冠心病合并肿瘤患者介入治疗后外科限期手术安全性的研究

发布时间：2018-05-26 17:34

本文选题：冠心病 + 冠状动脉介入治疗　；参考：《中国人民解放军医学院》2015年博士论文

【摘要】：研究背景及目的研究背景尽管随着医学的飞速发展以及诊疗技术的进步,心血管疾病和大部分肿瘤的死亡率明显下降,但是2013年最新人群死亡原因数据分析仍然显示缺血性心脏病和肿瘤为全球死亡原因前两位。冠心病和肿瘤已经成为严重威胁我国人群健康的多发病和常见病,特别是两者还具有相同的发病人群(老年人)和重叠的危险因素(如吸烟、不均衡饮食、缺少锻炼等),因此常常合并存在。随着我国人口老龄化的进程,在临床上冠心病合并肿瘤的患者也越来越多,针对这部分患者的诊断和治疗尤其是手术策略,越来越成为心血管医生和肿瘤专科医生不能忽视和不可回避的重要临床问题。在合并冠心病的肿瘤患者中,如果需要外科手术切除肿瘤病灶,一定会首先评估心脏情况,如果发现心脏处于严重的不稳定的缺血状态,会大大增加外科手术围术期的急性心脏事件发生的风险,或者不能耐受外科手术。对于这些患者,必须首先对心脏行再血管化治疗,才有机会行外科手术切除肿瘤病灶,并且心脏本身也需要尽快再血管化治疗,降低严重冠状动脉狭窄给心脏本身带来的风险。因此术前准确评估患者心脏缺血程度和风险,做好再血管化治疗,并在最短时间内进行肿瘤的外科限期手术,将会对这类患者产生巨大获益,具有重要的临床意义。由于治疗上存在有一定的矛盾,如何对冠心病合并肿瘤患者做好预防性的再血管化治疗,一直是困扰着心脏科和外科医生的难题,其中最核心的问题就是：如何平衡好患者的缺血出血风险和手术获益。AHA/ACC已经有明确指南,建议在非心脏手术前,对一些严重的心肌缺血患者应该进行预防性的再血管化治疗；而肿瘤病灶切除则属于外科限期手术,在各方面情况允许时应尽快手术。所以,目前争论的焦点主要集中在：一、冠状动脉介入手术后最快多长时间可以进行肿瘤手术?二、围术期抗血小板、抗栓药物如何应用?本研究回顾了解放军总医院近6年的冠心病合并肿瘤患者,分析了先冠状动脉介入治疗(PCI)后再行外科手术患者的临床资料、围术期用药及预后,对患者死亡原因的风险进行析因分析,探讨了PCI术后肿瘤切除最佳时机和围术期合理应用抗血小板、抗栓药物的问题。总结治疗经验以及对预后的影响,旨在为提高肿瘤合并冠心病患者的治疗疗效、延长患者寿命提供临床依据和指导。目的阐明冠状动脉介入治疗对肿瘤合并冠心病患者限期外科手术的安全性的影响,明确不同类型支架对肿瘤患者预后的影响是否不同。方法2006年03月-2012年03月在我科住院的冠心病合并肿瘤患者共209例,根据AHA/ACC对冠心病行非心脏手术前是否需要再血管化的指南,其中122例行先行冠状动脉支架植入术,4周后再行肿瘤病灶切除术,为支架+肿瘤切除组；另外87例行单纯冠状动脉造影后次日转外科行肿瘤病灶切除术,为造影+肿瘤切除组。比较分析两组患者的基本资料、外科围术期安全性。随访支架+肿瘤切除组患者的生存情况、科围术期心血管事件发生情况。采用单因素、多因素生存分析的方法分析影响PCI术后短期内行肿瘤切除手术患者预后的影响因素。结果1、122位冠心病合并肿瘤患者行冠脉介入治疗,共植入220枚支架,其中196(89.1%)枚为药物洗脱支架,24(10.9%)枚金属裸支架。手术即刻成功率为100%,支架后扩张率为100%。2、1例消化道肿瘤患者在冠状动脉支架术后3天出现消化道出血,立即给与输血,调整抗血小板、抗凝药物的使用,急诊行外科手术。75(61.5%)例患者在冠状动脉支架术后第4至6周在我院完成了肿瘤病灶切除术,26(21.3%)例患者在第6至10周内完成了肿瘤病灶切除术,20(16.4%)例患者在第10周之后完成了肿瘤病灶切除术。3、冠状动脉介入治疗术后,在外科围术期应用低分子肝素替代抗血小板药物治疗,患者术中出血量、术后引流量、手术时间、术后住院时间和应用抗血小板、抗凝药物的患者比较,无统计学差异；支架+肿瘤切除组患者在围术期没有支架内血栓发生。4、支架+肿瘤切除组患者中位随访时间31个月,2年生存率为82.79%,3年生存率为68.85%。单因素及多因素分析发现PCI至手术间隔时间、CEA水平和心率对PCI术后行肿瘤切除患者生存时间有影响,而植入支架类型、植入支架冠状动脉支数等因素对其生存时间无影响。结论1、对PCI术后短期内行外科肿瘤切除术的患者,围术期应用低分子肝素替代抗血小板药物治疗是安全的；2、PCI术后6周内行肿瘤切除、心率控制在90次/分以下,是影响该组患者预后的保护因素；3、植入药物洗脱支架和金属裸支架组患者相比,围术期安全性及远期预后均无统计学差异。
[Abstract]:Background and objective research background, although with the rapid development of medicine and the progress of diagnosis and treatment technology, the mortality of cardiovascular disease and most tumors has declined significantly, but the analysis of the cause of death of the latest population in 2013 still shows that two of the leading causes of global death are ischemic heart disease and tumor. In order to seriously threaten the prevalence and common diseases of the health of the population in our country, especially in the same population (old people) and the risk factors of overlapping (such as smoking, unbalanced diet, lack of exercise, etc.), it is often combined. With the aging process of our population, patients with coronary heart disease combined with tumors are becoming more and more in the clinic. More and more, the diagnosis and treatment of this part of the patients, especially the surgical strategy, are becoming more and more important and important clinical problems that can not be ignored and unavoidable. In the patients with coronary heart disease, if surgical resection of the tumor is needed, the heart condition will be evaluated first, if the heart is found. Severe and unstable ischemic state can greatly increase the risk of acute cardiac events during surgical perioperative period, or can not tolerate surgery. For these patients, it is necessary to revascularization of the heart first to have the opportunity to surgical resection of the tumor, and the heart itself needs to be revascularized as soon as possible. Treatment, reducing the risk of serious coronary artery stenosis to the heart itself. Therefore, accurate assessment of the degree and risk of heart ischemia, revascularization, and surgical limited surgery within the shortest time will be of great benefit to these patients and have important clinical significance. A certain contradiction, how to do preventive revascularization for patients with coronary heart disease and cancer has been a difficult problem for the cardiology department and surgeons. The most important problem is: how to balance the risk of ischemia and bleeding in patients and the benefit of operation.AHA/ACC has a clear guide, it is suggested that before the non cardiac surgery, some Patients with severe myocardial ischemia should be treated with prophylactic revascularization; tumor resection is a surgical