Patel V S, Radovancevic B, Springer W, Frazier O H, Massin E, Benrey J, Kadipasaoglu K, Cooley D A
Texas Heart Institute at St. Luke's Epsicopal Hospital, Houston 77030, USA.
Eur J Cardiothorac Surg. 1997 May;11(5):895-901. doi: 10.1016/s1010-7940(97)01167-6.
To assess the efficacy of revascularization in cardiac transplant patients who developed de novo coronary artery disease.
Eighteen patients underwent one or more of four methods of revascularization: percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revacularization (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3 +/- 6.6 months after transplantation. Six patients underwent PTCRA 83.3 +/- 11.2 months after transplantation. Five patients underwent CABG 54.0 +/- 12.6 months after transplantation; the mean left ventricular ejection fraction was 49.6 +/- 16.9 (20-65%); hypertrophy was present in two of these patients. One patient with distal coronary artery disease and New York Heart Association class IV symptoms underwent TMLR only. One patient underwent both CABG and TMLR because of triple vessel proximal disease, diffuse distal disease, and New York Heart Association class IV symptoms.
PTCA was successful in 10 procedures with decrease in mean stenosis from 87.7 +/- 2.7 to 24.3 +/- 6.0%. Follow-up, at 16.9 +/- 4.0 months, showed restenosis in two patients. PTCRA was successful in all patients with a decrease in mean stenosis from 83.4 +/- 4.4 to 11.7 +/- 1.9%. Short-term follow-up did not reveal reocclusion. Two CABG patients who had hypertrophy died of heart failure 2 and 9 days after their operations. One CABG patient with excellent cardiac function died after 15 days because of pulmonary failure. In one patient, left ventricular ejection fraction improved from 35 to 50%, and he is alive 64 months later. Six months after TMLR, the New York Heart Association class in one patient improved from IV to II, and his left ventricular ejection fraction improved from 29 to 42%. The ejection fraction in the patient who underwent both CABG and TMLR improved from 20 to 56% but the patient expired 7 weeks later.
It appears that revascularization procedures can be effective in patients with coronary artery disease after cardiac transplantation and that coronary angioplasty or atherectomy would be a therapy of choice for single proximal lesions. CABG should be used cautiously and only reserved for patients with multi-vessel disease without hypertrophy. Laser revascularization with or without bypass grafting has potential to become the therapy of choice for transplant coronary artery disease.
评估血管重建术对发生新生冠状动脉疾病的心脏移植患者的疗效。
18例患者接受了四种血管重建术方法中的一种或多种：经皮腔内冠状动脉成形术（PTCA）、经皮腔内冠状动脉旋切术（PTCRA）、冠状动脉旁路移植术（CABG）和经心肌激光血运重建术（TMLR）。10例患者在移植后55.3±6.6个月进行了11次PTCA手术。6例患者在移植后83.3±11.2个月接受了PTCRA。5例患者在移植后54.0±12.6个月接受了CABG；平均左心室射血分数为49.6±16.9（20-65%）；其中2例患者存在心肌肥厚。1例患有冠状动脉远端疾病且纽约心脏协会心功能IV级症状的患者仅接受了TMLR。1例因三支血管近端病变、弥漫性远端病变和纽约心脏协会心功能IV级症状同时接受了CABG和TMLR。
10次PTCA手术成功，平均狭窄率从87.7±2.7%降至24.3±6.0%。在16.9±4.0个月的随访中，2例患者出现再狭窄。所有接受PTCRA的患者均成功，平均狭窄率从83.4±4.4%降至11.7±1.9%。短期随访未发现再闭塞。2例接受CABG且有心肌肥厚的患者在术后2天和9天死于心力衰竭。1例心功能良好的CABG患者在术后15天因呼吸衰竭死亡。1例患者左心室射血分数从35%提高到50%，64个月后仍然存活。TMLR术后6个月，1例患者的纽约心脏协会心功能分级从IV级改善到II级，左心室射血分数从29%提高到42%。同时接受CABG和TMLR的患者射血分数从20%提高到56%，但该患者在7周后死亡。
血管重建术似乎对心脏移植术后患有冠状动脉疾病的患者有效，冠状动脉成形术或旋切术对于单一近端病变可能是首选治疗方法。CABG应谨慎使用，仅适用于无心肌肥厚的多支血管病变患者。无论是否进行旁路移植术，激光血运重建术都有可能成为移植冠状动脉疾病的首选治疗方法。
