无保护左主干末端病变接受经皮冠状动脉介入治疗或冠状动脉旁路移植术远期效果评价

Impact of revascularization on distal bifurcation lesions of unprotected left main coronary artery with different revascularization approaches

目的研究不同血管重建方式对无保护左主干(ULMCA)末端病变患者治疗的效果及预后意义。方法连续收录冠状动脉造影明确诊断为ULMCA末端病变的222例患者临床资料,其中106例置入药物洗脱支架(PCI组),116例行冠状动脉旁路移植手术(CABG组),观察两组患者在12个月及3年发生全因死亡、非致死性心肌梗死、靶血管重建和主要不良心脏事件发生率,研究不同血管重建方式对ULMCA末端病变治疗效果的影响。结果两组患者在12个月期间,主要终点事件如全因死亡、非致死性心肌梗死差别无统计学意义(分别为:χ2=1.05,P=0.32和χ2=1.04,P=0.38),靶血管重建以及主要不良心脏事件发生率差异有统计学意义(分别为:χ2=5.45,P=0.02和χ2=6.63,P=0.01)。累积3年随访,PCI组与CABG组相比全因死亡率降低33%(10.38%比12.07%,χ2=0.47,P=0.45),但非致死性心肌梗死是后者的1.87倍(2.1%比0,χ2=1.04,P=0.38)。PCI组靶血管重建率是CABG组4.17倍(20.76%比8.62%,χ2=6.63,P<0.01),而主要不良心脏事件两组相比差异有统计学意义(33.02%比20.68%,χ2=4.78,P=0.03)。结论 ULMCA末端病变采用PCI或CABG进行血管重建是安全有效的。对解剖结构适合PCI且患者拒绝或不宜行CABG的ULMCA末端病变患者来说,药物洗脱支架PCI术是一种可以选择的替代治疗方案。

Objective To compare the long-term outcome of percutaneous coronary intervention（PCI） and coronary artery bypass grafting（CABG） in patients with distal bifurcation lesions of unprotected left main coronary artery.Methods A total of 222 patients with distal bifurcation lesions of unprotected left main coronary artery,among whom 106 patients received drug-eluting stents（PCI group） and 116 patients underwent CABG（CABG group）,were recruited.Patients were studied for death rate,non-fatal myocardial infarction,target vessel revascularization（TVR） and major adverse cardiac events（MACE） at 12-month and 3-year follow-up after the procedure.Results Most of the baseline characteristics were similar between the two groups.The 12-month rates of death（4.72% vs.5.17%,P=0.32） and non-fatal MI（1.89% vs.0%,P=0.38） were similar between the two groups（χ2=1.05 and χ2=1.04）,but the rates of MACE（18.87% vs.12.07%,P0.01） and TVR（12.26% vs.6.90%,P=0.01） were significantly increased in the PCI group as compared with the CABG group（χ2=5.45,P=0.02 and χ2=6.63,P=0.01）.At 3 years,the rates of death and non-fatal MI were similar between the two groups（χ2 =0.47,P=0.45,relative risk 0.67,95% CI 0.23-1.08;χ2=1.04,P=0.38,relative risk 1.87,95% CI 0.12-3.27）,MACE and TVR were significantly higher in the PCI group（χ2=6.63,P0.01,relative risk 2.24,95% CI 1.08-3.07;χ2=4.78,P=0.03,relative risk 4.17,95% CI 2.53-5.20）.Conclusions For patients with bifurcation lesions of unprotected left main coronary artery,the group treated with PCI compared with CABG showed similar rates of death and non-fatal MI at 12 months or 3 years.Therefore,PCI could be considered an alternative to CABG in patients with anatomic conditions that are associated with a low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes.