左心室收缩功能不全合并无保护左主干病变患者行药物洗脱支架植入术后远期疗效

Long-term outcomes of implanting drug-eluting stents for unprotected left main coronary artery disease patients with left ventricular systolic dysfunction

目的分析无保护左主干（ULM）病变合并左心室收缩功能不全（LVSD）患者行药物洗脱支架（DES）植入术后的临床特点及预后。方法2005年1月至2012年1月入住北京安贞医院心内科的ULM病变行DES植入术患者511例。根据左心室射血分数（LVEF）将其分为3组，LVEF≤40％组104例，41％~〈LVEF≤49％组137例，LVEF≥50％组270例。回顾性分析各组患者的临床特点，评价LVSD对ULM病变患者DES植入疗效的影响。结果LVEF≤40％组、41％≤LVEF≤49％组、LVEF≥50％组3组患者临床特点比较，外周血管病史、陈旧性-tD肌梗死（OMI）史、多支病变、完全血运重建及慢性完全闭塞（CTO）患病率差异有统计学意义（P=0．002、P〈0．001、P〈0．001、P=0．049、P=0．001），其他临床特征3组患者比较差异均无统计学意义（均P〉0．05）。生存分析显示，LVEF≤40％组全因死亡、心源性死亡发生率均高于LVEF≥50％组（均P〈0．001），41％≤LVEF≤49％组与LVEF≥50％组全因死亡发生率比较差异无统计学意义，而心源性死亡发生率较LVEFI〉50％组高（P=0．027）。此外，主要不良心脑血管事件（MACCE）、心肌梗死、脑梗死、再次血运重建（TVR）率3组比较差异均无统计学意义。调整多因素后，LVEF≤40％组全因死亡、心源性死亡发生率均高于LVEF≥50％组（P=0．002，P〈0．001），而41％≤LVEF≤49％组与LVEFi〉50％组全因死亡、心源性死亡发生率比较差异均无统计学意义（均P〉0．05）；MACCE、心肌梗死、脑梗死、再次血运重建发生率3组比较差异均无统计学意义。结论LVSD合并ULM病变患者行DES植入术，是可行的手术治疗方案，但对于LVEF≤40％的严重LVSD患者（术后远期死亡率增高），需谨慎选择。

Objective To analyze the clinical characteristics and prognosis of implanting drug- eluting stents （DES） for unprotected left main （ULM） coronary artery disease patients with left ventricular systolic dysfunction （LVSD）. Methods A total of511 ULM coronary artery disease patients who underwent DES implantation from January 2005 to January 2012 in Department of Cardiology, Beijing Anzhen Hospital were included in the study. Based on left ventricular ejection fraction （LVEF） , the patients were divided into three groups： LVEF≤40% （n=104）, 41% ≤LVEF≤49% （n=137）, and LVEF≥50% （n= 270）. The clinical characteristics of patients undergoing DES implantation were retrospectively compared, and the effects of LVSD on ULM coronary artery disease were analyzed. Results After comparison of clinical baseline data among three different LVEF groups, the incidence of peripheral vascular diseases, old myocardial infarction （OMI）, multi-vessel lesions, complete revascularization and chronic total occlusion （CTO） was statistically different （P = 0.002, P 〈 0.001, P 〈 0.001, P=0.049, P = 0.001, respectively）. However, there was no significant difference in the incidence of other clinical characteristics （ all P 〉 0.05 ）. In terms of survival analysis, total mortality and cardiac mortality were both remarkably higher in LVEF≤40% group than those in LVEF≥50% group （both P 〈0. 001 ）. There was no statistical difference of total mortality between 41% ≤LVEF≤49% group and LVEF≥50% group （P 〉0. 05）, while cardiac mortality was higher in LVEF/〉 50% group （ P = 0. 027 ） . Besides, there was no significant difference among three groups in major adverse cardiac and cerebral events （MACCE）, myocardial infarction （MI）, cerebral infarction and target vessel revascularization （TVR） （all P 〉 0. 05 ）. After adjusting for multiple clinical factors, total mortality and cardiac mortality were both remarkably higher in LVEF≤40% group than those in LVEF≥50% group （P = 0. 002, P 〈 0. 001 ）, while there were no statistical differences of total mortality and cardiac mortality between 41%≤LVEF ≤ 49% group and LVEF t〉 50% group （both P 〉 0. 05）. In terms of MACCE, MI, cerebral infarction and TVR, there were also no significant differences among three groups （ all P 〉 0. 05 ）. Conclusion For ULM coronary artery disease patients with LVSD, implanting DES is safe and effective, but for those with severe LVSD （LVEF≤40%）, DES implantation showed an increased risk of long-term death and therefore should be selected with great care.