单中心经验——药物洗脱支架和冠脉搭桥治疗无保护左主干病变的对比研究

对介入心脏病医生来说无保护左主干病变的介入治疗始终是一个富有挑战性的难题。尽管目前PCI只是有选择的应用于某些无保护左主干病变中,但却取得了鼓舞人心的结果。操作技术、支架内再狭窄及易发生血栓的风险限制了PCI在无保护左主干病变中的应用,所以对于无保护左主干病变仍首选冠脉搭桥治疗。随着药物洗脱支架的出现,支架内再狭窄发生率显著降低,PCI治疗无保护左主干病变又再次引起人们的兴趣。前驱注册研究表明,无保护左主干植入药物洗脱支架确实可行并且非常安全。但是直到目前没有一项研究对药物洗脱支架和冠脉搭桥治疗无保护左主…     

无保护左主干病变的药物洗脱支架与冠脉搭桥治疗

无保护左主干病变一直是冠脉搭桥治疗的传统领地。随着经皮冠状动脉介入治疗的迅速发展,尤其是药物洗脱支架广泛应用以来,学者们正在用大量的试验证明应用药物洗脱支架治疗无保护左主干病变的安全性、可行性,比较与冠脉搭桥治疗孰优孰劣。随着技术的发展和器械的更新,药物洗脱支架介入治疗的适应证势必进一步拓宽,但是就目前而言,无保护左主干的介入治疗由于其自身不足,不能完全替代冠脉搭桥治疗。     

药物洗脱支架治疗冠脉无保护左主干病变的近中期疗效

目的：评价药物洗脱支架治疗冠脉无保护左主干病变的临床疗效。方法：回顾性分析2009年1月～2011年1月完成的65例无保护左主干病变药物洗脱支架置入术患者的临床资料。结果：65例无保护左主干病变患者全部成功置入支架,住院期间无主要心血管事件发生;术后6个月冠脉造影随访28例（43.1%）,其中2例发生再狭窄,再狭窄率7.1%;3年电话随访54例（83.1%）,其中8例患者心绞痛复发（14.8%）;2例（3.7%）行冠状动脉旁路移植术,余均无症状生存,3年生存率为100%。结论：药物洗脱支架治疗经选择的冠脉无保护左主干病变是安全可行的,有较理想的近期和中期疗效。     

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疗效比较

冠状动脉旁路移植术一直是无保护左主干病变的标准治疗手段。随着药物洗脱支架的出现,经皮冠状动脉介入治疗越来越多地应用于无保护左主干病变的治疗。比较与冠状动脉旁路移植术孰优孰劣,大量的研究已经证明应用药物洗脱支架治疗无保护左主干病变的安全性及有效性。药物洗脱支架介入治疗的适应证在进一步拓宽,介入治疗指南在不断更新,但就目前而言,无保护左主干病变的药物洗脱支架治疗由于其自身不足,尚不能完全替代冠状动脉旁路移植术。     

药物洗脱支架治疗老年冠心病无保护左主干病变近中期疗效观察

无保护左主干病变是冠心病介入治疗中最具挑战的病变之一。药物洗脱支架可使主要不良心脏事件发生率从金属裸支架的16.4%减至7.8%[1]。2002年10月~2005年4月间,我科应用药物洗脱支架治疗经选择的老年冠心病无保护左主干病变27例,现报道如下。1临床资料共有27例经冠状动脉(冠脉)     

TCT2008热点：无保护左主干病变——PCI还是CABG

1药物洗脱支架(DES)在左主干病变的治疗中比冠状动脉搭桥术(CABG)有更低的脑血管事件、死亡和心肌梗死发生率———注册数据显示左主干病变中支架置入越来越流行在无保护左主干冠脉病变中长期的数据似乎更支持经皮冠状动脉介入治疗(PCI)而不是CABG。意大利San Raffaele医院的Ch     

药物洗脱支架和冠状动脉旁路移植术治疗无保护左主干病变的疗效分析

背景冠状动脉无保护左主干病变(ULMCA)在冠脉病变患者中风险最高,预后最差,冠状动脉旁路移植术(CABG)能显著降低死亡率,延长患者生存期,故一直被认为是治疗冠脉无保护左主干病变的金标准。但随着冠脉介入技术的进步,药物洗脱支架(DES)能显著降低支架置入后再狭窄的风险和再介入的比例,因此也成为无保护左主干病变的治疗方法之一,而冠脉搭桥作为左主干病变治疗金标准的的地位正日益受到挑战。目的比较药物洗脱支架(DES)置入与冠状动脉旁路移植术(CABG)对冠状动脉无保护左主干病变患者的近期及远期疗效。方法回顾性收集2006年12月到2009年12月在苏州大学附属第一人民医院接受治疗的49例冠状动脉左主干狭窄患者的临床资料,其中26例置入药物洗脱支架(DES组),23例患者接受了冠脉旁路移植术(CABG组),记录两组患者围手术期、术后6月到3年的主要心脑血管不良事件(MAC-CE)发生率。结果 (1)两组患者一般临床特征比较无统计学意义;(2)平均随访(16.4±8.8)个月,DES组与CABG组的MACCE发生率分别为11.5%及13.0%,P>0.05;(3)DES组与CABG组术后2年无事件生存率分别为78.8%及85.0%,P>0.05。结论药物洗脱支架置入对于无保护左主干病变患者是安全、有效、可行的,有着与冠脉搭桥相似的近、远期疗效,但对于左主干累及分叉病变者,DES组因较高的血运重建率而疗效略差于CABG。     

