Sabik Joseph F, Blackstone Eugene H, Firstenberg Michael, Lytle Bruce W
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195, USA.
Circulation. 2007 Sep 11;116(11 Suppl):I232-9. doi: 10.1161/CIRCULATIONAHA.106.681478.
Left main trunk stenosis (> or = 50%) has traditionally been treated with coronary artery bypass grafting. Improvements in coronary stents have led some to advocate percutaneous coronary intervention. To provide a benchmark of outcomes against which percutaneous coronary intervention may be compared, we (1) assessed survival and freedom from coronary reintervention after coronary artery bypass grafting in these patients and (2) identified their risk factors.
From 1971 to 1998, the first 1000 primary coronary artery bypass grafting patients (n=26,927) were followed every 5 years. Of these, 3803 had left main trunk stenosis > or = 50%. A multivariable, nonproportional hazards, time-related analysis was performed to model survival and freedom from coronary reintervention (percutaneous coronary intervention or reoperation) and to identify their risk factors. Survival at 30 days, 1, 5, 10, 15, and 20 years was 97.6%, 93.6%, 83%, 64%, 44%, and 28%, respectively, and freedom from coronary reintervention was 99.7%, 98.9%, 96.6%, 89%, 76%, and 61%, respectively. Worse left ventricular function (P<0.0001), diabetes (P<0.0001), hypertension (P<0.001), peripheral arterial disease (P=0.0002), smoking (P<0.0001), and elevated triglycerides (P=0.01) decreased survival, and younger age (P<0.0001), elevated triglycerides (P=0.005), and incomplete revascularization (P=0.003) increased coronary reintervention. Internal thoracic artery grafting of the left anterior descending improved survival and decreased coronary reintervention.
This study provides a 20-year outcome benchmark for surgical treatment of left main trunk disease. It indicates that simple comparisons of new treatments are inadequate without risk adjustment. Risk factor adjustment should be used when comparing coronary artery bypass grafting with current and future treatment innovations and when selecting the best treatment strategy for individual patients.
传统上，左主干狭窄（≥50%）一直采用冠状动脉旁路移植术治疗。冠状动脉支架的改进使得一些人主张进行经皮冠状动脉介入治疗。为了提供一个可与经皮冠状动脉介入治疗相比较的结果基准，我们（1）评估了这些患者冠状动脉旁路移植术后的生存率和免于冠状动脉再次干预的情况，（2）确定了他们的危险因素。
从1971年到1998年，对首批1000例初次冠状动脉旁路移植术患者（共26927例）每5年进行一次随访。其中，3803例有左主干狭窄≥50%。进行了多变量、非比例风险、时间相关分析，以模拟生存率和免于冠状动脉再次干预（经皮冠状动脉介入治疗或再次手术）的情况，并确定其危险因素。30天、1年、5年、10年、15年和20年的生存率分别为97.6%、93.6%、83%、64%、44%和28%，免于冠状动脉再次干预的比例分别为99.7%、98.9%、96.6%、89%、76%和61%。较差的左心室功能（P<0.0001）、糖尿病（P<0.0001）、高血压（P<0.001）、外周动脉疾病（P=0.0002）、吸烟（P<0.0001）和甘油三酯升高（P=0.01）会降低生存率，而较年轻（P<0.0001）、甘油三酯升高（P=0.005）和不完全血运重建（P=0.003）会增加冠状动脉再次干预的发生率。左前降支采用胸廓内动脉移植可提高生存率并减少冠状动脉再次干预的发生率。
本研究为左主干疾病的外科治疗提供了一个20年的结果基准。这表明在没有风险调整的情况下，对新治疗方法进行简单比较是不够的。在将冠状动脉旁路移植术与当前和未来的治疗创新进行比较以及为个体患者选择最佳治疗策略时，应使用危险因素调整。
