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。     

药物洗脱支架置入术与冠状动脉旁路移植术治疗冠心病多支病变的临床对比研究

目的:探讨药物洗脱支架(DES)治疗冠心病多支冠状动脉(冠脉)病变患者的临床疗效,并与冠脉旁路移植术进行比较.方法:入选2005-01-2008-01在我院行血管重建术的215例冠心病多支冠脉病变患者,其中114例行DES置入术(DES组),101例行冠脉旁路移植术 (CABG组).比较2组住院期和随访期不良心血管事件(死亡、非致死性心肌梗死、再次血管重建术和脑血管意外)的发生情况.结果:2组的临床和冠脉病变特征相似, 与DES组比较,CABG组左主干病变(29.2%∶5.0%,P<0.01)、LVEF<50%发生率(39.7%∶19.2%,P<0.01) 和完全血管重建率(81.2%∶58.8%, P<0.01)较高.住院期2组总体不良心血管事件发生率无明显差异,但CABG组住院期病死率有增高趋势(6.9%∶1.8%,P＞0.05).平均临床随访12～36(17±9)个月,2组总体不良心血管事件发生率仍无明显差异(9.6% ∶13.4%,P＞0.05) ,但DES组再次血管重建的发生率较CABG组有增高趋势(9.8%∶2.1%,P＞0.05).结论:DES置入术应用在冠心病多支冠脉病变患者中安全可行,总体不良心血管事件发生率与CABG无明显差异.     

Percutaneous coronary intervention in unprotected left main coronary artery stenosis: Mid-term outcomes of a single-center observational study

BackgroundPercutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected left main coronary artery (ULMCA) disease in patients with low-to–intermediate anatomic complexity or when the patient refuses CABG even after adequate counselling by heart team. We assessed the safety, in-hospital and mid-term outcomes of ULMCA stenting with drug-eluting stents (DES) in Indian patients.MethodsOur study was a retrospective analysis of patients who had undergone ULMCA PCI at a tertiary center, between March 2011 and February 2020. Clinical characteristics, procedural data, and follow-up data were analyzed. The primary outcome was a composite of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospital stay and at follow-up. The median follow-up was 2.8 years (interquartile range: 1.5–4.1 years).Results661 patients (mean age, 63.5 ± 10.9 years) had undergone ULMCA PCI. The mean SYNTAX score was 27.9 ± 10.4 and the mean LVEF was 58.0 ± 11.1%. 3-vessel disease and distal lesions were noted in 54% and 70.6% patients, respectively. The incidence of in-hospital MACCE was 1.8% and the MACCE during follow-up was 11.5% (including 48 [8.4%] cardiac deaths). The overall survival rates after one, three, five, and nine years were 94%, 88%, 84%, and 82%, respectively. The multivariate analysis revealed that age >65 years and high SYNTAX scores were independent predictors of mid to long-term mortality.ConclusionULMCA PCI with DES is safe and has acceptable in-hospital and mid-term outcomes among patients with low-to–intermediate SYNTAX score.     

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.     

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   

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.     

