无保护左主干病变不同治疗策略远期临床效果

目的观察无保护左主干(ULM)冠状动脉病变不同治疗策略远期临床效果。方法比较211例冠状动脉内药物洗脱支架置入术(DES)(DES组)和176例冠状动脉搭桥术(CABG)(CABG组)治疗ULM病变后远期主要心脑血管事件(MACCE)发生率。结果 DES组远期再次血运重建率明显高于CABG组,心源性病死率明显低于CABG组(P<0.05)。采用倾向性得分法分析,血运重建方式与远期MACCE、总病死、心源性病死、心肌梗死和脑卒中发生率未见明显相关(P>0.05);DES与远期再次血运重建率明显相关,风险比为3.050,95%可信区间(1.289,7.217),P<0.05。结论与DES比较,CABG治疗的ULM病变患者临床状态更复杂,冠状动脉病变更严重。DES是接受血运重建的ULM病变患者远期再次血运重建的独立预测因子。     

2型糖尿病合并冠心病多支血管病变血运重建方式选择

目的：比较2型糖尿病（type 2 diabetes mellitus,T2DM）合并冠心病多支血管病变患者接受经皮冠状动脉介入治疗（ percutaneous coronary intervention ,PCI）或冠状动脉旁路移植术（ coronary artery by-pass graft,CABG）3年后的预后情况,探讨该类患者如何选择再血管化治疗方式。方法选择2009年5月1日至2010年5月31日于天津市胸科医院连续进行的冠状动脉造影（ coronary angiography ,CAG）确诊T2DM伴多支血管病变并成功行PCI或CABG治疗且病例及随访资料完整者,进行为期3年的随访,收集患者一般情况、临床指标、实验室检查指标等信息,分析死亡、心肌梗死、再次血运重建、再发心绞痛、心力衰竭、卒中等主要不良心脑血管事件（ major adverse cardio cerebral events ,MACCE）。结果3年期随访显示,PCI组MACCE发生率显著高于CABG组（31.58％ vs 17.68％,P＜0.01）,PCI组心源性死亡（4.82％vs 1.10％,P＜0.05）、心肌梗死（4.39％ vs 1.10％,P＜0.05）及再发心绞痛（17.27％ vs 10.50％, P＜0.05）发生率较高。结论与PCI相比,CABG仍然是目前T2DM合并多支血管病变患者血运重建治疗的更好方法。     

Coronary stenting versus bypass surgery in heart failure patients with preserved ejection fraction

Background  The optimal revascularization strategy in patients with heart failure with preserved ejection fraction (HFPEF) remains unclear. The aim of the present study was to compare the effects of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with HFPEF.

Methods  From July 2003 through September 2005, a total of 920 patients with coronary artery disease (CAD) and HFPEF (ejection fraction ≥50%) underwent PCI (n=350) or CABG (n=570). We compared the groups with respect to the primary outcome of mortality, and the secondary outcomes of main adverse cardiac and cerebral vascular events (MACCE), including death, myocardial infarction, stroke and repeat revascularization, at a median follow-up of 543 days.

Results  In-hospital mortality was significantly lower in the PCI group than in the CABG group (0.3% vs. 2.5%, adjusted P=0.016). During follow-up, there was no significant difference in the two groups with regard to mortality rates (2.3% vs. 3.5%, adjusted P=0.423). Patients receiving PCI had higher MACCE rates as compared with patients receiving CABG (13.4% vs. 4.0%, adjusted P <0.001), mainly due to higher rate of repeat revascularization (adjusted P <0.001). Independent predictors of mortality were age, New York Heart Association (NYHA) class and chronic total occlusion.

Conclusion  Among patients with CAD and HFPEF, PCI was shown to be as good as CABG with respect to the mortality rate, although there was a higher rate of repeat revascularization in patients undergoing PCI.

