Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Unprotected Left Main Trunk Intervention Multi-center Assessment.

The ULTIMA registry was a prospective, multicenter, international registry of 277 patients who underwent percutaneous coronary interventions of unprotected left main trunk stenosis. The 40 patients who underwent an emergency percutaneous left main intervention for acute myocardial infarction are the focus of this study. We compared the results of primary angioplasty with primary stenting, characterizing both the short-term (in-hospital) and long-term (12-month) outcomes. Of the 40 patients, 23 underwent primary angioplasty, whereas 17 underwent primary stenting. The angiographic success rate was an 88% for the cohort. The in-hospital death or coronary artery bypass grafting rate was 65% for the entire group, 74% for the percutaneous transluminal coronary angioplasty group (PTCA), and 53% for the stent group (p = 0.2). The in-hospital death rate was 55% for the entire cohort, 70% for the PTCA group, and 35% for the stent group (p = 0.1). The 12-month rate of death or bypass surgery was 83% and 58% for the PTCA and stent groups, respectively (p = 0.047). The 12-month survival rate was 35% and 53% for the PTCA and stent groups, respectively (p = 0.18). Bypass surgery was required in 6 patients in the PTCA group and 2 patients in the stent group (p = 0.07). Patients undergoing percutaneous interventions for unprotected left main myocardial stenosis during an acute myocardial infarction are critically ill; an initial percutaneous revascularization approach appears feasible and may be the preferred revascularization strategy. Primary stenting was associated with improved clinical outcomes.     

Comparison of direct stenting with conventional stent implantation in acute myocardial infarction

Small studies have suggested that direct stenting without balloon predilatation in ST-segment elevation myocardial infarction may reduce microcirculatory dysfunction. To examine the clinical benefits of direct stenting in a large cohort of patients who underwent primary percutaneous coronary intervention treated with contemporary pharmacotherapy, the 1-year outcomes from the multicenter, randomized Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial were analyzed. A total of 3,602 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled. The present study cohort consisted of 2,528 patients in whom single lesions (excluding bypass grafts) were treated with stent implantation. At operator discretion, direct stenting was attempted in 698 patients (27.6%), and stenting was performed after predilatation in 1,830 patients (72.4%). Propensity-score matching was performed to reduce bias. Direct stenting was successful in 677 patients (97.0%). ST-segment resolution at 60 minutes after the procedure was improved in patients who underwent direct compared to conventional stenting (median 74.8% vs 68.9%, respectively, p = 0.01). At 1-year follow-up, direct compared to conventional stenting was associated with a significantly lower rate of all-cause death (1.6% vs 3.8%, p = 0.01) and stroke (0.3% vs 1.1%, p = 0.049), with nonsignificant differences in target lesion revascularization, myocardial infarction, stent thrombosis, and major bleeding. Death at 1 year remained significantly lower in the direct stenting group after multivariate adjustment (hazard ratio 0.42, 95% confidence interval 0.21 to 0.86, p = 0.02) and in a propensity score-based analysis (hazard ratio 0.92, 95% confidence interval 0.88 to 0.95, p = 0.02). In conclusion, compared to stent implantation after predilatation, direct stenting is safe and effective in appropriately selected lesions in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention and may result in improved survival.     

血栓抽吸联合经皮腔内冠状动脉成形术治疗急性心肌梗死的疗效研究

目的了解在血栓负荷重的STEMI患者中血栓抽吸联合经皮腔内冠状动脉成形术的疗效,比较延迟支架置入与即刻支架置入两种方法对患者住院期间临床疗效的影响。方法分析我院心内科2009年8月—2011年8月因STEMI就诊,接受急诊介入手术治疗的55例患者。根据冠状动脉内介入治疗方法的不同分为:急诊血栓抽吸联合经皮腔内冠状动脉成形术(PTCA)+延迟支架置入术组(A组),PTCA+延迟支架置入术组(B组),急诊直接支架置入术组(C组)。比较3组住院期间发生支架内血栓、死亡、恶性心律失常、急性左心力衰竭、心源性休克的情况。结果3组住院期间心脏事件发生率分别为3%、8%和15%,死亡分别为0、3和3例,术后急性期支架内血栓1例,发生在C组,各组间比较差异无统计学意义(P>0.05);A组和B组发病10～14d行冠状动脉造影发现罪犯血管再次闭塞2例,发生在B组;罪犯血管远端达到TIMI血流Ⅲ级共17例(68%),分别为A组11例(73.3%),B组6例(60%),组间比较差异无统计学意义(P>0.05)。结论在STEMI急诊介入手术中对血栓负荷较重而不宜予支架置入治疗的患者,选择急诊血栓抽吸+经皮腔内冠状动脉成形术恢复罪犯血管血流,并在发病10d左右进行延迟支架置入术安全可靠,效果优于单纯直接支架置入术治疗。     

