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.     

Restoration of patency of left internal mammary artery graft with progression of the underlying left anterior descending coronary artery disease

The use of the left internal mammary artery (LIMA) to graft a borderline lesion in the left anterior descending coronary artery (LAD) has been associated with distal narrowing and occlusion of the LIMA. We present a patient in whom the LIMA occluded 1 year after coronary artery bypass, but was found to be fully patent 4 years later, after progression of the native LAD disease. Cathet. Cardiovasc. Diagn. 42:213–215, 1997. © 1997 Wiley-Liss, Inc.     

Coronary artery bypass graft surgery in dialysis patients

Objective—To examine the short term results and long term survival of patients on long term dialysis undergoing coronary artery bypass graft surgery.
Methods—A retrospective analysis of 19 patients on established dialysis who underwent coronary revascularisation between 1983 and 1995; 14 patients (73%) had class IV angina and five (25%) had unstable angina requiring heparin and nitrate infusions before surgery.
Results—The 30 day mortality was 5%. Follow up was completed in the remaining 18 patients. The mean follow up time was 34 months (range eight to 61). During the follow up period four patients died of cardiac causes. The actuarial survival at one, two, and three years was 87%, 78%, and 59%, respectively. The overall functional status was significantly improved compared to preoperative levels, with a mean Karnofsky score of 76% (p < 0.01) at three years.
Conclusions—Coronary artery bypass graft surgery can be performed with increased but acceptable morbidity and mortality in chronic dialysis patients. It results in considerable improvement in symptoms and functional status. However, long term survival is limited and this requires further investigation.

     

Minimally invasive coronary artery bypass grafting versus stenting for patients with proximal left anterior descending coronary artery disease

The purpose of this study was to compare the clinical outcomes of stenting and minimally invasive coronary artery bypass grafting (MIDCAB) in patients with proximal left anterior descending (LAD) coronary artery disease. The Patency, Outcome, Economics of Minimally invasive direct coronary bypass (POEM) study demonstrated that MIDCAB had similar safety and long-term efficacy for LAD revascularization compared with conventional coronary artery bypass grafting. Although LAD stenting is superior to conventional balloon angioplasty, whether it is comparable to MIDCAB is not known. We identified a matched population of 429 consecutive patients with 1-vessel disease who underwent elective proximal LAD stenting and compared their clinical outcomes with those of the 152 patients in the MIDCAB group of the POEM study. The in-hospital event rate was similar in both groups, except for a shorter length of hospital stay with LAD stenting compared with MIDCAB (2.68 vs 4.07 days, p <0.0001). At 6-month follow-up, the incidence of death and Q-wave myocardial infarction or that of cerebrovascular accident was not significantly different between these 2 groups. However, target vessel revascularization was significantly higher with LAD stenting than MIDCAB (13.3% vs 6.6%, p = 0.045). In the subgroup of patients without diabetes, all clinical events were similar in both groups, and the benefit of a shorter hospital stay associated with stenting was maintained. Compared with MIDCAB, LAD stenting is associated with higher repeat revascularization rates but offers the advantage of shorter hospitalization. For nondiabetics with proximal LAD disease, stenting may be the revascularization strategy of choice.     

Comparative long-term efficacy and safety of drug-eluting stent versus coronary artery bypass grafting in ostial left main coronary artery disease: analysis of the MAIN-COMPARE registry

Background : To date, drug‐eluting stent (DES) implantation has not been compared with coronary artery bypass grafting (CABG) for ostial left main coronary artery (LMCA) lesions. Methods : Of the 263 patients in the MAIN‐COMPARE registry with ostial LMCA stenosis, 123 were treated with percutaneous coronary intervention (PCI) with DES and 140 with CABG. We compared their 5‐year overall survival, composite outcomes of death, Q‐wave myocardial infarction (MI) or stroke, and target vessel revascularization (TVR) rates. Results : Unadjusted analysis showed no significant differences between CABG and DES in overall survival rates (95% confidence interval (CI) for hazard ratio (HR): 0.44 to 1.77, P = 0.71), composite outcomes (death, Q‐wave MI, or stroke)‐free survival rates (95% CI for HR: 0.41–1.63, P = 0.56), and TVR‐free survival rates (95% CI for HR: 0.79–5.03, P = 0.14). Multivariate adjusted Cox regression analysis also showed no significant between‐group differences in TVR (95% CI for HR: 0.52–3.79, P = 0.49), death (95% CI for HR: 0.79–2.82, P = 0.22) and the composite of death, Q‐wave MI, or stroke (95% CI for HR: 0.65–2.57, P = 0.46). These results were sustained after propensity score adjustment and propensity score matching analysis. Conclusions : DES implantation for ostial LMCA lesions showed similar 5‐year outcomes of death, major adverse events, and TVR compared with CABG. Although meticulous adjustments decreased baseline difference between the two treatments, the absence of statistical significance could be attributable to the size of the study sample and hidden bias. © 2012 Wiley Periodicals, Inc.     

