雷帕霉素药物涂层支架治疗冠脉前降支长病变45例

目的:评价雷帕霉素药物涂层支架(CYPHERTM,Cordis)治疗冠状动脉前降支长病变的长期临床疗效。方法:前降支长病变(病变长度≥20mm)患者45例置入CYPHERTM支架55个,病变长度20～45mm,平均25.2±7.8mm,术前病变狭窄程度(87.9±6.5)%;血管直径3.0±0.75mm。其中前降支病变>28mm10例置入2个支架重叠,1个长支架覆盖病变35例。结果:45例均手术成功,术后造影病变残余狭窄(3.5±2.8)%,支架覆盖病变完全,支架近、远端无夹层,血流TIMI3级。随访12个月,心绞痛消失39例,术后12个月复查冠状动脉造影,无血管再狭窄发生。结论:雷帕霉素药物涂层支架治疗前降支长病变是解决前降支长病变安全有效的方法。     

国产药物洗脱支架治疗冠心病前降支长病变近期疗效观察

药物洗脱支架（EMS）治疗冠心病的疗效已经有很多临床试验证实，显示出比金属裸支架更好的疗效，能显著降低再狭窄率，心血管不良事件。C—SIRIUS、E—SIRIUS均已经证实了药物洗脱支架（CYPHER）较金属裸支架能显著降低支架术后再狭窄率，心血管不良事件，及靶血管重建率。国产药物洗脱支架（FIREBIRD）也有大规模、多中心临床注册研究在进行中，一些初步结果证实了良好的安全性及有效性。但国产药物洗脱支架在前降支长病变的有效性及安全性仍值得在临床实际工作中加以验证，进口药物洗脱支架费用昂贵，给医疗带来了沉重的负担，观察实际工作中冠心病尤其是前降支长病变使用国产药物洗脱支架的有效性及安全性有一定的意义。     

冠脉内支架置入术治疗前降支开口部病变

目的:探讨冠脉内支架置入对前降支开口部病变的效果。方法:回顾分析了39例前降支开口部病变置入支架的早期成功率、支架置入对回旋支开口的影响及随访结果。结果:39例前降支开口病变置入支早期成功率100％,临床随访率100％,无急性期并发症,再狭窄率相对较高,前降支与回旋支夹角<90°者,部分患者支架置入后发生回旋支开口部狭窄,这部分患者随访期前降支开口部再狭窄发生较多。结论:前降支开口部病变的支架治疗早期成功率高,再狭窄率者相对较高,早期前降支与回旋支夹角<90°,易发生回旋支开口部狭窄。     

药物涂层支架内的血栓形成

支架内再狭窄的发生,对经皮冠状动脉成形术(PCI)的预后有显著的影响。经研究证明,糖尿病、冠脉直径、冠脉病变长度和部位等都是影响植入金属裸支架(BMS)后发生支架内再狭窄的相关因素[1]。至于支架内血栓形成的发生率,近来已引起临床医师越来越多的重视,特别是药物涂层支架引起的晚期支架内血栓形成[2]。经过对金属裸支架、西罗莫司涂层支架、聚合物的材料的紫杉醇药物涂层支架的对比研究,发现植入药物涂层支架(DES)患者有较高的晚期支架内血栓形成发生率[3]。关于晚期支架内血栓形成的定义,目前还没有统一的规定。一般认为支架植入后至…     

药物洗脱支架治疗左主干病变

冠状动脉搭桥术曾被认为是左主干病变治疗的首选,近年来随着药物洗脱支架的应用和操作技巧、器械的进步,越来越多的临床试验证实药物洗脱支架治疗左主干病变具有完全可行的疗效。现在左主干病变不再是介入治疗的禁忌证。本文从介入治疗左主干病变的适应证,药物洗脱支架及冠状动脉搭桥术治疗左主干病变的疗效对比加以阐述。     

