药物洗脱支架与冠状动脉旁路移植术治疗无保护左主干病变的临床疗效对比

目的:评估药物洗脱支架(DES)置入与冠状动脉旁路移植术(CABG)治疗无保护左主干病变的临床疗效。方法:分析2003-10-2010-09期间行血运重建的282例无保护左主干患者的临床资料,其中接受DES者143例(DES组),接受CABG者139例(CABG组),比较2组住院期和随访期心脑血管不良事件(死亡、非致死性心肌梗死、脑卒中和再次血运重建,即MACCE)的发生情况。结果:DES组手术成功率为100%,住院期间1例发生非致死性心肌梗死,无一例死亡、脑血管意外或需再次血运重建;CABG组手术成功率为95.7%,住院期间有1例发生非致死性急性心肌梗死,无一例需再次血运重建,共有6例死亡;CABG组住院期死亡率明显高于DES组(4.3%∶0,P<0.05),住院期CABG组总MACCE发生率也明显高于DES组(5.0%∶0.7%,P<0.05);随访期平均(17±8)个月,DES组临床心绞痛复发率和再次血运重建率较CABG组有增高趋势(7.8%∶2.7%,7.0%∶1.8%),但差异无统计学意义,其总MACCE发生率显著高于CABG组(14.8%∶7.1%,P<0.05);剔除新发病变及病变进展病例后,2组总MACCE发生率(7.8%∶7.1%)差异无统计学意义。结论:DES治疗无保护左主干病变安全和有效,可以作为CABG的一种替代治疗手段。     

Coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stent implantation in patients with multivessel coronary disease

BACKGROUND: Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after percutaneous coronary intervention (PCI). This study compared the clinical outcomes of PCI using DES versus coronary artery bypass graft (CABG) in patients with multivessel coronary artery disease (MVD) in real-world. METHODS: From January 2003 to December 2004, 466 consecutive patients with MVD underwent revascularization, 235 by PCI with DES and 231 by CABG. The study end-point was the incidence of major adverse cardiovascular events (MACEs) at the first 30 days after procedure and during follow-up. RESULTS: Most preoperative characteristics were similar in the two groups, but left main disease (24.7% vs 2.6%, P<0.001) and three-vessel disease (65% vs 54%, P = 0.02) were more prevalent in CABG group. The number of coronary lesions was also greater in CABG group (3.7 +/- 1.1 vs 3.3 +/- 1.1, P<0.001). Despite higher early morbidity (3.9% vs 0.8%, P = 0.03) associated with CABG, there were no significant differences in composite MACEs at the first 30 days between the two groups. During follow-up (mean 25+/-8 months), the incidence of death, myocardial infarction, or cerebrovascular event was similar in both groups (PCI 6.3% vs CABG 5.6%, P = 0.84). However, bypass surgery still afforded a lower need for repeat revascularization (2.8% vs 10.4%, p = 0.001). Consequently, overall MACE rate (14.5% vs 7.9%, P = 0.03) remained higher after PCI. CONCLUSION: PCI with DES is a safe and feasible alternative to CABG for selected patients with MVD. The reintervention gap was further narrowed in the era of DES. Aside from restenosis, progression of disease needs to receive substantial emphasis.     

Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.

The aim of this study was to assess the effects of percutaneous coronary intervention with drug-eluting stents (DESs) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery in the management of patients with proximal left anterior descending (LAD) coronary artery stenosis. Until recent years, despite the advantages of percutaneous transluminal coronary angioplasty (PTCA) with bare metal stent implantation, such as shorter hospital stays and recovery time, MIDCAB showed better results with regard to the need for repeated intervention in the target vessel than PTCA with proximal LAD lesions. Symptomatic patients (n = 189) were randomly assigned to DES group (n = 119) and MIDCAB group (n = 70). Patients with an isolated high-grade lesion (stenosis of > or = 70% of the luminal diameter) in the proximal LAD coronary artery (from the ostium to the first diagonal branch) were included in this study. During the 6-month follow-up period, 1.7% (n = 2) in the DES group needed repeated revascularization procedures for target lesion revascularization compared with 5.9% (n = 4) in the MIDCAB group (P = 0.196). The rates of death and myocardial infarction were similar in both groups [DES 0.0% (n = 0) vs. MIDCAB 2.9% (n = 2), P = 0.135; DES 1.7% (n = 2) vs. MIDCAB 2.9% (n = 2), P = 0.627; respectively] during 6 months of follow-up. In-hospital length of stay was significantly shorter in the DES group compared with the MIDCAB group (5.8 +/- 2.1 days vs. 8.9 +/- 2.6 days; P = 0.001). DES implantation and MIDCAB surgery showed similar rates of myocardial infarction, the need for repeated revascularization, and death during 6 months of follow-up. However, DES implantation resulted in lower average number of hospital stays and similar postoperative complications.     

