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1、冠心病外科的进展(up-to-date coronary surgery)阮新民,前 言,近年资料显示：我国城市乡村居民冠心病的病死率已由1988年的66.5/10万人上升到1996年的84.5/10万人，冠心病已成为疾病致死的主要原因之一。,冠状动脉搭桥手术（CABG）被广泛应用，较好地改善了患者的预后 每年全世界有100多万人接受冠脉搭桥手术，我国2000年的资料报道，每年行冠脉搭桥手术5000余例。,冠心病的治疗,内科疗法介入治疗外科手术,冠状动脉搭桥术,冠脉搭桥的作用,消除和减轻心绞痛预防心肌梗死延长生命,自体内乳动脉：10年通畅90%桡动脉、胃网膜右动脉、腹壁下动脉大(小)隐静脉：1
2、0年后50%狭窄 异体 同种静脉移植 1年内闭塞50%人造血管,搭桥用的材料,搭桥病人远期存活率,1年 955年 8810年 7515年 60,搭桥的适应证,3支血管病变，特别左室功能受累者(EF50%)左前降支(LAD)及回旋支(Cx)近端显著(70%)狭窄经皮腔内血管PTCA)失败或出现并发症，以及PCI术后再狭窄心肌梗塞后并发症（室间隔穿孔、心室破裂、室壁瘤）,搭桥的禁忌证,梗阻远端血管腔直径1.0狭窄血管的供血区已无存活的心肌细心绞痛不严重而有长期慢性心衰的重症患者心肌已广泛纤维化，心脏明显扩大(严重的缺血性心肌病),搭桥的相对禁忌证,左室功能差：LVEDP20mmHg，EF20%多脏
3、器功能不全：肾、肝,手术方法,标准方法（CCABG，常规体外循环下搭桥)微创方法：(1)微创冠脉搭桥(MIDCAB)(2)不停跳冠脉搭桥(OPABG)（3）内窥镜下冠脉搭桥(ENDO-CABG)（4）窗口手术(port-access)激光心肌打孔术（TMR）,常规体外循环下搭桥（CCABG),体外循环下冠脉搭桥术,微创大隐静脉取出术,微创大隐静脉取出术,微创大隐静脉取出术,内窥镜下内乳动脉取出术,微创冠脉搭桥(MIDCAB),微创冠脉搭桥(MIDCAB),窗口手术(port-access),不停跳冠脉搭桥(OPABG),ROBOTIC-ASSISTED CARDIAC SURGERY:HYBR
4、ID CORONARY BYPASS PROJECT,Fly by Wire Technology,冠脉搭桥的质量控制,冠脉搭桥的质量控制,冠脉搭桥的质量控制,冠脉搭桥的质量控制,激光心肌打孔术（TMR）,激光心肌打孔术（TMR）,激光心肌打孔术（TMR）,生物搭桥,骨髓干细胞移植细胞生长因子VEGFFGF,Randomized Trial,1.RITA trial2.CABRI3.King SB III4.ERACI 5.Hamm CW6.BARI-All balloon PCI vs CABG:similar mortality and MI rate,but freedom from r
5、epeat revascularization favor CABG,Randomized Trial,Bare Stent vs CABG 1.SoS trial2.MASS II 3.ERACI II4.ARTS lower restenosis rate in CABG,SoS Trial,The Stent sv Surgery Trial-1st Stent vs CABG trial in MVD with preserved LV function Conclusion:1.1y mortality in ACS pt:5.2%(stent)vs 5.6%in non-ACS p
6、t:7.0%(stent)vs 8.3%2.CABG more effective in relieving angina,increasing physical ability and quality of life than stent in 1 year 3.higher repeat revascularization(74/476 pt)in stent group Zhang Z,Circulation.2003;108,MASS II Trial,Favorite D,circulation 2003;108,ERACI II Trial,Rodriguez A,J Am Col
7、l Cardiol.2005 Aug 16;46,ARTS Trial,Serruys PW,J Am Coll Cardiol.2005 Aug 16;46,*,a meta-analysis of 13 randomized trials,-7,964 patients comparing PTCA with CABGRESULTS:1)1.9%absolute survival advantage favoring CABG over PTCA for all trials at five years(p 0.02),but no significant advantage at one
8、,three,or eight years.2)MVD subgroup analysis-CABG provided significant survival advantage at both five and eight years.3)PTCA group-more repeat revascularizations at all time points(risk difference RD 24%to 38%,p 0.001);4）with stents,this RD was reduced to 15%at one and three years.,5)DM patients-C
9、ABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years.CONCLUSIONS:CABG is associated with a lower five-year mortality,less angina,and fewer revascularization procedures.For patients with multivessel disease,CABG provided a survival advantage at five to eight years,a
10、nd for diabetics,a survival advantage at four years.The addition of stents reduced the need for repeat revascularization by about half.Hoffman SN,J Am Coll Cardiol.2003;41,Left Main,In hosp-3%Q-wave MI,4.5%non-Q-wave MI-0%mortality,3%CABGFollow up with CAG in 85%pt in 5 2m-restenosis rate:31.4%Follo
11、w up(31 23m)mortality:16.4%-repeat revascularization:23.9%,among 1/3 need CABG Takuro Takagi,Circulation 2002;106:698,DES,Randomized(TAXUS IV)trial of TAXUS stent in LAD Dangas G,J Am Coll Cardiol 2005 Apr,DES A meta-analysis of randomized controlled trials,-comparing sirolimus or paclitaxel eluting
12、 stents to bare stents.1)MACE was highly reduced with DES from 18.2%to 10.1%,p0.001).-a significant heterogeneity(p0.001)between subgroups according to the drug:MACE OR was 0.27(95%CI0.21-0.36)in the sirolimus(CYPHER)sub-group and 0.72(95%CI0.59-0.88)in the paclitaxel(TAXUS)sub-group.,2)Restenosis w
13、as highly reduced from 30.6%with bare stents to 8.7%with DES(p0.001)with a similar heterogeneity between sub-groups.3)Mortality was not significantly different between DES and control group:4)Conclusion:-confirms the overall benefit of DES on restenosis and MACE-with significant heterogeneity betwee
14、n drugs suggesting higher efficacy of sirolimus-eluting stents.Roiron C,Heart 2005.Oct,10,DES,Although lowered restenosis and TVR rate to about in the upper single-digit range for standard lesion,about 16%for complex lesion,but the 1 year mortality still similarUpcoming FREEDOM&CARDIA trial-DES vs C
15、ABG with DM&MVD pts.CYPHER stent cost US$3000,bare-metal stent$500-1000,Conclusion,-Stent Vs CABG:favor CABG on mortality,event free survival rate due to higher restenosis rate of Stent groupDES lowered the restenosis rate by half or 1/3 Waiting future trial of DES vs CABG on MVDAlso should consider
16、 the huge economic impact of DES on MVD,Conclusion,Evidence base medicine:“CABG still the best treatment for MVD and LM now”Cardiac Surgeon:What is left for us?-may change from time to timeBut the main point is as a doctor we concern more is“What is the best for the patient?”The patient need to know!-their right,