药物涂层球囊治疗冠状动脉支架内再狭窄和小血管病变的临床疗效

目的 观察药物涂层球囊(DCB)治疗冠状动脉支架内再狭窄(ISR)和小血管病变的临床疗效。方法 回顾性分析2018年1月至2019年10月入住我院行DCB治疗的冠心病患者48例,其中ISR 22例,小血管病变26例。另选取性别、病变血管及类型相同,年龄、合并基础疾病等相近的行药物涂层支架(DES)治疗的患者48例作为对照组。以心源性死亡、非致死性急性心肌梗死(AMI)、靶病变再次血运重建(TLR)等不良心血管事件(MACE)为主要终点观察指标,记录复查冠脉造影或冠脉CT结果。结果 平均随访(9.15±5.46)个月。DES组MACE发生率为8.34%,高于DCB组的4.17%,但差异无统计学意义(P0.05);两组均未发生心源性死亡病例,DCB组中无非致死性AMI,DES组发生1例(2.08%),组间比较差异无统计学意义(P0.05);DCB组行TLR 2例(4.17%),低于DES组4例(8.34%),但差异无统计学意义(P0.05)。DCB组在(9.24±4.02)个月有19例患者复查冠脉造影和4例复查冠脉CT,ISR患者10例(1例血管狭窄85%),小血管病变13例(1例血管狭窄90%);DES组在(8.34±5.28)个月有14例复查冠脉造影,ISR患者6例(1例血管狭窄80%),小血管病变8例(1例血管狭窄99%的非致死性AMI,2例血管狭窄75%和80%)。生存曲线分析显示,两组在随访过程中无MACE生存率比较,差异无统计学意义(P=0.406)。结论 药物涂层球囊治疗冠状动脉支架内再狭窄和小血管病变的疗效不劣于药物涂层支架,可作为临床冠脉血运重建的重要策略。     

药物涂层支架的研究现况

近年来大量的基础和临床研究发现 ,球囊术后的再狭窄可能与血管的弹性回缩 ,血栓形成 ,细胞过度增殖及血管的再塑型 (ｒｅｍｏｄｅｒｌｉｎｇ)等因素有关 ;而支架术后的再狭窄则几乎都是由于支架与动脉壁接触部位的内膜过度增生所致。针对再狭窄发生的机制 ,人们已对许多药物和基因进行了十分深入的研究 ,包括血小板受体阻断剂、血管紧张素转换酶抑制剂、抗凝剂、溶栓剂、抗氧化剂、抗炎剂、环氧化酶抑制剂以及血管内皮生长基因 ,细胞周期调控基因、抗癌基因、一氧化氮合成酶基因等等。但这些药物或基因往往是动物试验有效 ,临床应用低效或…     

双源CT评价急诊PGI中药物涂层支架及裸支架植入术后再狭窄

目的 通过双源CT评价急诊PCI药物涂层支架及金属裸支架植入术后支架内再狭窄.方法 85例急性心梗并行急诊支架植入术后1年的患者行双源CT检查,分析其管腔丢失及支架内再狭窄发生率.结果 ①双源CT获得80例(94.1％)患者共88枚(93.6％)冠状动脉支架清晰图像.②在管腔丢失方面药物涂层支架与金属裸支架比较有统计学意义;两者在支架内再狭窄方面无统计学意义.结论 双源CT可作为支架术后患者的无创随访手段;在急性心梗中使用药物涂层支架可减少管腔丢失.     

双源CT评价急诊PCI中药物涂层支架及裸支架植入术后再狭窄

目的通过双源CT评价急诊PCI药物涂层支架及金属裸支架植入术后支架内再狭窄。方法 85例急性心梗并行急诊支架植入术后1年的患者行双源CT检查,分析其管腔丢失及支架内再狭窄发生率。结果①双源CT获得80例(94.1%)患者共88枚(93.6%)冠状动脉支架清晰图像。②在管腔丢失方面药物涂层支架与金属裸支架比较有统计学意义;两者在支架内再狭窄方面无统计学意义。结论双源CT可作为支架术后患者的无创随访手段;在急性心梗中使用药物涂层支架可减少管腔丢失。     

