左主干冠状动脉疾病患者经外科手术、经皮介入或药物治疗的预后：长期随访。

Prognosis in patients with left main coronary artery disease managed surgically, percutaneously or medically: a long-term follow-up.

机构信息

Uniwersytet Medyczny w Białymstoku.

出版信息

Kardiol Pol. 2013;71(8):787-95. doi: 10.5603/KP.2013.0189.

DOI:10.5603/KP.2013.0189

PMID:24049017

Abstract

BACKGROUND

Left main stenosis (LMS) occurs in 5-7% of patients with coronary artery disease. Half of patients with left main coronary artery (LMCA) disease die within few years after the diagnosis.

AIM

To evaluate survival of patients with LMCA disease treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or managed medically due to lack of consent for CABG or being considered unsuitable candidatesfor CABG/PCI.

METHODS

In 2006-2008, a significant LMS was found in 257 (5.14%) patients, and 98.44% of these patients were followed upfor on average 15.1 months. The patients were divided into 5 groups according to the treatment used. CABG was performedin 67% of patients, PCI of an unprotected LMS in 8% of patients, and 12% of patients were treated with PCI after a previous CABG (protected LMS). The remaining patients were managed medically: 4% were not considered suitable for CABG, and9% did not give their consent for CABG.

RESULTS

Total mortality in the overall study group (n = 253) was 14.6%. Multivessel disease was more frequent in the CABG group (60.9% vs. 15.8%, p < 0.001). Mortality in CABG and PCI groups was comparable (11.4% vs. 15.8%). Patients in the PCI group were more frequently hospitalised due to recurrent angina (21.1% vs. 3.0%, p < 0.001) and the need for repeated revascularisation (15.8% vs. 1.2%, p < 0.001). Compared to the CABG group, patients considered not suitable for CABG hadlower left ventricular ejection fraction (LVEF) (36.55% vs. 51.04%, p < 0.001) and a higher mortality risk as estimated by the EuroScore. Mortality among patients deemed unsuitable for CABG was 54.6% (p < 0.001) and myocardial infarctions were observed more frequently in this group (18.2% vs. 2.4%, p < 0.01). In comparison to the CABG group, patients who did not consent to CABG were older (71.04 vs. 65.99 years, p = 0.027), had lower LVEF (44.05% vs. 51.04%, p = 0.004), were less frequently hospitalised due to acute coronary syndromes (17.4% vs. 40.8%, p = 0.03), and had a smaller degree of LMS (63%vs. 71%, p = 0.027). Mortality in this group was comparable to the CABG group (17.4% vs. 11.4%). The majority of patients who underwent previous CABG needed repeated revascularisation: PCI of a protected LMS was performed in 27% of patients,PCI of other native coronary arteries in 39% of patients, and PCI of a bypass graft in 7% of patients.

CONCLUSIONS

PCI of unprotected LMCA may be an equally effective revascularisation method as CABG. High mortality (55%) due to concomitant diseases was observed among patients with LMS who were deemed unsuitable candidates for CABG. Prognosis among patients who declined CABG was relatively good and might have been related to the small number of patients and different patient characteristics in this group.

摘要

背景

左主干狭窄（LMS）发生在 5-7%的冠心病患者中。左冠状动脉主干（LMCA）疾病患者中有一半在诊断后几年内死亡。

目的

评估因冠状动脉旁路移植术（CABG）、经皮冠状动脉介入治疗（PCI）或因不同意 CABG 或不适合 CABG/PCI 而未接受治疗的 LMCA 疾病患者的生存情况。

方法

2006-2008 年，257 名患者（5.14%）发现显著的 LMS，其中 98.44%的患者接受了平均 15.1 个月的随访。根据所用治疗方法将患者分为 5 组。67%的患者接受了 CABG 治疗，8%的患者接受了未保护的 LMS 的 PCI 治疗，12%的患者在先前 CABG（保护的 LMS）后接受了 PCI 治疗。其余患者接受了药物治疗：4%的患者不适合 CABG，9%的患者不同意 CABG。

结果

在整个研究组（n=253）中，总死亡率为 14.6%。CABG 组多血管疾病更为常见（60.9% vs. 15.8%，p<0.001）。CABG 和 PCI 组的死亡率相当（11.4% vs. 15.8%）。PCI 组因复发性心绞痛（21.1% vs. 3.0%，p<0.001）和需要重复血运重建（15.8% vs. 1.2%，p<0.001）而住院的患者更为频繁。与 CABG 组相比，不适合 CABG 的患者左心室射血分数（LVEF）较低（36.55% vs. 51.04%，p<0.001），并且根据 EuroScore 估计的死亡率风险更高。被认为不适合 CABG 的患者的死亡率为 54.6%（p<0.001），并且该组更频繁地观察到心肌梗死（18.2% vs. 2.4%，p<0.01）。与 CABG 组相比，不同意 CABG 的患者年龄较大（71.04 岁 vs. 65.99 岁，p=0.027），LVEF 较低（44.05% vs. 51.04%，p=0.004），因急性冠状动脉综合征住院的频率较低（17.4% vs. 40.8%，p=0.03），并且 LMS 程度较小（63% vs. 71%，p=0.027）。该组的死亡率与 CABG 组相当（17.4% vs. 11.4%）。大多数先前接受过 CABG 的患者需要重复血运重建：27%的患者接受了保护的 LMCA 的 PCI，39%的患者接受了其他原生冠状动脉的 PCI，7%的患者接受了旁路移植的 PCI。