1、藥物支架與冠狀動(dòng)脈搭橋手術(shù)治療冠心病多支病變療效對(duì)比胡盛壽 2008年12月-來自單中心的三年隨訪結(jié)果 背景 真實(shí)世界里，藥物支架與冠狀動(dòng)脈搭橋治療冠心病多支病變的爭論一直未停止。解放軍胸科醫(yī)院 衛(wèi)生部心血管疾病防治中心，阜外心血管病醫(yī)院中國第一臺(tái)CABG中國第一臺(tái)冠狀動(dòng)脈造影術(shù)中國第一臺(tái)非體外搭橋手術(shù)中國第一枚藥物支架植入 國家心臟病中心1956196219741957199620032007 阜外一覽： 方案 阜外一覽： 方案CABG- 手術(shù)量與死亡率(1997-2007)1537 casesPCI與CAG的手術(shù)量(2003-2007)阜外醫(yī)院的兩項(xiàng)注冊(cè)登記研究 方案 Fuwai Hosp

2、ital CABG Registry (1999now) Fuwai Hospital PCI Registry (2002now) Am Heart J, HEART 兩項(xiàng)注冊(cè)登記研究包含了患者的詳細(xì)信息； 統(tǒng)一的參數(shù)標(biāo)準(zhǔn)； 專用的電子化數(shù)據(jù)收集和報(bào)告系統(tǒng)。JTCVS, EJCTS, HEART 研究人群 (2004年5月至 2005年12月) 方案 三支病變的患者 接受了單純搭橋手術(shù)或接受至少一枚藥物支架治療的患者 先前接受過再血管化治療 合并左主干病變 發(fā)生于24小時(shí)內(nèi)的急性心肌梗死 入選標(biāo)準(zhǔn)排除標(biāo)準(zhǔn)入選3,720 患者: CABG (n=1,886) ; DES (n=1,834) 觀

3、察終點(diǎn): 早期: 院內(nèi) / 30天 死亡； 遠(yuǎn)期: 死亡； 心梗； 靶血管再血管化。 定義：死亡:任何原因?qū)е滤劳觯?心肌梗死: 在隨訪過程中出現(xiàn)異常Q波或再入院時(shí)出現(xiàn)的心肌梗死 或因心肌梗死再入院；靶血管血運(yùn)重建:經(jīng)血運(yùn)重建的血管需要再次血管化。 方案搭橋組, n=1886 896 例(47.5%) 行OPCAB 1850 例(98.1%) 接受至少1根乳內(nèi)動(dòng)脈橋 平均搭橋支數(shù): 2.86 平均末梢吻合個(gè)數(shù): 4.28 藥物支架治療組, n=1834 當(dāng)個(gè)患者平均支架植入枚數(shù)： 2.680.95 (2.251.25 DES and 0.430.72 BMS). 平均支架直徑 3.050.46

4、mm. 兩聯(lián)抗血小板治療: 阿司匹林 + 波力維 結(jié)果遵照當(dāng)前的指南行冠狀動(dòng)脈搭橋及PCI術(shù) 結(jié)果 結(jié)果 結(jié)果全組傾向配對(duì)792對(duì)患者配對(duì)組的Kaplan-Meier分析 結(jié)果全組傾向配對(duì)792對(duì)患者配對(duì)組的Kaplan-Meier分析 結(jié)果我們的主要發(fā)現(xiàn)CABG組有較低的死亡率，心梗發(fā)生率及靶血管再血管化率四個(gè)亞組（糖尿病，年齡大于70歲，3支病變，2支病變）的數(shù)據(jù)分析提示CABG有更好遠(yuǎn)期安全性及有效性。 討論與評(píng)論冠心病多支病變的再血管化: DES vs. Bypass 仍存爭議！ 討論與評(píng)論冠心病多支病變的再血管化: DES vs. Bypass 仍存爭議！ 討論與評(píng)論 CABG 治療

5、多支病變的優(yōu)勢(shì)? PCI治療 “罪犯” 病變 . CABG作用于血管包括了 “罪犯”病變和未來可能的“罪犯”病變CABG的優(yōu)勢(shì)即在于此不同F(xiàn)uwai Database 討論與評(píng)論Cleveland Database CABG 治療多支病變的優(yōu)勢(shì)? 搭橋手術(shù)數(shù)量增多，圍手術(shù)期結(jié)果改善 阜外外科醫(yī)師培訓(xùn) 討論與評(píng)論LIMA前降支搭橋的金標(biāo)準(zhǔn)Tatoulis JTCVS,2004 CABG 治療多支病變的優(yōu)勢(shì)? 3-5年先心病手術(shù)3-5年瓣膜手術(shù)搭橋手術(shù) 行CABG的患者效果更佳（死亡率，心梗率，再血管化率），盡管他們病情更重， 亞組（糖尿病，年齡大于70歲，3支病變，2支病變）分析也提示CABG組

6、有更好遠(yuǎn)期安全性及有效性。 討論與評(píng)論我們的研究提示 非隨機(jī)性 選擇偏差 單中心 研究局限 討論與評(píng)論鳴謝兩個(gè)數(shù)據(jù)庫的所有工作團(tuán)隊(duì)阜外-牛津中心統(tǒng)計(jì)研究中心Thank you！Comparison of Drug-Eluting Stents and Coronary Artery Bypass Surgery for the Treatment of Multivessel Coronary DiseaseShengshou Hu M.D., FACCDepartment of Cardiac SurgeryNational Heart Center & Fu Wai Hospital, B

