目标血管及冠状动脉介入治疗对慢性完全闭塞病变长期预后的影响

发布时间：2018-03-11 01:37

  本文选题：慢性完全闭塞病变　切入点：介入治疗　出处：《浙江大学》2015年博士论文　论文类型：学位论文

【摘要】：背景：慢性完全闭塞病变(CTO)在冠心病中发生率高,而目前经皮冠状动脉介入治疗(PCI)率仍低,除了受到技术难度和操作风险的限制,CTO-PCI临床获益的不确定性亦对治疗决策的选择造成困扰。虽然多数大型观察性研究已肯定了CTO-PCI的长期疗效,但仍不乏反对声音。随着介入技术的日新月异,对于CTO-PCI临床获益的结论需要与技术更新同步的数据支持。此外,已有前人研究提出CTO-PCI的生存获益因目标血管的不同而存在差异。本研究立足于明确CTO-PCI的长期临床获益,并尝试探讨开通不同部位CTO病变对于疗效影响的差异性。 方法：本研究收集了2006年9月至2011年12月,浙江大学医学院附属邵逸夫医院心内科收治的209名尝试经介入治疗开通单支CTO病变的患者信息,并排除了存在1月内急性心梗、左主干或桥血管慢性闭塞以及含多个CTO病变的患者。209人中,有183人通过了至少36个月的长期随访。本研究以主要不良心血管事件(MACE)(包括全因死亡、非致死性心梗和紧急目标血管血运重建)作为联合观察终点,比较了CTO-PCI成功与否对患者无MACE生存时间和择期再次血运重建的影响。 结果：209名患者中,右冠状动脉(RCA)病变者101人(48.3%),左前降支(LAD)病变者62人(29.7%),左回旋支(LCX)病变者有46人(22.0%)RCA CTO患者高血压发病率和既往行PCI治疗率更高,而LAD CTO患者中男性和吸烟者所占比例大。从冠脉造影特点来看,RCA CTO合并三支病变(80.2%vs.29.0%vs.66.0%, P0.001)及侧枝循环开放(72.2%vs.59.7%vs.42.0%,P=0.001)的比例显著高于LAD和LCX组。患者的总体造影成功率为79.4%,手术操作成功率为75.4%,不同目标血管分组间在造影和手术操作成功率上无显著差异。在平均44.6个月的随访中,手术操作成功能显著改善总体患者的无MACE生存时间(P0.001)。不同病变部位的亚组之间比较,仅RCA CTO患者PCI术显著延长无MACE生存时间(P0.001),而非RCA组中并无统计学差异(P=0.053)。经过Cox多元回归分析,手术操作成功仍是RCA CTO患者长期MACE的独立预测因子(HR3.30,95%CI:1.30-8.39, P=0.012) 结论：本研究结果提示CTO-PCI能显著改善长期无MACE生存情况,尤其对RCA病变患者获益更大。这一结论将有助于优化CTO-PCI的患者选择。
[Abstract]:Background: the incidence of chronic total occlusive lesions (CTO) in coronary heart disease is high, but the rate of percutaneous coronary intervention (PCI) is still low. In addition to being limited by technical difficulties and operational risks, the uncertainty of the clinical benefits of CTO-PCI also bothers the choice of treatment decisions, although most large observational studies have confirmed the long-term efficacy of CTO-PCI. But there is still a lot of opposition. With the rapid development of interventional techniques, conclusions about the clinical benefits of CTO-PCI need to be supported by data that are synchronized with technical updates. Previous studies have suggested that the survival benefits of CTO-PCI vary with the target vessels. This study is based on the long-term clinical benefits of CTO-PCI and attempts to explore the difference of the effect of opening different sites of CTO lesions on the efficacy. Methods: from September 2006 to December 2011, we collected information of 209 patients who were admitted to Department of Cardiology, affiliated to run run run Shaw Hospital, Zhejiang University Medical College, and excluded the presence of acute myocardial infarction within January. Of the .209 patients with chronic occlusion of the left main or graft vessels and with multiple CTO lesions, 183 passed at least 36 months of long-term follow-up. Non-fatal myocardial infarction and emergency target vascular revascularization) were used as the combined observation endpoints to compare the effects of CTO-PCI success on the survival time without MACE and recurrent revascularization. Results among the 209 patients, 101 patients had right coronary artery stenosis (RCA), 62 had left anterior descending artery (lad) lesions, and 46 had left circumflex branch (LCX) lesions. The incidence of hypertension and the rate of previous PCI treatment were higher in 46 patients with RCA CTO. However, the proportion of male and smoker in LAD CTO patients was higher than that in LAD and LCX groups. The ratio of RCA CTO with three vessel lesions was 80.2 vs 29.0vs.66.0 (P0.001) and 72.2 vs.59.7vs.42.0vs.42.0P0.001). The overall successful rate of angiography was 79.4%. The operative success rate was 75.4, and there was no significant difference between different target vessel groups in angiographic and operative success rates. The successful operation could significantly improve the survival time without MACE of the overall patients (P 0.001). Only PCI in patients with RCA CTO significantly prolonged the survival time without MACE (P 0.001), but there was no statistical difference in the non-#en4# group. By Cox multiple regression analysis, the success of the operation was still the independent predictor of long-term MACE in RCA CTO patients (HR3.30 ~ 95% CI: 1.30-8.39, P0. 012). Conclusion: the results of this study suggest that CTO-PCI can significantly improve the long-term MACE free survival, especially for the patients with RCA lesions. This conclusion will be helpful to optimize the choice of CTO-PCI patients.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R541.4

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