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。     

Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease

This study was conducted to compare the clinical outcomes of drug-eluting stents (DESs) with those of standard bypass surgery for the treatment of patients with left main lesions in a single-center experience. From January 2000 to October 2005, a total of 96 patients with significant unprotected left main disease were treated with DES implantation, and 245 with bypass surgery. Baseline features, such as Euroscore, were similar between groups, except for diabetes and hypertension, which were more frequent in the surgical group. The combination of death, Q-wave myocardial infarction, stroke, and repeated revascularization (major adverse cardiac and cerebrovascular events [MACCEs]) at 30 days occurred in 2.1% after DES implant and 9.0% after surgery (p=0.03). At 1 year, DES-treated patients more frequently needed repeat revascularization (5.2% vs 0.8%; p=0.02), although combined MACCE rates were similar (10.4% for DES, 11.4% for surgery; p=0.50). Moreover, after a mean follow-up of 1.3+/-0.8 and 3.2+/-1.6 years for the DES and surgical groups, there were no significant differences in MACCEs, respectively. In conclusion, in our experience, percutaneous treatment of patients with unprotected left main disease with DESs provided similar clinical results compared with surgical revascularization at a midterm follow-up.     

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.     

无保护左主干病变冠状动脉搭桥术与雷帕霉素洗脱支架治疗的对比研究

目的:回顾性分析无保护左主干病变患者使用雷帕霉素洗脱支架(DES)的经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植手术(CABG)治疗的中、远期疗效,并探讨应用SYNTAX SCORE来评估病变风险与临床事件的相关性。方法:本研究回顾性收集了176例无保护左主干病变患者,其中CABG组80例,PCI-DES组96例。收集患者的基本情况、左主干病变特点及SYNTAX评分、CABG和PCI手术情况,随访患者术后3年的主要不良心脑血管事件(MACCE)的发生率。结果:术后3年随访,PCI-DES组与CABG组的MACCE发生率及无MACCE生存率比较差异无统计学意义,但PCI组靶血管再次血运重建率(TVR)明显高于CABG组(P<0.05)。用SYNTAX SCORE把PCI-DES和CABG两组患者分为高积分组(≥30.0)和低积分组(<30.0):高积分组,术后3年PCI-DES亚组MACCE事件发生率高于CABG亚组(23.53%∶18.05%,P<0.05),无MACCE事件生存率低于CABG亚组(51.47%∶70.83%,P<0.05)。低积分组,术后3年MACCE事件发生率CABG亚组高于PCI-DES亚组(12.50%∶7.14%,P>0.05),而无MACCE事件生存率低于PCI-DES亚组(75.00%∶82.14%,P<0.05)。结论:PCI-DES与CABG治疗无保护左主干病变患者总体疗效相似。用SYNTAX SCORE指导无保护左主干病变血管重建方式的选择有重要价值,但在不同的患者人群中,仍应结合临床特征和冠状动脉病变特点选择恰当的血运重建术。     

第二代药物洗脱支架治疗无保护左主干病变的疗效及安全性分析

目的探讨第二代药物洗脱支架（DES）置入治疗无保护左主干（ULM）病变患者的疗效及安全性。方法回顾性研究南京医科大学附属南京医院诊断为ULM病变并接受DES治疗的患者216例。接受第一代DES的患者121例为F组,接受第二代DES的患者95例为S组。患者术后常规服用阿司匹林100 mg,每日一次;氯吡格雷150 mg,每日一次（维持至少1年）。主要研究终点为主要不良心血管事件（MACE）,包括心源性死亡、非致死性心肌梗死和再次靶血管血运重建（TVR）;次要终点为12个月时定量冠状动脉造影（CAG）参数。结果在（342±23）d随访期内,总体复合MACE 22例（10.2%）,主要构成为TVR 16例（7.4%）。S组复合MACE为5.3%显著低于F组14.0%（χ2=4.491,P=0.034,RR 2.669,95%CI 1.022~6.975）。S组复合MACE的减少主要表现为TVR减少（χ2=4.465,P=0.035,RR 3.402,95%CI 0.998~11.60）。随访血管造影再狭窄F组与S组分别为17例（14.5%）和8例（8.4%）,差异无统计学意义（χ2=1.647,P=0.199）。血管内超声提示的晚期获得性支架贴壁不良于F组和S组分别为7例（5.8%）和1例（1.1%）,F组有增加趋势,但差异无统计学意义（χ2=3.342,P=0.068）。结论与第一代DES相比较,使用第二代DES治疗ULM病变MACE发生率低,主要表现为TVR减少;第二代DES治疗ULM病变具有更好的疗效和安全性。     

