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DES与CABG治疗冠状动脉无保护左主干病变合并慢性肾衰竭患者的预后分析

Prognostic analysis of drug-eluting stent implantation and coronary artery bypass grafting in patients with unprotected left main coronary artery disease complicated with chronic renal failure

摘要:

目的:分析无保护左主干(ULM)冠状动脉(冠脉)病变合并慢性肾衰竭(CRF)患者行药物洗脱支架置入术(DES)或冠状动脉旁路移植术(CABG)的远期预后。方法:入选首都医科大学附属北京安贞医院心内科冠心病监护病房(ICU)及心外科监护室UML冠脉病变合并CRF患者。根据估算肾小球滤过率(eGFR)分为两层,分析各分层中DES患者与CABG患者的临床特点;采用Log-Rank法及Cox回归分析两种手术策略患者的冠脉病变及远期临床预后。结果:共入选353例患者,其中eGFR<45 mL·min -1·1.73 m -2者150例(DES 67例、CABG 83例),eGFR 45~59 mL·min -1·1.73 m -2者203例(DES 80例、CABG 123例)。人口学和临床病史方面,在各eGFR分层中,与CABG组比较,DES组完全血运重建比例低,合并慢性完全闭塞病变(CTO)、多支病变的比例低。所有患者平均随访(30.74±15.05)个月。Log-Rank分析显示,在各eGFR分层中,DES组与CABG组主要心脑血管不良事件(MACCE)、全因死亡、心源性死亡及脑卒中发生率差异均无统计学意义。在eGFR 45~59 mL·min -1·1.73 m -2分层中,DES组再次血运重建术(TVR)比例高于CABG组(18.8%比0.8%, P<0.01);在eGFR<45 mL·min -1·1.73 m -2分层中,DES组心肌梗死发生率高于CABG组(10.4%比1.2%, P<0.05)。Cox分析显示,经调整年龄、性别、高血压史、糖尿病史、左室射血分数、吸烟史、既往脑血管疾病史、是否完全血运重建、合并多支病变、有无CTO等相关因素后,eGFR 45~59 mL·min -1·1.73 m -2分层中,DES组TVR比例仍高于CABG组〔风险比( HR)=46.463,95%可信区间(95% CI)为4.558~473.693, P=0.001〕;在eGFR<45 mL·min -1·1.73 m -2分层中,DES组心肌梗死发生率仍高于CABG组( HR=14.098,95% CI为1.123~176.988, P=0.040),而两种手术方式TVR比例无差异。 结论:eGFR<45 mL·min -1·1.73 m -2是ULM病变患者行DES的独立危险因素。对于ULM病变合并CRF患者,DES较为安全、有效;而对于较为严重的CRF患者(eGFR<45 mL·min -1·1.73 m -2),DES相对于CABG可能会带来更多的心肌梗死,需谨慎选择。

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abstracts:

Objective:To analyze the long-term prognosis of undergoing drug-eluting stent implantation (DES) or coronary artery bypass grafting (CABG) in patients with unprotected left main (ULM) coronary artery disease complicated with chronic renal failure (CRF).Methods:Patients with UML coronary artery disease complicated with CRF admitted to the department of cardiology intensive care unit (ICU) and cardiac surgery ICU of Beijing Anzhen Hospital Affiliated to Capital Medical University were enrolled. According to the estimated glomerular filtration rate (eGFR), the patients were divided into two layers, and the clinical characteristics of DES patients and CABG patients were analyzed. Log-Rank method and Cox regression were used to analyze the coronary artery disease and long-term clinical prognosis of patients with two surgical strategies.Results:A total of 353 patients were enrolled, including 150 patients with eGFR < 45 mL·min -1·1.73 m -2 (DES 67 cases, CABG 83 cases), eGFR 45-59 mL·min -1·1.73 m -2 in 203 cases (DES 80 cases, CABG 123 cases). In terms of demography and clinical history, compared with CABG group, DES group had lower proportion of complete revascularization and lower proportion of chronic totalocclusion (CTO) and multi vessel disease in each eGFR level. All patients were followed up for an average of (30.74±15.05) months. Log-Rank analysis showed that there was no significant difference in the incidence of major cardiovascular and cerebrovascular adverse events (MACCE), all-cause death, cardiogenic death and stroke between DES group and CABG group in each eGFR level. In eGFR 45-59 mL·min -1·1.73 m -2, the proportion of target vessel revascularization (TVR) in DES group was higher than that in CABG group (18.8% vs. 0.8%, P < 0.01); in eGFR < 45 mL·min -1·1.73 m -2, the incidence of myocardial infarction in DES group was higher than that in CABG group (10.4% vs. 1.2%, P < 0.05). Cox analysis showed that after adjusting for age, gender, history of hypertension, diabetes, left ventricular ejection fraction, smoking history, previous cerebrovascular disease, complete revascularization, multiple vessel disease and CTO, TVR proportion in DES group was still higher than that in CABG group in eGFR 45-59 mL·min -1·1.73 m -2 [hazard ratio ( HR) = 46.463, 95% confidence interval (95% CI) was 4.558-473.693, P = 0.001]; in eGFR < 45 mL·min -1·1.73 m -2, the incidence of myocardial infarction in DES group was still higher than that in CABG group ( HR = 14.098, 95% CI was 1.123-176.988, P = 0.040), there was no difference in TVR proportion between the two methods. Conclusions:eGFR < 45 mL·min -1·1.73 m -2 is an independent risk factor for DES in ULM patients. DES is safe and effective for ULM patients with CRF, but for patients with more severe CRF (eGFR < 45 mL·min -1·1.73 m -2), there was more myocardial infarction in DES group than that in CABG group, which should be carefully selected.

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作者: 潘昱 [1] 穆煜 [2] 张宇晨 [1] 何继强 [1] 仇琪 [2]
期刊: 《中华危重病急救医学》2020年32卷10期 1203-1207页 MEDLINEISTICPKUCSCD
栏目名称: 论著·重症心脏
DOI: 10.3760/cma.j.cn121430-20200518-00391
发布时间: 2021-01-11
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