药物涂层支架预防冠状动脉再狭窄的研究进展

冠状动脉内支架植入术已经是目前应用最广泛的冠心病介入治疗技术,虽然与单纯的经皮腔内冠状动脉成形术(PTCA)相比较,支架植入术后的再狭窄率已大大降低,在局限性病变和直径>3.0mm血管的病变中,支架内再狭窄(in-stentrestenosis,ISR)的发生率大约是10％～20％,如果合并有糖尿病等危险因素,弥漫性病变或是直径<3.0mm血管的病变,则ISR的发生率高达30％～60％,所以如何降低冠状动脉内支架植入术后的再狭窄率,是一个迫切需要解决的问题。 再狭窄的发生机制主要有:①血管弹性回缩;②血管重建;③血管内皮增生。支架植入术可以防止血管弹性回缩和血管重建所引起的再狭窄的发生,但却加剧了血管内皮的增生。这是因为支架植入引起了血管损伤及排异反应,从而启动了血管壁     

Coronary artery anomalies: the left main coronary artery or left anterior descending coronary artery originating from the proximal of right coronary artery

Coronary artery anomalies （CAAs） are present at birth, but are usually asymptomatic and are found during coronary angiography or multi-slice computed tomography （MSCT） examinations. Their prevalence is less than 1.3% based published series.1＇2 The most common coronary anomaly is separate origin of the left anterior descending coronary artery （LAD） and left circumflex coronary artery （LCX） from the left sinus of the Valsalva. The second most common anomaly is the origin of the LCX artery from the right coronary artery （RCA） or right sinus of the Valsalva. We present two cases of coronary artery anomalies： one is the left main coronary artery （LMCA） arising from the proximal RCA, the other is the LAD originating from the proximal RCA.     

Drug-eluting stent for the treatment of small coronary lesion: comparison between sirolimus- and paclitaxel-eluting stent

Background  Patients with small coronary lesions are at increased risk for repeat interventions after coronary angioplasty and stenting. The efficacy of drug-eluting stents (DES) has been demonstrated to improve the outcomes of these patients and is a focus of interest. Currently, two platforms of DES are available (sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES)). However, it has less been known that DES, SES vs PES, is superior for the treatment of small coronary lesions.
Methods  In this retrospective study, 87 consecutive patients with 151 lesions underwent implantation of coronary SES (n=68) and PES (n=83). Quantitative coronary angiography (QCA) was performed at the time of stent implantation and subsequently at 8 months post-stenting. Small vessel disease was defined as lesions in vessels with diameter 2.5 mm measured by QCA. Major adverse cardiac events (MACE) including death, thrombosis, nonfatal myocardial infarction and target lesion revascularization (TLR) were compared between the two groups.
Results  Baseline clinical characteristics and angiographic parameters were similar between the two groups. At clinical and angiographic follow-up, overall thrombosis rates were similar in both groups (0 vs 1.2%, P>0.05). The TLR and in-segment restenosis were not significantly different (19.1% vs 25.3%; 10.3% vs 10.8%, P=0.365 and P=0.913 respectively) between the two groups. The in-stent restenosis rate, however, was significantly higher in the PES group (4.4% vs 21.7%; P=0.002). Similarly, the late loss was significantly higher in the PES group ((0.140.38) mm vs (0.490.61) mm; P<0.001).
Conclusions  In this small sample-size, non-randomized study, the data indicated that implantation of SES for the treatment of patients with small coronary lesion showed more favorable results in respect of restenosis compared with PES implantation.

     

Multiple myocardial bridges affecting left anterior descending artery and right coronary artery with hypertrophic cardiomyopathy: a case report

The prevalence of myocardial bridging in hypertrophic cardiomyopathy （HCM） is relatively higher, and it usually occurs in the middle and distal portions of the left anterior descending artery. It is rarely reported that multiple lesions of myocardial bridging affecting not only the left anterior descending artery but also right coronary artery. We reported a 56-year-old man suffering from chest discomfort on exertion. Echocardiography and ventriculography showed hypertrophy of the apex involving the anterior and lateral wall. Coronary angiograph revealed multiple myocardial bridges affecting the left anterior descending artery and the right posterior descending artery.     