Long-term results of coronary angioplasty for single vessel, proximal, left anterior descending disease

The acute and long-term results of coronary angioplasty in 295 patients with isolated, proximal left anterior descending coronary stenosis are reported. The angiographic success rate was 83.4% overall, but 90.5% for non-occluded arteries treated since 1985. Clinical success at hospital discharge was achieved in 79.7%. The median duration of follow-up was 2.9 years and vital status was established in 99.7% at census. Cumulative 5-year cardiac survival was 96.2% after successful angioplasty and 95.6% for all patients. Five-year freedom from all cardiac events including cardiac death, myocardial infarction and repeat intervention was 73.8% amongst successfully treated patients, and 63.0% for all patients. After angioplasty, patients had less angina, required less anti-anginal medication and were more likely to be in gainful employment. Our data indicate that coronary angioplasty is an effective long-term treatment for selected patients with single vessel disease involving the proximal left anterior descending coronary artery.     

Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis.

The aim of this study was to assess the effects of percutaneous coronary intervention with drug-eluting stents (DESs) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery in the management of patients with proximal left anterior descending (LAD) coronary artery stenosis. Until recent years, despite the advantages of percutaneous transluminal coronary angioplasty (PTCA) with bare metal stent implantation, such as shorter hospital stays and recovery time, MIDCAB showed better results with regard to the need for repeated intervention in the target vessel than PTCA with proximal LAD lesions. Symptomatic patients (n = 189) were randomly assigned to DES group (n = 119) and MIDCAB group (n = 70). Patients with an isolated high-grade lesion (stenosis of > or = 70% of the luminal diameter) in the proximal LAD coronary artery (from the ostium to the first diagonal branch) were included in this study. During the 6-month follow-up period, 1.7% (n = 2) in the DES group needed repeated revascularization procedures for target lesion revascularization compared with 5.9% (n = 4) in the MIDCAB group (P = 0.196). The rates of death and myocardial infarction were similar in both groups [DES 0.0% (n = 0) vs. MIDCAB 2.9% (n = 2), P = 0.135; DES 1.7% (n = 2) vs. MIDCAB 2.9% (n = 2), P = 0.627; respectively] during 6 months of follow-up. In-hospital length of stay was significantly shorter in the DES group compared with the MIDCAB group (5.8 +/- 2.1 days vs. 8.9 +/- 2.6 days; P = 0.001). DES implantation and MIDCAB surgery showed similar rates of myocardial infarction, the need for repeated revascularization, and death during 6 months of follow-up. However, DES implantation resulted in lower average number of hospital stays and similar postoperative complications.     

Outcomes of left internal mammary artery with saphenous vein composite graft to bypass the left anterior descending artery: a propensity-matched study

BackgroundThis study aimed to evaluate the early and mid-term outcomes of a novel strategy of using the in-situ left internal mammary artery (LIMA) with the great saphenous vein graft (SVG) to bypass the left anterior descending artery (LAD) in coronary artery bypass grafting (CABG).MethodsA total of 979 patients took part in this retrospective observational study; 83 patients were propensity-score matched to the LIMA + SVG group and 83 to the LIMA − LAD group. Early mortality, postoperative complications, mid-term major adverse cardiovascular and cerebrovascular events (MACCE) were compared among the two matched groups after the procedure.ResultsNo significant differences in early mortality and postoperative complications rates were detected between the two matched groups. For mid-term outcomes, the incidence of MACCE was slightly higher in the LIMA + SVG group, but there was no significant statistical difference (14.9% vs. 12.8%, hazard ratio =1.20, 95% CI, 0.24 to 7.95; P=0.70) between the matched groups. Computed tomography coronary artery angiography (CTCA) images showed a LIMA + SVG composite graft patency rate of 94% (32/34) 25 months after the procedure.ConclusionsUsing the in situ LIMA with SVG to revascularize LAD was associated with comparable early and mid-term outcomes. These findings may provide an alternative emergency strategy when in situ LIMA cannot bypass LAD. Further study needs to be conducted to test longer-term outcomes.     