老年多支血管病变患者置入药物洗脱支架与冠状动脉旁路移植术后近远期临床结果

目的:本研究旨在比较老年(年龄≥75岁)稳定性冠心病合并多支血管病变患者行经皮冠状动脉介入治疗(PCI)置入药物洗脱支架(DES)与冠状动脉旁路移植术(CABG)的近远期临床结果。方法:本研究于2003年7月至2006年12月,连续入选年龄≥75岁稳定性冠心病合并多支血管病变患者363例,在我院行PCI置入DES(n=269)或CABG(n=94)治疗。主要终点为24个月时主要不良心脑血管事件(MACCE),次要终点为24个月时全因死亡及非致死性心肌梗死(MI)、脑血管事件和再次血运重建以及全因死亡、非致死性MI和脑血管事件复合终点事件。结果:住院期间,CABG组的病死率(7.4%vs.1.9%,P=0.023)和非致死性MI的发生率(3.2%vs.0,P=0.023),明显高于DES组,CABG组的MACCE的发生率也明显高于DES组(10.6%vs.1.9%,P=0.001)。多因素回归分析结果显示:24个月时,CABG组和DES组的主要终点事件的风险未见明显差异[22.3%vs.15.2%,风险比(HR)=1.62,95%CI 0.63～3.31,P=0.379],两组的全因死亡、心源性死亡、非致死性MI、脑血管事件和再次血运重建的风险也没有明显差异;CABG组全因死亡、非致死性MI和脑血管事件复合终点事件的风险明显高于DES组(19.1%vs.8.2%,HR 3.87,95%CI:1.24～12.37,P=0.009)。结论:本研究提示,与DES相比,CABG可能会增加75岁以上多支血管病变患者的远期全因死亡、非致死性MI和脑血管事件复合终点事件的风险,而未降低再次血运重建和MACCE。     

A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged > or =75 years).

AIMS: In this study, we compared the clinical outcomes of elderly patients with unprotected left main coronary artery (ULMCA) stenosis treated with either coronary artery bypass grafting (CABG) or drug-eluting stent (DES). METHODS AND RESULTS: From January 2003 to April 2006, 259 patients with ULMCA stenosis and age > or =75 years underwent coronary revascularization with either CABG or DES. One hundred and sixty-one patients were treated with CABG and 98 with DES. The cumulative unadjusted rates of 2-year mortality were 17% in CABG-treated patients and 18% in those treated with DES (P = 0.71). The adjusted rates of 2-year survival were 85% for CABG-treated patients and 87% for DES-treated patients (P = 0.74). The incidence of 2-year myocardial infarction was 6% in CABG-treated patients and 4% in DES-treated patients (P = 0.11). The incidence of target lesion revascularization (TLR) was 3% in CABG-treated patients and 25% in DES-treated patients (P < 0.0001). In the multivariable analysis, peripheral vascular disease, left ventricular ejection fraction and acute coronary syndrome were independent predictors of 2-year mortality. CONCLUSION: In this study, we could not demonstrate a difference in mortality between CABG-treated patients and those treated with DES. However, the rate of TLR was higher in the DES group.     

PCI versus CABG for multivessel coronary disease in diabetics

Objectives: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug‐eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. Background: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES‐PCI versus CABG in DM patients with MVD. Methods: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES‐PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. Results: Compared with PCI patients, CABG patients had higher prevalence of 3‐vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2‐year follow‐up, MACCE were not different between CABG group and DES‐PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES‐PCI increased the risk of 24‐month MACCE in total population (OR 1.8; P = 0.04). Conclusions: For patients with DM and MVD, a clinical judgment‐based revascularization by DES‐PCI is not associated with worse 2‐year outcome compared with CABG. © 2008 Wiley‐Liss, Inc.     