Long-term follow-up of drug-eluting stents when inserted for on- and off-label indications

This study reports long-term follow-up of the on- and off-label implantation of drug-eluting stents (DESs) in a retrospective study of 1,044 patients. Off-label implantation of DESs was performed for left main coronary artery lesions, bifurcation lesions, bare metal stent restenosis, ostial disease, chronic total occlusions, saphenous vein graft lesions, internal mammary artery graft lesions, left ventricular ejection fraction <30%, and acute myocardial infarction. End points examined were procedural complications, in-hospital myocardial infarction, and acute stent thrombosis; end points examined at follow-up were subacute stent thrombosis, late stent thrombosis, target vessel revascularization, myocardial infarction, death, and major adverse clinical events (MACEs; a composite of death, myocardial infarction, and target vessel revascularization). The study included 364 patients who received a DES on an on-label basis and 680 patients who received a DES on an off-label basis. Patient characteristics were not significantly different between the 2 groups, and there was no difference in procedural complications or acute stent thrombosis (on-label, 0%; off-label, 0.3%; p=0.55). There were no significant differences in subacute stent thrombosis (0% vs 0.6%, p=0.3), late stent thrombosis (1.4% vs 1.2%, p=0.78), death at follow-up (4.9% vs 4.1%, p=0.53), or myocardial infarction (1.9% vs 2.4%, p=0.83). Off-label DES implantation was associated with higher rates of target vessel revascularization (13.2% vs 24.1%, p=0.0001) and MACEs (17.6% vs 28.2%, p=0.0001). Multivariate analysis showed associations between target vessel revascularization and MACEs (respective p values) with bare metal stent restenosis (p=0.001 and p=0.001), diabetes mellitus (p=0.002 and p=0.001), and previous coronary artery bypass grafting (p=0.04 and p=0.01), but not off-label DES implantation (p=1.36 and p=1.16). In conclusion, DES use in the off-label situations studied was safe and was not associated with increased stent thrombosis, myocardial infarction, or death. Multivariate analysis showed that off-label DES implantation was not a risk factor for target vessel revascularization or MACEs.     

Stenting of unprotected left main stem stenosis: Results from a German single-centre registry

OBJECTIVE: To elucidate the influence of drug-eluting stents (DESs) on interventional therapy of de novo unprotected left main stem (LMS) lesions in a hospital with on-site cardiac surgery. METHODS AND RESULTS: A retrospective study of all patients with unprotected LMS angioplasty from 1999 to 2005 was conducted with regard to clinical and procedural data, and follow-up data. Fifty-four patients with unprotected LMS stenosis were treated inter-ventionally. Of these patients, 16 were treated with DESs. Seven patients presented with cardiogenic shock. During their hospital stay, four patients died (all treated with bare metal stents [BMSs], three initially presenting with cardiogenic shock). Follow-up data for 53 patients (98%) were obtained. Median follow-up time was 24 months (25th percentile, 12 months; 75th percentile, 35 months). Survival after nine months was 87% (81% from the BMS-treated group, and 100% from the DES-treated group). Control angiography had been performed in 36 patients (67%). Patients with unprotected LMS with an angiographic follow-up had a higher nine-month survival rate than patients without (36 of 36 patients [100%] versus 10 of 17 patients [59%], respectively; P<0.0001). Target lesion revascularization rate was 19% in both the BMS and the DES groups. Methods of revascularization did not vary significantly between the groups. CONCLUSIONS: In the present study of selected patients with LMS stenosis, the use of DESs showed a low mortality rate but did not have a clear effect on target lesion revascularization rate compared with BMSs. A close follow-up appears to be mandatory to achieve acceptable results.     

