无保护左主干病变处理策略

1. 无保护左主干病变处理策略 中国医学科学院　阜外心血管病医院 　　　　　　　高润霖 ２０１１．7．23 CICI

2. 左主干(>50%)病变预后CABG—治疗的金标准 Circulation 1976, 51(Suppl)111:107

4. 当代PCI治疗无保护左主干（UPLM）病变有无地位？当代PCI治疗无保护左主干（UPLM）病变有无地位？

5. Contemporary Trials of LM PCI vs CABG(> 100 pts, 2000-8) * Studies with >100 patients per arm reported 2000-2008ND=no difference; n/a=not available/not reported

6. SYNTAX Trial Design + 62 EU Sites 23 US Sites Heart Team (surgeon & interventionalist) Total enrollment N=3075 Amenable for both treatment options Amenable for only one treatment approach Stratification: LM and Diabetes Stratification: LM and Diabetes Randomized Arms N=1800 Two Registry ArmsN=1275 Randomized Arms n=1800 Two Registry Arms PCI n=198 PCI all captured w/ follow up CABG n=1077 CABG n=1077 CABG 2500 750 w/ f/u CABG n=897 TAXUS n=903 PCI n=198 TAXUS* n=903 vs CABG n=897 no f/u n=428 5yr f/u n=649 vs LM 33.7% 3VD 66.3% 3VD 65.4% LM 34.6% *TAXUS Express

7. SYNTAX score Patient Profiling Local Heart team (surgeon & interventional cardiologist) assessed each patient in regards to: • Patient’s operative risk (EuroSCORE & Parsonnet score) • Coronary lesion complexity (newly developed SYNTAX score) • The goal of the SYNTAX score is to provide a tool to assist physicians in their revascularization strategies for patients with high risk lesions Number & location of lesions Dominance Left Main Calcification 3 Vessel Thrombus Total Occlusion Bifurcation Tortuosity • Leaman score, Circ 1981;63:285-299 • Lesions classification ACC/AHA , Circ 2001;103:3019-3041 • Bifurcation classification, CCI 2000;49:274-283 • CTO classification, J Am Coll Cardiol 1997;30:649-656 Sianos et al, EuroIntervention 2005;1:219-227 Valgimigli et al, Am J Cardiol 2007;99:1072-1081 Serruys et al, EuroIntervention 2007;3:450-459 Coronary tree segments based on the classification proposed by the AHA and modified for the ARTS study Circulation 1975; 51:31-3 & Semin Interv Cardiol 1999; 4:209-19

8. LM 99% SYNTAX SCORE 17 SYNTAX SCORE 52

9. MACCE to 12 Months TAXUS*(N=903) CABG(N=897) 20 10 Cumulative Event Rate (%) 0 0 6 12 Months Since Allocation P=0.0015* 17.8% 12.1% Event Rate ± 1.5 SE. *Fisher’s Exact Test ITT population Serruys PW, at TCT 2008 .

10. SYNTAX Trial Adverse Events to 12 Months CVA (Stroke) All Death Myocardial Infarction Revascularization TAXUS* (N=903) CABG (N=897) ITT population Event Rate ± 1.5 SE, *Fisher exact test . Serruys PW, at TCT 2008

11. SYNTAX Study

12. TAXUS (N=357) CABG (N=348) 40 20 0 12 24 36 SYNTAX: MACCE to 3 YearsLM Subset P=0.20 Before 1 year* 13.7% vs 15.8% P=0.44 1-2 years* 7.5% vs 10.3% P=0.22 2-3 years* 5.2% vs 5.7% P=0.78 26.8% Cumulative Event Rate (%) 22.3% 0 Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; *Binary rates ITT population

13. MACCE to 3 Years by SYNTAX Score Tercile Low Scores (0-22) CABG (N=104) TAXUS (N=118) 40 30 Cumulative Event Rate (%) 20 10 0 0 12 24 36 Months Since Allocation Left Main > > P=0.33 23.0% < Cumulative Event Rate (%) 18.0% > < Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported Data; ITT population

14. MACCE to 3 Years by SYNTAX Score Tercile Intermediate Scores (23-32) CABG (N=92) TAXUS (N=103) 40 30 Cumulative Event Rate (%) 20 10 0 0 12 24 36 Months Since Allocation Left Main > > P=0.90 23.4% < 23.4% > < Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported Data; ITT population

