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无保护左主干分叉病变患者血运重建的长期预后

Comparison on the long-term outcomes post percutaneous coronary intervention or coronary artery bypass grafting for bifurcation lesions in unprotected left main coronary artery

摘要:

目的:比较无保护左主干分叉病变患者接受经皮冠状动脉介入术(PCI)或冠状动脉旁路移植术( CABG)的长期预后。方法连续入选2003年1月至2009年7月北京安贞医院行PCI或CABG治疗的无保护左主干分叉病变患者663例进行回顾性分析,其中PCI组316例,CABG组347例。研究终点包括全因死亡、非致命性心肌梗死(心梗)、卒中、再次血运重建、心原性死亡/心梗/卒中联合硬终点以及主要不良心脑血管事件( MACCE,包括心原性死亡、非致命性心梗、卒中及再次血运重建的联合终点)。为增加组间可比性,本研究运用logistic回归进行倾向性评分匹配分析。采用Kaplan-Meier法描述生存率,用Cox比例风险模型计算匹配前后两组人群的风险比( HR)、95%CI及多因素校正分析。结果随访时间7.2(5.1,8.3)年。多因素校正前的结果显示,PCI组和CABG组间不良事件发生率:MACCE (44.5%比45.7%, P =0.036)、再次血运重建(33.7%比19.5%, P <0.001)、心原性死亡/心梗/卒中联合硬终点(20.4%比34.3%,P=0.032)和卒中(3.7%比23.5%, P<0.001)发生率差异有统计学意义;全因死亡(13.0%比18.9%, P =0.12)和心梗(11.3%比6.1%,P=0.108)发生率差异无统计学意义。 Cox多因素分析显示,PCI组MACCE发生率仍明显高于CABG组(55.2%比41.9%,P=0.011),主要归因于PCI组较CABG组明显升高的再次血运重建率(HR=2.46,95%CI 1.662~3.642,P<0.001);两组间全因死亡(P=0.286)、心梗(P=0.165)和心原性死亡/心梗/卒中联合硬终点( P=0.305)发生率差异均无统计学意义;CABG组卒中发生率明显高于PCI组(P=0.001)。经倾向性评分匹配后,共有202对无保护左主干分叉病变配比成功。 PCI组心梗发生率明显高于CABG组(12.7%比3.8%,P=0.039),其余终点事件发生率与Cox多因素校正结果一致。结论 CABG和PCI治疗无保护左主干分叉病变患者的长期生存率相似,PCI组再次血运重建率明显升高,而CABG组卒中发生率明显升高。倾向性评分匹配样本分析显示,PCI组不仅再次血运重建率明显升高,且心梗发生率也明显升高,但仍未转化为病死率上的差异。提示PCI可以作为无保护左主干分叉病变血运重建一个合理的选择。

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abstracts:

Objective To compare the long-term clinical outcomes of consecutive patients treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for bifurcation lesions in unprotected left main coronary artery (ULMCA).Methods A total of 663 consecutively patients with unprotected left main bifurcation disease ( defined as stenosis≥50%) who received either drug-eluting stents (DES) implantation (n=316) or underwent CABG (n=347) between January 2003 and July 2009 in Beijing Anzhen Hospital were enrolled retrospectively in this study.The endpoints of the study were death, repeat revascularization, myocardial infarction (MI), stroke, the&nbsp;composite of cardiac death , MI or stroke and MACCE ( major adverse cardiac and cerebrovascular events , the composite of cardiac death , MI, stroke or repeat revascularization ).To reduce the bias between two compared groups ,our study applid propensity score matching by logistic regression.Cumulative survival rate was calculated by Kaplan-Meier method.Multiple regression analyses, hazard ratio(HR) and 95%CI were tested by Cox proportional hazard models with the CABG group as the reference category .Results The median follow-up was 7.2 years ( interquartile range 5.1 to 8.3 years ) in the overall patients.Unadjusted analysis showed that MACCE rate ( PCI 44.5% vs.CABG 45.7%, P =0.036 ) , the rate of repeat revascularization ( PCI 33.7% vs.CABG 19.5%, P <0.001 ) , the composite rate of serious outcomes (cardiac death, MI or stroke) (PCI 20.4% vs.CABG 34.3%,P=0.032), stroke rate (PCI 3.7% vs.CABG 23.5%,P<0.001 ) were significantly different for patients undergoing PCI or CABG.Death rate (PCI 13.0%vs.CABG 18.9%,P=0.12) and MI rate (PCI 11.3%vs.CABG 6.1%,P=0.108) were similar between PCI and CABG group .After adjusting covariates with multivariate Cox hazard regression model,there was no significant difference in rates of death (P=0.286),MI(P=0.165) and the composite rate of serious outcomes ( cardiac death , MI or stroke ) ( P=0.305 ) between the two groups.Patients in PCI group suffered significant higher rates of MACCE ( P=0.011 ) , mainly driven by the significant higher rates of repeat revascularization(HR=2.46,95%CI 1.662-3.642,P<0.001).However, stroke rate was still significantly higher in CABG group than in PCI group ( P=0.001 ) after multivariate adjusting.After propensity score matching (PSM), there was no more significant difference for all covariates in the matched cohorts (202 pairs).Further PSM analysis showed that overall findings were consistent with multivariate Cox hazard regression model except for MI (PCI 12.7%vs.CABG 3.8%,P=0.039).Conclusions During a follow-up up to 8.3 years,the survival rate is similar between the PCI and the CABG group in patients with unprotected left main bifurcation disease.The rate of repeat revascularization is significantly higher whereas stroke rate is significantly lower in the PCI group compared to CABG group.After propensity score matching , PCI group not only had a significant higher rate of repeat revascularization , but also had significantly higher risk of MI in the matched cohorts; while they did not seem to translate into any disparity of mortality in ULMCA bifurcation disease patients.Accordingly , PCI for ULMCA disease can be used as a reasonable treatment option alternative to CABG.

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作者: 杨帮国 [1] 玉献鹏 [1] 陈方 [1] 吕树铮 [1] 李全 [1] 何继强 [1] 苑飞 [1]
期刊: 《中华心血管病杂志》2017年45卷1期 19-25页 MEDLINEISTICPKUCSCD
栏目名称: 介入治疗
DOI: 10.3760/cma.j.issn.0253-3758.2017.01.005
发布时间: 2017-03-17
基金项目:
北京市医院管理局临床医学发展专项经费( XMLX201406)Fund programBeijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support
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