冠狀動(dòng)脈旁路移植術(shù)與藥物洗脫支架治療無(wú)保護(hù)左主干冠心病療效比較

周保國(guó) 王兆東 王靜 王麗君 呂洪福 李珂

（1.青島阜外心血管病醫(yī)院心臟外科，山東青島 266034；2.山東青島思達(dá)心臟醫(yī)院心臟外科，山東青島 266000）

冠狀動(dòng)脈旁路移植術(shù)與藥物洗脫支架治療無(wú)保護(hù)左主干冠心病療效比較

周保國(guó)1王兆東2王靜1王麗君1呂洪福1李珂1

（1.青島阜外心血管病醫(yī)院心臟外科，山東青島 266034；2.山東青島思達(dá)心臟醫(yī)院心臟外科，山東青島 266000）

目的：探討無(wú)保護(hù)左主干病變患者選用冠狀動(dòng)脈旁路移植術(shù)與藥物洗脫支架治療的療效。方法：選擇100例在我院行血運(yùn)重建術(shù)的無(wú)保護(hù)左主干患者，根據(jù)患者選擇的手術(shù)方式不同隨機(jī)分為兩組：A組（藥物洗脫支架組，n=48例）、B組（冠狀動(dòng)脈旁路移植術(shù)組，n=52例）。統(tǒng)計(jì)兩組患者一般情況、心功能指標(biāo)、冠狀動(dòng)脈病變特點(diǎn)、住院期間療效及術(shù)后3年不良心腦血管事件的發(fā)生率。結(jié)果：兩組患者左主干病變的主要位置位于開(kāi)口部和體部，A組患者左主干+多支血管病變的發(fā)生率及Syntax積分明顯低于B組，差異有統(tǒng)計(jì)學(xué)意義；A組患者術(shù)后平均住院天數(shù)明顯低于B組患者，差異有統(tǒng)計(jì)學(xué)意義，血運(yùn)完全重建人數(shù)低于B組患者，差異有統(tǒng)計(jì)學(xué)意義，兩組患者住院期間總死亡人數(shù)相比差異無(wú)統(tǒng)計(jì)學(xué)意義；術(shù)后3年兩組患者心腦血管事件總?cè)藬?shù)、總死亡人數(shù)、腦卒中、非致死性心肌梗死的發(fā)生情況相比差異無(wú)統(tǒng)計(jì)學(xué)意義，A組患者靶血管再次血運(yùn)重建的發(fā)生率明顯高于B組患者，差異有統(tǒng)計(jì)學(xué)意義。結(jié)論：無(wú)保護(hù)左主干病變患者采用藥物洗脫支架治療方法可減少患者圍術(shù)期的住院時(shí)間且不增加患者心腦血管事件的發(fā)生及死亡率，但與冠狀動(dòng)脈旁路移植術(shù)相比會(huì)增加患者遠(yuǎn)期靶血管再次血運(yùn)重建。

冠心??；無(wú)保護(hù)左主干；藥物洗脫支架；冠狀動(dòng)脈旁路移植術(shù)

心臟左主干主要供應(yīng)左心室的血液[1-2]，因而左主干病變患者是冠狀動(dòng)脈粥樣硬化性心臟病中的高危人群。無(wú)保護(hù)的左主干病變患者由于缺少側(cè)支循環(huán)，死亡風(fēng)險(xiǎn)更高[3-4]，一旦血流改變可能立刻引起患者心源性休克甚至死亡[5]。冠狀動(dòng)脈旁路移植術(shù)是治療無(wú)保護(hù)左主干病變的主要方法，可以明顯改善患者的生存率[6-7]。隨著冠狀動(dòng)脈介入手術(shù)的成熟和藥物洗脫支架的研發(fā)，藥物洗脫支架植入成為左主干病變血運(yùn)重建的新方法[8]。因而本研究將探討無(wú)保護(hù)左主干病變患者選用冠狀動(dòng)脈旁路移植術(shù)與藥物洗脫支架治療的近遠(yuǎn)期療效。

1 資料與方法

1.1 一般資料

選擇于我院行血運(yùn)重建術(shù)的無(wú)保護(hù)左主干患者100例，排除急性心肌梗死、其它原因所致左主干病變者，再次血運(yùn)重建患者、既往有冠狀動(dòng)脈旁路移植術(shù)手術(shù)史、術(shù)后不能長(zhǎng)期耐受抗血小板藥物治療等患者。所有患者術(shù)前均行冠狀動(dòng)脈造影確診為左主干病變（狹窄程度≥50%且左前降支或回旋支無(wú)側(cè)支循環(huán)及血管橋），隨機(jī)并根據(jù)患者意愿選擇手術(shù)方式。兩組分別為：A組（藥物洗脫支架組，n=48例）、B組（冠狀動(dòng)脈旁路移植術(shù)組，n=52例）。本研究經(jīng)我院倫理委員會(huì)批準(zhǔn)且所有患者均簽署知情同意書(shū)。