SYNTAX评分对无保护左主干病变选择不同血运重建方式的价值研究

目的:应用SYNTAX评分评估冠状动脉(冠脉)无保护左主干病变(ULMCA)的复杂程度及其与临床事件的相关性,探讨冠脉无保护左主干病变患者的最佳血运重建方式。方法:回顾性收集了206例从2003-02至2008-01采用经皮冠脉介入治疗—药物洗脱支架(PCI-DES)和冠脉旁路移植术(CABG)的无保护左主干病变患者,其中CABG组94例,PCI-DES组112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)发生率以及冠脉造影复查情况。结果:①两组患者基本情况、左主干病变特点及SYNTAX评分等方面差异均无统计学意义(P>0.05),但CABG组合并三支血管病变多于PCI-DES组,差异有统计学意义[74.47%(70例)vs.41.07%(46例),P<0.01]。②住院期间CABG组的MACCE发生率较PCI-DES组高(P<0.05)。术后3年随访,两组的MACCE发生率及无MACCE生存率比较差异无统计学意义,但PCI-DES组靶血管再次血运重建率明显高于CABG组(P<0.05)。③两组间SYNTAX评分差异无统计学意义(P>0.05)。PCI-DES组中,高积分(≥30.0)患者术后3年MACCE发生率明显高于低积分(<30.0)患者(P<0.01),而术后3年无MACCE生存率低于低积分患者(P<0.01)。CABG组中,高积分和低积分患者术后3年MACCE发生率及无MACCE生存率比较差异无统计学意义(P>0.05)。高积分患者中,术后3年PCI-DES组MACCE发生率高于CABG组,无MACCE生存率低于CABG组(P均<0.05)。低积分患者中,术后3年PCI-DES组MACCE发生率低于CABG组,无MACCE生存率PCI-DES组高于CABG组(P均<0.05),差异均有统计学意义。结论:用SYNTAX评分指导无保护左主干病变的血管重建方式选择有重要价值,但在不同的患者中,仍应结合临床特征和冠脉病变特点选择恰当的血运重建术。     

Late loss of early benefit from drug-eluting stents when compared with bare-metal stents and coronary artery bypass surgery: 3 years follow-up of the ERACI III registry.

Aims: Long-term benefit from coronary revascularization with drug-eluting stents (DES) relative to bare metal stents (BMS) and coronary artery bypass grafting (CABG) has not been established. One year follow-up of the ERACI III registry study showed better outcome with DES. To compare major adverse cardiac and cerebrovascular event (MACCE) rates in patients with multivessel cardiovascular disease (CVD) who received DES with those patients treated with BMS or CABG in the ERACI II trial. METHODS AND RESULTS: Patients with multivessel CVD who met the ERACI II trial, clinical and angiographic inclusion criteria were treated with DES and enrolled in the ERACI III registry. The primary endpoint was 3-year MACCE. ERACI III-DES patients (n = 225) were compared with the BMS (n = 225) and CABG (n = 225) arms of ERACI II. Patients treated with DES were older, more often smokers, more often high risk by euroSCORE and less frequently had unstable angina. They also had higher incidence of type C lesions and received more stents than the BMS-treated cohort. Three year MACCE was lower in ERACI III-DES (22.7%) than in ERACI II-BMS (29.8%, P = 0.015), mainly reflecting less target vessel revascularization (14.2 vs. 24.4%, P = 0.009). MACCE rates at 3 years were similar in DES and CABG-treated patients (22.7%, P = 1.0), in contrast to results at 1 year (12 vs. 19.6%, P = 0.038). MACCE rates in ERACI III-DES were higher in diabetics (RR 0.81, 0.66-0.99; P = 0.018). Death or non-fatal MI at 3 years trended higher in the DES (10.2%) than BMS cohort (6.2%, P = 0.08) and lower than in CABG patients (15.1%, P = 0.07). Sub-acute late-stent thrombosis (LST) (>30 days) occurred in nine DES patients and no BMS patients (P = 0.008). CONCLUSION: In patients with multivessel CVD, the initial advantage for PCI with DES over CABG observed at 1 year was not apparent by 3 years. Furthermore, despite continued lower incidence of MACCE, initial advantage over BMS appeared to decrease with time. LST occurred more frequent in DES-treated patients.     

Comparison of coronary drug-eluting stents versus coronary artery bypass grafting in patients with diabetes mellitus