     

COMPARISON BETWEEN CORONARY ARTERY BYPASS SURGERY AND DRUG-ELUTING STENTS IMPLANTATION TO DIABETIC PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE

Objective To evaluate the safety and efficacy of drug-elating stents （DES） implantation in diabetic patients with multivessel coronary artery disease （MVD） compared with coronary artery bypass graft （CABG） on the clinical outcomes. Methods From May 2003 to April 2005, 150 consecutive type 2 diabetic patients with MVD underwent revascularization, 84 by percutaneous coronary intervention （PC1） with DES and 66 by CABG. The study end point was the incidence of major adverse cardiovascular events （MACEs） during hospital interval after procedure and follow-up. Results Most preoperative characteristics were similar in two groups, but left main disease （30% vs 4%, P = 0. 001 ） and three-vessel disease （ 70% vs 54%, P = 0. 045 ） were more prevalent in CABG group. Complete revascularization was achieved in more patients in CABG group than that in PC1 group （82% vs 67%, P =0. 037）. Cumulative incidence of MACEs in hospital was similar between two groups （2.4% PC1 vs 9. 1% CABG , P =0. 069） despite the higher early morbidity （6. 1% vs 0%, P =0. 022） associated with CABG. Patients were followed up clinically for a mean of 18 - 8 months （ range 13- 36 months）. The incidence of MACEs remained higher after PC1 with multiple DES （21.4% vs 9. 1%, P =0. 041 ） mainly driven by a more require for repeat revascularization （ 13. 1% vs 3. 0%, P = 0. 030 ）. Conclusion PC1 with DES implantation, combined with tight glycemic control, aggressive cardiovascular risk factor modification and antiplatelet treatment, may be a safe and feasible alternative to CABG for selected diabetic patients with multivessel disease.     

SYNTAX评分系统在冠脉多支病变患者血运重建方式选择中的应用

目的应用SYNTAXSCORE评估冠状动脉多支病变的复杂程度及其与临床事件的相关性,探讨它对多支病变患者临床结果的预测价值和冠脉多支病变患者的最佳血运重建方式．方法回顾性分析2006年1月至2013年1月经冠脉造影证实为多支病变并接受药物洗脱支架治疗（PCI-DES）和冠脉旁路移植术（CABG）的316例患者．其中CABG组151例,PCI-DES组165例．收集患者的基本情况、SYNTAX评分、冠脉旁路移植手术和PCI手术情况,并通过门诊或电话随访主要不良心脑血管事件（MACCE）,包括全因死亡、非致命性心肌梗死、再次血运重建、中风以及冠脉造影复查情况．结果（1）PCI-DES与CABG2组在患者基线资料方面相比无显著性差异（P〉0．05）．（2）住院期间CABG组的MACCE事件发生率较PCI组高（P〈0．05）．术后36个月随访,2组的MACCE发生率及无MACCE生存率比较差异无统计学意义（P〉0．05）,但PCI组靶血管再次血运重建率（TvR）都明显高于CABG组（P〈0．05）．（3）PCI-DES和CABG2组间SYNTAXSCORE评分差异无统计学意义（P〉0．05）．多因素分析结果显示,SYNTAX积分〉24分是MACCE的独立预测因子（P=O．O1,OR=18．715,95％可信区间1．316至273．624）．PCI-DES组中,高积分亚组术后36个月MACCE事件发生率明显多于低积分亚组〈24．0（P〈0．01）．CABG组中,高积分和低积分两亚组术后36个月MACCE事件发生率及无MACCE事件生存率比较差异无统计学意义（P〉0．05）．高积分患者中,术后36个月PCI-DES亚组MACCE事件发生率高于CABG亚组（P〈0．05）．低积分患者中,术后36个月MACCE事件发生率CABG亚组高于PCI-DES亚组（P〉0．05）．结论SYNTAX评分系统在冠脉多支病变患者血管重建方式的选择和预后评估中具有重要价值．     

Major risk-stratification models fail to predict outcomes in patients with multivessel coronary artery disease undergoing simultaneous hybrid procedure

Background  The hybrid procedure for coronary heart disease combines minimally invasive coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) and is an alternative to revascularization treatment. We sought to assess the predictive value of four risk-stratification models for risk assessment of major adverse cardiac and cerebrovascular events (MACCE) in patients with multivessel disease undergoing hybrid coronary revascularization.