经胸超声冠状动脉血流显像评价左前降支狭窄的价值

目的应用经胸超声冠状动脉血流显像技术(TTDE)评价冠状动脉左前降支(LAD)全程显著狭窄(≥70%)。方法90例患者于冠状动脉造影(CAG)前用TTDE测量LAD各项血流指标,对比CAG分析结果。结果56段血管狭窄≥70%(狭窄组),121段血管无狭窄(对照组),两组比较,近、中段指标均存在差异,远段Vd/Vs、MVd/MVs,P<0.05。Vd/Vs、MVd/MVs≤1.7时,评价LAD显著狭窄的敏感度、特异度处于最佳点。结论应用TTDE检测LAD狭窄,无创、实用,具有临床价值。     

经640层容积CT评估左冠状动脉解剖结构与左前降支狭窄关系的研究

目的 运用640层容积CT测量结果探讨左冠状动脉解剖结构与左前降支狭窄程度的关系。方法 选取锦州医科大学附属第一医院2018年1月—2019年3月行冠状动脉CT血管造影（CTA）及冠状动脉造影（CAG）的左冠状动脉多发斑块患者116例,测量左主干（LM）长度,左前降支与左回旋支（LAD-LCX）夹角,左主干与左前降支（LM-LAD）夹角。根据左前降支（LAD）是否显著狭窄分为LAD显著狭窄组（LAD狭窄≥ 50%）和LAD非显著狭窄组（LAD狭窄<50%）。并纳入年龄、性别、高血压、高血糖、高血脂、有吸烟史各临床指标,分析LM长度、各夹角及临床指标与LAD狭窄的关系。对差异有统计学意义的因素运用Logistic回归模型,得出独立预测LAD显著狭窄的左冠状动脉解剖因素。绘制受试者工作特征（ROC）曲线获得独立预测LAD显著狭窄的左冠状动脉解剖因素的临界值。结果 单因素分析显示,LAD显著狭窄组的LM长度、LAD-LCX夹角、LM-LAD夹角大于LAD非显著狭窄组（P?<0.05）。Logistic回归分析显示,LAD显著狭窄的独立预测因素为LM长度[OlR=1.167（95% CI：1.008,1.350）]、LAD-LCX夹角（OlR=1.066（95% CI：1.018,1.115）]。LM长度预测LAD显著狭窄的临界值为10.3?mm、敏感性为71.20%（95% CI：0.587,0.817）、特异性为66.00%（95% CI：0.512,0.788）、曲线下面积（AUC）为0.716（95% CI：0.620,0.810）;LAD-LCX夹角预测LAD显著狭窄的临界值为80°、敏感性为66.10%（95% CI：0.433,0.683）、特异性为88.00%（95% CI： 0.757,0.955）、AUC为0.762（95% CI：0.680,0.850）。结论 较长的LM长度、较大的LAD-LCX夹角能用来鉴别冠状动脉粥样硬化性心脏病的风险等级。     

PCI和药物治疗血流储备分数处于临界值的单纯左前降支近端中度狭窄效果的比较

目的:探讨血流储备分数(FFR)处于临界值的单纯左前降支近端中度狭窄患者治疗方案的选择。方法:选择50例冠状动脉造影显示单纯左前降支近端中度狭窄(50%~70%)且FFR处于临界值(0.75~0.80)的患者,分为两组,一组行经皮冠状动脉介入(PCI)治疗,另一组行药物保守治疗。随访2 a,观察两组患者主要不良心血管事件(心源性猝死、非致死性心肌梗死、再行PCI)的发生率及2 a后左前降支近端的狭窄程度。结果:PCI治疗组和药物治疗组主要不良心血管事件的发生率分别为9.1%(2/22)和10.7%(3/28),差异无统计学意义(P>0.999);2 a后血管狭窄程度分别降低了(9±2)%和(8±3)%,差异亦无统计学意义(t=0.492,P>0.05)。结论:FFR处于临界值的单纯左前降支近端中度狭窄患者介入治疗和药物保守治疗的近期预后无差别。     