Unprotected Left Main Coronary Intervention with Drug-Eluting Stents

The accepted treatment of unprotected left main coronary artery disease is coronary artery bypass surgery (CABG). The approval of drug-eluting stents (DES) has increasingly led to their off-label use in this patient population. Currently, the data supporting the safety and efficacy of DES for unprotected left main disease are derived from nonrandomized, single-center studies. Several conclusions can be drawn from these studies despite their inherent limitations. Procedural mortality in elective patients with low surgical risk is minimal. One year mortality and 1 year major adverse cardiac events appear to be similar to that of CABG. Technical difficulty and clinical outcome depend crucially on the anatomic location of the left main obstruction. While DES implantation for ostial and shaft lesions is technically straightforward and provides excellent results over follow-up, distal left main lesions are technically challenging and efficacy is limited largely by target vessel revascularization, most frequently for restenosis within the branch ostia. A systematic approach to the left main lesion can help provide safe and more effective results. Prospective, randomized trials comparing DES to CABG must be completed before percutaneous coronary intervention for unprotected left main coronary artery disease can be considered standard-of-care.     

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.     

Comparison of long-term outcome of off-pump coronary artery bypass grafting versus drug-eluting stents in triple-vessel coronary artery disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.     

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Technique of left main stenting is dependent on lesion location and distal branch protection.

The purpose of this study was to review our experience with left main stenting and evaluate initial results with drug-eluting stents (DESs). Drug-eluting stents delivered with contemporary techniques could change the traditional surgical approach to patients with significant left main disease. One hundred sixty-one patients underwent left main stenting (100 bare metal, 61 drug-eluting) after being excluded from surgery. In group A, disease was confined to the ostium or main stem; in group B, disease involved the bifurcation. Patients were classified as either unprotected (U) or protected (P) depending on the presence of a patent bypass graft. Study endpoints were any major adverse cardiac event (MACE). In-hospital MACE was 6% with no deaths; 74% of patients in group A underwent direct stenting, whereas 89% of the patients in group B had predilatation performed prior to stent implantation. A total of 98% of patients in BU had kissing balloon inflations after stent deployment; provisional side-branch stenting was required in one patient. V-stenting was performed in 13% of patients in group BU. The 1-year mortality in the bare metal stent group was 9% with the majority of deaths in group BU. There was one noncardiac death in the DES group at 6 months and five patients (8.2%) underwent target vessel revascularization for restenosis. Event-free survival at 6 months in group BU treated with DESs was 87%. Significant left main disease presents a spectrum of angiographic abnormalities and different interventional techniques are required depending on lesion location and distal protection. Although in-hospital complications with left main stenting were low in this single-center study, follow-up events were common in patients treated with bare metal stents. A randomized multicenter trial will be required to determine whether drug-eluting stents will improve survival in patients with left main disease.     

Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection.

BACKGROUND: The study served to present the in-hospital and six-month clinical outcome and also the long-term survival data of a consecutive series of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease. METHODS: Revascularization with coronary bypass surgery has been generally recommended for treatment of left main coronary stenosis. Improvements in angioplasty and coronary stent techniques and equipment may result in the wider applicability of a percutaneous approach. A total of 92 consecutive patients underwent unprotected LMCA stenting between March 1994 and December 1998. For the initial 39 patients (group I) angioplasty was performed only when surgical revascularization was contraindicated. The remaining 53 patients (group II) also included patients in whom surgery was feasible. Patients were followed for 7.3 +/- 5.8 months (median 239 days; range 49 to 1,477 days). RESULTS: Compared to group I, group II patients had higher left ventricular ejection fraction (60 +/- 12% vs. 51 +/- 16%, p < 0.01), less severe LMCA stenosis (68 +/- 12% vs. 80 +/- 10%, p < 0.001), lower surgical risk score (13 +/- 7 vs. 20 +/- 7, p < 0.001), and had angioplasty more often performed via the radial approach (88% vs. 23%, p < 0.001) with smaller guiding catheters (6F: 49% vs. 15%; 8F: 2% vs. 77%, p < 0.001). The procedural success rate was 100%. In-hospital mortality was 4% (4 deaths, 3 cardiac). During follow-up there were six deaths, 13 patients required repeat percutaneous transluminal coronary angioplasty (4 LMCA), and two required coronary artery bypass graft surgery. Estimated survival (+/- SEE) was 89 +/- 6.3% at 500 days and 85 +/- 12% at 1,000 days post-stenting. Overall mortality was 3.8% in group II and 20.5% in group I (p < 0.02). CONCLUSIONS: Coronary stenting can be performed safely in high-risk individuals with acceptable intermediate-term outcome. It may be feasible to broaden the application of this technique in selected patients needing revascularization for left main coronary disease.     