Methods  The data of 120 patients were retrospectively collected and the SYNTAX score, EuroSCORE, SinoSCORE and the Global Risk Classification (GRC) calculated for each patient. The outcomes of interest were 2.7-year incidences of MACCE, including death, myocardial infarction, stroke, and any-vessel revascularization.

Results  During a mean of 2.7-year follow-up, actuarial survival was 99.17%, and no myocardial infarctions occurred. The discriminatory power (area under curve (AUC)) of the SYNTAX score, EuroSCORE, SinoSCORE and GRC for 2.7-year MACCE was 0.60 (95% confidence interval 0.42–0.77), 0.65 (0.47–0.82), 0.57 (0.39–0.75) and 0.65 (0.46–0.83), respectively. The calibration characteristics of the SYNTAX score, EuroSCORE, SinoSCORE and GRC were 3.92 (P=0.86), 5.39 (P=0.37), 13.81 (P=0.32) and 0.02 (P=0.89), respectively.

Conclusions  In patients with multivessel disease undergoing a hybrid procedure, the SYNTAX score, EuroSCORE, SinoSCORE and GRC were inaccurate in predicting MACCE. Modifying risk-stratification models to improve the predictive value for a hybrid procedure is needed.

     

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background:

There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events.

Methods:

All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups.

Results:

Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3–8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group.

Conclusions:

During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.     

冠状动脉慢性完全闭塞性病变治疗策略选择的相关影响因素

目的从临床基线资料、病变影像学特征等方面,对影响冠状动脉慢性完全闭塞性(CTO)病变治疗策略选择的相关因素进行探讨。方法 2004年1月—2008年12月在复旦大学附属中山医院经冠状动脉造影检查发现的完全闭塞性病变患者1485例,其中638例确诊为CTO病变,平均年龄为(64.1±11.0)岁。依据首选经皮冠状动脉介入治疗(PCI)、行冠状动脉旁路移植术(CABG)或因无法耐受手术而接受单纯药物治疗将患者分为PCI组(447例)和非PCI组(191例),比较两组间临床基线资料及病变特点等方面的差异。结果 PCI组患者的平均年龄为(63.4±10.4)岁,显著小于非PCI组的(65.7±12.0)岁(P<0.05);中位胸痛时间为160(24,262)周,显著短于非PCI组的242(40,382)周(P<0.05);两组间性别构成及高血压、高血脂、心肌梗死、糖尿病患者的构成比的差异均无统计学意义(P值均>0.05)。PCI组患者的总胆固醇及低密度脂蛋白胆固醇水平分别为(4.18±1.1)和(2.28±1.00)mmol/L,均显著低于非PCI组的(4.39±1.19)及(2.55±1.08)mmol/L(P值分别<0.05、0.01);两组间血清葡萄糖、三酰甘油、高密度脂蛋白胆固醇、肌钙蛋白T、肌酸激酶同工酶和氨基末端脑钠素前体水平的差异均无统计学意义(P值均>0.05)。PCI组冠状动脉造影检查示近段血管严重迂曲、病变钙化、靶血管开口闭塞,以及合并三支病变、左主干病变及靶血管外闭塞的发生率均显著低于非PCI组(P值均<0.01);而闭塞端缺如的发生率显著高于非PCI组(P<0.01)。多元逐步Logistic回归分析结果显示,胸痛时间>3年(OR=0.998,95%CI0.997～1.000,P=0.004)、合并三支病变(OR=0.288,95%CI0.172～0.482,P=0.000)及靶血管开口闭塞(OR=0.288,95%CI0.172～0.482,P=0.000)为CTO病变行PCI的独立负性预测因素。结论胸痛时间>3年、靶血管开口闭塞、合并三支病变为CTO病变行PCI的独立负性预测因素,应权衡患者的临床因素及病变特点选择个体化的治疗策略。     

Can “Hybrid stent implantation” improve long-term safety without adversely affecting efficacy when treating multilesion coronary artery disease in the drug-eluting stent era?

Background  Though drug-eluting stent (DES) almost solved a problem of restenosis, safety issues related to stent thrombosis are still the major concern of DES. We hypothesized that hybrid stent implantation may decrease the use of DES, probably improving the long-term safety but not affecting efficacy adversely when treating multilesion coronary artery disease in the DES era.

