无保护左主干病变患者经皮介入治疗的即刻及远期疗效分析

目的探讨无保护左主干病变患者经皮冠状动脉介入治疗(PCI)的近、远期疗效。方法解放军总医院2001年12月~2006年8月接受PCI的77例左主干病变的病例资料,2006年8月对上述患者进行随访,包括造影及电话随访。结果即刻成功率100%,无严重术中并发症,住院期间无死亡。术后随访0.5~54(12.95±10.31)个月,其中1例术后6个月行冠状动脉CT检查,支架内无狭窄;20例患者进行了冠状动脉造影检查,1例术后30天出现支架内亚急性血栓;10例分别在1~12个月造影时显示支架内再狭窄,其中4例发生在左主干支架内,其余再狭窄均发生在分叉远端,并分别进行了处理。其余患者进行了电话随访,1例复发心绞痛,接受药物治疗。结论对经过选择的无保护左主干病变患者进行支架置入是可行和安全的,并有良好的近、远期疗效。     

A unique pitfall in percutaneous coronary angioplasty of in-stent restenosis: guidewire passage out of the stent.

Three cases of in-stent restenosis are narrated, wherein, during balloon angioplasty of the lesion, the guidewire inadvertently exited out of the stent. The forward balloon progress was halted in this region. In the first case, the situation could only be realized when dilatation of a forcefully pushed small balloon avulsed the well-embedded stent. The mishap was averted in the subsequent two cases by reintroduction of a new guidewire. Some suggestions to avoid this eventuality are offered. Though the cases pertain to in-stent restenosis, the observations may be applicable to the procedures in general that entail passage of a guidewire through a stented area.     

Comparison of single‐ versus two‐stent techniques in treatment of unprotected left main coronary bifurcation disease

Background : This study sought to compare 3‐year outcomes of single‐ versus two‐stent techniques in patients with distal unprotected left main coronary artery (LMCA) disease treated with drug‐eluting stents (DES). Methods and Results : A total of 392 patients with distal unprotected LMCA disease who underwent DES implantation with single‐ (n = 234) or two‐ (n = 158) stent techniques were evaluated. The primary end point was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). The two‐stent group was more likely to have extensive coronary artery stenosis. After adjustment with weighted Cox model using the inverse probability of treatment weighting, the 3‐year risk of death was similar in the single‐ and two‐stent groups (hazard ratio [HR], 0.77, 95% confidence interval [CI], 0.28–2.13, P = 0.62). However, the 3‐year risks of MI (HR, 0.38, 95% CI, 0.19–0.78, P = 0.008), TLR (HR, 0.16, 95% CI, 0.05–0.57, P = 0.005), and MACE (HR, 0.89, 95% CI, 0.22–0.67, P = 0.0007) were significantly lower in the single‐stent group. Conclusion : Compared with the two‐stent technique, the single‐stent technique showed more favorable long‐term clinical outcomes in patients with distal unprotected LMCA disease who received DES. © 2011 Wiley‐Liss, Inc.     

旁路移植术和介入治疗无保护左主干病变的疗效分析

目的:分析无保护左主干病变(ULMCA)经外科旁路移植术(CABG)和冠状动脉介入术(PCI)治疗的临床效果。方法:回顾性分析ULMCA196例,其中PCI95例,CABG105例,比较2组围术期并发症,左心室大小和心功能,主要心血管事件(MACE)。结果:围术期死亡:PCI组4例,占4.4%,CABG组8例,占7.6%;主动脉球囊反搏使用:PCI组12例(13.2%),CABG组23例(22.0%);MACE:PCI组15例(16.5%),CABG组22例(21.0%),P<0.05;平均随访(13±5)个月,PCI组死亡3例,免于MACE77.6%,MACE19例(22.4%),CABG组死亡3例,免于MACE87.6%,MACE12例(12.4%),射血分数改变PCI组1.2%±0.7%,CABG组2.3%±1.1%,P<0.05;左心室舒张末期直径大小变化PCI组(3.5±0.2)mm,CABG组(4.6±0.7)mm,P<0.03,纽约心功能分级PCI组(2.5±0.6)级,CABG组(1.5±0.3)级,P<0.02。结论:PCI和CABG术对ULMCA治疗都有较好的近、远期结果,但围术期PCI疗效优于CABG,对左主干累及分叉病变,CABG则优于PCI。     

