无心外科支持下经皮冠状动脉介入治疗临床研究
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摘要
目的:评价在无心外科支持下开展择期经皮冠状动脉介入治疗的安全性和可行性。
方法:回顾性收集2008年1月至2009年12月红河州第一人民医院、开远市人民医院、曲靖市第一人民医院、楚雄州人民医院、德宏州人民医院连续进行的390例择期PCI患者的临床资料,并设为无心外科支持组。作为对照,也回顾性收集2009年1月至2009年12月昆明医学院附一院心内科冠脉介入组连续进行的433例择期PCI患者的临床资料,并设为有心外科支持组。资料收集包括患者的基本临床资料(年龄,性别,体重,LVEF,冠心病危险因素,合并疾病,临床诊断),靶血管/病变特征,介入治疗情况,住院期间及30d随访临床结果。比较两组PCI手术成功率、并发症发生率、30d MACE发生率。
结果:
1.基本临床资料比较:整体而言,无心外科支持组的临床基本特征较有心外科支持组相对低危。平均年龄无心外科支持组较有心外科支持组低(60.74±10.86V63.33±10.70,P=0.000),年龄＞75岁无心外科支持组较有心外科支持组所占比例少(10.3%V15.2%,P=0.033),2型糖尿病无心外科支持组较有心外科支持组所占比例少(28.2%V35.6%,P=0.024),陈旧性心肌梗死(OMI)无心外科支持组较有心外科支持组所占比例少(12.6%V20.3%,P=0.003),经皮冠状动脉介入治疗(PCI)史无心外科支持组较有心外科支持组所占比例少(3.1%V10.6%,P=0.000),ST段抬高型心肌梗死(STEMI)无心外科支持组较有心外科支持组所占比例多(23.3%V17.1%,P=0.026)。其余各指标均无显著性差异(P≥0.05)。
2.靶血管/病变特征比较:左主干病变无心外科支持组较有心外科支持组所占比例少(0.8%V2.6%,P=0.021),靶病变狭窄程度无心外科支持组较有心外科支持组狭窄程度轻(0.85±0.13V0.87±0.12,P=0.029),C型病变无心外科支持组较有心外科支持组所占比例少(19.9%V26.1%,P=0.036),CTO病变无心外科支持组较有心外科支持组所占比例少(5.7%V8.7%,P=0.048)。两组在靶血管分布、病变分型及钙化病变、分叉病变上无显著性差异(P≥0.05)。整体而言,无心外科支持组的靶血管/病变特征较有心外科支持组相对低危。
3.介入治疗情况比较:无心外科支持组经肱动脉/经尺动脉路径所占比例较有心外科支持组少(0.0%V2.8%,P=0.001)。其余无显著性差异(P≥0.05)。
4.住院期间及30d随访临床结果比较:两组手术成功率为(96.4%V95.2%,P=0.371)、PCI主要并发症发生率为(0.8%V1.4%,P=0.511)、住院期间死亡率为(0.0%V0.5%,P=0.501)、急性心肌梗死发生率为(0.0%V0.0%)、急诊外科手术发生率为(0.0%V0.2%,P=1.000)、急性冠脉闭塞发生率为(0.0%V0.2%,P=1.000)、冠脉夹层发生率为(0.3%V0.0%,P=0.474)、冠脉穿孔/冠脉破裂/心包填塞发生率为(0.0%V0.7%,P=0.251)、30天MACE发生率为(0.3%V0.3%,P=1.00),两组之间比较差异无显著性(P≥0.05)。
结论:
1.无心外科支持的医院可以安全、有效地对低风险病例实施择期经皮冠状动脉介入治疗(PCI)。
2.高例数术者到低例数中心实施PCI具有可行性。
Purpose:evaluate the safety and feasibility of elective percutaneous coronary intervention(PCI) performed without cardiac surgery backup.
Methods:from January 2008 to December 2009,we retrospectively collected the clinical data of 390 patients underwent elective PCI provided consecutively by Honghe Prefecture No.1 People's Hospital,Kaiyuan City People's Hospital,Qujing City No.1 People's Hospital,Chuxiong Prefecture People's Hospital and Dehong Prefecture People's Hospital and regarded it as the group without cardiac surgery backup.For the sake of contrast,we also retrospectively collected the clinical data of 433 patients underwent PCI provided consecutively by the coronary intervention team of Cardiac Internal Medicine Department of No.1 Affiliated Hospital of Kunming Medical University from January 2009 to December 2009 and regarded it as the group with cardiac surgery backup.Data collection includes the basic clinical data(age, gender,weight,LVEF,risk factors of coronary heart disease,complications and clinical diagnosis) of the patients,target vessel/lesion features,intervention, in-hospital period and clinical outcome at a 30-day follow-up.We compared the PCI procedural success rate,incidence rate of complications and incidence rate of 30d MACE of the two groups.
