Naqvi Syed Yaseen, Klein Jordan, Saha Tisa, McCormick Daniel J, Goldberg Sheldon
Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Am J Cardiol. 2017 Feb 15;119(4):520-527. doi: 10.1016/j.amjcard.2016.11.003. Epub 2016 Nov 16.
Coronary artery bypass grafting (CABG) decreases mortality in patients with significant left main (LM) coronary artery disease and for years remained the therapy of choice for patients with this ominous lesion. Advances in percutaneous coronary intervention (PCI) have enabled it to become an alternative to CABG. The results of observational registries and randomized comparisons have shown the safety and efficacy of PCI in appropriately selected patients with low or intermediate angiographic risk scores. Furthermore, the use of physiological measures of flow limitation and the use of intracoronary imaging techniques has added benefit and improved outcomes. The use of fractional flow reserve to more accurately evaluate the significance of intermediate lesions and guide the extent of revascularization has been an important refinement. Intravascular ultrasound and optical coherence tomography assessment of optimal stent deployment has led to reductions in restenosis. Newer generation stents, combined with improvements in specific techniques, especially at the LM bifurcation have extended PCI to more complex anatomic scenarios. The availability of left ventricular support devices in patients with complex coronary anatomy and severely depressed left ventricular function has added a margin of safety to LM and multivessel intervention. Randomized comparisons of CABG with PCI in carefully selected patients, using contemporaneous surgical and interventional techniques and optimal medical therapy, will further aid heart teams in the decision-making process. In conclusion, this review will give a concise overview of the management of unprotected LM disease.
冠状动脉旁路移植术（CABG）可降低严重左主干（LM）冠状动脉疾病患者的死亡率，多年来一直是患有这种严重病变患者的首选治疗方法。经皮冠状动脉介入治疗（PCI）的进展使其成为CABG的替代方法。观察性注册研究和随机对照研究结果表明，在适当选择的血管造影风险评分低或中等的患者中，PCI具有安全性和有效性。此外，使用血流限制的生理测量方法和冠状动脉内成像技术增加了益处并改善了治疗结果。使用血流储备分数更准确地评估中度病变的严重程度并指导血运重建范围是一项重要的改进。血管内超声和光学相干断层扫描对最佳支架置入的评估已导致再狭窄率降低。新一代支架，结合特定技术的改进，特别是在LM分叉处，已将PCI扩展到更复杂的解剖学情况。对于具有复杂冠状动脉解剖结构和严重左心室功能不全的患者，左心室支持装置的可用性为LM和多支血管介入增加了安全边际。在精心挑选的患者中，使用同期手术和介入技术以及最佳药物治疗，对CABG与PCI进行随机对照研究，将进一步帮助心脏团队进行决策。总之，本综述将简要概述无保护左主干疾病的管理。