Long-term clinical outcome of rescue balloon angioplasty compared with rescue stenting after failed thrombolysis

Failed thrombolysis following acute myocardial infarction is associated with a poor prognosis. Balloon angioplasty with or without stenting is an established procedure in acute myocardial infarction and for failed thrombolysis (rescue percutaneous transluminal coronary angioplasty [PTCA]). Intracoronary stenting improves initial success rates, decreases incidence of abrupt closure, and reduces the rate of restenosis after angioplasty. The purpose of this study was to compare the effect of rescue PTCA with rescue stenting in the treatment of acute myocardial infarction after failed thrombolysis. Clinical data are from a retrospective review of 102 patients requiring rescue balloon angioplasty or stenting after failed thrombolysis for acute myocardial infarction. There was a greater incidence of recurrent angina in 11 patients (22%) in the rescue PTCA group versus 2 patients (4%) in the rescue stenting group. The in-hospital recurrent myocardial infarction rate was 14% in the rescue PTCA group versus 2% in the stented group. In the rescue PTCA cohort, 11 patients (22%) required in-hospital repeat revascularization versus 2 patients in the stented group. The in-hospital mortality rate was higher in the PTCA group (10%) versus that in the stent group (2%). There was no significant difference in the incidence of postdischarge deaths. Rescue stenting is superior to rescue angioplasty. The procedure is associated with lower in-hospital angina and recurrent myocardial infarction, and the need for fewer repeat revascularizations. Long-term patients treated with stents required fewer revascularization procedures. Overall, rescue stenting was associated with a significantly lower mortality.     

Stenting in chronic coronary occlusion (SICCO): A randomized,controlled trial of adding stent implantation after successful angioplasty

Objectives. This study investigated whether stenting improves long-term results after recanalization of chronic coronary occlusions.Background. Restenosis is common after percutaneous transluminal coronary angioplasty (PTCA) of chronic coronary occlusions. Stenting has been suggested as a means of improving results, but its use has not previously been investigated in a randomized trial.Methods. We randomly assigned 119 patients with a satisfactory result after successful recanalization by PTCA of a chronic coronary occlusion to 1) a control (PTCA) group with no other intervention, or 2) a group in which PTCA was followed by implantation of Palmaz-Schatz stents with full anticoagulation. Coronary angiography was performed before randomization, after stenting and at 6-month follow-up.Results. Inguinal bleeding was more frequent in the stent group. There were no deaths. One patient with stenting had a myocardial infarction. Subacute occlusion within 2 weeks occurred in four patients in the stent group and in three in the PTCA group. At follow-up, 57% of patients with stenting were free from angina compared with 24% of patients with PTCA only (p < 0.001). Angiographic follow-up data were available in 114 patients. Restenosis (≥50% diameter stenosis) developed in 32% of patients with stenting and in 74% of patients with PTCA only (p < 0.001); reocclusion occurred in 12% and 26%, respectively (p = 0.058). Minimal lumen diameter (mean ± SD) at follow-up was 1.92 ± 0.95 mm and 1.11 ± 0.78 mm, respectively (p < 0.001). Target lesion revascularization within 300 days was less frequent in patients with stenting than in patients with PTCA only (22% vs. 42%, p = 0.025).Conclusions. Stent implantation improved long-term angiographic and clinical results after PTCA of chronic coronary occlusions and is thus recommended regardless of the primary PTCA result.     

Results (>6 months) of stenting of >1 major coronary artery in multivessel coronary artery disease.

