Oelert H
Klinik für Herz-, Thorax- und Gefässchirurgie, Universitätskliniken Mainz.
Z Kardiol. 1996;85 Suppl 6:303-8.
Interventional cardiologists and cardiac surgeons agree in the treatment of symptomatic coronary artery stenosis: high risk patients with severe coronary disease (such as left main stem stenosis, triple vessel disease and double vessel disease with involvement of the proximal LAD in particular with severely impaired ventricular function) are treated preferentially with coronary artery bypass grafting (CABG); less severe cases allow alternatively PTCA treatment. However, even in controlled and randomised studies (RITA, GABI, ERACI, CABRI, and BARI-studies) looking into these alternatives (PTCA versus CABG) it was found that 1.1% to 10.1% of all PTCA incidents required a surgical emergency procedure. Although, in favourable conditions the risk is considerably lower than the above value and despite of improvement of catheter techniques (stent implantation, perfusion catheters) in less favourable conditions which reduced the risk to a similar value, the results of surgical emergency procedures are still significantly impaired compared with elective procedures. Moreover it has been shown that there is a relation between the outcome of the surgical procedure and the time elapsed between PTCA-incident and surgical intervention. Perioperative myocardial infarction and mortality are much lower if there is no delay caused by occupied theaters, unsolved transportation problems and/or time intensive attempts of recanalisation by catheter. Considering the high numbers of PTCA procedures, in some centers even performed simultaneously, it seems acceptable to perform a dilatation in the low risk group without surgical standby. If strict observance of the indication criteria is provided early complication rate and mortality of PTCA is even less than in CABG-procedures. On the other hand (from a cardiosurgical point of view), it has to be emphasized that PTCA procedures in the high risk group potentially endangering large myocardial areas, a cardiosurgical standby has to be available and emergency surgery should be performed ultimately within 60 minutes (after myocardial infarction).
患有严重冠心病的高危患者（如左主干狭窄、三支血管病变以及特别是累及左前降支近端且心室功能严重受损的双支血管病变）优先接受冠状动脉旁路移植术（CABG）治疗；病情较轻的病例可选择经皮冠状动脉腔内血管成形术（PTCA）治疗。然而，即使在对这些替代方案（PTCA与CABG）进行研究的对照和随机研究（RITA、GABI、ERACI、CABRI和BARI研究）中也发现，所有PTCA病例中有1.1%至10.1%需要进行外科急诊手术。尽管在有利条件下风险远低于上述数值，并且尽管导管技术（支架植入、灌注导管）有所改进，在不太有利的条件下风险也降低到了类似数值，但与择期手术相比，外科急诊手术的结果仍然明显受损。此外，研究表明外科手术的结果与PTCA事件和外科干预之间的时间间隔有关。如果没有因手术室占用、未解决的运输问题和/或导管再通的耗时尝试而导致延误，围手术期心肌梗死和死亡率会低得多。考虑到PTCA手术的数量众多，在一些中心甚至同时进行，在低风险组中进行扩张而不进行外科备用似乎是可以接受的。如果严格遵守适应证标准，PTCA的早期并发症发生率和死亡率甚至低于CABG手术。另一方面（从心脏外科的角度来看），必须强调的是，在高危组中进行可能危及大面积心肌的PTCA手术时，必须有心脏外科备用，并且最终应在60分钟内（心肌梗死后）进行急诊手术。