Methods  From April 2004 to October 2006, 848 patients with multilesion disease underwent hybrid stent implantation. During the same period 5647 patients with multilesion coronary heart disease were treated by exclusive DES implantation in Fu Wai Hospital. According to propensity score matching, we chose 823 pairs of patients with multileison coronary artery disease for inclusion into our study. We obtained the 24-month clinical outcome including death, myocardial infarction (MI), thrombosis, target lesion revascularization (TLR), target vessel revascularization (TVR), and major adverse cardiac events (MACE, the composite of death, MI, and TVR). We used Cox’s proportional-hazard models to assess relative risks of all the outcome measures after propensity match.

Results  At 24 months, patients in the hybrid stent implantation group showed a significantly higher risk of TLR (8.39% vs. 3.28%, HR 2.38, 95% CI: 1.50–3.70), TVR (11.07% vs. 6.32%, HR 1.61, 95% CI: 1.15–2.27) and MACE (13.75% vs. 8.75%, HR 1.37, 95% CI: 1.02–1.85). No significant difference was apparent in terms of mortality (1.22% vs. 1.70%, HR 0.55, 95% CI: 0.24–1.25), MI (1.95% vs. 2.31%, HR 0.73, 95% CI: 0.37–1.42), or thrombosis (definite+probable) (0.73% vs. 1.58%, HR 0.40, 95% CI: 0.15–1.05).

Conclusions  In patients with multilesion coronary artery disease, the exclusive DES implantation was associated with significantly lower risks of TLR, TVR and MACE, and the hybrid stent implantation did not result in any significant improvements regarding safety issues. Prospective studies are needed to confirm our results.

     

Long-term efficacy and safety of drug-eluting stent implantation for patients with multiple coronary chronic total occlusions

Background Data on the efficacy and safety of drug-eluting stent （DES） for treatment of multiple coronary chronic total occlusion （CTO） lesions are scanty. The aim of the present study was to compare the long-term outcomes of DES versus bare metal stent （BMS） implantation for multiple coronary CTO lesions.Methods We analyzed 188 patients who underwent coronary stenting for at least two de novo CTO lesions in our center from November 2000 to November 2006. Among them, 118 patients （62.8%） received DES and 70 patients （37.2%） received BMS implantation after the recanalization for CTO lesions. All patients were followed up for up to 5 years for the occurrence of major adverse cardiac events （MACE）. Long-term survival rates were estimated with the Kaplan-Meier method.Results There were no significant differences in baseline clinical characteristics and procedural success rate between DES group and BMS group. Compared with the BMS group, the DES group showed a significantly higher rate of long CTO （≥15 mm） （62.0% vs. 50.6%, P=0.023）. The number of stents per lesion （1.39±0.71 vs. 1.17±0.66, P=0.007） and the mean length of stents in the DES group were also higher than those in the BMS group （（40.8±11.4） mm vs. （23.4±8.7） mm, P〈0.001）. But the mean diameter of stents in the DES group was smaller than that in the BMS group （（3.1 ±0.2） mm vs. （3.3±0.5） mm, P〈0.001）. Average follow-up time was 4.8±0.7 （1.5-5.0） years in the BMS group and 4.3±0.5 （1.3-5.0） years in the DES group. Both the 5-year cumulative survival rates and the target vessel revascularization （TVR）-free survival rates of the DES group were significantly higher than those in the BMS group （83.1% vs. 72.9%, Log-rank P=0.044; 77.1% vs. 62.9%, Log-rank P=0.009）. The cumulative MACE-free survival rates in the DES group were significantly higher than those in the BMS group （71.2% vs. 51.4%, Log-rank P=0.001）. Multivariable Cox regression analysis demonstrated that DES implantation for multiple CTO lesions could significantly reduce the long-term MACE risk after percutaneous coronary intervention （PCI） （HR. 0.436; 95%C/ 0.327-0.665, P 〈0.001）. Age over 65 years （HR. 2.018; 95%CI1.491-3.127, P〈0.001） and left ventricular ejection fraction 〈50% （HR. 1.494; 95%CI1.125-2.376, P 〈0.001） were identified as the independent predictors of long-term MACE.Conclusion This study demonstrates the long-term （up to 5 years） efficacy and safety of DES for treatment of multiple coronary CTO lesions, and its superiority compared to BMS in reducing the rates of TVR and MACE.     