Multivessel percutaneous transluminal coronary angioplasty (PTCA) is associated with a high requirement for further revascularization procedures. Although stenting can reduce restenosis and clinical events after 1-vessel intervention, little information is available after multivessel coronary stenting. We followed up 136 patients (9% of 1,481 undergoing stenting in our center) who had had stent implantation in at least 2 different major native coronary arteries and were followed-up for >6 months. Each patient had received a mean of 2.3 +/- 0.6 stents (1.13 +/- 0.4 stents per lesion) and procedural success was 95%. In-hospital complications included 1 death, 1 Q-wave infarction, 5 non-Q-wave myocardial infarctions, and 1 repeat PTCA. After a mean of 18 +/- 13 months, 7 patients died (3 of heart failure, 4 of noncardiac causes), 2 required coronary bypass surgery, 1 had a myocardial infarction, 13 target vessel repeat PTCA, and 4 non-target vessel PTCA. Survival free of major cardiac events was 75% at 3 years. A history of heart failure, dilation of a restenotic lesion, and 3-vessel dilation were independent negative predictors of event-free survival. Angiographic follow-up was available in 86 patients: 56 (65%) were restenosis free, 23 (27%) had 1-vessel restenosis, and 6 (7%) had 2-vessel and 1 patient 3-vessel restenosis. Restenosis per vessel was 23% (41 of 177). Reference diameter, past-PTCA minimal luminal diameter, and length of the stent were independent predictors of restenosis. We conclude that multivessel stenting provides good midterm results in selected patients with multivessel coronary artery disease. Midterm events are less frequent than previously reported after balloon PTCA.     

经皮冠状动脉腔内成形术及置入支架的长期预后分析

目的探讨经皮冠状动脉腔内成形术（PTCA）和PTCA＋支架治疗对我国冠心病患者的远期疗效。方法对1986年12月～1998年6月期间在我院接受PTCA和PTCA＋支架治疗的938例冠心病患者中的790例进行了随访,随访率84.2%。随访方式包括门诊随访和信访。随访时间为0.9－12.7(3.5±2.4)年。结果随访期中死亡4例(0.5%),非致命性急性心肌梗死22例(2.8%),重复PTCA98例(12.4%),行冠状动脉旁路移植术10例(1.3%)。以Kaplan-Meier法计算术后12年的生存率为99.5%,无心脏事件生存率1年为88.2%,12年为80.6%。Cox回归分析显示,陈旧性心肌梗死病史和是否放置支架与心脏事件呈负相关,而病变支数与心脏事件正相关。与单纯PTCA组比较,PTCA＋支架组急性心肌梗死发生率和再次PTCA率均显著降低。结论PTCA、特别是PTCA＋支架治疗对我国冠心病患者有良好的疗效,可作为血管重建治疗的首选方法。     

血管内窥镜评价急性心肌梗塞患者的介入治疗

目的：探讨介入治疗后出现的血栓形态与介入治疗方法的关系。　　方法：应用血管内窥镜观察经介入治疗后３１ 例急性心肌梗塞（ＡＭＩ）患者经皮冠状动脉腔内再通术（ＰＴＣＲ）组１４例,经皮冠状动脉腔内成形术（ＰＴＣＡ）组１０ 例,支架置入组１５ 例（其中８例行ＰＴＣＡ后支架置入）冠状动脉血栓形态。　　结果：在支架置入组均为附壁血栓,无一例是管腔内血栓;而在ＰＴＣＲ组和ＰＴＣＡ组中管腔内血栓分别占８６％ 和９０％ ,比支架置入组管腔内血栓有意义地增多（Ｐ＜ ０．００１）。　　结论：３种ＡＭＩ介入治疗中,支架植入术在降低急性冠状动脉闭塞及再狭窄等并发症的发生率方面,优于ＰＴＣＲ和ＰＴＣＡ。     

Comparative efficacy of primary angioplasty with stent implantation and thrombolysis in restoring basal coronary artery flow in acute ST segment elevation myocardial infarction: quantitative assessment using the corrected TIMI frame count