We compared 1-year outcome after drug-eluting stent (DES) implantation with off-pump bypass grafing (OPCABG) in patients with type 2 diabetes mellitus and multivessel coronary artery disease involving the proximal segment of the left anterior descending coronary artery. All consecutive diabetic patients treated by DES (DES group) or OPCABG (CABG group) in our institution from April 2002 to December 2004 because of de novo coronary lesions were included. Patients in the CABG group (n = 149) were older and had a higher rate of 3-vessel disease than those in the DES group (n = 69). At 12 months, major adverse cardiac and cerebrovascular events occurred in 29% of the DES group and 20.5% of the CABG group (unadjusted analysis, odds ratio 1.20, 95% confidence interval [CI] 0.93 to 1.54, p = 0.17). After propensity score analysis, adjusting for baseline differences between the 2 cohorts, DESs increased the risk of 12-month major adverse cardiac and cerebrovascular events (hazard ratio 1.88, 95% CI 1.09 to 3.02, p = 0.020). This was due to the higher rate for repeat revascularization in the DES group (19% vs 5%, odds ratio 2.05, 95% CI 1.12 to 3.75, p = 0.001). In contrast, there was no difference in the rate of the composite end points of death, myocardial infarction, and stroke (DES group 13%, CABG group 12%; adjusted analysis, hazard ratio 0.80, 95% CI 0.80 to 1.35, p = 0.40). In conclusion, at 1 year in diabetic patients with multivessel coronary artery disease involving the proximal left anterior descending coronary artery, the advantage of OPCABG over DES implantation seems to be limited at a lower rate of repeat revascularization. No difference seems to exist in the rate of death, stroke, and myocardial infarction.     

One‐Year Follow‐Up of Nonrandomized Comparison between Coronary Artery Bypass Grafting Surgery and Drug‐Eluting Stent for the Treatment of Unprotected Left Main Coronary Artery Disease in Elderly Patients (Aged ≥75 Years)

Purpose: The present observational study compares in‐hospital and 12‐month clinical outcomes in elderly patients with unprotected left main coronary artery disease treated either with coronary artery bypass grafting or drug‐eluting stent. Methods: From January 2004 to December 2007, 211 patients (pts) with unprotected left main coronary artery (ULMCA) stenosis, aged 75 or older, underwent coronary revascularization either with coronary artery bypass graft (CABG) (106 pts) or drug‐eluting stent (DES) (105 pts). The decision to treat with CABG or percutaneous coronary intervention (PCI) was dependent on the patient's and the physician's choice. The occurrence of major adverse cardiac or cerebrovascular events (MACCE: death, nonfatal myocardial infarction, or stroke) and revascularizations was recorded after 1 year of follow‐up. A multivariate logistic regression analysis was performed using a propensity score method to take potential baseline differences between groups into account. Results: In‐hospital MACCE rates were 5.7% and 3.8% in the CABG and PCI groups, respectively (P = 0.748). After 1 year of follow‐up, these rates were, respectively, 13.9% and 14.9% (P = 0.841), and rates for target vessel revascularization at 12 months were 1.0% and 13.9% (P < 0.001). The PCI group was significantly associated with older age, dyslipidemia, history of cancer, high Euroscore, elevated creatininemia, single‐vessel disease, fewer chronic occlusions of the left anterior descending artery, and more LMCA stenosis ≥70%. The multivariate logistic regression analysis was adjusted for age, diabetes, left ventricular ejection fraction, Euroscore, and plasma creatininemia and stratified on the score of propensity to be treated with PCI. In the subgroup below median propensity score, the adjusted odds ratio for 1‐year MACCE was OR = 0.91 (95% confidence interval: 0.14 to 5.98; P = 0.924) whereas OR was 0.16 (0.04–0.69; P = 0.013) in the subgroup above median propensity score. Conclusions: In patients with a high probability of being treated with PCI (older age, high Euroscore, high creatininemia, single‐vessel disease, …), the 1‐year risk of MACCE was significantly lower in PCI‐ than in CABG‐treated subjects. No significant difference was found in other cases.     