经皮冠脉介入治疗老年冠心病患者的预后及其影响因素

［摘要］目的: 分析老年(≥65岁)冠心病患者接受经皮冠脉介入治疗(PCI)术后影响其预后的因素。方法: 入选3 473例接受PCI术的冠心病患者,根据年龄分为老年组(≥65岁, n=2 005)和非老年组 (＜65岁, n=1 468),对患者进行随访,随访时间中位数为577 d,比较并分析两组患者预后的差异及其影响因素。结果： PCI术后老年组总死亡率(3.6%)及主要心脑血管不良事件（MACCE）发生率(12.3%)均明显高于非老年组（分别为1.5%和3.3%,P均<0.001)。相较于非老年组,老年组患者高血压、糖尿病、脑血管病及陈旧性心肌梗死患病率和完全血运重建率明显增加。冠脉病变更严重,ST段抬高型心肌梗死、3支病变、左主干病变及慢性闭塞性病变发生率高,而内生肌酐清除率则明显低于非老年组。Cox多因素回归分析显示,糖尿病(HR=1.857,95% CI：1.121~3.142,P=0.012),陈旧性心肌梗死史(HR=2.211,95% CI:1.113~4.112, P=0.015),3支血管病变(HR=1.751,95% CI:1.135~2.653, P=0.006)及老年(HR=4.585,95% CI:2.013~9.201, P<0.001)是总死亡率增加的独立危险因素;而左主干病变(HR=1.976,95%CI:1.173~2.874,P<0.001) ,内生肌酐清除率(HR=1.975,95%CI:1.101~3.215,P<0.001 )及3支血管病变(HR=1.573,95%CI:1.263~1.886,P<0.001)是MACCE发生率增加的独立危险因素。 结论： 糖尿病、3支血管病变、老年是老年冠心病患者PCI全因死亡率增加的独立危险因素,而左主干病变、内生肌酐清除率、3支血管病变是MACCE发生率增加的独立危险因素。     

药物洗脱支架对首诊心内科患者转行冠状动脉搭桥治疗的影响

目的了解药物洗脱支架（DES）对首诊于心内科的冠心病患者转诊行冠状动脉搭桥术（CABG）的影响。方法入选2001年7月1日至2002年6月30日（BMS时代）以及2003年7月1日至2004年6月30日（DES时代）首诊于北京安贞医院心内科并接受经皮冠状动脉介入（PCI）或冠状动脉搭桥（CABG）的2598例患者,分析BMS时代与DES时代患者转行CABG术的临床及冠状动脉病变特征,评价DES对转诊CABG治疗的影响。结果DES时代1333例（80．1％）患者接受PCI治疗,331例（19．9％）患者转行CABG术,BMS时代721例（77．2％）患者接受PCI治疗,213例（22．8％）患者转行CABG术,转诊率下降约12．7％。与BMS时代相比,DES时代左主干病变（1．4％比3．2％,P=0．025）前降支近端（39．8％比44．2％,P=0．047）与弥漫长病变患者（11．2％比19．7％,P=0．021）接受PCI治疗的比例明显增加,但无论是否置入DES,左主干病变、慢性闭塞病变、前降支近段病变以及开口病变的患者仍是接受CABG治疗的最常见冠状动脉病变类型。DES时代接受PCI治疗的患者再次血管重建率明显低于BMS时代（12．7％比7．1％,P〈0．001）。多变量Logistic分析显示,病变血管支数、左主干病变、慢性闭塞病变以及前降支近端病变是选择CABG的主要预测因素。结论DES对冠心病患者血管重建方式及策略产生了一定的影响,在非DES时代需要转诊行CABG治疗的冠状动脉病变,在DES时代接受PCI治疗置入DES。     