Results of percutaneous drug‐eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function

Objectives: We aimed to appraise the early and long‐term outcome after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). Background: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. Setting and Patients: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% <EF ≤50% and those with EF ≤40%. The primary end‐point was the rate of major adverse cerebro‐cardiovascular events (MACCE, ie death, myocardial infarction [MI], stroke, repeat PCI or bypass surgery). Results: A total of 197 patients were included, 57.4% with EF >50%, 32.0% with 40% <EF ≤50%, and 10.6% with EF ≤40%. In‐hospital mortality was significantly higher in those with EF ≤40% (9.5% vs. 0 and 3.2%, P < 0.001). A total of 96% patients were followed for 23 ± 14 months, yielding a MACCE rate of 44.2% (41.6% in those with EF >50%, 41.6% in those with 40% <EF ≤50%, and 61.9% in those with EF ≤40%, P = 0.4). Specifically, death occurred in 2.7%, 7.9%, and 28.6% (P < 0.001), cardiac death in 1.8%, 4.8%, and 23.8% (P = 0.001), MI in 8.0%, 7.9% and 0 (P = 0.4), and TVR in 15.9%, 11.1% and 33.3% (P = 0.6). Conclusion: Systolic ventricular dysfunction is highly correlated with in‐hospital and long term death rates in patients undergoing PCI with DES for ULM disease. However it does not confer an increased risk of nonfatal adverse events or stent thrombosis. © 2009 Wiley‐Liss, Inc.     

Early and long‐term results of percutaneous coronary intervention for unprotected left main trifurcation disease

Objectives: We aimed to conduct a retrospective cohort study focusing on our 5‐year experience in the percutaneous treatment of unprotected left main (ULM) trifurcation disease. Background: Percutaneous treatment of ULM trifurcation remains a challenging and rare procedure for most interventional cardiologists. Moreover, data on long‐term outcomes are lacking. Methods: We retrieved all patients with ULM trifurcation disease treated percutaneously at our Institution since 2002, and adjudicated baseline, procedural, and outcome data. The primary end point was the long‐term rate of major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, bypass surgery, or target vessel revascularization). Results: A total of 27 patients underwent percutaneous coronary intervention with stent implantation for ULM trifurcation disease, with 14 (52%) cases of true trifurcations, i.e., with concomitant significant stenoses of the distal ULM/ostial left anterior descending plus ostial ramus intermedius and ostial circumflex. Bare‐metal stents were implanted in 8 (29%) patients and drug‐eluting stents (DES) in 26 (96%), with a main branch stent only strategy in 11 (40%), T stenting in 9 (33%), and V stenting in 6 (27%). Procedural and clinical success occurred in 26 (96%), with one postprocedural death. Angiographic follow‐up was obtained in 22 patients (81%), and clinical follow‐up was completed in all subjects after a median of 28 ± 17 months, showing overall MACE in 9 (33%), with cardiac death in 4 (15%), myocardial infarction in 1 (4%), coronary artery bypass grafting (CABG) in 4 (15%), and percutaneous target vessel revascularization in 5 (19%). Definite stent thrombosis was adjudicated in 1 (3%) patient. Treatment of a true trifurcation lesion and recurrence of angina during follow‐up were significantly associated with an increased risk of MACE (P = 0.029 and P = 0.050, respectively). Conclusions: Percutaneous treatment of ULM trifurcation disease is feasible, associated with favorable mid‐term results, and may be considered given its low invasiveness in patients at high surgical risk or with multiple comorbidities. © 2008 Wiley‐Liss, Inc.     

Frequency of percutaneous coronary interventions at facilities without on-site cardiac surgical backup--a report from the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

The practice of performing percutaneous coronary intervention (PCI) in centers without on-site cardiac surgical backup is controversial. Using data from facilities that participated in the American College of Cardiology/National Cardiovascular Data Registry, the incidence of PCI without on-site surgical backup was evaluated. From January 1, 2001 through December 31, 2004, 39 of 449 (8.7%) centers were identified as sites that performed PCI without on-site surgical backup. By the end of 2005, 75 of 463 (16%) participating facilities were performing PCI without on-site backup. By using standardized data element definitions, it was possible to differentiate between patients who underwent elective PCI and those who had urgent nonelective PCI for acute ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction. This analysis showed that the number of elective and nonelective PCI procedures with or without on-site surgical backup per quarter had increased significantly (p <0.0001) from 2001 to 2004. The number of PCI procedures performed without on-site surgical backup continued to increase in 2005. In conclusion, the significant increase in elective PCIs performed at facilities without on-site surgical backup occurred despite national guidelines that state elective PCI should not be done in centers without on-site cardiac surgery.     