无保护左主干病变支架介入治疗后冠状动脉造影随访结果分析

目的观察无保护左主干病变,应用药物洗脱支架介入治疗后冠状动脉造影随访结果,并分析其影响因素。方法选择无保护左主干病变患者150例,其中48例在平均(10.0±7.5)个月进行了冠状动脉造影复查,根据冠状动脉造影显示有无狭窄分为:再狭窄组12例和无再狭窄组36例。结果与无再狭窄组比较,再狭窄组患者随访时最小管腔直径明显减小[(2.7±1.0)mm vs (3.5±0.4)mm,P=0.0001]、直径狭窄率明显升高[(31.4±26.4)% vs (8.3±5.3)%,P=0.0000]、晚期管腔丢失明显升高[(0.8±0.7)mm vs (0.2±0.3)mm,P=0.0000];双支架置入术的再狭窄率明显高于单支架置入术[(75.0% vs 13.9%),P=0.0011]。结论左主干远端分叉病变双支架置入术的疗效较差,冠状动脉旁路移植术应作为首选。     

左主干病变不同血运重建治疗方法对比评价

目的 评价真实临床环境下不同血运重建方法对冠心病左主干病变患者的近期及远期疗效.方法 将我院1995年至2005年10年期间接受血运重建治疗的左主干病变冠心病患者分为金属裸支架(BMS)治疗组、西罗莫司洗脱支架(SES)治疗组以及冠状动脉旁路移植术(CABG)组,记录患者围手术期、术后6个月、术后1年不良心脑血管事件(MACCEs)发生率;接受支架治疗的患者术后6～9个月均要求复查冠状动脉造影;所有患者每月心内科门诊就诊,记录患者心绞痛复发等情况.结果 (1)自1995年至2005年期间我院共收治左主干病变冠心病患者415例,其中1995年10月至1999年8月共有97例接受了BMS治疗,1999年9月至2005年5月共有122例接受了SES治疗,1995年至2005年共有196例接受CABG治疗;(2)CABG组糖尿病患者比例高于BMS组及SES组,而在PCI组(包括MS组和SES组)合并肾功能不全、脑血管疾患及肺功能障碍患者比例高于CABG组;(3)BMS组、SES组及CABG组手术、住院期间及术后30 d内的MACCEs事件发生率分别为3.09%、4.01%及10.71%,P＜0.01;BMS组及SES组住院时间显著短于CABG组(分别为5 d、5 d及8.5 d);(4)SES组造影再狭窄率显著低于BMS组(9.9%比23.6%,P＜0.01);(5)平均随访1年SES组与CABG组无MACCEs事件生存率显著高于BMS组(分别为85%、84%、64%,P＜0.01).结论 真实临床环境下左主干病变血运重建治疗即刻手术成功率高,PCI组围手术期不良心脑血管事件发生率低于CABG组,SES组与CABG组1年无事件生存率类似,均显著高于BMS组.     

Treatment of unprotected left main disease with drug-eluting stents in patients at high risk for coronary artery bypass grafting.

BACKGROUND: Percutaneous coronary intervention (PCI) for high-grade stenosis of the left main coronary artery with bare-metal stents has been limited by restenosis, and most patients are managed with coronary artery bypass grafting (CABG). Recently, drug-eluting stents (DES) have reduced instent restenosis after PCI, but their role in the treatment of left main disease remains unclear. AIMS: The aim of this study was to determine the outcomes after utilizing DES to treat left main disease. METHODS: Twenty consecutive symptomatic patients with >50% angiographic stenosis of the left main coronary artery with no prior history of CABG ["unprotected left main" (ULM)] underwent PCI with DES. Patients were divided into two groups based on the presence (Group A, n=5) or absence (Group B, n=15) of preprocedural cardiogenic shock. At follow up (median, 14 months), cumulative major adverse cardiac events (MACE-death, myocardial infarction, or target vessel revascularization) were determined. RESULTS: Sixteen (80%) of 20 patients were at high risk for CABG because of comorbidity, advanced age, or cardiogenic shock. Procedural success was 100% (20/20). Three of five patients in Group A (60%) died in hospital and the two surviving patients experienced no MACE at follow up. In Group B (n=15), there was no in-hospital MACE, but one patient died suddenly 8 weeks postprocedure [cumulative MACE of 7% (1/15)]. CONCLUSIONS: Our study demonstrates the feasibility of ULM treatment with DES with acceptable medium-term outcomes. While CABG remains the best form of revascularization for the majority of patients with ULM, DES should be considered in those who are at high risk.     