Left main coronary angioplasty: early and late results of 127 acute and elective procedures

The results of 127 left main (LM) coronary angioplasties were reviewed to assess short- and long-term effectiveness. Three major subgroups were considered: (1) elective "protected" (defined as the presence of a patent bypass graft to the left coronary circulation) patients (n = 84); (2) elective "unprotected" patients (n = 33); and (3) acute patients, in whom LM coronary angioplasty was performed in the setting of an acute myocardial infarction (n = 10). Successful LM dilation was achieved in 94% of elective patients and 90% of acute patients. Procedural mortality was 4.3% in elective patients (2.4 and 9.1% in protected and unprotected patients, respectively, p = 0.14) and 50% in the acute subgroup. Long-term follow-up data, available for 98% of patients, revealed actuarial 3-year survival rates of 90 and 36% in elective protected and unprotected subgroups, respectively (p less than 0.0005). In the acute subgroup, 3 patients (30%) were alive at the time of follow-up; all had undergone coronary artery bypass surgery. Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option. In contrast, elective angioplasty of a protected LM coronary artery can be accomplished safely with good long-term results. LM coronary angioplasty for acute myocardial infarction can be effective as a salvage procedure; however, adjunctive coronary bypass surgery is important for long-term survival.     

Comparison of outcomes between bare metal stents and drug-eluting stents for percutaneous revascularization of internal mammary grafts

Drug-eluting stents (DESs) decrease the need for repeat revascularization in native coronary arteries and vein grafts. This study examined the safety and efficacy of DESs for the treatment of lesions in the internal mammary artery (IMA) conduits and compared the outcomes with those from bare metal stents (BMSs). Records of 69 consecutive patients who underwent stenting of the IMA from 2001 to 2004 were reviewed and analyzed. Of these, 30 patients were treated with DESs (sirolimus- or paclitaxel-eluting stents) and 39 patients with BMSs. In-hospital and 6-month clinical outcomes were recorded and compared. Baseline characteristics were comparable between the 2 groups. Lesion location and characteristics were also similar, except for a trend toward longer stent lengths in the DES group (DES 20.2 +/- 7.7 mm vs BMS 14.8 +/- 3.5 mm, p = 0.255). There was no late thrombosis in either group. There were no significant differences in in-hospital and 1- and 6-month outcomes between the 2 groups, including target lesion revascularization with DESs (DESs 3.33% vs BMSs 10%, p = 0.38). In conclusion, DES implantation into IMAs appears safe and is associated with low rates of recurrences. These results may support expansion of use of DESs for the management of IMA stenotic lesions.     

Percutaneous angioplasty of unprotected left main coronary disease with implantation of systematic stenting. Immediate and mid-term results

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.     

Utilization of drug-eluting stents in the Veterans Health Administration

Little is known about how drug-eluting stents (DESs) are used and perform in everyday clinical practice. This report identifies factors associated with the use of DESs in the Veterans Health Administration and compares mortality and the need for coronary artery bypass graft surgery in patients who received DESs or bare metal stents. There was rapid adoption of DESs from the end of 2002 to September 2004, when 52% of percutaneous coronary interventions used DESs. Ten-day death rates in DES and bare metal stent groups were similar (0.8% vs 1.1%), as were 10-day bypass surgery rates (0.2% vs 0.4%). In summary, in a large health care system, DESs were used widely with low rates of death and bypass surgery.     

Technical feasibility,safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing

This study was performed to evaluate the acute and long-term results of stenting for unprotected left main coronary artery (LMCA) bifurcation lesions. Sixty-three consecutive patients with an unprotected LMCA bifurcation lesion and normal left ventricular function were included. Stenting was performed with (n = 32) or without debulking atherectomy (n = 31) at the operator's discretion. Slotted-tube stents, coil stents, or bifurcation stents were used. The procedural success rate was 100%. In-hospital events including stent thrombosis, Q-wave myocardial infarction, and emergency bypass surgery did not occur in any patients. The angiographic follow-up rate was 86% (43 of the 50 eligible patients), and the restenosis rate was 28% (parent vessel only 14%, side branch only 9%, and both 5%). Restenosis at the parent vessel occurred less frequently in the debulking group than in the nondebulking group (5% vs 33%, respectively, p = 0.02). In multivariate analysis, the debulking procedure was an independent predictive factor of restenosis for the parent vessel (odds ratio 0.10, 95% confidence intervals 0.01 to 0.91, p = 0.04). Clinical follow-up was obtained in all patients at 19.9 +/- 13.7 months. There were 2 deaths (noncardiac origin), but no myocardial infarction during follow-up. Target lesion revascularization was required in 6 patients. The event-free survival rate (death, nonfatal myocardial infarction, and repeat revascularization) was 86% at the end of the follow-up period. In conclusion, stenting for an unprotected LMCA bifurcation lesion may be performed with a high procedural success rate and a favorable clinical outcome in selected patients with normal left ventricular function, suggesting that stenting would be an effective alternative to surgery in these patients.     