Outcomes:
1.Basic clinical data comparison:as a whole,the risk of basic clinical features of the group without cardiac surgery backup was lower than that with cardiac surgery backup.The average age of the group without cardiac surgery backup was lower than that with cardiac surgery backup(60.74±10.86V63.33±10.70,P=0.000).The proportion of the group without cardiac surgery backup elder than 75 was less than that with cardiac surgery backup(10.3%V15.2%,P=0.033);the proportion of the group without cardiac surgery backup with Type 2 diabetes was less than that with cardiac surgery backup(28.2%V35.6%,P=0.024);the proportion of the group without cardiac surgery backup suffering from old myocardial infarction(OMI) was less than that with cardiac surgery backup(12.6%V20.3%,P=0.003);the proportion of the group without cardiac surgery backup underwent percutaneous coronary intervention (PCI) previously was less than that with cardiac surgery backup(3.1%V10.6%, P=0.000) and the proportion of the group without cardiac surgery backup suffering from ST segment elevation myocardial infarction(STEMI) was more than that with cardiac surgery backup(23.3%V17.1%,P=0.026).All the rest indicators showed no significant differences(P＞0.05).
2.Target vessel/lesion features comparison:the proportion of the group without cardiac surgery backup suffering from left main disease was less than that with cardiac surgery backup(0.8%V2.6%,P=0.021);the target lesion stegnosis degree of the group without cardiac surgery backup was minor than that with cardiac surgery backup(0.85±0.13V0.87±0.12,P=0.029);the proportion of the group without cardiac surgery backup suffering from Type C lesion change was less than that with cardiac surgery backup(19.9%V26.1%,P=0.036) and the proportion of the group without cardiac surgery backup suffering from CTO lesion change was less than that with cardiac surgery backup(5.7%V8.7%,P=0.048).The two groups showed no significant differences in target vessel distribution,lesion classification and bifurcation lesion(P＞0.05).As a whole,the risks of target vessel/lesion features of the group without cardiac surgery backup were relatively lower than that with cardiac surgery backup.
3.Intervention comparison:the proportion of the group without cardiac surgery backup through brachial artery/ulnar artery pathways was less than that with cardiac surgery backup(0.0%V2.8%,P=0.001).The rest showed no significant differences (P＞0.05).
4.Clinical outcomes comparison during in-hospital period and at 30d follow-up: the procedural success rate of the two groups(96.4%V95.2%,P=0.371);incidence rate of PCI main complications(0.8%V1.4%,P=0.511);in-hospital death (0.0%V0.5%,P=0.501);incidence rate of acute myocardial infarction(0.0%V0.0%); incidence rate of transfer for urgent cardiac surgeries(0.0%V0.2%,P=1.000); incidence rate of acute coronary closure(0.0%V0.2%,P=1.000);incidence rate of coronary artery dissection(0.3%V0.0%,P=0.474);incidence rates of coronary artery perforation/coronary artery rupture/pericardium tamponade(0.0%V0.7%,P=0.251) and the incidence rate of 30d MACE(0.3%V0.3%,P=1.00).The two groups showed no significant differences(P＞0.05).
Conclusions:
1.Hospitals without cardiac surgery backup can safely and effectively perform elective percutaneous coronary intervention(PCI) on low-risk cases.
2.The high-volume operator going to the center of low-volume for performing PCI is feasible.