limit operation and should be operated as soon as possible in all aspects. Therefore, the focus of the current debate is: (1) how soon after coronary intervention is the fastest time for tumor surgery? Two, perioperative period How to use antiplatelet and antithrombotic drugs? This study reviewed the recent 6 years of coronary heart disease combined with tumor patients in the General Hospital of PLA, analyzed the clinical data of patients undergoing coronary intervention (PCI), the perioperative medication and prognosis, analysis of the risk of death of the patients, and discussed the tumor resection after PCI. In order to improve the therapeutic efficacy of the patients with coronary heart disease and prolong the life span of the patients with coronary heart disease, the aim of this study is to provide the clinical basis and guidance to improve the therapeutic effect and prolong the life span of the patients with coronary heart disease. The effect of the safety of the operation is to determine whether different types of stents have different effects on the prognosis of cancer patients. Methods 209 cases of coronary heart disease combined with tumors were hospitalized in our department in 2006, -2012, 03 months, according to the guidelines for revascularization for coronary heart disease before non cardiac surgery, and 122 of them were first coronary artery branch. 4 weeks later, the tumor resection was performed for the stent plus tumor resection group, and the other 87 cases were treated with the tumor resection group after the simple coronary angiography. The basic data of the two groups were compared and analyzed. The safety of surgical perioperative period was compared and the survival of the patients in the stent and tumor resection group was followed up. A single factor and multifactor survival analysis were used to analyze the factors affecting the prognosis of patients undergoing PCI resection in the short term. Results 1122 patients with CAD and tumor were treated with coronary intervention, and 220 stents were implanted, of which 196 (89.1%) were drug-eluting stents and 24 (10.9%). A bare metal stent. The immediate success rate of the operation was 100%. The poststent dilatation rate was 3 days after the coronary stent implantation in 100%.2,1 patients with digestive tract tumors. The blood transfusion was given immediately, the antiplatelet and anticoagulants were adjusted, and the emergency operation was performed in.75 (61.5%) patients fourth to 6 weeks after coronary artery stenting. Tumor excision was performed in the hospital. 26 (21.3%) patients completed tumor resection in sixth to 10 weeks. 20 (16.4%) patients completed tumor resection.3 after tenth weeks. After coronary intervention, low molecular weight heparin was used to replace antiplatelet drugs in surgical perioperative period. The amount of intraoperative bleeding and postoperative bleeding were observed. There was no statistical difference in the flow rate, the time of operation, the time of postoperative hospitalization and the use of antiplatelet and anticoagulant drugs. There was no stent thrombosis in the perioperative period of the stent plus tumor resection group.4, the median follow-up time of the stent + tumor resection group was 31 months, the 2 year survival rate was 82.79%, and the 3 year survival rate was 68.85%. single factor and more. Factor analysis found that PCI to operation interval time, CEA level and heart rate have an influence on the survival time of the patients undergoing tumor resection after PCI, and the type of stent implantation and the number of coronary artery support implantation have no influence on the survival time. Conclusion 1, low molecular weight heparin (LMWH) was used in the perioperative period of postoperative intraoperative surgical swollen tumor resection for PCI. The replacement of antiplatelet drugs was safe; 2, the tumor resection was performed within 6 weeks after PCI and the heart rate control was below 90 times per cent. It was a protective factor affecting the prognosis of the patients in this group. 3, there was no statistical difference between the perioperative safety and the long term after implantation of drug eluting stents and bare metal stents.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R541.4;R730.5

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