15. MACCE to 3 Years by SYNTAX Score Tercile Left Main SYNTAX Score 33 CABG (N=149) TAXUS (N=135) 40 30 Cumulative Event Rate (%) 20 10 0 0 12 24 36 Months Since Allocation Left Main Left Main < P=0.003 37.3% > < 21.2% < < Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported Data; ITT population

17. 稳定性冠心病血运重建策略 Silber S, TCT 2010

18. 对UPLM狭窄病变治疗临床决策的过程 1.病变复杂程度（SYNTAX积分的高低） SYNTAX积分属低、中度者（＜32分）， 可考虑支架置入， ≥33分者应首选 CABG。

19. 临床决策的过程（2） 2. 对UPLM狭窄病变合并多支病变者是否能达到完全性血管重建 对冠状动脉右优势型患者，如果完全闭塞的右冠状动脉有重要功能意义（非梗死相关动脉）而PCI不能再通者，应选择CABG；对左优势型冠状动脉的UPLM狭窄病变支架置入也需十分慎重 SYNTAX SCORE 52

20. 临床决策的过程（3） 3.患者左心功能如何 左室EF降低对CABG及PCI均是高危因素，EF降低合并多支病变者应首先考虑CABG。 若考虑支架置入应预先置入主动脉内球囊反搏（IABP）予以保护。

21. Predictors of MACE by Logistic Regression OR=1.841, 95%CI [0.984, 3.445], P=0.056 Female OR=2.978, 95%CI [1.010, 8.779] P=0.048 LVEF<40% Max. pressure <15atm OR=2.287, 95%CI [1.277, 4.095] P=0.005 Incomplete Revascularization OR=3.654, 95%CI [1.231, 10.849] P=0.020 Univariable test (p<0.1): LM BMS use (p=0.029), female gender (p=0.051), low LVEF (p=0.009), LM pre-procedure %DS by visual estimate (p=0.043), low LM stenting maximal pressure (p=0.003), no LM post-dilatation (p=0.028) and incomplete revascularization (p=0.006) were enrolled. Gao R,Am Heart J 2008:155:553

22. 临床决策的过程（4） 4.患者是否可耐受至少一年的双重抗血小板治疗 术前必须认真评价患者是否能耐受长期的双重抗血小板治疗，若患者有出血倾向、消化性溃疡、消化道出血史，或抗血小板药过敏、不能耐受等情况，则是支架置入的禁忌，应选择CABG。

23. 临床决策的过程（5） 5.患者是否有合并疾患而不适宜CABG 如患者有慢性阻塞性肺疾病（COPD）等禁忌手术的合并疾患，对病变适宜者可行支架置入。

24. 临床决策的过程（6) 6.术者的技术水平 一些研究表明，术者的经验及技术水平与患者预后相关，UPLM狭窄的PCI治疗应在治疗病例较多的中心由有经验的术者进行。 7.在合理的情况下尊重患者意愿和选择

25. Ostial Left Main左主干开口部病变（IIa适应证） Case 1. Male, 59yrs Prior PCI HT, HL Smoker Effort AP 3m LV normal RCA normal

26. 左主干分叉病变处理(IIb类适应证）策略选择的依据左主干分叉病变处理(IIb类适应证）策略选择的依据 • LAD和LCX开口是否受累 • LM，LAD和LCX 血管直径 • LAD和LCX之间夹角

27. Cross-over andProvisional Stenting Strategy单支架跨过回旋支必要时回旋支置入支架 Case_2 Case 2Male, 65yrs, SAP 6m, Risk factors: HT, HL, smoke RCA normal, EF=66%,Syntax=23

29. Stent Crush or Mini Crushor T Stent Technique支架挤压技术或T型支架技术 Case3 M, 58yrs, Unstable angina, DM,hypertension, hyperlipidemiaSyntax=29

31. “V” or Simultaneous Kissing StentV型支架或对吻支架 Case 4 F, 56 yrs, unstable angina, Syntax=29

33. 小结 • 对左主干开口或孤立性体部病变不累及分叉者，DES可作为CABG替代治疗。 • 左主干分叉病变或合并其他血管病变、SYNTAX Score ≤32、PCI可达到完全性血管重建者，可考虑DES置入术，但远期疗效仍待确定。 • PCI支架置入技术的选择取决于LAD和LCX开口是否受累，LM、LAD和LCX 血管直径及LAD和LCX之间夹角 。 • 左主干PCI要求达到完美结果。

34. Thank you