冠状动脉药物洗脱支架置入术后支架内再狭窄的临床研究进展

药物洗脱支架虽然很大程度上降低了再狭窄的发生率，但仍有部分患者在随访期间发生再狭窄，甚至需要再次干预病变血管。目前关于药物洗脱支架置入术后再狭窄的临床研究主要集中在预测因素、治疗上，本文就相关临床研究的最新进展作一综述。     

急性前壁心肌梗死时心电图对预测前降支闭塞部位的作用

目的:探讨心电图对预测急性前壁心肌梗死时前降支闭塞部位的作用。方法:对74例患者的心电图和冠状动脉造影资料进行对比分析。结果:①前间壁AMI患者,血管闭塞部位均发生于大对角支开口远端。②前壁伴高侧壁AMI患者,血管闭塞部位在大对角支开口近端者占74.1%。③前壁AMI患者合并下壁导联ST段抬高时,73.3%为前降支优势动脉远端病变,合并下壁导联ST段压低者,前降支非优势动脉近端病变占60%,下壁导联ST段无改变组中,前降支优势动脉近端和非优势动脉远端病变所占比例近似。结论:前壁AMI时,心电图对前降支长度及闭塞部位有重要预测价值。     

Rapid development of late stent malappositon and coronary aneurysm following implantation of a paclitaxel-eluting coronary stent

Late stent malapposition （LSM）, an unusual intravascular ultrasound （IVUS） finding at follow-up,has been reported to be more common alter drug-eluting stem （DES） implantation than after bare metal stent （BMS） implantation. However, there has been no clear elucidation of time course and mechanism. We reported a case who developed LSM and coronary aneurysm very early after paclitaxel-eluting stent （PES） implantation. A review of the literature reveals no previous report describing rapid development of LSM and coronary aneurysm after PES implantation.     

Age-based clinical and angiographic outcomes after sirolimus-eluting stent implantation in patients with coronary artery disease

Background Advanced age independently predicts early and late mortality and major adverse cardiac events （MACE） after percutaneous coronary intervention （PCI）. Randomized clinical trials indicate that siroUmus-eluting stent （SES） implantation reduces target lesion revascularization （TLR）, but there are limited data on the impact of age on outcomes following SES implantation in patients with coronary artery disease （CAD） in real-world practice. Methods A total of 333 CAD patients with 453 lesions were enrolled in this study. Subjects were divided into two groups according to age： a young group （〈65 years old, 244 patients with 369 lesions） and elderly group （≥65 years old, 89 patients with 113 lesions）. Clinical follow-up and quantitative coronary angiography （QCA） were performed seven months after PCh Results Baseline clinical, demographic, angiographic, and procedural chararcteristics were similar in both groups, except that there were more female patients in the elderly group （21.3% vs 9.8%, P=-0.006）. Primary success rate was similar in both groups （96.5% in young group vs 95.7% in elderly group, P〉0.05）. During angiographic follow-up at 7 months, binary in-stent restenosis and in-segment restenosis rates were not significantly different between the two groups （4.7% vs 1.8%; 9.7% vs 8.8%, P〉0.05 respectively）. Both sub-acute and late thrombosis rates were similar in the two groups （0.3% vs 0.9% and 1.2% vs 0.9%, P〉0.05 respectively. TLFI was not significantly different between the two groups （6.5% vs 3.5%;P=-0.246）. The rates of bleeding, stroke, angina rehospitalization during the, follow-up period were also similar in both groups （P〉0.05 respectively）. Conclusion Despite a high-risk clinical profile, coronary SES implantation can be safely and effectively performed in elderly patients with a similar procedural success rate, a low complication rate, and excellent 7-month outcomes.