1.2 方法

A組患者術(shù)前一周開(kāi)始采用阿司匹林腸溶片300mg/天、氯吡格雷75mg/天口服，術(shù)中根據(jù)患者情況選擇橈動(dòng)脈或股動(dòng)脈穿刺行藥物洗脫支架置入術(shù)，對(duì)于左主干遠(yuǎn)端分叉無(wú)病變的患者采用單支架置入術(shù)，合并遠(yuǎn)端分叉病變的患者采用雙支架置入術(shù)，術(shù)后阿司匹林腸溶片改為100mg/天長(zhǎng)期服用，氯吡格雷75mg/天服用一年。B組患者術(shù)前一周停用阿司匹林腸溶片、氯吡格雷等藥物，改為低分子肝素40～60mg/次，2次/天，皮下注射，術(shù)中據(jù)情況采用體外循環(huán)或非體外循環(huán)下冠狀動(dòng)脈旁路移植術(shù)，術(shù)后長(zhǎng)期口服阿司匹林腸溶片100mg/天。兩組患者術(shù)后據(jù)情況加用調(diào)脂（阿托伐他汀鈣片或瑞舒伐他汀鈣）、改善循環(huán)（硝酸酯類）、降壓藥物。

1.3 觀察指標(biāo)

統(tǒng)計(jì)兩組患者一般情況、心功能指標(biāo)、冠狀動(dòng)脈病變特點(diǎn)、住院期間療效及術(shù)后3年不良心腦血管事件（總死亡人數(shù)、腦卒中、非致死性心肌梗死、靶血管再次血運(yùn)重建）的發(fā)生率。Syntax評(píng)分指標(biāo)具體如下：syntax評(píng)分系統(tǒng)將冠狀動(dòng)脈分為16段，對(duì)直徑≥1.5mm，狹窄程度≥50%的冠脈血管進(jìn)行評(píng)分主要包括冠狀動(dòng)脈優(yōu)勢(shì)分布類型、病變血管數(shù)目、病變節(jié)段及特征等，所得的總分即為Syntax總分。采用SPSS19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

兩組患者年齡、性別比、高血壓病史、糖尿病病史、高脂血癥病史、吸煙史、心功能指標(biāo)相比差異無(wú)統(tǒng)計(jì)學(xué)意義。

患者左主干病變的主要位置位于開(kāi)口部和體部，A組患者左主干+多支血管病變的發(fā)生率及Syntax積分明顯低于B組，差異有統(tǒng)計(jì)學(xué)意義，見(jiàn)表1。

表1 兩組患者冠狀動(dòng)脈病變特點(diǎn)比較

A組患者術(shù)后平均住院天數(shù)（4.5±1.9）天，明顯低于B組的（15.8±6.7）天，差異有統(tǒng)計(jì)學(xué)意義，P＜0.05，兩組血運(yùn)完全重建人數(shù)38vs49，死亡人數(shù)0vs3，A組完全重建人數(shù)低于B組，差異有統(tǒng)計(jì)學(xué)意義，P＜0.05；死亡率比較差異無(wú)統(tǒng)計(jì)學(xué)意義。

術(shù)后隨訪3年不良心腦血管事件的發(fā)生情況，兩組心腦血管事件總?cè)藬?shù)相比差異無(wú)統(tǒng)計(jì)學(xué)意義，其中總死亡人數(shù)、腦卒中、非致死性心肌梗死的發(fā)生情況相比差異無(wú)統(tǒng)計(jì)學(xué)意義，P＞0.05，A組患者靶血管再次血運(yùn)重建的發(fā)生率18.75%明顯高于B組患者的3.85%，差異有統(tǒng)計(jì)學(xué)意義，P＜0.05。

3 討論

左冠狀動(dòng)脈是供應(yīng)左心血供的主要?jiǎng)用}，病變率約為5%，患者極易出現(xiàn)心律失常、心肌梗死、心源性休克等危及生命的并發(fā)癥，早期診斷治療無(wú)保護(hù)左主干病變可以明顯改善患者預(yù)后[9-11]。有研究表明冠狀動(dòng)脈旁路移植術(shù)可明顯改善無(wú)保護(hù)左主干患者的生存率[12]，且患者無(wú)主要心血管事件生存率明顯高于冠狀動(dòng)脈支架置入術(shù)，因而冠脈旁路移植術(shù)是無(wú)保護(hù)左主干患者首選治療方案。但冠狀動(dòng)脈粥樣硬化的患者多為中老年患者，且多合并糖尿病、心功能不全、外周血管疾病等，外科手術(shù)創(chuàng)傷及術(shù)后并發(fā)癥也成為患者中遠(yuǎn)期生存率的影響因素[13-14]。也有研究表明無(wú)保護(hù)左主干患者采用介入手術(shù)治療也可獲得較高的生存率[15]，但合并多血管病變的PCI手術(shù)難度較大，因而對(duì)于左主干多血管病變的處理策略選擇更應(yīng)慎重。