Comparison of percutaneous coronary intervention(with drug-eluting stents) versus coronary artery bypass grafting in women with severe narrowing of the left main coronary artery(from the Women-Drug-Eluting Stent for Left Main Coronary Artery Disease Regist

Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery(ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention(PCI) with drug-eluting stents versus coronary artery bypass grafting(CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489(59.8%) underwent treatment with PCI with drug-eluting stents versus 328(40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at longterm follow-up there were no differences in all-cause(odds ratio [OR] 0.722, 95% confidence interval [CI]0.357 to 1.461, P = 0.365) or cardiovascular(OR 1.100, 95% CI 0.455 to 2.660, P = 0.832) mortality, myocardial infarction(MI; OR 0.362, 95% CI 0.094 to 1.388, P = 0.138), or cerebrovascular accident(CVA;OR 1.200, 95% CI 0.359 to 4.007, P = 0.767) resulting in no difference in the primary study objective of death, MI, or CVA(OR 0.711, 95% CI 0.387 to 1.308, P = 0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events(OR 0.429, 95% CI 0.254 to 0.723, P =0.001), driven exclusively by target vessel revascularization(OR 0.185, 95% CI 0.079 to 0.432, P 0.001).In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI,and CVA at long-term follow-up.     

老年无保护左主干病变置人药物洗脱支架与行冠状动脉旁路移植术的预后比较

目的 对比老年无保护左主干病变患者置入药物洗脱支架(DES)和行冠状动脉旁路移植术(CABG)后2年的临床预后.方法 入选2004年1月至2006年6月因无保护左主干病变置入DES或行CABG的老年患者(≥70岁)共295例.随访2年,记录患者发生全因死亡、非致死性心肌梗死及靶病变血管重建的情况.结果 共206例患者行CABG,89例患者置入DES.随访2年的累积死亡率CABG组为10.2%,DES组为13.3%,两组之间差异无统计学意义(P=0.428).生存分析表明2年生存率CABG组为89.2%,DES组为86.4%,两组之间差异无统计学意义(P=0.668).2年心肌梗死发生率CABG组为10.1%,DES组为7.8%,两组之间差异无统计学意义(P=0.501).DES组2年内靶病变血管重建的发生率明显高于CABG组(13.5%比4.9%,P=0.015).多因素分析表明,年龄(HR:1.04,95% CI:1.01～1.09,P=0.024)、左心室功能不全(LVEF<30%)(HR:4.97,95%CI:1.22～24.85,P=0.018)以及2型糖尿病(HR:2.22,95%CI:1.31～4.86,P=0.001)均是死亡的独立危险因素.结论 对于≥170岁的老无保护左主干病变患者,行CABG和置入DES后2年的生存率相当,但置入DES的患者靶病变血管重建发生率明显高于行CABG的患者.     

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.     

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。     

Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with drug‐eluting stents in patients with myocardial infarction

Background: Patients who present with myocardial infarction (MI) and unprotected left main coronary artery (ULMCA) disease represent an extremely high‐risk subset of patients. ULMCA percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in MI patients has not been extensively studied. Methods: In this retrospective multicenter international registry, we evaluated the clinical outcomes of 62 consecutive patients with MI who underwent ULMCA PCI with DES (23 ST‐elevation MI [STEMI] and 39 non‐ST‐elevation MI [NSTEMI]) from 2002 to 2006. Results: The mean age was 70 ± 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 ± 8. Angiographic success was achieved in all patients. Overall in‐hospital major adverse cardiac event (MACE) rate was 10%, mortality was 8%, all due to cardiac deaths from cardiogenic shock, and one patient suffered a periprocedural MI. At 586 ± 431 days, 18 patients (29%) experienced MACE, 12 patients (19%) died (the mortality rate was 47% in patients with cardiogenic shock), and target vessel revascularization was performed in four patients, all of whom had distal bifurcation involvement (two patients underwent repeat PCI and two patients underwent bypass surgery). There was no additional MI. Two patients had probable stent thrombosis and one had possible stent thrombosis. Diabetes [hazard ratio (HR) 4.22, 95% confidence interval (CI) (1.07–17.36), P = 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90–0.98), P = 0.005), and intubation [HR 7.00, 95% CI (1.62–30.21), P = 0.009) were significantly associated with increased mortality. Conclusions: Patients with MI and ULMCA disease represent a very high‐risk subgroup of patients who are critically ill. PCI with DES appears to be technically feasible, associated with acceptable long‐term outcomes, and a reasonable alternative to surgical revascularization for MI patients with ULMCA disease. Randomized trials are needed to determine the ideal revascularization strategy for these patients. © 2008 Wiley‐Liss, Inc.     

