Jones E L, King S B, Craver J M, Douglas J S, Kaplan J A, Morgan E A, Brown E M, Bradford J M, Hatcher C R
J Thorac Cardiovasc Surg. 1980 Jan;79(1):109-16.
A total of 178 patients having a diagnosis of left main coronary artery stenosis were divided into three groups as follows: surgical, Group I (n = 135 patients); operable medically treated, Group II (n = 21 patients); and inoperable, Group III (n = 22 patients). Groups 1 and 2 were comparable with regard to clinical profile, extent of anatomic coronary disease, and left ventricular function. Inoperable patients had a much higher incidence of prior myocardial infarction (especially anterior), more severe distal coronary disease, and markedly depressed left ventricular function. The hospital mortality rate for surgical patients was 4% (6/135). The late mortality rate, (median follow-up = 23.4 months) was 7% (9/135). For operable patients, the late mortality rate was 43% (9/21) at 28 months. In the inoperable group, the late death rate at 20 months was 59% (13/22). Actuarial survival at 24 months for the three groups was: 88%, 66%, and 42%, respectively. Of the nine patients who died in the operable group, two had less than 75% obstruction of the left main coronary artery and two had normal left ventricular wall motion. Although patients with higher grades of left main coronary artery stenosis and reduced left ventricular function are at greater risk, patients with less obstruction and good left ventricular function are also at risk and should have myocardial revascularization with some sense of urgency. The population of left main coronary artery stenosis is a heterogeneous one, and comparison of surgical versus medical therapy should exclude inoperable patients. The operative mortality rate has been greatly reduced in recent years (2% in the last 100 cases); this is attributed to careful monitoring in the critical prebypass period, aggressive pharmacologic treatment of increased preload, tachycardia, and hypertension, and improved aurgical technique, with emphasis on careful myocardial preservation. Adherence to these principles makes frequent use of the intra-aortic balloon either before or after revascularization unnecessary.
共有178例被诊断为左主干冠状动脉狭窄的患者被分为以下三组：手术组，第一组（n = 135例患者）；可手术治疗的内科治疗组，第二组（n = 21例患者）；不可手术组，第三组（n = 22例患者）。第一组和第二组在临床特征、冠状动脉疾病解剖范围和左心室功能方面具有可比性。不可手术的患者既往心肌梗死（尤其是前壁心肌梗死）的发生率更高，远端冠状动脉疾病更严重，左心室功能明显降低。手术患者的医院死亡率为4%（6/135）。晚期死亡率（中位随访时间 = 23.4个月）为7%（9/135）。对于可手术治疗的患者，28个月时的晚期死亡率为43%（9/21）。在不可手术组中，20个月时的晚期死亡率为59%（13/22）。三组在24个月时的精算生存率分别为：88%、66%和42%。在可手术治疗组死亡的9例患者中，2例左主干冠状动脉狭窄程度小于75%，2例左心室壁运动正常。虽然左主干冠状动脉狭窄程度较高且左心室功能降低的患者风险更大，但狭窄程度较轻且左心室功能良好的患者也有风险，应在一定程度上紧急进行心肌血运重建。左主干冠状动脉狭窄患者群体是异质性的，手术治疗与内科治疗的比较应排除不可手术的患者。近年来手术死亡率已大幅降低（最近100例中的2%）；这归因于在体外循环前关键时期的仔细监测、对前负荷增加、心动过速和高血压的积极药物治疗以及手术技术的改进，重点是小心保护心肌。遵循这些原则使得在血运重建之前或之后频繁使用主动脉内球囊变得不必要。