7、eijing, ChinaThree-Year Follow-Up Results from a Single center BackgroundWe therefore compared the long-term safety and efficacy of PCI with DES and CABG in patients with MVD.Chest Hospital Cardiovascular Institute & Fuwai HospitalFirst CABG in ChinaFirst Coronary Angiography in ChinaFirst OPCAB in

8、ChinaFirst DES implantation in China National Heart Center1956196219741957199620032007 A Glance at Fuwai Hospital Methods A Glance at Fuwai Hospital MethodsCABG- Amounts and Mortalities(1997-2007)1537 cases Amounts of PCI and CAG(2003-2007)Two Registries of Fuwai Hospital Methods Fuwai Hospital CABG

9、 Registry (1999now) Fuwai Hospital PCI Registry (2002now) Am Heart J, HEART The two registries contain detailed information. Uniform definitions for these elements are used in our study. Data were prospectively collected with the use of a dedicated computer-based reporting system.JTCVS, EJCTS, HEART

10、 Study Population (From Apr. 2004, to Dec. 2005) Methods Patients with MVD Treated with isolated CABG or DES (with or without BMS) Previously undergone revascularization With left main disease Acute MI within 24 hrs before revascularization InclusionExclusion3,720 MVD patients: CABG (n=1,886) ; DES

11、(n=1,834) End points: Early: In-hospital / 30-day death; Long-term: Death; MI; target-vessel revascularization (TVR) during follow-up. DefinitionsDeath: death from any cause. MI: documentation of a new abnormal Q wave after the index treatment or myocardial infarctions at readmission (emergency admi

12、ssion with a principal diagnosis of MI). TVR: the need for revascularization of the target (treated) vessel. Methods Follow-up Office visit Telephone contact Medical records Independent events adjudication committee 33.1 months for DES group 38.9 months for CABG group MethodsStatistical Analysis : O

13、bservational study * Treatment-selection bias * Potential confounding variables Robust adjustment was performed * Stepwise logistic regression model for in- hospital / 30-day mortality * Stepwise Cox proportional hazards models for long-term outcomes. * Propensity analysis 2-tailed, and a significan

14、t level of 0.05 SPSS version 13.0 and MATLAB 6.1 MethodsCABG group, n=1886 896 patients (47.5%) underwent OPCAB 1850 patients (98.1%) received at least one ITA The mean number of bypass grafts per patient: 2.86 The mean number of distal anastomoses per patient: 4.28 Drug-eluting stents group, n=1834

15、 The mean total number of stents implanted in a patient was 2.680.95 (2.251.25 DES and 0.430.72 BMS). The mean stent diameter was 3.050.46mm. Dual anti-platelet therapy: Aspirin + Plavix ResultsBoth CABG and PCI with DES were performed according to current guidelines Results Results No significant d

16、ifference in the risk-adjusted rate of in-hospital/30-day mortality Adjusted OR, 0.779; 95% CI, 0.514 to 1.186; P = 0.269 Unadjusted in-hospital/30 day mortality 0.9 % for CABG vs 0.6 % for DES Results Results Adjusted for candidate variables in Table 1 Propensity matching for the entire cohort crea

17、ted 792 matched pairs of patientsCox multivariable analyses ResultsTarget-vessel revascularization36-month unadjusted curves for target-vessel revascularization after the initial procedure for the entire cohort. ResultsPropensity matching for the entire cohort created 792 matched pairs of patientsKa

18、plan-Meier analysis in the matched Cohort ResultsPropensity matching for the entire cohort created 792 matched pairs of patientsKaplan-Meier analysis in the matched Cohort ResultsPrincipal Findings of Our Data Patients treated with CABG had lower rates of death, MI, and TVR than those treated with D

19、ES In four subgroups of patients (DM, 70 + yrs of age, 3-VD, 2-VD), our data still favored CABG for long-term safety and efficacy. Discussion and CommentMultivessel Revascularization: DES vs. Bypass Controversial!End pointCABG (%)DES (%)pDeath 2.94.40.18Stroke 1.90.80.09MI 2.65.20.04Revascularizatio

20、n 5.414.70.001Death/stroke/MI 6.47.90.39MACCE11.219.10.001 12-mo end points in 3VD subsetMohr EF TCT 2008; Discussion and CommentThe results of the much-awaited SYNTAX trial Multivessel Revascularization: DES vs. Bypass Controversial! Discussion and CommentMultivessel Revascularization: DES vs. Bypa

21、ss Controversial! Discussion and CommentIs the advantage of CABG for multivessel revascularization explicable? PCI is targeted at the “culprit” lesion or lesions. CABG is directed at the vessel including the “culprit” lesion or lesions and future culprits. The difference accounts for the superiority of CABGFuwai Database Discussion and CommentCleveland Database Is the advantage of CABG for multivessel revascularization explicable? Improved peri-operative outcomes of bypass surgerySurgical training in Fuwai Discussion and CommentLIMAThe Go