左主病變治療

LeftMainDisease:

DESorCABG?

ChenYundaiMDDirectorofDepartmentofCardiology,CapitalUniversityofMedicalScienceAffiliatedBeijingAnzhenHospital,ChinaBackgroundLeftmaincoronarystenosisisaninfrequentdisease(3-7%ofCA)butremainsassociatedwithpoorprognosticCABGPCID.E.S.CardiacSurgeonsaid:InterventionalCardiologistsaid:CABGinLMDiseaseLMCAisnowtheindicationforsurgeryin20-25%ofCABGcasesLMdiseaseisanindependentpredictorformortalityandmorbiditypostCABGOperativemortalityis3-4%forLMCAOPB-CABGmayofferamortalitybenifitU.S.PenetrationofDES28%(2003)75%(2004)Cypherasof4/03andTaxusasof3/0420032004GapofMACEsbetweenCABGandBMSOneyearsurvivaliscomparableRestenosisDESvsCABG?PCIvs.CABG

RepeatRevascularizationCABG=DESARTSII:multi-vesselCypherStentSIRIUSCABGARTSDeath2.5%2.8%Stroke1.7%2.0%MI5.3%4.0%TLR4.7%3.0%MACE14.2%12.2%ARTS-IandII:1yearadverseeventrate(MACE)ARTS-IIN=607ARTS-I(CABG)N=602ARTS(PCI)N=600Death%1.02.72.7CVA%0.81.81.8MI%1.23.55.0(re-CABG)%2.00.74.7Re-PCI%5.43.012.3AnyMACCE%10.411.626.5LMStenting:ImpactofD.E.S.AuthorNFU(m)NatFUDeathMITLRChieffo41SES,44PES856853.5%-14.1%ArampatzisSES175.1166%12%0PARKSES10211.7102002%DeLezoSES521250002%AgostonlSES&PES5814585%3%7%LMStenting:ImpactofD.E.S.In-hospitalFollow-upTotalChieffo4.7%20%24.7%Arampatzis18%018%PARK02%2%DeLezo4%2%6%Agostonl7%7%15%MACE:2-25%LMStenting:ImpactofD.E.S.In-hospitalFollow-upTotalChieffoTLRTVR0014.1%18.8%14.1%18.8%Arampatzis000PARK02%2%DeLezo02%2%Agostonl07%7%TLR:0-19%LMStenting:ImpactofD.E.S.OverallDistalNonDistalChieffo19%19%0Arampatzis000PARK7%7%0DeLezo3%3%0Agostonl---Restenosis:0-19%Distal:0-19%nondistal:0ULMCAStenting:

RemainingIssuesTechnicaldifficultyofdistalLMstentingRestenosisStentthrombosisRiskofmortalityASA-Plavix++So,wecanknowthatinthe“realworld”,DESinLMCAlesion,……

But,MoreefficacydatainspecificlesionsubsetssuchasLMdiseases(esp.distalbifurcationlesion)shouldbe......SyntaxTrialDesignCABGonlypopulationPCIonlypopulationPatient/physicianpreferenceamenablefor≤1interventionaltreatmentPatientswithdenovo3-vessel-diseaseand/orleftmaindiseasescreeningPhysicianTeam(surgeonandinterventionalist)registrationTAXUSCABGvsRandomizationRegistriesamenableforbothtreatmentsoptionsMulti-centerrandomizedcontrolledtrialDiabetesMellitusw/2-3VDRandomizedArmN=2400(1:1)amenableforonetreatmentapproachamenableforbothtreatmentsoptionsDESCABGvsTwoRegistryArmsN=2000CABGAllcapturedandfollowedPCIAllcapturedandfollowedfollow-up:30d,6m,1-5yrsGoal:todefinethemostappropriatetreatmentfordiabeticpatientsthroughrandomizedtrialmethodsConsensusexiststhatonlyonetreatmentoption(CABGvsPCI)isappropriateGoal:tocompareoutcomeswithrandomizedgroupFREEDOMTrialDesignSurgeonandinterventionalistCASE:CABGVSDES?Female,62yrsCABG(2000.4):SVG-RCA-LAD,forthereasonthatseverecalcificationofleftIMAandaorticarteryUnstableanginapectorisfor4monthsandadmissionin2004.9Angiographicresults(2004.09)DISSCUSSION1Re-CABGorPCI?IfintheeraofDES,youshouldselectPCIorCABGatfirstforthispatient?GC:Cordis6FJL4.0

GW:CordisStablizersupersoft

Balloon:SORINHypro2.0

15mm

AnotherGW:CordisStablizersupersoft

Stent:CordisCypherselect3.0

18mm

Stent:MUSTANGFirebird3.5

23mm

FinalresultDISSCUSSION2PCI/CABG?Lesioncharacteristics:calcification,tortuousIncompleterevascularizationforthispatients.LM-PCI：ACC/AHA/ESCguildlineGUIDLINECLINICAL/REVASCULARIZATIONINDICATION/EVIDENCE2001ACC/AHAPCISCADUA/NSTEMIIII/B2002ACC/AHAUA/NSTEMI適合CABGpt不適合CABG者III/BIIb/C2002ACC/AHAStable-CAD不適合CABG者適合CABG者IIb/CIII/B2004ACC/AHASTEMI急診CABG－年齡大于75歲者－年齡小于75歲者－心梗后擇期CABGIIa/BI/BI/A2005ESCPCI不適合CABG者置入DESIIb/CIIa/CACC/AHAGuidelinesforLM-PCIshouldbefromIIBtoIB!

BecauseIntherealworld,withglobalDESuse,theTLRevent-freesurvivalofLM