方法:回顾性收集2008年1月至2009年12月红河州第一人民医院、开远市人民医院、曲靖市第一人民医院、楚雄州人民医院、德宏州人民医院连续进行的390例择期PCI患者的临床资料,并设为无心外科支持组。作为对照,也回顾性收集2009年1月至2009年12月昆明医学院附一院心内科冠脉介入组连续进行的433例择期PCI患者的临床资料,并设为有心外科支持组。资料收集包括患者的基本临床资料(年龄,性别,体重,LVEF,冠心病危险因素,合并疾病,临床诊断),靶血管/病变特征,介入治疗情况,住院期间及30d随访临床结果。比较两组PCI手术成功率、并发症发生率、30d MACE发生率。
结果:
1.基本临床资料比较:整体而言,无心外科支持组的临床基本特征较有心外科支持组相对低危。平均年龄无心外科支持组较有心外科支持组低(60.74±10.86V63.33±10.70,P=0.000),年龄＞75岁无心外科支持组较有心外科支持组所占比例少(10.3%V15.2%,P=0.033),2型糖尿病无心外科支持组较有心外科支持组所占比例少(28.2%V35.6%,P=0.024),陈旧性心肌梗死(OMI)无心外科支持组较有心外科支持组所占比例少(12.6%V20.3%,P=0.003),经皮冠状动脉介入治疗(PCI)史无心外科支持组较有心外科支持组所占比例少(3.1%V10.6%,P=0.000),ST段抬高型心肌梗死(STEMI)无心外科支持组较有心外科支持组所占比例多(23.3%V17.1%,P=0.026)。其余各指标均无显著性差异(P≥0.05)。
2.靶血管/病变特征比较:左主干病变无心外科支持组较有心外科支持组所占比例少(0.8%V2.6%,P=0.021),靶病变狭窄程度无心外科支持组较有心外科支持组狭窄程度轻(0.85±0.13V0.87±0.12,P=0.029),C型病变无心外科支持组较有心外科支持组所占比例少(19.9%V26.1%,P=0.036),CTO病变无心外科支持组较有心外科支持组所占比例少(5.7%V8.7%,P=0.048)。两组在靶血管分布、病变分型及钙化病变、分叉病变上无显著性差异(P≥0.05)。整体而言,无心外科支持组的靶血管/病变特征较有心外科支持组相对低危。
3.介入治疗情况比较:无心外科支持组经肱动脉/经尺动脉路径所占比例较有心外科支持组少(0.0%V2.8%,P=0.001)。其余无显著性差异(P≥0.05)。
4.住院期间及30d随访临床结果比较:两组手术成功率为(96.4%V95.2%,P=0.371)、PCI主要并发症发生率为(0.8%V1.4%,P=0.511)、住院期间死亡率为(0.0%V0.5%,P=0.501)、急性心肌梗死发生率为(0.0%V0.0%)、急诊外科手术发生率为(0.0%V0.2%,P=1.000)、急性冠脉闭塞发生率为(0.0%V0.2%,P=1.000)、冠脉夹层发生率为(0.3%V0.0%,P=0.474)、冠脉穿孔/冠脉破裂/心包填塞发生率为(0.0%V0.7%,P=0.251)、30天MACE发生率为(0.3%V0.3%,P=1.00),两组之间比较差异无显著性(P≥0.05)。
结论:
1.无心外科支持的医院可以安全、有效地对低风险病例实施择期经皮冠状动脉介入治疗(PCI)。
2.高例数术者到低例数中心实施PCI具有可行性。
Purpose:evaluate the safety and feasibility of elective percutaneous coronary intervention(PCI) performed without cardiac surgery backup.
Methods:from January 2008 to December 2009,we retrospectively collected the clinical data of 390 patients underwent elective PCI provided consecutively by Honghe Prefecture No.1 People's Hospital,Kaiyuan City People's Hospital,Qujing City No.1 People's Hospital,Chuxiong Prefecture People's Hospital and Dehong Prefecture People's Hospital and regarded it as the group without cardiac surgery backup.For the sake of contrast,we also retrospectively collected the clinical data of 433 patients underwent PCI provided consecutively by the coronary intervention team of Cardiac Internal Medicine Department of No.1 Affiliated Hospital of Kunming Medical University from January 2009 to December 2009 and regarded it as the group with cardiac surgery backup.Data collection includes the basic clinical data(age, gender,weight,LVEF,risk factors of coronary heart disease,complications and clinical diagnosis) of the patients,target vessel/lesion features,intervention, in-hospital period and clinical outcome at a 30-day follow-up.We compared the PCI procedural success rate,incidence rate of complications and incidence rate of 30d MACE of the two groups.