Results of percutaneous coronary intervention of the unprotected left main coronary artery in 143 patients and comparison of 30-day mortality to results of coronary artery bypass grafting

Percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (LMCA) is controversial. In 143 patients who underwent PCI of the unprotected LMCA, 30-day mortality was compared with predicted cumulative risk-adjusted perioperative surgical mortality based on logistic European System for Cardiac Operative Risk Evaluation. One-year clinical follow-up was completed in all patients. The overall major adverse cardiac event rate at 1 year was 34.3%, reflecting the high-risk profile of the patient population. Twelve patients (8%) experienced an acute myocardial infarction and 16 (11%) underwent target lesion revascularization. In 31 patients (22%) who died during the first year, median logistic European System for Cardiac Operative Risk Evaluation was 30%. Calculated RRs showed significantly lower 30-day mortality using PCI compared with predicted surgical mortality (RR 0.54, 95% confidence interval 0.31 to 0.86). Angiographic follow-up in 90 of the 118 patients alive at 6 months showed binary restenosis of 6% in patients treated with drug-eluting stents versus 29% in patients receiving bare-metal stents (p < or =0.01). In conclusion, PCI for unprotected LMCA disease was associated with acceptable short- and medium-term outcomes in patients at low to intermediate risk of bypass surgery. Mortality remains high in very high-risk patients unsuitable for surgery. However, in selected indications, PCI of the LMCA can offer an alternative to surgery, especially when using drug-eluting stents.     

Revascularization of left anterior descending coronary artery in patients with single and multivessel disease: comparison between off-pump internal thoracic artery and drug-eluting stent

STUDY OBJECTIVES: The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD). DESIGN: Matched-groups, retrospective cohort comparison between the DES and OPCAB. PATIENTS: From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of <30%, old myocardial infarction, and use of an intraaortic balloon pump were more prevalent in the OPCAB group. RESULTS: The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group. CONCLUSIONS: The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD.     

二代支架时代数据中糖尿病对无保护左主干患者不同血运重建术预后的影响

目的:在二代支架时代,糖尿病对不同血运重建策略治疗无保护左主干冠状动脉疾病患者的影响尚未可知。方法:回顾性入选823例无保护左主干冠状动脉疾病的患者,其中接受二代药物洗脱支架(DES)置入治疗的患者331例(糖尿病患者,n=99;非糖尿病患者,n=232),接受冠状动脉旁路移植术(CABG)患者492例(糖尿病患者,n=127;非糖尿病患者,n=365)。我们根据不同的血运重建策略比较了糖尿病对临床结果的影响。结果:在接受血运重建的无保护左主干病变患者中,糖尿病患者占27.5%(226/823)。经过平均25.3个月的随访后发现,在接受DES治疗的人群中,糖尿病患者与非糖尿病患者的全因死亡率、心源性死亡率、血运重建发生率、卒中和主要不良心脑血管事件的发生率没有显著差异。然而,在全因死亡/心肌梗死/卒中联合终点(糖尿病组21.5%vs.非糖尿病7.2%,P=0.001)及心肌梗死发生率(糖尿病组15.4%vs.非糖尿病组1.6%,P<0.001)中,糖尿病患者明显高于非糖尿病患者。在接受CABG治疗的群体中,糖尿病组和非糖尿病组所有临床终点发生率相似。结论:在二代药物洗脱支架治疗无保护左主干病变的患者中,合并糖尿病的患者较非糖尿病组预后较差,在接受CABG的患者中,糖尿病和非糖尿病组预后相似。     

Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting.

OBJECTIVE: We compared the outcome of drug eluting stent (DES) implantation (Sirolimus or Paclitaxel) in patients with ischemic cardiomyopathy and severe left ventricular (LV) dysfunction with the outcome of a similar group of patients undergoing coronary artery by-pass grafting (CABG). BACKGROUND: Revascularization provides long-term benefits in patients with severe LV dysfunction. However the modality to achieve it is still unsettled in this high risk group of patients. METHODS: Two-hundred-twenty patients (20% women) with severe LV dysfunction (LV Ejection Fraction 相似文献