药物洗脱支架再狭窄治疗后未保护的左主干远端的临床和操作预测因素：米兰和新东京（MITO）登记处。

Clinical and procedural predictors of suboptimal outcome after the treatment of drug-eluting stent restenosis in the unprotected distal left main stem: the Milan and New-Tokyo (MITO) registry.

机构信息

Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.

出版信息

Circ Cardiovasc Interv. 2012 Aug 1;5(4):491-8. doi: 10.1161/CIRCINTERVENTIONS.111.964874. Epub 2012 Jul 31.

DOI:10.1161/CIRCINTERVENTIONS.111.964874

PMID:22851528

Abstract

BACKGROUND

Few data are available regarding the optimal revascularization strategy for unprotected distal left main coronary artery (UDLM) in-stent restenosis (ISR).

METHODS AND RESULTS

Between April 2002 and December 2008, UDLM-ISR following drug-eluting stent (DES) implantation occurred in 92 of 474 patients (19.4%). Of these, 8 (8.7%) who underwent a coronary artery bypass graft (CABG) were excluded, and the remaining 84 (91.3%) who underwent percutaneous coronary intervention (PCI) (43 plain old balloon angioplasty [POBA] and 41 DES) were analyzed to assess the feasibility of PCI for UDLM-ISR. The overall cardiac death, myocardial infarction (MI), and major adverse cardiac events during the follow-up period (median, 24 months) occurred in 4, 2, and 31 patients, respectively. Repeat target lesion revascularization (TLR) occurred in 28 patients. The incidence of repeat TLR was higher following PCI with POBA than with DES (hazard ratio [HR], 2.79; 95% CI, 1.23-6.34; P=0.014). On Cox regression analysis, the independent predictors of repeat TLR were treatment with POBA (HR, 3.29; 95% CI, 1.41-7.69; P=0.006) and EuroSCORE (European System for Cardiac Operative Risk Evaluation) >6 (HR, 2.53; 95% CI, 1.02-6.28; P=0.045). More complex lesions requiring a 2-stent strategy were associated with a higher occurrence of TLR for restenosis of the left circumflex coronary artery ostium (LCX-ISR) (HR, 2.51; 95% CI, 1.59-3.97; P=0.001) as well as repeat TLR for recurrent LCX-ISR (HR, 4.32; 95% CI, 0.97-19.20; P=0.05) compared to a 1-stent strategy. No cardiac death at 2 years occurred in patients with LCX-ISR.

CONCLUSIONS

UDLM restenosis is better treated with DES than with POBA. The rate of recurrent ISR following repeat PCI was high, whereas the rates of MI and death were relatively low. Complex lesions requiring a 2-stent strategy had a higher recurrence rate at the ostial LCX but without an associated increased risk of MI and death.

摘要

背景

关于药物洗脱支架（DES）置入后无保护左主干远端（UDLM）再狭窄（ISR）的最佳血运重建策略，目前仅有少量数据。

方法和结果

2002 年 4 月至 2008 年 12 月，474 例患者中发生 UDLM-ISR 92 例（19.4%）。其中 8 例（8.7%）接受冠状动脉旁路移植术（CABG）治疗，排除这 8 例患者后，其余 84 例（91.3%）接受经皮冠状动脉介入治疗（PCI）（43 例单纯球囊血管成形术（POBA），41 例 DES），评估 PCI 治疗 UDLM-ISR 的可行性。随访期间（中位数 24 个月），共发生心脏死亡 4 例，心肌梗死（MI）2 例，主要不良心脏事件（MACE）31 例。28 例患者发生再次靶病变血运重建（TLR）。POBA 组再次 TLR 发生率高于 DES 组（危险比[HR]，2.79；95%可信区间[CI]，1.23-6.34；P=0.014）。多因素 Cox 回归分析显示，再次 TLR 的独立预测因素为 POBA 治疗（HR，3.29；95%CI，1.41-7.69；P=0.006）和 EuroSCORE（欧洲心脏手术风险评估系统）>6（HR，2.53；95%CI，1.02-6.28；P=0.045）。需要双支架策略的复杂病变与左回旋支（LCX）开口再狭窄（LCX-ISR）的 TLR 发生率（HR，2.51；95%CI，1.59-3.97；P=0.001）和复发性 LCX-ISR 的 TLR 发生率（HR，4.32；95%CI，0.97-19.20；P=0.05）较高相关，而与单支架策略相比。LCX-ISR 患者 2 年无心脏死亡。