Outcomes:
1.Basic clinical data comparison:as a whole,the risk of basic clinical features of the group without cardiac surgery backup was lower than that with cardiac surgery backup.The average age of the group without cardiac surgery backup was lower than that with cardiac surgery backup(60.74±10.86V63.33±10.70,P=0.000).The proportion of the group without cardiac surgery backup elder than 75 was less than that with cardiac surgery backup(10.3%V15.2%,P=0.033);the proportion of the group without cardiac surgery backup with Type 2 diabetes was less than that with cardiac surgery backup(28.2%V35.6%,P=0.024);the proportion of the group without cardiac surgery backup suffering from old myocardial infarction(OMI) was less than that with cardiac surgery backup(12.6%V20.3%,P=0.003);the proportion of the group without cardiac surgery backup underwent percutaneous coronary intervention (PCI) previously was less than that with cardiac surgery backup(3.1%V10.6%, P=0.000) and the proportion of the group without cardiac surgery backup suffering from ST segment elevation myocardial infarction(STEMI) was more than that with cardiac surgery backup(23.3%V17.1%,P=0.026).All the rest indicators showed no significant differences(P＞0.05).
2.Target vessel/lesion features comparison:the proportion of the group without cardiac surgery backup suffering from left main disease was less than that with cardiac surgery backup(0.8%V2.6%,P=0.021);the target lesion stegnosis degree of the group without cardiac surgery backup was minor than that with cardiac surgery backup(0.85±0.13V0.87±0.12,P=0.029);the proportion of the group without cardiac surgery backup suffering from Type C lesion change was less than that with cardiac surgery backup(19.9%V26.1%,P=0.036) and the proportion of the group without cardiac surgery backup suffering from CTO lesion change was less than that with cardiac surgery backup(5.7%V8.7%,P=0.048).The two groups showed no significant differences in target vessel distribution,lesion classification and bifurcation lesion(P＞0.05).As a whole,the risks of target vessel/lesion features of the group without cardiac surgery backup were relatively lower than that with cardiac surgery backup.
3.Intervention comparison:the proportion of the group without cardiac surgery backup through brachial artery/ulnar artery pathways was less than that with cardiac surgery backup(0.0%V2.8%,P=0.001).The rest showed no significant differences (P＞0.05).
4.Clinical outcomes comparison during in-hospital period and at 30d follow-up: the procedural success rate of the two groups(96.4%V95.2%,P=0.371);incidence rate of PCI main complications(0.8%V1.4%,P=0.511);in-hospital death (0.0%V0.5%,P=0.501);incidence rate of acute myocardial infarction(0.0%V0.0%); incidence rate of transfer for urgent cardiac surgeries(0.0%V0.2%,P=1.000); incidence rate of acute coronary closure(0.0%V0.2%,P=1.000);incidence rate of coronary artery dissection(0.3%V0.0%,P=0.474);incidence rates of coronary artery perforation/coronary artery rupture/pericardium tamponade(0.0%V0.7%,P=0.251) and the incidence rate of 30d MACE(0.3%V0.3%,P=1.00).The two groups showed no significant differences(P＞0.05).
Conclusions:
1.Hospitals without cardiac surgery backup can safely and effectively perform elective percutaneous coronary intervention(PCI) on low-risk cases.
2.The high-volume operator going to the center of low-volume for performing PCI is feasible.
引文
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[39].Ronana RK,Arab D,Joyal D,et a.l Coronary artery perforation during percutaneous coronary intervention:incidence and outcomes in the new interventional era[J].J InvasCardio,1 2005,17(11):606-608.
[40].姚刚,周芳,章宏伟,等.正常成人尺、桡动脉供血优越的临床意义.江苏医药,2006.32:223-224.
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[43].Ge L,Cosgrave J,Iakovou I,etal.Long-term outcomes following drug-eluting stent implantation in unprotected left main bifurcation lesions.Chin Med J (Engl),2007,120:545-551.
[44].Seung KB,park DW,kim YH,etal.stents versus coronary artery bypass qrafting for left main coronary artery disease.N Engl J Med,2008,358:1781-1792.
[45].Lotfi M,Mackie K,Dzavik V,et al.Impact of delays to cardiac surgery after failed angioplasty and stenting.J Am Coll Cardiol 2004;43:337-42.
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[47]. Loubeyre C, Morice MC, Berzin B, Virot P, Commeau P, Drobinski G,Ethevewot G, Moquet B, Marco J, Labrunie P, Cattan S, Coste P, Aubrey P,Ferrier A. Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a Frenchmulticenter registry. Catheter Cardiovasc Interv 1999;47:441-8.
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[49]. Rosenthal GE, Vaughan Sarrazin M, et al. In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals. Med Care 2003 ;41: 522-35.
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[41].Lanspa TJ,WilliamsMA,Heirigs RL.Effectiveness of ulnar artery catheterization after failed attemp t to cannulate a radial artery.Am J Cardiol,2005,96:1529-1530.