药物洗脱支架与切割球囊预扩张后置入金属裸支架治疗前降支开口病变的近、远期临床疗效比较

目的 探讨药物洗脱支架(DES)治疗前降支开口病变的近、远期临床疗效,并与早期应用切割球囊预扩张后(CBA)置入金属裸支架(BMS)的近、远期临床疗效进行比较.方法 自2003年11月至2005年5月采用DES对51例连续前降支开口病变的患者进行介入治疗,选自2000年5月至2003年11月应用CBA+BMS治疗前降支开口病变的连续50例患者作为对照组,要求所有患者在介入治疗后6～8个月进行冠状动脉造影复查,DES组与CBA+BMS组患者分别完成了2年和4年的临床随访.结果 在DES组中1例于住院期间发生急性心肌梗死,住院期间主要不良心脏事件(MACE)发生率为1.96%(1/51),29例完成了6～8个月的冠状动脉造影复查,再狭窄发生率为10.3%(3/29).在2年临床随访中1例死亡,靶病变重建4例,MACE发生率为9.8%(5/51).在CBA+BMS组中住院期间无心脏事件,28例完成了6～8个月的冠状动脉造影复查,再狭窄发生率为17.9%(5/28).2年临床随访中1例死亡,行靶病变重建5例,MACE发生率为12%(6/50).结论 在2年的临床随访中,支架内再狭窄、MACE发生率两组比较差异均无统计学意义,研究结果 提示无论是采用DES还是CBA+BMS治疗前降支开口病变均有良好的近、远期疗效.     

Long term outcomes of drug-eluting stent versus coronary artery bypass grafting for left main coronary artery disease: a meta-analysis

Background It is still controversial whether percutaneous coronary intervention with drug-eluting stent (DES) is safe and effective compared to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease at long-term follow up (≥ 3 years). Methods Eligible studies were selected by searching PubMed, EMBASE, and Cochrane Library up to December 6, 2016. The primary endpoint was a composite of death, myocardial infarction (MI) or stroke during the longest follow-up. Death, cardiac death, MI, stroke and repeat revascularization were the secondary outcomes. Results Four randomized controlled trials and twelve adjusted observational studies involving 14,130 patients were included. DES was comparable to CABG regarding the occurrence of the primary endpoint (HR = 0.94, 95% CI: 0.86-1.03). Besides, DES was significantly associated with higher incidence of MI (HR = 1.56, 95% CI: 1.09-2.22) and repeat revascularization (HR = 3.09, 95% CI: 2.33-4.10) compared with CABG, while no difference was found between the two strategies regard as the rate of death, cardiac death and stroke. Furthermore, DES can reduce the risk of the composite endpoint of death, MI or stroke (HR = 0.80, 95% CI: 0.67-0.95) for ULMCA lesions with SYNTAX score ≤ 32. Conclusions Although with higher risk of repeat revascularization, PCI with DES appears to be as safe as CABG for ULMCA disease at long-term follow up. In addition, treatment with DES could be an alternative interventional strategy to CABG for ULMCA lesions with low to intermediate anatomic complexity.     

Coronary artery bypass surgery in patients with severe left ventricular dysfunction

Objective: The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated. Methods: Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7). Results: Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival. Conclusion: CABG on patients with poor left ventricular function: (1) Can be performed with an acceptable mortality. (2) Mid term results are encouraging. (3) Preoperative IABP support improves the chance of survival.     

Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction

To determine whether or not ST segment deviation on admissionelectrocardiograms can identify patients with anterior acutgemyocardial infarction due to proximal left anterior descendingartery occlusion, the magnitude and location of ST segment elevationor depression were compared between patients with proximal leftanterior descending artery occlusion (group A, n=47) and thosewith distal left anterior descending artery occlusion (groupB, n =59). ST segment depression in each of the inferior leadswas significantly greater in group A than in group B. The incidenceof ST segment depression 1 mm in each of the inferior leads(II; 81% vs 27%, III; 85% vs 54%, aVF; 87% vs 47%, P<0·01)was significantly higher in group A than in group B. In addition,the incidence of ST segment depression 1 mm in all of the inferiorleads was significantly greater in group A than in group B (77%vs 22%, P<0·01). In group A, maximal ST segment elevationwas more frequent in lead V alone (43% vs 14%, P<0·01).Group A had greater ST segment elevation in lead a VL than groupB, and the incidence of ST segment elevation 1 mm in lead aVL was significantly higher in group A than in group B (66%vs 47%, P<0·05). ST segment depression 1 mm in allof the inferior leads was most valuable for identifying groupA patients (77% sensitivity and 78% specificity). In contrast,the maximal ST segment elevation in lead V₂ alone or ST segmentelevation 1 mm in lead a VL had a low diagnostic value (43%sensitivity and 86% specificity, 66% sensitivity and 53% specificity,respectively). In conclusion, this study indicates that analysisof ST segment deviation in the inferior leads is useful foridentifying patients with acute anterior myocardial infarctiondue to proximal left anterior descending occlusion.     

