左心室射血分数减低患者冠状动脉慢性完全闭塞病变介入治疗的安全性及远期疗效

Safety and Long-term Clinical Efficacy of Percutaneous Coronary Intervention on Patients With Coronary Chronic Total Occlusion and Left Ventricular Ejection Fraction≤50%

目的:评价左心室射血分数(LVEF)减低(LVEF≤50%)对冠状动脉慢性完全闭塞(CTO)病变经皮冠状动脉介入治疗(PCI)安全性及远期(5年)疗效的影响。方法:回顾性分析2010年1月至2013年12月于中国医学科学院阜外医院成功行CTO-PCI的患者资料,选取术前LVEF≤50%患者303例(LVEF≤50%组),经倾向性评分匹配(1:1)LVEF>50%患者303例(LVEF>50%组)。随访5年,以复合终点(心原性死亡+靶血管相关心肌梗死+靶血管再次血运重建)作为主要研究终点;以手术成功率、并发症发生率、心原性死亡、靶血管相关心肌梗死、靶血管再次血运重建、心力衰竭再住院作为次要研究终点。结果:LVEF≤50%组SYNTAX评分明显高于LVEF>50%组[(19.27±9.03)分vs(.17.09±9.22)分,P=0.00]。两组间支架成功置入率(71.9%vs.74.3%,P=0.52)和并发症发生率(35.0%vs.34.3%,P=0.86)相近。548例(90.4%)患者完成5年随访,LVEF≤50%组5年主要研究终点事件率明显高于LVEF>50%组(18.5%vs.12.5%,P<0.05),差异主要由靶血管再次血运重建事件(12.9%vs.7.9%,P<0.05)驱动。LVEF≤50%组5年次要研究终点事件,除靶血管再次血运重建率高于LVEF>50%组外,其余次要研究终点心原性死亡、靶血管相关心肌梗死、心力衰竭再住院,差异均无统计学意义(P均>0.05)。Logistic多因素分析发现,长期服用氯吡格雷可降低主要研究终点事件发生风险(HR=0.52,95%CI:0.31~0.88,P=0.02)。结论:LVEF≤50%的CTO患者PCI后即刻手术安全性、有效性良好,但远期主要研究终点事件风险高于LVEF>50%组,特别是靶血管再次血运重建风险突出,长期服用氯吡格雷可降低相关风险。

Objectives:To evaluate the safety and long-term(5-years)clinical efficacy of percutaneous coronary intervention(PCI)on patients with chronic total occlusion(CTO)lesions and left ventricular ejection fraction(LVEF)≤50%.Methods:Clinical data of 303 patients with LVEF≤50%(LVEF≤50%group),who underwent interventional therapy for CTO in Fuwai hospital from January 2010 to December 2013,were analyzed.By propensity score matching(1:1),another 303 cases with LVEF>50%was included(LVEF>50%group)as control.The patients were followed up to 5th years after PCI.The primary composite endpoint was defined as cardiac death or target vessel related MI or target vessel revascularization(TVR).Secondary endpoint was defined as:success rate,complication,death,cardiac death,target vessel related myocardial infarction(TV-MI),TVR,heart failure for rehospitalization.Results:The SYNTAX scores were significant higher in LVEF≤50%group than in LVEF>50%group(19.27±9.03 vs.17.09±9.22,P=0.00).The rate of success PCI(71.9%vs.74.3%,P=0.52)and complication(35.0%vs.34.3%,P=0.86)were comparable between the two groups.A total of 548 cases(90.4%)were followed up to 5 years.The primary endpoint rate at 5 years was significant higher in LVEF≤50%group than in LVEF>50%group(18.5%vs.12.5%,P<0.05),mostly driven by TVR(12.9%vs.7.9%,P<0.05).There were no significant difference on other secondary endpoints(cardiac death,TV-MI,heart failure for rehospitalization,all P>0.05)between the two groups.The logistic regression analysis showed that long-term clopidogrel use was associated with reduced rates of the primary endpoints.Conclusions:Short-term safety and efficacy of CTO-PCI are similar between patients with LVEF≤50%and LVEF>50%,but the long-term primary endpoint rate is significantly higher in LVEF≤50%group mainly driven from TVR and long-term medication with clopidogrel could decrease the related risk.