本研究中， A組患者多為左主干+單支血管病變，因而其Syntax評(píng)分低于B組。A組患者術(shù)后平均住院天數(shù)明顯低于B組患者，差異有統(tǒng)計(jì)學(xué)意義，表明藥物洗脫支架置入術(shù)創(chuàng)傷小，術(shù)后患者恢復(fù)快。兩組患者住院期間總死亡人數(shù)相比差異無(wú)統(tǒng)計(jì)學(xué)意義，表明藥物洗脫支架置入術(shù)安全性高，并不增加患者圍術(shù)期的死亡率。A組患者血運(yùn)完全重建人數(shù)低于B組患者，這可能和術(shù)中操作有關(guān)，由于藥物洗脫支架置入術(shù)要求冠脈造影清楚顯示病變血管、支架能夠盡可能伸展、貼合覆蓋病變血管，但術(shù)中支架置入和釋放均在透視下進(jìn)行，因而可能存在操作上的誤差[16]。術(shù)后3年隨訪結(jié)果表明術(shù)后血管再狹窄是影響藥物洗脫支架療效的重要因素，其可能的機(jī)制和血管重塑、血管彈性回縮、血管內(nèi)血栓及新生內(nèi)膜增生形成有關(guān)，同時(shí)糖尿病、高脂血癥、急性心肌梗死等也可導(dǎo)致介入手術(shù)數(shù)周后支架內(nèi)再狹窄。再次血運(yùn)重建的血管不僅包括既往的病變血管也包括新狹窄的病變血管，因而病變的新進(jìn)展和新發(fā)病變是限制藥物洗脫支架治療遠(yuǎn)期效果的重要原因，控制冠狀動(dòng)脈粥樣硬化的危險(xiǎn)因素，調(diào)整患者的血糖、血壓、血脂可能有效降低遠(yuǎn)期血管再次血運(yùn)重建的發(fā)生率[17-18]。以上研究結(jié)果可以看出藥物洗脫支架治療具有創(chuàng)傷小、患者住院時(shí)間短、術(shù)后恢復(fù)快等優(yōu)點(diǎn)，降低其再狹窄率可顯著提高其遠(yuǎn)期療效。冠狀動(dòng)脈旁路移植術(shù)雖然完全血運(yùn)重建率高，但創(chuàng)傷大、患者圍術(shù)期并發(fā)癥、死亡率高。因而對(duì)于無(wú)保護(hù)左主干病變患者的手術(shù)方式應(yīng)具體化、個(gè)體化。

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The effect comparison between coronary artery bypass grafting and drug eluting stent on the treatment of unprotected left main coronary artery disease

ZHOU Baoguo1, WANG Zhaodong2, WANG Jing1, WANG Lijun1, LYU Hongfu1, LI Ke1.
（1. Department of Cardiac surgery,Qingdao Fuwai Cardiovascular Disease Hospital,Qingdao 266034 china；2. Department of Cardiac surgery,Qingdao starr heart hospital,Qingdao 266000,china）

Objective: The objective of this study was to compare the effect of coronary artery bypass grafting and drug eluting stent on the treatment of unprotected left main coronary artery disease. Methods: A total of 100 cases of patients with unprotected left main coronary artery disease applying revascularization treated in our hospital were randomly divided into group A ( drug eluting stent, n=48) and group B (coronary artery bypass grafting, n=52). The general conditions, cardiac parameters, coronary artery lesion characteristics, curative effect during hospitalization and the incidence of adverse cardiovascular and cerebrovascular events after 3 years of surgery were recorded. Results: The main sites of left main coronary artery disease of two groups were found in ostial and body. The incidence of left main coronary artery plus multi-vessel disease and Syntax score were remarkable lower than that of B group and the difference was statistically signif i cant; the average length of stay of A group was shorter than B group while the number of revascularization of group A was less than group B and the difference was statistically signif i cant. The difference of total death toll during hospitalization between two groups was not statistically signif i cant; the difference of the total number of cardiovascular and cerebrovascular events, total death toll, stroke and the incidence of non-lethal myocardial infarction between two groups after 3 years of treatment was of no statistical signif i cance. The incidence of target vessel revascularization of group A was higher than group B and the difference was statistically significant. Conclusions: The therapy of drug eluting stent on unprotected left main coronary artery disease can decrease the perioperative hospitalization time without adding the morality rate of cardiovascular and cerebrovascular events, however, it will increase the target vessel revascularization comparing with the coronary artery bypass grafting.

coronary heart disease; unprotected left main coronary artery; drug eluting stent; coronary artery bypass grafting

R654.3

A

2095-5200(2017)04-028-03

10.11876/mimt201704013

周保國(guó)，本科，主治醫(yī)師，研究方向：心外疾病臨床，Email：guobaozhou231@163.com。