Assessment of left ventricular function in patients with isolated severe disease of the left anterior descending artery: Clinical,electrocardiographic, hemodynamic,and angiographic correlations

The purpose of this study was to define the spectrum of left ventriculographic (LV) abnormalities in 60 patients with isolated ≥90% diameter narrowing of the left anterior descending artery (LAD). The patients were divided into three groups: Group I (26 patients) had normal left ventricular (LV) function with ejection fraction (EF) of >60% and no akinetic-dyskinetic segment representing abnormal contracting segments (ACS) of the left ventricular wall; Group II (15 patients) had mild to moderate LV dysfunction with EF of 40–60% and an akinetic-dyskinetic segment of < 30% of the end diastolic perimeter (0–30%; mean, 11.6%) and Group III (19 patients) had severe LV dysfunction with EF <40%, or an akinetic-dyskinetic segment of ≥30 % (30–81%; mean, 41.5%) or both. The data obtained from the history, physical examination, electrocardiogram (ECG), chest x-ray studies, hemodynamic studies, left ventriculography, and coronary arteriography were entered and filed on a memory disc in an IBM 370-168 computer. Analysis of the results showed: (1) more severe LV dysfunction is associated with increased incidence of large hearts, gallops, decreased cardiac output, and occlusion of the LAD. (2) ECG evidence of infarction is also associated with higher incidence of the abnormalities of the indices of LV dysfunction. (3) LAD occlusion (versus stenosis) has a higher incidence of severe LV dysfunction and prior infarction. (4) The site of LAD disease did not predict the extent of left ventricular dysfunction. (5) Collaterals did not protect against severe LV dysfunction.     

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.     

80岁以上冠状动脉旁路移植术的临床观察

目的:总结80岁以上超高龄患者冠状动脉旁路移植术(CABG)的临床特点和结果。方法:对阜外心血管病医院2003年8月至2013年7月期间,112例行CABG的80岁以上患者的临床资料进行回顾性分析。记录术前一般情况、冠状动脉病变、合并疾病、治疗情况、术中手术方式、术后恢复情况以及并发症和病死率。结果:术前3支病变或合并左主干病变的患者占72%,66%的患者合并高血压,52%高血脂,22%心律失常,31%糖尿病,19%呼吸功能不全,58%不稳定心绞痛,9.8%急性心肌梗死,23%陈旧性心肌梗死,22%脑卒中史。70例患者常温下行CABG术,42例体外循环下行CABG术,其中3例为CABG+室壁瘤切除术。平均旁路移植数量为(2.7±0.6)支。全组死亡3例,围术期心肌梗死2例,延迟苏醒5例,肺部感染8例,机械通气时间延长13例,新发生脑卒中2例,肾替代治疗4例,出血需二次手术6例。结论:80岁以上的超高龄冠心病患者,体外循环和非体外循环CABG均可提供安全有效的治疗效果,对于术前冠状动脉病变程度较重,术中需要再血管化搭桥数量较多、合并室壁瘤切除或其他心脏直视手术的患者,采用体外循环下手术。对于冠状动脉病变适合不停跳条件下就可以充分再血管化的患者,采用非体外循环CABG是适宜的手术方式。     

Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction

To determine whether or not ST segment deviation on admissionelectrocardiograms can identify patients with anterior acutgemyocardial infarction due to proximal left anterior descendingartery occlusion, the magnitude and location of ST segment elevationor depression were compared between patients with proximal leftanterior descending artery occlusion (group A, n=47) and thosewith distal left anterior descending artery occlusion (groupB, n =59). ST segment depression in each of the inferior leadswas significantly greater in group A than in group B. The incidenceof ST segment depression 1 mm in each of the inferior leads(II; 81% vs 27%, III; 85% vs 54%, aVF; 87% vs 47%, P<0.01)was significantly higher in group A than in group B. In addition,the incidence of ST segment depression 1 mm in all of the inferiorleads was significantly greater in group A than in group B (77%vs 22%, P<0.01). In group A, maximal ST segment elevationwas more frequent in lead V alone (43% vs 14%, P<0.01). GroupA had greater ST segment elevation in lead a VL than group B,and the incidence of ST segment elevation 1 mm in lead a VLwas significantly higher in group A than in group B (66% vs47%, P<0.05). ST segment depression 1 mm in all of the inferiorleads was most valuable for identifying group A patients (77%sensitivity and 78% specificity). In contrast, the maximal STsegment elevation in lead V₂ alone or ST segment elevation 1 mm in lead a VL had a low diagnostic value (43% sensitivityand 86% specificity, 66% sensitivity and 53% specificity, respectively).In conclusion, this study indicates that analysis of ST segmentdeviation in the inferior leads is useful for identifying patientswith acute anterior myocardial infarction due to proximal leftanterior descending occlusion.     

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。