Following thrombolysis and primary percutaneous transluminal coronary angioplasty (PTCA) for acute ST segment elevation myocardial infarction, basal flow in the culprit artery is known to influence prognosis. The purpose of this study was to determine if differences exist in basal flow in culprit and nonculprit coronary arteries in patients with acute ST segment elevation myocardial infarction who were treated with thrombolysis or primary PTCA with stent implantation. Twenty patients were randomized to thrombolysis (with recombinant tissue plasminogen activator) and 24 to primary PTCA with stent implantation within 3 hours of onset of acute ST segment elevation myocardial infarction. Coronary angiography was performed 90-120 minutes after thrombolysis or immediately after PTCA with stent implantation and again at 18-36 hours after intervention in both groups. Patients who failed to achieve thrombolysis in myocardial infarction (TIMI) grade 2 or 3 flow were excluded. The corrected TIMI frame count was used as the index of basal coronary artery flow. Early after intervention the mean corrected TIMI frame count in the culprit coronary artery was significantly lower in the primary PTCA with stent group (27.4 +/- 7.7 frames) than in the thrombolysis group (39.8 +/- 10 frames, p < 0.001). Eight thrombolysis patients (40%) and 20 primary PTCA patients (83%, p < 0.01) achieved TIMI grade 3 flow early after intervention. By 18-36 hours after intervention there were no significant differences in the mean correct TIMI frame count between the thrombolysis and primary PTCA with stent groups. There were no significant differences in the mean corrected TIMI frame count between these two groups in the nonculprit coronary artery, either early after intervention or at 18-36 hours. In successfully reperfused coronary arteries following acute ST segment elevation myocardial infarction, primary angioplasty with stent implantation reestablished TIMI grade 2 or 3 flow faster and more effectively than thrombolysis did.     

1999年阜外心血管病医院冠心病介入治疗--单中心经验分析

目的 :总结分析我院 1999年全年冠心病介入治疗的效果和并发症。　　方法 :回顾性分析 1999年 1月 1日至 1999年 12月 31日我院连续进行的冠心病介入治疗 6 18例 ,其中单支病变437例 ,双支病变 15 4例 ,3支病变 2 7例 ,包括 1例单纯左冠状动脉主干 (左主干 )和 7例合并左主干病变。 12 1例患者为慢性完全闭塞性病变。 5 38例患者置入了冠状动脉支架。　　结果 :5 4.3%的患者为复杂病变 (B2或 C型 ) ,共有 997处病变。全部病例的成功率为 95 .0 % ,支架置入成功率为99.4%。院内并发症 :2例死亡 ,3例发生心肌梗塞 ,6例发生急性闭塞 ,4例冠状动脉穿孔 ,9例发生支架内血栓形成。1例患者于术后 14天发生支架内亚急性血栓形成。　　结论 :1999年阜外心血管病医院冠心病介入治疗数量明显增加 ,并发症发生率保持在低水平。     

Long-term mortality benefit with the combination of stents and abciximab for cardiogenic shock complicating acute myocardial infarction.

Cardiogenic shock secondary to ischemic heart disease is associated with a high mortality rate, and recent trials have established the benefit of an early invasive approach. However, the role of adjunctive abciximab and stenting for cardiogenic shock has not been established. We prospectively examined collected data from 96 consecutive patients who underwent emergent percutaneous coronary intervention for cardiogenic shock over the past 7 years. Patients were classified as receiving stent plus abciximab, stent alone, percutaneous transluminal coronary angiopplasty (PTCA) plus abciximab, or PTCA alone. Baseline characteristics of the 4 groups were similar. During 2.5 years of follow-up, the mortality rates for stent plus abciximab, stent only, PTCA plus abciximab, and PTCA alone were 33%, 43%, 61%, and 68%, respectively (log-rank p = 0.028). Achievement of postprocedural Thrombolysis In Myocardial Infarction 3 flow was higher with stent plus abciximab than with the other interventions (85% vs 65%, p = 0.048). By multivariate analysis, absence of stent use (hazard ratio 2.58, 95% confidence interval 1.36 to 4.90, p = 0.004) and left ventricular ejection function 相似文献   

Outcomes of optimal or "stent-like"balloon angioplasty in acutemyocardial infarction: the CADILLAC trial

