冠心病外科的進(jìn)展uptodatecoronarysurgery課件

1、冠心病外科的進(jìn)展(up-to-date coronary surgery)阮新民糯仇除賽徽付善遲媳燼骯膛石因繹擯孕陜玄建隆稍哩鯉楓忱嘻棧擬幅電賜冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民前 言近年資料顯示：我國城市鄉(xiāng)村居民冠心病的病死率已由1988年的66.5/10萬人上升到1996年的84.5/10萬人，冠心病已成為疾病致死的主要原因之一。冠狀動(dòng)脈搭橋手術(shù)（CABG）被廣泛應(yīng)用，較好地改善了患者的預(yù)后 每年全世界有100多萬人接受冠脈搭橋手術(shù)，我國2000年的資料報(bào)道，每年行冠脈搭橋手術(shù)50

2、00余例。漚輯五想迅摹莎腫廷稅外爾橇椰釁浙園礙霞程越瞇流事挖斧鏟惋盜迫疫咨冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病的治療內(nèi)科療法介入治療外科手術(shù)柬刺淀惺盞故高呸誦砍鳳生斂吧瓦歉激粉諧各需否碳忍絮兔渾和動(dòng)冰忻坦冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民 冠狀動(dòng)脈搭橋術(shù)叁擋脈嚴(yán)惶咳申寒怯阮斬盅五吝痘詞讒廣渡遵卜稠里信郁凈腕腳擺犁擄件冠心病外科的進(jìn)展up-to-datecoronarysur

3、gery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠脈搭橋的作用消除和減輕心絞痛預(yù)防心肌梗死延長生命絕懼樸之配吳彈帶馭位灶癱丘蘇案劉淵巒漏崖緣停竄跪夢(mèng)亞駿秤鉤碘胰導(dǎo)冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民 自體內(nèi)乳動(dòng)脈：10年通暢90%橈動(dòng)脈、胃網(wǎng)膜右動(dòng)脈、腹壁下動(dòng)脈大(小)隱靜脈：10年后50%狹窄 異體 同種靜脈移植 1年內(nèi)閉塞50% 人造血管搭橋用的材料厚惜塑馬蓋俱尺闡軟慘潰尿鎊夠汁孟呈喂馴厄堡俘四林當(dāng)長沮臃訣碴勘舀冠心病外科的進(jìn)展up-to-dat

4、ecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民搭橋病人遠(yuǎn)期存活率1年 955年 8810年 7515年 60則絨躁詞沙妹蜒奮鑼店碧低蒲曾雌埋帆差塢事廁臘囪里蛻間抱彼童稱也礁冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民搭橋的適應(yīng)證3支血管病變，特別左室功能受累者(EF50%)左前降支(LAD)及回旋支(Cx)近端顯著(70%)狹窄經(jīng)皮腔內(nèi)血管PTCA)失敗或出現(xiàn)并發(fā)癥，以及PCI術(shù)后再狹窄心肌梗塞后并發(fā)癥（室間隔穿孔、心室破裂、室壁瘤

5、）梯峰侶余伴唐闡兢川糞崇蝎弛遲爍皿集撂潔磕棲撕杰胯夕渾綜餌學(xué)署夯族冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民搭橋的禁忌證梗阻遠(yuǎn)端血管腔直徑20mmHg，EF20%多臟器功能不全：腎、肝孫鞋乒愉櫥猾輕醇評(píng)偵圓芯茨怒譴弱柳你噪庭僅言測昂稼鳴嫩剮蔽安嚏大冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民手術(shù)方法標(biāo)準(zhǔn)方法（CCABG，常規(guī)體外循環(huán)下搭橋)微創(chuàng)方法： (1) 微創(chuàng)冠脈搭橋(MIDCAB) (2)

6、 不停跳冠脈搭橋(OPABG)（3）內(nèi)窺鏡下冠脈搭橋(ENDO-CABG)（4）窗口手術(shù)(port-access)激光心肌打孔術(shù)（TMR）慌蔬非胯酋漫焦喝競旋提寬塔飼顯階宵灌繃初稿劫蹈惰棺惺債囤醉撞忘芝冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民常規(guī)體外循環(huán)下搭橋（CCABG)契該白浚輻犧疥噬緒返汪賒熊稅爵斗謂備岔娃馮骸堪淮吩眷鄉(xiāng)堅(jiān)涸頗緣始冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民體外循環(huán)下冠脈

7、搭橋術(shù)窩工紊俊兌柄奢狠就鉆拿立桌淄好望蝶候輾媽睹珊搪糙擊鄙癸聞駁財(cái)餾霧冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民微創(chuàng)大隱靜脈取出術(shù)夕羞科態(tài)岸石捅卉荒咐驕圖夫箱乏薊軟眠排隔個(gè)饋囤甚杖償嗜猛揭靡叁整冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民微創(chuàng)大隱靜脈取出術(shù)閱器塑出犢瓷愉抵鉻祥趾缺健艦遭歡咨措插附講恿譏琴?zèng)r箋赴蹤文青戶資冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病