非顺应球囊后扩张对置入药物洗脱支架预后的影响

目的评估使用非顺应性球囊后扩张对经置入药物洗脱支架冠状动脉粥样硬化性心脏病(以下简称冠心病)患者的疗效。方法回顾性分析2011年1月至2011年5月共356例行药物洗脱支架植入且使用非顺应性球囊后扩张的患者,采用倾向性评分抽取同期356例行药物洗脱支架植入术而未后扩张的患者与之1∶1匹配。结果 2组在年龄、性别、临床表现、主要危险因素及冠状动脉病变特征方面比较,差异无统计学意义(P>0.05),具有可比性。平均随访时间18个月,后扩张组主要不良心血管事件(major adverse cardiac events,MACE)明显低于未后扩张组(10.1%vs 15.7%,P=0.020),主要是靶血管重建(6.2%vs10.7%,P=0.010)、支架内血栓(1.1%vs 3.7%,P=0.030)发生率比较,差异有统计学意义(P<0.05),而心肌梗死(3.9%vs4.6%,P=0.700)、死亡(1.1%vs 1.7%,P=0.760)比较,差异没有统计学意义。结论冠心病患者置入药物洗脱支架后使用非顺应性球囊后扩张安全,可改善患者的临床预后。     

临床SYNTAX积分预测行经皮冠状动脉介入治疗复杂冠心病患者预后作用的研究

目的探讨临床SYNTAX积分对行经皮冠状动脉介入治疗(PCI)冠心病患者预后的预测作用。方法回顾性分析2007年1月—2008年12月北京安贞医院经造影证实三支病变和(或)左主干病变并接受PCI的患者。对每1例患者进行临床SYNTAX积分,通过门诊或电话随访患者主要不良心脑血管事件(MACCE)。结果随访期间29例患者发生MACCE,其中低分组7例,发生率14.9%;中分组5例,发生率9.8%;高分组17例,发生率30.6%。中分组与低分组比较差异无统计学意义[HR=0.70,95%CI(0.22,2.19),P=0.53];高分组与中分组比较差异有统计学意义[HR=3.87,95%CI(1.43,10.49),P=0.008];高分组与低分组比较差异有统计学意义[HR=1.66,95%CI(1.07,2.57),P=0.025]。Cox比例危险模型预测MACCE单因素分析结果显示,临床SYNTAX积分和糖尿病是MACCE的独立风险预测因子(P<0.05)。Cox多因素分析将临床SYNTAX积分和糖尿病作为协变量纳入模型,分析结果显示两者均为MACCE的独立预测因子(P<0.05)。结论临床SYNTAX积分是预测PCI预后的较理想工具,该积分系统也适用于中国冠心病三支病变和(或)左主干病变患者PCI术后预后的预测。     

Outcomes of Second Revascularization Procedures after Stent Implantation

Drug-eluting stents (DES) reduce subsequent revascularization procedures. Although randomized trials have compared DES to brachytherapy and balloon angioplasty (PTCA) for in-stent restenosis, few long-term comparisons have been made to bare metal stents (BMS) or bypass surgery (CABG), particularly following second procedures. We sought to assess the association between revascularization modality and long-term clinical outcomes of patients receiving a second procedure for coronary artery disease. Between January 2000 and July 2005, 4,666 consecutive patients underwent initial coronary stent implantation (DES or BMS). From this population we identified 569 patients undergoing a second target vessel revascularization (DES, BMS, PTCA or CABG). Outcomes were assessed at 6, 12, and 24 months after the second procedure, with follow-up through September 2006. Adjusted cumulative incidence rates were calculated using inverse probability weighted estimators. We found that at 24 months, there were no significant differences in death or myocardial infarction for PTCA, BMS, DES, and CABG (17.7%, 14.9%, 7.5%, and 10.2%, p = 0.26[3df]). DES patients had lower rates of death or myocardial infarction or third target vessel procedures than patients receiving PTCA (14.6% vs. 30.0%, p = 0.01) and BMS (14.6% vs. 42.2%, p < 0.01), but rates similar to CABG patients (14.6% vs. 14.6%, p = 0.99). For patients undergoing a second revascularization procedure, PTCA, BMS, DES, and CABG are associated with a similar risk of death or non-fatal myocardial infarction. DES and CABG are associated with lower rates of third revascularization procedures compared to PTCA and BMS. Further studies are needed to determine the optimum application for CABG vs. DES as a second or third revascularization procedure.     

