌梗死患者的比例高于非介入治疗组，而三支病变患者的比例低于非介入治疗组。结果：介入治疗组急诊手术比例为27．6％，高于非介入治疗组的13．3％，而OPCAB实施率为91．3％，低于非介入治疗组的97．2％。介入治疗组远端吻合口数目少于非介入治疗组。介入治疗组手术死亡6例，其中3例死于泵衰竭，1例死于心室纤颤，1例死于脑部并发症，1例死于肾功能衰竭，其手术死亡率(7．9％)高于非介入治疗组(1．9％)。介入治疗组发生围术期心梗4例(5．3％)，其发生率高于非介入治疗。随访远期死亡1例，复发心绞痛1例。结论：对于介入治疗后再狭窄、不能达到完全再血管化和引起急性并发症的患者，冠状动脉旁路移植术常常是最为有效而必要的治疗方法。及时合理地处理介入治疗急性并发症，是降低死亡率的主要措施。     

高龄冠心病患者介入治疗的临床分析

目的探讨高龄冠心病患者行冠状动脉介入治疗(PCI)的临床疗效及安全性。方法回顾性分析45例行PCI治疗的高龄冠心病患者的临床资料,观察其冠状动脉造影结果、介入治疗成功率、并发症及术后随访情况。结果 45例患者成功41例,总成功率91.1%,植入支架50只,并发症发生率为11.1%,术后随访6～12个月,3例再次出现胸痛发作,其中1例为原有支架闭塞;1例急性心肌梗死死亡。结论 PCI治疗高龄冠心病患者成功率高,是一种安全、有效方法。     

梗死相关血管PCI和择期完全PCI策略在急性ST段抬高型心肌梗死合并多支病变患者中的预后分析

目的评价开通梗死相关血管后择期完全血运重建经皮冠状动脉介入(PCI)策略和仅梗死相关血管PCI策略对急性ST段抬高型心肌梗死(STEMI)合并多支病变患者预后的影响。方法纳入2012年4月—2013年12月北京安贞医院急诊科行急诊PCI的合并多支血管病变的STEMI患者59例。根据是否在同次住院期间择期行非梗死相关血管PCI分为2组:择期完全PCI组25例和仅梗死相关血管PCI组34例。观察比较2组患者基本临床资料、冠状动脉造影和PCI情况,记录3个月内相关不良事件(包括死亡、非致死性心肌梗死、顽固性心绞痛、再次血运重建)。结果择期完全PCI组和仅梗死相关血管PCI组冠状动脉造影(包括每支血管植入支架数、支架长度、支架直径等)和PCI情况(包括发病到血管开通时间、介入操作时间、围术期用药情况等)比较,差异均无统计学意义(P>0.05),出院后用药情况(包括阿司匹林、氯吡格雷、α-受体阻滞剂等)差异亦无统计学意义(P>0.05)。随访3个月,择期完全PCI组失访1例,仅梗死相关血管PCI组失访3例。仅梗死相关血管PCI组总不良事件比例高于择期完全PCI组(38.7%vs.12.5%,x²=4.685,P<0.05)。仅梗死相关血管PCI组出现顽固性心绞痛的比例高于择期完全PCI组(32.3%vs.8.3%,x2=4.685,P<0.05)。仅梗死相关血管PCI组出现顽固性心绞痛的比例高于择期完全PCI组(32.3%vs.8.3%,x²=4.539,P<0.05)。2组均未出现死亡病例。结论择期完全处理非梗死相关血管策略能够改善STEMI合并多支病变患者预后,预防顽固性心绞痛的发生。     

药物洗脱支架内再狭窄的介入治疗

目的评价药物洗脱支架(DES)内再狭窄患者中根据再狭窄模式选择介入治疗的远期预后。方法选择2006年6月—2009年12月因DES内再狭窄于上海交通大学附属胸科医院行再次介入治疗的冠状动脉性心脏病患者,根据再狭窄部位及类型选择介入治疗方案。对于累及DES节段的再狭窄者行再次植入DES术;对于狭窄部位局限于DES内的Ⅰ型病变者行高压球囊扩张术;对于狭窄部位局限于DES内的Ⅱ～Ⅳ型病变者先行球囊扩张,再根据扩张后的结果由术者决定是否再次植入DES。所有患者均前瞻性随访主要心血管不良事件(MACE),包括死亡、靶病变重建(TLR)和心肌梗死(MI)。结果共88例行介入治疗,其中42例行单纯球囊血管成形(POBA)术(POBA组),46例行再次植入DES(DES组)。两组间各靶病变部位及各种原植入DES的涂层药物类型构成比的差异均无统计学意义(P值均>0.05),两组间再狭窄病变部位及类型构成比的差异均有统计学意义(P值均<0.05)。POBA组、DES组的支架内再狭窄(ISR)的发生率分别为(72.5±11.9)%、(76.2±9.1)%,两组间的差异无统计学意义(P>0.05)。平均随访时间为(2.2±1.0)年,两组间MACE、TLR、MI的发生率及病死率的差异均无统计学意义(P值均>0.05)。结论根据DES内再狭窄部位及类型选择介入治疗方案是有效的。对于局灶型ISR可行POBA术,而对于非局灶型或节段内ISR病变则需要再次植入DES。     

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background:

There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events.

Methods:

All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups.

Results:

Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3–8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group.

Conclusions:

During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.