[42].Cherradi R,Ouldzein H,Zouaoui W,etal.Clinical and angiographic results angioplasty with a paclitaxel-eluting stent for unprotected left main coronary artery disease.Arch Cardiovasc Dis.2008Jan:11-17.
[43].Ge L,Cosgrave J,Iakovou I,etal.Long-term outcomes following drug-eluting stent implantation in unprotected left main bifurcation lesions.Chin Med J (Engl),2007,120:545-551.
[44].Seung KB,park DW,kim YH,etal.stents versus coronary artery bypass qrafting for left main coronary artery disease.N Engl J Med,2008,358:1781-1792.
[45].Lotfi M,Mackie K,Dzavik V,et al.Impact of delays to cardiac surgery after failed angioplasty and stenting.J Am Coll Cardiol 2004;43:337-42.
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[49]. Rosenthal GE, Vaughan Sarrazin M, et al. In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals. Med Care 2003 ;41: 522-35.
1.马长生,盖鲁粤,张奎俊,等.介入心脏病学[M].北京:人民卫生出版社,1998:425-430.
2.Ellis SG,Ajluni S,Arnold AZ,et al.Increased coronary perforation in the new device era:Incidence,classification,management,and outcome[J].Circulation,1994,90:2725-2730.
3.GrubergL,PinnowE,Flood R,et al.Incidence,management,and outcome of coronary artery perforation during percutaneous coronary intervention[J].Am J Cardiol,2000,86:680-682.
4.Fukutomi T,Suzuki T,Popma JJ,et al.Early and late clinical outcomes following coronary perforation in patientsundergoing percutaneous coronary intervention [J].Circulation Journal,2002,66:349-356-
5.GunningMG,Williams IL,Jewitt DE,et al.Coronary artery perforation during percutaneous intervention:incidence and outcome[J].Heart,2002,88:495-498.
6.Saito S,Arai H,Kim K,et al.Pseudoaneurysm of coronary artery following rupture of coronary artery during coronary angioplasty[J]-Cathet Cardiovasc Diagn,1992,26:304-307"
7.Iga K,Fujikawa T,Ueda Y,et al.Massive hemopericardium as a first manifestation of coronary aneurysm:successful surgical management[J].AmHeart J,1996,131:618-620
8.Schmitt J,Duray G,Gersh BJ,et al.Atrial fibrillation in acute myocardial infarction:a systematic review of the incidence,clinical features and prognostic implications[J].Eur Heart J,2009,30(9):1038-1045.
9.Boxt LM,Megerovitz MF,Taus RH,et al.Side branch occlusion complicating percutaneous transluminal coronary angioplasty[J].Radiology,1986,161:681-683.
10.Furukawa E,Hibi K,Kosuge M,et al.Intravascular ultrasound predictors of side branch occlusion in bifurcation lesions after percutaneous coronary intervention [J].Circ J,2005,69:325-330.
11.Aliabadi D,Tilli FV,Bowers TR,et al.Incidence and angiographic predictors of side branch occlusion following high pressure intracoronary stenting[J].Am J Cardiol,1997,80:994-997.
12.Cho GY,Lee CW,Hong MK,et al.Effects of stent design on side branch occlusion after coronary stent placement[J].Cathet Cardiovasc Intervent,2001,52:18-23.
13.孟红燕.冠心病介入治疗术后常见护理问题及对策[J].现代护理,2005,11(7):547-548.
14.韩雅玲.老年经皮冠状动脉介入治疗的并发症及其防治[J].解放军保健医学杂志,2005,7(4):200-202.
15.杨跃进,经皮冠状动脉介入治疗的并发症及其防治[J].上海医学,2003,26(3):165-167.
16.张海军,李洪军,靳 芳.经皮冠状动脉介入治疗并发症的防治[J].Journal of Handan Medical College October,2005,118(5):506-507.
17.张建军,胡大一.心脏介入性治疗一起低血压和心率减慢的原因分析和处理[J].中华心律失常学杂志,2002,6(6):337.
18.薛钋,苏希风,安丽莎,张有英.经皮冠状动脉介入治疗术中并发症的监测及处理[J].中国误诊学杂志2007,7(3)3046-3047.
19.黎观妹,袁岩.经皮冠状动脉介入治疗术中并发症的监测及护理[J].南方护理学报,2005,12(7):7249.
20.那开宪,余平,顾复生,等。选择性冠状动脉造影发生心室颤动11例分析.中 国介入心脏病学杂志,2002,10(2):85-86.