单中心经验——药物洗脱支架和冠脉搭桥治疗无保护左主干病变的对比研究

对介入心脏病医生来说无保护左主干病变的介入治疗始终是一个富有挑战性的难题。尽管目前PCI只是有选择的应用于某些无保护左主干病变中，但却取得了鼓舞人心的结果。操作技术、支架内再狭窄及易发生血栓的风险限制了PCI在无保护左主干病变中的应用，所以对于无保护左主干病变仍首选冠脉搭桥治疗。随着药物洗脱支架的出现，支架内再狭窄发生率显著降低，     

药物洗脱支架年代无保护左主干病变血运重建策略的选择

冠状动脉旁路移植术一直被认为是治疗无保护左主干病变的金标准.近年来,由于经皮冠状动脉介入治疗技术及器械的迅速发展,特别是药物洗脱支架的广泛应用,使冠状动脉介入治疗术后由再狭窄导致的再次靶病变血运重建率明显降低,经皮冠状动脉介入治疗无保护左主干病变研究以及和冠状动脉旁路移植术疗效对比研究越来越多,并且显示药物洗脱支架对无保护左主干病变有良好的疗效,其安全性与冠状动脉旁路移植术相似,甚至在某些方面具有优势.现就近年来冠状动脉旁路移植术和冠状动脉介入治疗无保护左主干病变的研究进展做一综述,探讨在药物洗脱支架年代无保护左主干病变治疗策略的选择.     

药物支架时代无保护左主干病变介入治疗的新策略

冠状动脉左主干病变的介入治疗十分具有挑战性,本文从左主干介入治疗发展史、不同病变部位的疗效分析、远端分叉不同术式的比较,以及辅助治疗技术等方面进行了详细的阐述.系列临床试验证实药物洗脱支架治疗左主干病变安全可行,但在左主干远端分叉病变还存在再狭窄率高等问题.对于有选择左主干病变,药物洗脱支架是可行和安全的.     

Revascularization of unprotected left main coronary artery disease with percutaneous coronary intervention: the role of drug-eluting stents

The percutaneous revascularization of left main coronary artery stenosis has until recently been reserved for patients at prohibitive surgical risk or for selected emergent cases. This adopted practice of coronary artery bypass grafting, as the standard of care for left main coronary artery stenosis, has largely occurred secondary to disappointing results with bare metal stents implanted in the left main coronary artery. However, in the current era of drug-eluting stents (DES) which significantly reduce restenosis compared to bare metal stents, there has been a renewed interest in examining the role of percutaneous coronary intervention as a means of revascularization of left main disease. This article discusses recent and ongoing studies investigating the role of percutaneous intervention of left main disease, with an emphasis on the use of DES for this purpose.     

Drug-eluting stents versus bypass surgery for multivessel coronary disease

Since the advent of coronary artery bypass graft (CABG) surgery and the development of percutaneous coronary intervention (PCI), there has been debate as to which is the most optimal revascularization strategy for patients with multivessel coronary artery disease. Over the past decade, this controversy has been heightened with the introduction into the PCI armamentarium of drug-eluting stents (DES) and their profound reduction of restenosis and subsequent repeat revascularization. This article reviews the key registries and randomized clinical trials of PCI-DES and CABG in multivessel disease. Focus is placed on the recent data and evidence for long-term outcomes in patients treated with DES or CABG for complex multivessel coronary disease, including unprotected left main disease. The article also discusses risk models and the decision process for appropriate selection of revascularization techniques in patients with multivessel coronary disease.     

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.     