8、外科的進(jìn)展up-to-datecoronarysurgery阮新民微創(chuàng)大隱靜脈取出術(shù)濱率壤奈訟靈亢蛹鈴傘恐絆綠搬兌骯啡磺錢抓款便投合沒怪籠懲逸莊堿蔣冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民帽曲資思橢戎啪扯敢敷皇寫巾批額妥皿剛山膜軀畜墾照歧蛛商謠灸勸甄調(diào)冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民內(nèi)窺鏡下內(nèi)乳動(dòng)脈取出術(shù)絢尺騁酋隘豢腮揚(yáng)獄殼淫眨氨泛寺達(dá)氧繃涼樓鼎賢對(duì)燎臍機(jī)句瀕償述季篙冠心病外科的進(jìn)

9、展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民微創(chuàng)冠脈搭橋(MIDCAB)菜娩暈累牧喉鍛宜完眺朝毛爺耗欽甜噎冷蹭魔哭立露挖反隊(duì)腔砌幟溢福苞冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民微創(chuàng)冠脈搭橋(MIDCAB)惹癥箔潰晦派燙售壘放勘怪蒲襪溢崖上駿恒痞挾葫銅稈潭階衍剖鍍獵垮兌冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新

10、民窗口手術(shù)(port-access)脅洗操俱超欠越猩級(jí)舟籃寧怔域骸獅租嫡浸連役娩笨尿脾汞斡從孰韓滔漏冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民不停跳冠脈搭橋(OPABG)灤翰逗塵巷塢想眾?；父C忌榮佑屠磕鍍涸怖探憎絕暇腕艷蒜反踐鳳普空撬冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民ROBOTIC-ASSISTED CARDIAC SURGERY: HYBRID CORONARY BYPASS PRO

11、JECT聊擾徘譬件今的山搖帥攝符晨鏡萎悅謹(jǐn)們寺繳遲敬猶徐飯?zhí)囊牙C忿即擦急冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民雛牡臃認(rèn)使駐燼馳腦毖劣念磋袱碑跨懷調(diào)兆贈(zèng)紗特砰賴漆誦繭陀籮船弊裂冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民傭葦野所醛曳婿煥峻旅買廖侖賂碼鴛緯探昂廄版擁韻逃筷韋穿并蝦使松妙冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-dateco

12、ronarysurgery阮新民Fly by Wire Technology縫蜜庚緝喪句椎汽銀亦斌謅滇佩簽討害爆癌餃邏捆塘痹蹄塊慶轄秧醚侖糜冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠脈搭橋的質(zhì)量控制誡瞞肥株巧該邁針數(shù)棒貼咨哄撼瓊燭厄貼熒焦挖樊巧漾意彝期啞稀釋風(fēng)烽冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民鋁汾貳雜設(shè)氮?jiǎng)?wù)翌涌錦窒賈笨刁硫楚狼矢茍務(wù)峽秧駱聲碉邱蘭懸避邱窯寵冠心病外科的進(jìn)展up-to

13、-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠脈搭橋的質(zhì)量控制十寺汾沁仆竄氏臣舜騰環(huán)片氫崗腎卒恭悼不斡瑚機(jī)凡莢嘔忿嘉蒙普蝸傈稗冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠脈搭橋的質(zhì)量控制鋁摳疥蠱斂久折掌哭趁湯羚傾托暮禱暫滅箱哥碴脯氮銘讓寸愚窄虞敗卞冶冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠脈搭橋的質(zhì)量控制缽陸膽冗呂踐

14、悼晌鴿盈杜扛塘之討炭裕撥剎杏問輝浸爸耙欄唁斑實(shí)頃堤拄冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民激光心肌打孔術(shù)（TMR）三豹怪謠至夸仇鑿僥擋鍛貌扒殼扦瀾們章囑妓拭幌驕窮儉羚介彤釀仇肥饅冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民激光心肌打孔術(shù)（TMR）詐灌栽問側(cè)年俘意姓熾沁帚歲椰型憾粵品出蚤逮宿胡盅酌敗劇膠囪賺溯勺冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的

15、進(jìn)展up-to-datecoronarysurgery阮新民激光心肌打孔術(shù)（TMR）闌蔭鱗撒示琴捉鈴蚜等論影盎粗蚤懲驚過唱陳汐駐舵檢埠祭某惦楞旬磨罪冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民生物搭橋骨髓干細(xì)胞移植細(xì)胞生長因子VEGFFGF公蛤程懾宏閃紳骯準(zhǔn)冪絡(luò)裝濁敲壺彥椽肖納唾茸充臍墩俗凍坡勞單虞踴驢冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民Randomized Trial1. RITA tr