A Comparison Between Coronary Artery Bypass Grafting Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease

Background:

Unprotected left main coronary artery (ULMCA) disease occurs in 3% to 5% of patients with coronary artery disease and is mainly treated by coronary artery bypass grafting (CABG) surgery. Drug‐eluting stents (DESs) have renewed interest for the percutaneous coronary intervention (PCI) treatment of ULMCA stenosis. This study compared the long‐term clinical outcome of PCI with DESs or CABG in real world patients with ULMCA disease.

Hypothesis:

PCI with DESs may be a better treatment for ULMCA disease compared with CABG.

Methods:

Consecutive patients who had coronary revascularization because of ULMCA disease in Zhongshan Hospital, from May 2003 to November 2009, were retrospectively enrolled. They were classified in the PCI or the CABG group according to treatments that were given initially. Of 515 patients having follow‐up data, 233 were treated by PCI, whereas 282 were treated by CABG. The patients in the CABG group were of older age, had higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Synergy Between PCI With Taxus Drug‐Eluting Stent and Cardiac Surgery (SYNTAX) scores, and had longer hospitalization stays than the PCI group.

Results:

At the end of follow‐up, there was no difference in major adverse cardiac and cerebrovascular events between the 2 groups. However, the incidence of cardiac death (0.4% vs 4.6%) in the PCI group was less than that in the CABG group, whereas target vessel revascularization (7.3% vs 3.2%) was higher in the PCI group.

Conclusions:

In ULMCA disease, CABG tends to be chosen in patients with higher risk according to the EuroSCORE and SYNTAX scores. PCI with DESs seemed to have favorable early and long‐term clinical outcomes compared with CABG in our center. Clin. Cardiol. 2012 DOI: 10.1002/clc.22070 Qing Qin, MD, and Juying Qian, MD, contributed equally to this work. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Drug eluting stents versus coronary artery bypass surgery in patients with isolated proximal lesion in left anterior descending artery suffering from chronic stable angina.

OBJECTIVE: To compare the efficacy of drug eluting stents (DES) compared with bypass surgery (CABG) with left internal mammary artery (LIMA) in patients with single vessel disease suffering from chronic stable angina. BACKGROUND: There are a limited number of studies investigating this group of patients. METHODS: We included 257 consecutive patients with isolated lesion in the proximal segment of left anterior descending artery (LAD). All patients suffered from chronic stable angina or from stress-induced ischemia. Of 257 patients, 147 underwent DES implantation and 110 CABG with LIMA. All patients were followed-up clinically for major adverse cardiac events. RESULTS: The baseline demographic and angiographic characteristics were similar between the two groups. In the DES group we used sirolimus-, paclitaxel-, and ABT-578-eluting stents. The mean duration of hospitalization after CABG was 7.86 +/- 3.84 days vs. 1.02 +/- 0.19 days after PCI (P < 0.01). The incidence of MACE was 2.72% in the DES and 2.72% in the surgical group during a mean follow-up period of 18.71 +/- 6.27 months for PCI and 18.70 +/- 7.31 months for CABG (P = 0.99). There was one cardiac related death in the DES group and two in the surgical group (P = 0.58). There were three reinterventions in the DES group versus none in the surgical group (P = 0.26). Recurrence of angina was observed in 4.08% of pts in the DES group versus 6.36% in the CABG group (P = 0.57). CONCLUSIONS: The present study demonstrated that patients suffering from chronic stable angina with isolated lesion in the proximal segment of LAD have excellent long-term outcome in both surgical and DES treatment.