PCI和CABG治疗单纯左主干病变效果进展

随着基础医学、医疗设备、高新技术的进展和循证医学的广泛开展,血运重建技术已经取得了快速的进展。左主干病变可通过内科和外科手段实现心肌血运重建,缓解症状,改善预后和延长寿命。目前血运重建措施有经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)。但是对于更适当的治疗措施尚无定论。故本文就PCI和CABG在左主干病变患者的治疗效果做一综述。     

The Role of Revascularization Versus Medical Therapy in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease

Patients with type 2 diabetes mellitus (T2DM) are at increased risk for cardiovascular clinical events, adverse nonfatal outcomes, and death. There has been considerable improvement in the medical management of patients with T2DM in an attempt to alter the metabolic cascade that is triggered by insulin resistance. Recent trials have demonstrated that medical management of patients with diabetes mellitus and stable coronary artery disease (CAD) is equivalent to revascularization in terms of morality benefit and rates of major adverse cardiovascular events, particularly in patients who do not have extensive CAD. Nonetheless, in those diabetic patients with additional high-risk features including left main disease, reduced left ventricular ejection fraction (LVEF), severe ischemia, or acute coronary syndrome, revascularization remains the best treatment option. Although the evidence still supports coronary artery bypass grafting (CABG) as the standard of care for revascularization of diabetic patients with multivessel CAD and/or reduced LVEF, percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has resulted in at least partial closure of the gap in benefit between surgery and catheter-based intervention. Ongoing trials of diabetic patients with CAD randomized to PCI or CABG will help further elucidate the role of PCI with DES as a potential revascularization option for this patient population.     

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。     

Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes

Surgical and percutaneous coronary artery intervention revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Concerns regarding safety and feasibility of such an approach exist. We examined the safety, feasibility, and early outcomes of a simultaneous hybrid revascularization strategy (minimally invasive direct coronary bypass grafting of the left anterior descending [LAD] artery and drug-eluting stent [DES] to non-LAD lesions) in 13 patients with multivessel coronary artery disease that underwent left internal mammary artery to LAD minimally invasive direct coronary bypass performed through a lateral thoracotomy, followed by stenting of non-LAD lesions, in a fluoroscopy-equipped operating room. Assessment of coagulation parameters was also undertaken. Inhospital and postdischarge outcomes of these patients were compared to a group of 26 propensity score matched parallel controls that underwent standard off-pump coronary artery bypass. Baseline characteristics were similar in both groups. All hybrid patients were successfully treated with DES and no inhospital mortality occurred in either group. Hybrid patients had a shorter length of stay (3.6 +/- 1.5 vs 6.3 +/- 2.3 days, P < .0001) and intubation times (0.5 +/- 1.3 vs 11.7 +/- 9.6 hours, P < .02). Despite aggressive anticoagulation and confirmed platelet inhibition, hybrid patients had less blood loss (581 +/- 402 vs 1242 +/- 941 mL, P < .05) and decreased transfusions (0.33 +/- 0.49 vs 1.47 +/- 1.53 U, P < .01). Six-month angiographic vessel patency and major adverse cardiac events were similar in the hybrid and off-pump coronary artery bypass groups. A simultaneous hybrid approach consisting of minimally invasive coronary artery bypass grafting with left internal mammary artery to LAD combined with revascularization of the remaining coronary targets using percutaneous coronary artery intervention with DES is a feasible option accomplished with acceptable clinical outcomes without increased bleeding risk.     

How to treat diabetic patients with multivesseal disease in the DES era

Patients with type 2 diabetes mellitus represent the 25% of those requiring myocardial revascularization. Choice of treatment in diabetic patients is much more controversial than in non-diabetics: this because coronary artery disease is more often complex and diffuse, left ventricular function is depressed, and concomitant multiple risk factors are present. These subset of patients experience worse outcomes than non diabetic patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). Large randomized trials performed both in the early era of PCI and in the stent era suggest that CABG is superior to bare metal stent implantation in the treatment of diabetic patients with multivessel coronary artery disease. These findings are reflected in current guidelines, which favor CABG over PCI in most diabetics who require revascularization. However, substantial variability exists in practice patterns among individual hospital, suggesting a lack of clinical consensus. The major advantage of CABG over bare metal stent implantation in diabetic patients is the lower risk of repeat revascularization procedures through the follow-up. Better angiographic results have been demonstrated in the new era of drug-eluting stents (DES). Data from both the sirolimus and paclitaxel-eluting stents trials support the potential advantage of DES implantation both in diabetic and non-diabetic patients. Preliminary data from studies comparing DES versus CABG in diabetic patients with multivessel coronary artery disease suggests that 1) no significant difference exists in the 12-month rate of death, myocardial infarction and cerebrovascular events in patients treated with DES as compared to off-pump bypass surgery, 2) a difference of 7.1% in the rate of repeat revascularization at 12-month exists in favor of bypass surgery and 3) diabetic retinopathy identifies a subgroup with poor outcome after both percutaneous and surgical myocardial revascularization.     

无保护左主干病变血运重建的临床评价

冠脉旁路移植术为无保护左主干病变的首选治疗。随着经皮冠脉介入治疗技术的进步,在有选择的无保护左主干患者中,PCI与CABG的疗效相当。本文对无保护左主干病变几种血运重建方法进行综述。