Ad hoc percutaneous coronary interventions in patients with stable coronary artery disease--a study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR).

OBJECTIVE: To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) to monitor the performance and safety of ad hoc PCIs. BACKGROUND: The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day. METHODS: We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001-2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success. RESULTS: Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2-60.3%), hospital PCI volume (67-50.2%), hospital owner (89.7-59.6%), and geographic area (75.5-47.4%). Ad hoc PCI per se was not independently related to PCI success or complications. CONCLUSIONS: PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times.     

雷帕霉素药物洗脱支架治疗冠状动脉小血管病变的临床即刻效果

目的评价国产雷帕霉素药物洗脱支架(Firebird支架)治疗冠状动脉小血管病变(直径≤2.5mm)的临床即刻效果。方法采用前瞻性、非随机对比研究方法,根据入选和剔除标准,连续入选2004年6月~2007年2月我院行冠状动脉造影(CAG)确诊,首次接受经皮冠状动脉介入治疗(PCI)的靶血管为小血管病变且达到完全血运重建的160例患者,根据所置入的支架分为Firebird组(82例)和Cypher组(78例);支架置入后以相同的方法进行CAG,观察对比反映临床即刻效果的相关参数。结果术中全部Cypher及Firebird支架均顺利到达并释放于靶病变部位。两组支架的PCI手术成功率均为100%。Firebird组病变部位狭窄程度由术前的(78.7±15.6)%减至(7.20±10.69)%,P=0.0005;而Cypher组病变部位狭窄程度由术前的(79.8±15.8)%减至(7.10±10.61)%,P=0.0004。在急性管腔直径获得方面,Firebird组(1.76±0.52)mm与Cypher组(1.77±0.53)mm之间无显著差异(P=0.46)。结论Cypher和Firebird支架治疗冠状动脉小血管病变安全可行,临床即刻效果好。     

Retrograde dilatation of a totally occluded ostial left anterior descending artery from saphenous venous graft in the descending aorta following stenting of the aorto-ostial graft restenosis in a patient with left main coronary artery stenosis.

Treatment of native coronary and saphenous vein graft aorto-ostial stenoses with balloon angioplasty is associated with lower procedural success rates and more complications compared with percutaneous transluminal coronary angioplasty of nonostial stenoses. A patient with totally occluded ostial left anterior descending artery at ostium following aortocoronary bypass developed ostial stenosis at the saphenous vein graft in the descending aorta. The aorto-ostial lesion of saphenous vein graft was successfully stented and was followed by retrograde dilatation of the left anterior descending artery, and the totally occluded ostial lesion was reopened. The ischemia was eliminated following the procedure.     

Time delay in the treatment of acute myocardial infarction (AMI): a comparison of primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolysis

Abstract Background: If primary percutaneous transluminal coronary angioplasty (PTCA) cannot be performed within times comparable to thrombolysis, the possible advantages of that management may be offset by the logistic difficulties associated with its delivery.
Aim: To measure and compare the time delay involved in administration of thrombolysis and primary PTCA over a one year period and examine causes for delay greater than 60 minutes.
Method: Prospective data collection on all patients treated with primary PTCA or thrombolysis. A quality improvement process was applied.
Results: Eighty-five patients were treated with thrombolysis with a delay of 39±8 (SD) minutes, 12 patients being treated more than 60 minutes after presentation. Primary PTCA was used in 79 patients with a delay of 48±12 (SD) minutes, 21 patients being treated after more than 60 minutes. Time delays in the two management groups were significantly different (p=0.03) but that in primary PTCA during routine hours was not significantly different from that in thrombolysis treated patients (p=0.07). Causes for revascularisation delay greater than 60 minutes from presentation are discussed.
Conclusions: With appropriate facilities and organisation, patients with acute myocardial infarction presenting within normal working hours can be treated with primary PTCA without compromising their care due to time delay. Many patients managed with primary revascularisation by thrombolysis or primary PTCA with a delay of more than 60 minutes have identifiable clinically appropriate delays.