OBJECTIVES: We sought to compare outcomes between patients with acute myocardial infarction (AMI) undergoing percutaneous transluminal coronary angioplasty (PTCA) with an optimal or "stent-like" result versus patients who underwent routine stent placement. BACKGROUND: Recent studies in patients with AMI undergoing stent implantation have suggested that PTCA may no longer be a relevant treatment modality for stent eligible lesions. However, whether routine stent placement is superior or necessary when an optimal PTCA or "stent-like" result is achieved is unknown. METHODS: In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 2,082 patients with AMI were randomly assigned to undergo PTCA alone, PTCA + abciximab, stenting alone, or stenting + abciximab. Outcomes were compared in patients achieving an optimal acute PTCA result (residual core laboratory diameter stenosis <30% without significant dissection) versus those assigned to routine stenting. RESULTS: Optimal PTCA was achieved in 40.7% of patients randomized to balloon angioplasty, including 38.5% and 42.7% assigned to PTCA alone and PTCA + abciximab, respectively. Ischemic target vessel revascularization (TVR) at 30 days occurred more frequently after optimal PTCA than routine stenting (5.1% vs. 2.3%, p = 0.007). The one-year composite adverse event rate (death, reinfarction, disabling stroke, or TVR) was greater after optimal PTCA than routine stenting (21.9% vs. 13.8%, p < 0.001), driven largely by increased rates of ischemic TVR (19.1% vs. 9.1%, p < 0.001); no significant differences were present in the rates of death, reinfarction, or disabling stroke between the two groups. Angiographic restenosis also was more common with optimal PTCA than routine stenting (36.2% vs. 22.2%, p = 0.003). Even a post-PTCA diameter stenosis of <20% (realized in 12% of patients) did not result in outcomes equivalent to stenting. CONCLUSIONS: Even if an optimal result is achieved after primary PTCA in AMI, early and late outcomes can be further improved with routine stent implantation.     

Synergy between intracoronary stenting and abciximab in improving angiographic and clinical outcomes of primary angioplasty in acute myocardial infarction

This study examined 650 consecutive patients who presented with an acute myocardial infarction and were treated with primary angioplasty within 12 hours of symptom onset between August 1995 and December 1998. Patients were placed into 4 treatment groups depending on the adjunctive therapy they received: group 1, percutaneous transluminal coronary angioplasty (PTCA) ("balloon PTCA alone"; n = 220); group 2, PTCA plus intracoronary stent placement ("stent"; n = 128); group 3, PTCA plus abciximab therapy ("abciximab"; n = 104); and group 4, PTCA plus intracoronary stent placement plus abciximab therapy ("stent/abciximab"; n = 198). The patients' clinical characteristics, severity of disease, and total ischemia time on presentation were similar. At baseline, abciximab and stent/abciximab groups had a higher incidence of thrombus on coronary angiography. Postprocedural quantitative coronary analysis showed a significantly larger minimum luminal diameter in the stent and stent/abciximab groups than PTCA alone. Overall, stents were most efficacious in reducing target vessel revascularization rate, whereas abciximab was associated with a higher postprocedural Thrombolysis In Myocardial Infarction-3 trial flow and less "no reflow." The best angiographic result was achieved in the stent/abciximab group. Similarly, the primary combined end point of death, myocardial infarction, and target vessel revascularization at 30 days was the lowest (6.1%) in the stent/abciximab group. The combination of abciximab and stenting in primary angioplasty for acute myocardial infarction is thus synergistic and is associated with improved angiographic and clinical results at 30-day follow-up.     

Comparison of stenting with balloon angioplasty for lesions of small coronary vessels in patients with diabetes mellitus.