无保护左主干病变合并急性冠状动脉综合征介入与手术治疗对比研究

目的:探讨急性冠状动脉综合征(ACS)合并无保护左主干病变患者经桡动脉介入治疗(TRI)与冠状动脉旁路移植术(CABG)二者的疗效。方法:连续入选2008年3月至2010年12月,于北京安贞医院行经桡动脉介入治疗(n=236)或冠状动脉旁路移植术(n=354)的无保护左主干病变合并ACS患者。对于患者的临床基线特征及冠状动脉病变特征纳入倾向性评分模型进行匹配,得到154对患者。结果:平均随访时间27个月。经过倾向性评分模型进行校正,两组患者的基线资料及病变特征无显著差异。结果显示TRI与CABG两组全因病死率(4.5%vs.6.5%;P=0.454)及心肌梗死发生率(5.2%vs.7.8%;P=0.355)并差异无统计学意义。CABG组患者脑卒中发生率显著增加(零vs.2.6%;P=0.044),而TRI组靶血管重建率(TVR)显著增加(13.0%vs.5.2%;P=0.017)。两组患者复合终点(死亡/心肌梗死/靶血管重建),差异无统计学意义(7.1%vs.12.3%;P=0.124)。结论:对于ACS合并无保护左主干病变患者TRI与CABG的临床复合终点事件风险相似,然而尽管应用药物洗脱支架CABG组患者靶血管重建率仍显著低于介入治疗组。     

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。     

High-risk diabetic patients with unprotected left main coronary artery disease: characteristics and medium-term outcomes of percutaneous revascularization with drug-eluting stents

Percutaneous coronary intervention with drug-eluting stents is an alternative for patients with high-risk unprotected left main coronary artery disease; those with diabetes mellitus are at even higher risk. Recent advances in percutaneous coronary intervention could lead to better results. The aim of this study was to evaluate medium-term results in a real-world sample of high-risk diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.From 3 tertiary hospitals, we retrospectively identified 334 high-risk patients, of whom 141 (42%) were diabetic and 193 (58%) were nondiabetic. The diabetes mellitus group showed a higher prevalence of peripheral vascular disease and left ventricular dysfunction. Angiographic and procedural characteristics did not differ significantly, with the exception of poor distal vessels in the diabetes mellitus group (44.5% vs 28.5%, P = 0.006). The use of intra-aortic balloon pumping and intravascular ultrasonography was low in both diabetic and nondiabetic patients. After a median follow-up of 22.4 months, cardiac death was higher in the diabetes mellitus group (16.2% vs 7.5%, P = 0.015), especially in insulin-dependent diabetic patients (25.8%). The incidence of major adverse cardiac events, including cardiac death, target-lesion revascularization, and myocardial infarction was similar in both groups (23.8% vs 18.3%, P = NS).High-risk diabetic patients who undergo percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease present with a worse clinical profile that carries a higher cardiac mortality rate in the medium term, especially in insulin-dependent diabetic patients.     

Early and long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents in patients with non-ST-elevation acute coronary syndrome

Background

Patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unprotected left main coronary disease (ULMCD) are among the highest risk patients but current consensus guidelines do not address the optimal timing and mode of revascularization for these individuals.

Methods

In this single-centre registry, we evaluated the clinical outcomes of 151 consecutive patients with NSTE-ACS and ULMCD who underwent percutaneous coronary intervention with drug-eluting stents from 2005 to 2009.

Results

Overall in-hospital major adverse cardiac event (MACE) rate was 5.3%, mortality rate was 0.7%. At 30 months ± 15 months, 30 patients (19.9%) experienced MACE. The 4-year cumulative survival rate of no MACE was 73.2% and cumulative survival rate was 90.6%. Left ventricular ejection fraction (hazard ratio [HR] 0.947; 95% confidence interval [CI], 0.898-0.998; P = 0.043) and SYNTAX [SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery] score ≥ 33 (HR 1.28; 95% CI, 1.025-1.433; P = 0.029) were associated with MACE, while only left ventricular ejection fraction (HR 0.82; 95% CI, 0.69-0.973; P = 0.023) was associated with mortality.

Conclusions

Our study demonstrates the feasibility of percutaneous coronary intervention with drug-eluting stents in patients with NSTE-ACS and ULMCD. The early and long-term outcomes were acceptable. Left ventricular ejection fraction and SYNTAX score ≥ 33 predict MACE and only left ventricular ejection fraction predicts mortality.