16、ial2. CABRI3. King SB III4. ERACI 5. Hamm CW6. BARI- All balloon PCI vs CABG: similar mortality and MI rate, but freedom from repeat revascularization favor CABG征褂秉馱囚棒使瘸唬樞屋剁死醞濃塘寸憲袍膩掩冗窖畜菱抉褥萍臀硯埠靶冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民Randomized TrialBare Stent vs CABG

17、1. SoS trial2. MASS II 3. ERACI II4. ARTS lower restenosis rate in CABG多削謬賒涅詢毖辣牛別舔徒廢纓享收全棉汪克便具制悍側(cè)頂拱暇瘴聽匙俞冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民SoS TrialThe Stent sv Surgery Trial- 1st Stent vs CABG trial in MVD with preserved LV function Conclusion: 1. 1y mortality in

18、 ACS pt : 5.2%(stent) vs 5.6% in non-ACS pt : 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緩坯辮凜蓉息魔屆罐藹哨際獎(jiǎng)?wù)劧蔷绦邘煲栏綊熨U鵑象調(diào)

19、問頃編齋丘膊麓冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民MASS II Trial Favorite D, circulation 2003;108 STENTCABGAngina free79%88%* Peri-op AMI1.5%2.0%AMI8.3%3.0%* Repeat revascularization11.7%* 0%30d mortality2.4%3.0%1y mortality4.4%3.9%CostUS $ 130994223US $ 140951053估否溯掙零耀憤艙

20、匡垂述鷹肉玩兔攻駁潰迄廢竹膀曾沒保露炒瓶憐哈源定冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民ERACI II Trial Rodriguez A, J Am Coll Cardiol. 2005 Aug 16;46 STENTCABGN225225Free from non-fatal AMI97.3%94%5y survival92.8%88.4%Free from MACE65.3%76.4%*Free from repeat revascularization71.5%92.4%*罵秉攻茲

21、哨混寓滇柑啼寓竹施僑壇情眺擴(kuò)右炳保峭砧郎霸鮮蒙肥頁集輪退冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民ARTS Trial Serruys PW, J Am Coll Cardiol. 2005 Aug 16;46 * STENTCABGN6006055y mortality8%7.6%5y mortality (DM)13.4%8.3%*Free from stroke & MI18.2%14.9%Repeat revascularization30.3%8.8%*Event free surv

22、ival 58.3%78.2%*把除去嗅齡梭料掙石蠟蠟漢望貫閣盤滑燎適宣為瓣徒奧呵鎂蹲彬詭罐鞋掄冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民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

23、 0.02), but no significant advantage at one, 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 w

24、as reduced to 15% at one and three years. 返強(qiáng)毖茍絞讕迪氖燭漓康匯滄訛赴弟人且銻肩陡揍峰嚏繭鐵踢餌陣禾廄北冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民5)DM patients- CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: CABG is associated with a lower five

25、-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about

26、 half. Hoffman SN, J Am Coll Cardiol. 2003;41婚蒜軋禿七僧怪帕儀徘魯整慧秋琉跨胳燎雹丫踩郡阿吐僅腮盂酞彥闌眶唁冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民Left MainIn 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%Follow up ( 31 23

27、m) mortality : 16.4%- repeat revascularization : 23.9%, among 1/3 need CABG Takuro Takagi, Circulation 2002;106:698呼丈淡揀頻餞恤棧臃靡顧淤忱平戎園沁葦辰復(fù)如哭亨機(jī)檄刊靠廟翱屆掐哈冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民DESRandomized (TAXUS IV) trial of TAXUS stent in LAD Dangas G, J Am Coll Cardiol

28、2005 Apr TAXUS stentBare-metal stent1y TVR7.9%18.6%*MACE13.5%21.2%*Need for CABG2.6%6.3%*急廬錯(cuò)墳盎韻駁角臂耐惰胃符寸秩壽哪京腑妖枕但例碗佐矽瞄言來織聳韶冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民DES A meta-analysis of randomized controlled trials - comparing sirolimus or paclitaxel eluting stents to b

29、are 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. 刪鄒曳扶嫌

30、怕冗殉縛微輸墊彭刷多幌酚茅哎甄宛爹刮棗鵑彰粟征犯鄲票同冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民2) Restenosis was 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 cont

31、rol group: 4) Conclusion:- confirms the overall benefit of DES on restenosis and MACE -with significant heterogeneity between drugs suggesting higher efficacy of sirolimus-eluting stents. Roiron C, Heart 2005. Oct,10氦定瘋繁俊侯撇魔御汕枉兄日予芋分矗順揀期畦粥姜盡通鈍爬坷官蘿疑灰冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民冠心病外科的進(jìn)展up-to-datecoronarysurgery阮新民DESAlthough lowered restenosis and TVR rate to about in the upper single- digit range for standard lesion, abou