临床 SYNTAX 积分和 SYNTAX 积分预测复杂冠状动脉性心脏病 患者经皮冠状动脉介入治疗预后的对比研究

目的比较临床SYNTAX积分和SYNTAX积分对冠状动脉性心脏病(简称冠心病)3支病变和/或左主干病变患者经皮冠状动脉介入治疗(PCI)预后的预测作用。方法回顾性分析2007年1月至2008年12月北京安贞医院经造影证实3支病变和/或左主干病变并接受PCI治疗的患者。对每例患者进行SYNTAX积分和临床SYNTAX积分,通过门诊或电话随访患者主要不良心脑血管事件(MACCE),包括全因死亡、非致命性心肌梗死、再次血运重建、中风等。结果符合入选条件的患者总计190例,其中29例观察到MACCE,MACCE发生率18.5%。多因素分析结果显示,临床SYNTAX积分和SYNTAX积分均为MACCE的独立预测因子[临床SYNTAX积分,风险比(HR):2.07,95%可信区间(CI):1.25～3.44,P=0.005;SYNTAX积分,HR:1.86,95%CI:1.14～3.06,P=0.014]。受试者工作特征(ROC)曲线分析显示,SYNTAX积分曲线下面积(AUC)=0.667(95%CI:0.564～0.770,P=0.004),临床SYNTAX积分AUC=0.636(95%CI:0.519～0.753,P=0.020),两者均对MACCE有预测价值,加入了年龄肌酐射血分数(ACEF)积分的临床SYNTAX积分未能提高SYNTAX积分对MACCE的预测能力。结论临床SYNTAX积分和SYN-TAX积分均是预测复杂冠心病患者PCI预后的较理想工具,且临床SYNTAX积分并不优于SYNTAX积分。     

冠心病血运重建患者再发主要不良心血管事件危险因素的临床研究

目的探讨冠心病患者接受血运重建后再次发生主要不良心血管事件（MACCE）的危险因素。方法选择于我院接受血运重建治疗的患者为研究对象,记录其临床基本资料、生化指标、冠脉造影及血运重建情况。比较随访期间发生MACCE和未发生MACCE患者上述指标的差异,并采用Logistic回归分析法进行多因素分析,探讨冠心病血运重建患者再发MACCE的危险因素。结果（1）MACCE组老龄（年龄≥65岁）、男性、糖代谢异常、三支病变及MS患者所占比例均高于非MACCE组,差异有统计学意义（P〈0．05）;（2）Logistic回归分析显示代谢综合征（MS）、三支病变及高龄均为MACCE的危险因素。结论在冠心病血运重建患者中,MS、三支病变及高龄为再发MACCE的危险因素。     

Comparison of drug-eluting stents with bare metal stents implantation for the treatment of acute ST-elevation myocardial infarction: 2-year clinical outcomes from single-center registry

Background  Some larger scale, randomized studies have demonstrated the superiority of drug-eluting stents (DES) over bare metal stents (BMS) for the treatment of acute myocardial infarction (AMI). This study aimed to investigate the impact of DES, in comparison with BMS, on the 2-year clinical outcomes in patients with ST-elevation myocardial infarction (STEMI).

Methods  From January 2002 to December 2008, a total of 1301 consecutive STEMI patients treated with coronary stenting in Shenyang Northern Hospital were prospectively registered. Patients received BMS (n=868) or DES (n=435) implantation in the infarction related artery according to physician’s discretion. A propensity score analysis was performed and two well matched subgroups were selected (BMS, n=288; DES, n=288) to evaluate the 2-year clinical outcomes. The primary outcome was the occurrence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, myocardial infarction (MI), or target vessel revascularization (TVR).

