慢性肾脏病合并冠状动脉无保护左主干病变行药物涂层支架植入术的安全性

Security analysis of implanting drug-eluting stents for unprotected left main coronary artery disease patients with chronic kidney disease

目的 分析无保护左主干（ULM）冠状动脉病变合并慢性肾脏病（CKD）患者行药物涂层支架（DES）植入术后的临床特点及预后.方法 收集2005年1月至2010年3月北京安贞医院心内科的ULM冠脉病变行DES植入术患者267例.根据术前肾小球滤过率估计值（eGFR）将其分为两组,eGFR ＜60 ml·min^-1·1.73 m^-2组77例,eGFR≥60 ml·min^-1·1.73 m^-2组190例.对比分析两组患者临床特点,比较不同治疗策略疗效及临床预后.结果 eGFR ＜60 ml·min^-1· 1.73 m^-2组患者既往脑血管疾病史（13.0％比5.3％）、既往高血压史（70.1％比53.2％）、既往冠状动脉旁路移植术（CABG）史（7.8％比2.1％）、慢性闭塞性病变（CTO）比例（28.6％比12.1％）高于eGFR≥60 ml·min^-1·1.73 m^-2组患者,吸烟患者比例（35.1％比50.5％）、开口病变比例（1.2％比8.4％）低于eGFR≥60 ml·min^-1· 1.73 m^-2组,差异均有统计学意义（均P＜ 0.05）.eGFR≥60 ml·min^-1· 1.73 m^-2组患者左室射血分数（LVEF）较高[（64.2±7.4）％比（60.7±11.6）％,P=0.011].eGFR＜ 60 ml·min^-·1.73 m^-2组患者全因死亡与心源性死亡发生率较高（P=0.016,P=0.006）.多因素分析显示eGFR＜ 60 ml·min^-1·1.73 m^-2是ULM病变患者行DES植入术术后全因死亡（P=0.042）和心源性死亡（P =0.023）的独立危险因素.结论 慢性肾脏病合并ULM病变患者行DES植入术术后远期死亡率增高,需谨慎选择.慢性肾脏病是ULM病变患者行DES植入术后发生心血管事件的危险因素.

Objective To study the clinical characteristics and prognosis of unprotected left main （ULM） coronary artery disease patients with chronic kidney disease after drug-eluting stents （DES） implantation.Methods 267 ULM coronary artery disease patients who has implanted DES were included in the study from January 2005 to March 2010.Patients were divided into two groups according to their estimated glomerular filtration rate （eGFR）：eGFR 〈 60 ml · min^-1 · 1.73 m^-2 （77 patients）,and eGFR≥ 60 ml· min^-1 · 1.73 m^-2（190 patients）.The clinical parameters and prognosis of ULM patients treated with DES in different eGFR groups were retrospectively compared.Results In higher eGFR group,left ventricular ejection fraction （LVEF） and morbidity of coronary ostial lesions were higher than the other group.Cerebrovascular diseases （13.0% vs 5.3%）,chronic total occlusion （CTO,28.6% vs 12.1%）,hypertension （70.1% vs 53.2%） were more common in lower eGFR patients （all P 〈 0.05）.Total mortality and cardiac mortality were higher in eGFR 〈60 ml · min^-1 · 1.73 m^-2 group （P =0.016,0.006,respectively）.Low eGFR level was an independent risk factor after adjusting multiple factors.Conclusion For the ULM disease patients with reduction in kidney function （eGFR 〈 60 ml · min^-1 · 1.73 m^-2）,DES should be selected with a careful study considering its increasing risk of death.Chronic renal insufficiency is a risk factor and may predict poor prognosis for patients with ULM after DES implantation.