PURPOSE: We sought to assess whether stenting is a better treatment strategy than percutaneous transluminal coronary angioplasty (PTCA) for lesions in small coronary vessels of diabetic patients. METHODS: We studied the 100 diabetic patients who were enrolled in the Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries trial; 51 patients were randomly assigned to receive a stent and 49 to PTCA alone. Small vessels were considered those with a reference diameter of 2.0 to 2.8 mm. The primary endpoint of the study was the incidence of restenosis, defined as 50% or greater diameter stenosis at follow-up angiography (performed in 83 of the 100 patients). The secondary endpoint was clinical restenosis, defined as the need for target vessel revascularization within 1 year. RESULTS: Angiographic restenosis occurred in 18 (44%) of the patients who received a stent and in 19 (45%) of the PTCA patients (P = 0.90). Target vessel revascularization was needed in 13 (25%) of the stent patients and 10 (20%) of the PTCA patients (P = 0.55). During the 1-year follow-up, 5 (10%) of the stent patients died or incurred myocardial infarction, compared with 3 (6%) of the PTCA patients (P = 0.50). CONCLUSIONS: Patients with diabetes who undergo percutaneous coronary interventions for lesions in small vessels have an especially high risk of restenosis that does not appear to be attenuated by stenting.     

Cardiac events after non-cardiac surgery in patients with previous coronary intervention in the drug-eluting stent era

The peri-operative risk for patients with coronary drug-eluting stents (DES) who subsequently have non-cardiac surgery (NCS) is unclear. We performed this retrospective study of all patients in our institution who had coronary intervention and subsequent NCS from 2003 through December 2008 to evaluate the incidence of major adverse cardiac events (MACE) in patients who received DES compared to those who received bare-metal stents (BMS) or had percutaneous transluminal coronary angioplasty (PTCA) during the same time period. The main outcome measures were 30-day post-operative myocardial infarction, stent thrombosis, target vessel revascularization (TVR) and cardiac death. During the 6-year study period, 1,770 coronary interventions were performed and 238 patients subsequently had NCS in 8 days to 49 months. Eighteen patients had PTCA, 79 BMS and 141 DES. Acute myocardial infarction occurred in 1 patient who had PTCA, 2 who had BMS and 14 who had DES (p = 0.10). Stent thrombosis occurred in 6 patients who had DES and none who had BMS (p = 0.09). Seven patients who had DES had TVR compared to 1 patient who had BMS and none who had PTCA (p = 0.41). Cardiac mortality occurred in 2 patients who had DES and none who had PTCA or BMS (p = 0.35). In conclusion, the 30-day MACE in patients who received coronary DES and undergone NCS were not significantly different compared to those who received BMS or had PTCA only, with a trend toward higher stent thrombosis in the DES group.     

急诊冠状动脉介入治疗急性心肌梗死的临床研究

目的通过回顾性分析,探讨急诊经皮冠状动脉介入治疗(PCI)对急性心肌梗死(AMl)的安全性和治疗效果.方法我院收治的ST段抬高的急性心肌梗死患者,发病时间在12h内,行急诊冠状动脉造影、急诊PCI和支架植入术.如果梗死相关血管(IRA)前向血流为TIMI 0～2级或虽达到TIMI 3级,但残余狭窄≥90%者采取急诊PCI治疗.结果入选急性心肌梗死患者119例行急诊冠状动脉造影,男82例,女37例,年龄35～86岁,平均(58.8±12.7)岁,冠状动脉造影显示:IRA为前降支72例;右冠状动脉为43例;回旋支为4例.110例患者IRA行球囊扩张和支架植入,有7例患者行球囊扩张后残余狭窄＜20%,TIMI 3级,未进一步行支架置入.行PCI的117例患者,成功率98.8%,IRA的前向血流达到TIMI 3级的达95.4%.随访30d,95例患者(80%)无事件生存,住院期间死亡5例,发生急性和亚急性闭塞5例.结论急性心肌梗死行紧急PCI,疗效明显且安全,应在有条件的医院大力开展,推广应用.     