Results  Survival salvage analysis showed that 2-year cumulative hazards were not significantly different between the two groups with respect to TVR (2.8% vs. 3.1%, log-rank P=0.780), stent thrombosis (1.7% vs. 4.2%, log-rank P=0.079) and MACE (8% vs. 10.8%, log-rank P=0.236). Multivariate analysis showed that DES was an independent protective factor of MI (HR: 0.211, 95% CI: 0.049 to 0.908) and stent thrombosis (HR: 0.327, 95% CI: 0.107 to 0.994).

Conclusion  DES was associated with similar 2-year clinical outcomes to those of BMS for the treatment of STEMI in daily practice.

     

Clinical outcomes after recanalization of a chronic total occluded vessel with bifurcation lesions: results from single-center, prospective, chronic total occlusion registry study

Background  Stenting strategies and clinical outcomes of bifurcation lesions in a chronic total occlusion (CTO) vessel after successful recanalization remain to be unknown.

Methods  Between January 2001 and December 2009, 195 (41.1%) patients with 254 (47.0%) bifurcation lesions in CTO vessels from a pool of 564 patients with 659 CTO lesions were included and divided into proximal (n=134) and distal (n=120) groups, according to the location of the bifurcation lesions. The primary endpoint was the occurrence of major adverse cardiac events (MACE) at the end of clinical follow-up, including cardiac death, myocardial infarction, or target vessel revascularization (TVR).

Results  Collaterals with Rentrop class 3 were seen more in distal group (100% and 68.3%), compared to proximal group (76.9% and 45.6%). Two-stent technique for proximal bifurcation lesions was used in 24.6%, significantly different from the distal group (6.7%, P <0.001), without significant difference in composite MACE between proximal and distal groups, or between one- and two-stent subgroups in proximal group. The composite MACE after 1-year in complete revascularization subgroup was 17.9% relative to 29.6% in the incomplete revascularization group (P=0.044). Stents in long false lumen in main vessel were mainly attributive to decreased TIMI grade flow, with resultant increased in-stent restenosis, total occlusion, TVR and coronary aneurysms. Imcomplete revasculzarization (HR 2.028, P=0.049, 95% CI 1.002–4.105) and post-stenting TIMI flow (HR 6.122, P=0.020, 95% CI 1.334–28.092) were two independent predictors of composite MACE at the 1-year follow-up.

Conclusions  Two-stent was more used for proximal bifurcation lesions. No significant difference was observed in MACE between proximal and distal, or between one- and two-stent subgroups in the proximal group. Placement of a safety wire was critical for proximal bifurcation lesions. Complete revascularization was mandatory to improve clinical outcomes.

     

Impact of depressed left ventricular function on outcomes in patients with three-vessel coronary disease undergoing percutaneous coronary intervention

Background  Patients with multivessel coronary artery disease and depressed left ventricular ejection fraction (LVEF) represent a high risk group of patients for coronary revascularization. There are limited data on percutaneous coronary intervention treatment in this population.  

Methods  Among a cohort of 4335 patients with three-vessel disease with or without left main disease undergoing percutaneous coronary intervention, 191 patients had LVEF <40% (low ejection fraction (EF)) and 4144 patients had LVEF ≥40%. In-hospital and long-term outcomes were examined according to LVEF.

Results  The estimated two-year rates of major adverse cardiac events, cardiac death, and myocardial infarction were significantly higher in the low EF group (19.64% vs. 8.73%, Log-rank test: P <0.01; 10.30% vs. 1.33%, Log-rank test: P <0.01, and 10.32% vs. 2.28%, Log-rank test: P <0.01 respectively), but there was no difference in the rates of target vessel revascularization (6.18% vs. 6.11%, Log-rank test: P=0.96). Using the Cox proportional hazard models, LVEF <40% was a significant risk factor for cardiac death, myocardial infarction, and major adverse cardiac events (OR (95% CI): 4.779 (2.369–9.637), 2.673 (1.353–5.282), and 1.827 (1.187–2.813) respectively), but was not a statistically significant risk factor for target vessel revascularization (OR (95% CI): 1.094 (0.558–2.147)).

Conclusion  Among patients undergoing percutaneous coronary intervention for multivessel coronary artery disease, left ventricular dysfunction remains associated with further risk of cardiac death in-hospital and during long-term follow-up.