Almeda Francis Q, Parrillo Joseph E, Klein Lloyd W
Rush Heart Institute, Rush-Presbyterian-St. Luke's Medical Center and Rush Medical College, Chicago, Illinois 60612, USA.
Catheter Cardiovasc Interv. 2003 Sep;60(1):57-66. doi: 10.1002/ccd.10454.
Although there have been remarkable advances in medical therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery, complete revascularization remains a challenge given the more complex coronary artery disease prevalent in contemporary practice. The lack of donors for cardiac transplantation will fuel the search for effective alternative strategies for dealing with patients with severe ischemic heart disease not amenable to conventional revascularization techniques. Percutaneous laser revascularization clearly diminishes anginal symptoms; however, the blinded trials have provided conflicting results, with one study showing a definite decrease in angina and another suggesting that the placebo effect may play a major role in this modality. Similarly, surgical transmyocardial laser revascularization is limited by the lack of consistent improvement in objective measurements of ischemia and the potential confounding mechanisms of denervation and the placebo effect, and thus should be reserved for only the most highly selected patients. Although enhanced external counterpulsation is associated with an improvement in anginal symptoms and exercise tolerance, this modality is limited by its availability, tolerability, and rigid exclusion criteria. Of the alternative strategies available, therapeutic angiogenesis holds the most promise. However, the long-term results of ongoing randomized clinical trials require further scrutiny. Novel methods for vascular reconstruction are evolving techniques, but should be viewed currently as mainly experimental methods. The common goals of these new treatment options would be to reduce symptoms, decrease morbidity, and potentially improve mortality by reducing ischemia through favorably impacting myocardial oxygen supply and demand. The optimal management of patients with severe end-stage coronary artery disease not amenable to conventional revascularization techniques will continue to remain a challenge for the clinician and will be the main focus of basic cardiovascular research and clinical trials in the new millennium.
尽管在药物治疗、经皮冠状动脉介入治疗和冠状动脉旁路移植手术方面已经取得了显著进展，但鉴于当代实践中普遍存在的更为复杂的冠状动脉疾病，实现完全血运重建仍然是一项挑战。心脏移植供体的短缺将促使人们寻找有效的替代策略，以应对那些不适合传统血运重建技术的严重缺血性心脏病患者。经皮激光血运重建术确实能减轻心绞痛症状；然而，盲法试验得出了相互矛盾的结果，一项研究显示心绞痛明显减轻，而另一项研究则表明安慰剂效应可能在这种治疗方式中起主要作用。同样，外科经心肌激光血运重建术受到缺血客观测量结果缺乏持续改善以及去神经支配和安慰剂效应等潜在混杂机制的限制，因此应仅用于经过严格筛选的患者。尽管增强型体外反搏与心绞痛症状改善和运动耐量提高有关，但这种治疗方式受到其可及性、耐受性和严格排除标准的限制。在现有的替代策略中，治疗性血管生成最具前景。然而，正在进行的随机临床试验的长期结果需要进一步审查。新型血管重建方法仍在不断发展，但目前应主要视为实验方法。这些新治疗选择的共同目标是通过有利地影响心肌氧供需来减少缺血，从而减轻症状、降低发病率并可能改善死亡率。对于那些不适合传统血运重建技术的严重终末期冠状动脉疾病患者，最佳管理对临床医生来说仍将是一项挑战，并且将成为新千年基础心血管研究和临床试验的主要重点。