A Clinical Trial Comparing Primary Stenting of the Infarct-Related Artery With Optimal Primary Angioplasty for Acute Myocardial Infarction: Results From the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO) Trial

Objectives. This study sought to compare stenting of the primary infarct-related artery (IRA) with optimal primary percutaneous transluminal coronary angioplasty (PTCA) with respect to clinical and angiographic outcomes of patients with an acute myocardial infarction.Background. Early and late restenosis or reocclusion of the IRA after successful primary PTCA significantly contributes to increased patient morbidity and mortality. Coronary stenting results in a lower rate of angiographic and clinical restenosis than standard PTCA in patients with angina and with previously untreated, noncomplex lesions.Methods. After successful primary PTCA, 150 patients were randomly assigned to elective stenting or no further intervention. The primary end point of the trial was a composite end point, defined as death, reinfarction or repeat target vessel revascularization as a consequence of recurrent ischemia within 6 months of randomization. The secondary end point was angiographic evidence of restenosis or reocclusion at 6 months after randomization.Results. Stenting of the IRA was successful in all patients randomized to stent treatment. At 6 months, the incidence of the primary end point was 9% in the stent group and 28% in the PTCA group (p = 0.003); the incidence of restenosis or reocclusion was 17% in the stent group and 43% in the PTCA group (p = 0.001).Conclusions. Primary stenting of the IRA, compared with optimal primary angioplasty, results in a lower rate of major adverse events related to recurrent ischemia and a lower rate of angiographically detected restenosis or reocclusion of the IRA.     

球囊预扩张充盈压对冠脉支架植入术临床疗效的影响

目的 :评估球囊低压力预扩张对冠脉内支架术后临床疗效的影响。方法 :依据不同球囊预扩张压力将入选的91例冠心病患者分为低压力组 （最大扩张压力≤ 12 atm ）、高压力组 （>12 atm ） ,观察住院期间严重临床事件率和术后 6～ 18个月无心脏事件存活率。结果 :低压力组球囊最大预扩张压力为 8.3± 1.6 atm ,高压力组为 13.9± 0 .3atm （P<0 .0 5 ） ,144个支架均成功置入。低压力组和高压力组在术中的血管夹层及撕裂的发生率分别为 8.2 %和19.0 % （P<0 .0 5 ） ,住院期间低压力组发生死亡为 0例 ,高压力组为 1例 ;6 8例患者接受了术后 6～ 18个月的临床随访 ,无心脏事件存活率低压力组为 74% ,高压力组为 6 1% ,其中 13例在随机冠状动脉造影随访中发现支架内再狭窄 ,低压力组为 6例 ,高压力组为 7例。结论 :低压力球囊预扩张可减少支架术中的急性血管并发症 ,不影响支架置入的远期疗效。     

Primary stenting produces earlier and more efficient myocardial reperfusion than primary PTCA alone in patients with acute ST segment elevation MI

Restoration of blood flow in the infarct-related artery and subsequent myocardial reperfusion are major goals of both thrombolysis and primary percutaneous interventions. Whether percutaneous transluminal coronary angioplasty (PTCA) with immediate stenting (primary stenting) produces reperfusion more rapidly than primary PTCA alone is uncertain. This study determines whether primary stenting produces earlier myocardial reperfusion than primary PTCA alone in patients with acute ST segment elevation myocardial infarction using troponin T release kinetics. Primary stenting was performed on 60 patients and primary PTCA alone on 44 patients with typical ischemic chest pain and greater than 1.5 MV ST segment elevation in more than 2 contiguous electrocardiographic leads. Serum troponin T concentrations were measured before and after intervention; every 6 hours for 24 hours; then at 36, 48 and 72 hours. The mean time from onset of chest pain to peak serum troponin T concentration was 7.8 +/- 2.7 hours after primary stenting and 14.5 +/- 4.4 hours after primary PTCA (p < 0.0005). The mean peak serum troponin T concentration was 9.8 +/- 6.3 ng/dL after primary stenting and 13.6 +/-6.4 ng/dL after primary PTCA (p < 0.012). A significant univariate association with time to peak concentration of serum troponin T was identified for primary stenting (p < 0.0005), time from onset of chest pain to intervention (p < 0.04), and diabetes mellitus (p < 0.01). The only significant univariate marker associated with peak concentration of serum troponin T was primary stenting (p < 0.012). Multivariate analysis indicated that primary stenting (p < 0.0005), time from onset of chest pain to intervention (p < 0.048), and diabetes mellitus (p < 0.022) significantly influenced time to peak serum concentration or troponin T. Primary stenting produces earlier myocardial reperfusion than primary PTCA in patients with acute ST segment elevation myocardial infarction.     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.