药物支架与冠状动脉搭桥手术治疗冠心病多支病变疗效对比胡盛寿

1、会计学1药物支架与冠状动脉搭桥手术治疗冠心药物支架与冠状动脉搭桥手术治疗冠心病多支病变疗效对比胡盛寿病多支病变疗效对比胡盛寿 背景 真实世界里，药物支架与冠状动脉搭桥治疗冠心病多支病变的争论一直未停止。 1956196219741957199620032007 方案 方案CABG- 手术量与死亡率(1997-2007)1537 casesPCI与CAG的手术量(2003-2007)阜外医院的两项注册登记研究 方案u Fuwai Hospital CABG Registry (1999now)u Fuwai Hospital PCI Registry (2002now) Am Heart J,

2、HEART 两项注册登记研究包含了患者的详细信息； 统一的参数标准； 专用的电子化数据收集和报告系统。JTCVS, EJCTS, HEART 研究人群 (2004年5月至 2005年12月) 方案 三支病变的患者 接受了单纯搭桥手术或接受至少一枚药物支架治疗的患者 先前接受过再血管化治疗 合并左主干病变 发生于24小时内的急性心肌梗死 入选标准排除标准入选3,720 患者: CABG (n=1,886) ; DES (n=1,834)n 定义：死亡:任何原因导致死亡； 心肌梗死: 在随访过程中出现异常Q波或再入院时出现的心肌梗死 或因心肌梗死再入院；靶血管血运重建:经血运重建的血管需要再次血管

3、化。 方案n 随访 临床随访 电话随访 病例记录 独立的事件鉴定委员会（内、外科医生） 药物支架组平均随访33.1个月 搭桥组平均随访38.9个月 方案 方案 结果遵照当前的指南行冠状动脉搭桥及PCI术 结果 结果非调整住院/30 天死亡率： 0.9 % for CABG vs 0.6 % for DES 结果 结果 Table 1中变量经危险度调整后的对比全组倾向配对792对患者Cox 多变量分析 结果靶血管重建 治疗后36个月以内未经调整过的靶血管重建率曲线 结果全组倾向配对792对患者配对组的Kaplan-Meier分析 结果全组倾向配对792对患者配对组的Kaplan-Meier分析

4、结果 讨论与评论n冠心病多支病变的再血管化: DES vs. Bypass 仍存争议！终点终点CABG (%)DES (%)p死亡死亡 2.94.40.18卒中卒中 1.90.80.09心梗心梗 2.65.20.04再血管化再血管化 5.414.70.001复合事件复合事件 6.47.90.39MACCE11.219.10.001 3支病变组观察第12个月Mohr EF TCT 2008; 讨论与评论SYNTAX trial的结果 讨论与评论n冠心病多支病变的再血管化: DES vs. Bypass 仍存争议！ 讨论与评论 CABG 治疗多支病变的优势? PCI治疗 “罪犯” 病变 . CAB

5、G作用于血管包括了 “罪犯”病变和未来可能的“罪犯”病变CABG的优势即在于此不同Fuwai Database 讨论与评论Cleveland Database CABG 治疗多支病变的优势? 搭桥手术数量增多，围手术期结果改善 阜外外科医师培训 讨论与评论LIMA前降支搭桥的金标准Tatoulis JTCVS,2004 CABG 治疗多支病变的优势? 3-5年先心病手术3-5年瓣膜手术搭桥手术 行CABG的患者效果更佳（死亡率，心梗率，再血管化率），尽管他们病情更重， 亚组（糖尿病，年龄大于70岁，3支病变，2支病变）分析也提示CABG组有更好远期安全性及有效性。 讨论与评论我们的研究提示p

6、非随机性p 选择偏差p 单中心n 研究局限 讨论与评论鸣谢n两个数据库的所有工作团队n阜外-牛津中心n统计研究中心Thank you！Shengshou Hu M.D., FACCDepartment of Cardiac SurgeryNational Heart Center & Fu Wai Hospital, Beijing, ChinaThree-Year Follow-Up Results from a Single center BackgroundWe therefore compared the long-term safety and efficacy of PCI

7、 with DES and CABG in patients with MVD. 1956196219741957199620032007 Methods MethodsCABG- Amounts and Mortalities(1997-2007)1537 cases Amounts of PCI and CAG(2003-2007)Two Registries of Fuwai Hospital Methodsu Fuwai Hospital CABG Registry (1999now)u Fuwai Hospital PCI Registry (2002now) Am Heart J,

8、 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 Study Population (From Apr. 2004, to Dec. 2005) Methods Patients wit

9、h 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 (n=1,834)p DefinitionsDeath: death from any cause. MI: documentation

10、of a new abnormal Q wave after the index treatment or myocardial infarctions at readmission (emergency admission 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

11、adjudication committee 33.1 months for DES group 38.9 months for CABG group Methods Methods ResultsBoth CABG and PCI with DES were performed according to current guidelines Results ResultsUnadjusted in-hospital/30 day mortality 0.9 % for CABG vs 0.6 % for DES Results Results Adjusted for candidate v

12、ariables in Table 1 Propensity matching for the entire cohort created 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 matc

13、hing for the entire cohort created 792 matched pairs of patientsKaplan-Meier analysis in the matched Cohort ResultsPropensity matching for the entire cohort created 792 matched pairs of patientsKaplan-Meier analysis in the matched Cohort Results Discussion and CommentnMultivessel Revascularization:

14、DES vs. Bypass Controversial!End pointCABG (%)DES (%)pDeath 2.94.40.18Stroke 1.90.80.09MI 2.65.20.04Revascularization 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 Discussion

15、 and CommentnMultivessel Revascularization: DES vs. Bypass 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 futu

16、re 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

17、lden Standard for LADTatoulis JTCVS,2004 Is the advantage of CABG for multivessel revascularization explicable? Congenital heart surgery, 3-5yrsValvular surgery, 3-5yrsCABGp CABG is preferred (death, MI and TVR) Albeit patients undergoing CABG were sickerp In four subgroups of patients (DM, 70 + yrs

18、 of age, 3-VD, 2-VD), our data still favored CABG for long-term safety and efficacy. Discussion and Commentn Clinical Finding of our Data The nonrandomized nature of the observational data Subjected to a selection biasSingle institutional results nStudy Limitation Discussion and Commentn Acknowledgementsp All relative staffs work for the two data-basesp Fuwai-Oxford Collaborative Research Centre p statistic research centreThank you! 结果 结果 Table 1中变量经危险度调整后的对比全组倾向配对792对患者Cox 多变量分析 结果 BackgroundWe therefore compared the long-term safety and efficacy of PCI with DES and C