冠脉闭塞病变：保守？介入治疗_课件

1、冠脉闭塞病变：保守？介入治疗？大连医科大学附属第一医院心内科周旭晨CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )冠脉至少有一支血管慢性完全闭塞(时间30天)Puma JA, Sketch Jr MH, Tcheng JE, et al. Percutaneous revascularizationof chronic coronary occlusions: an overview. J Am Coll Cardiol2019;26(1):111.Question是否有临床症状?闭塞的血管是否是优势血管?有侧枝循环否? 正常人冠脉供血的正

2、常平衡CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )冠心病病人的病态平衡正常1支病变(CTO) 死亡1+1支病变2支(CTO)病变2+1支病变病态冠脉血管病变的临床意义CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )临床表现1支CTO病变(侧枝循环好/差)LAD:心绞痛/左心功能不全LCX,RCA优势:无症状/不稳定心绞痛LCX,RCA非优势:无症状/症状不典型10年生存率90%CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )1支C

3、TO病变(侧枝循环良好)常见于:陈旧性下壁心肌梗死陈旧性前壁心肌梗死陈旧性侧壁心肌梗死心电图遗留定位性病理性Q波无明显临床症状稳态如能保持,可长期生存CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )1支CTO的危险性1+1支新病变不稳定心绞痛/左心功能不全NSTEMISTEMI猝死!5年生存率50%心电图遗留定位性病理性Q波新出现ST-T变化有明显临床症状不能保持稳态,危险分层很高CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )1支CTO的危险性:冠脉造影常见模式LAD(CTO)+ RC

4、A(Donated Artery)新病变Or vise versa：严重的左心功能受损,A-V Block,心脏骤停LAD(CTO)+LCX(Donated Artery)新病变Or vise versa：严重的左心功能不全, A-V Block,心脏骤停RCA(CTO)+LCX (Donated Artery)新病变Or vise versa：严重的右心功能不全, A-V Block,心脏骤停CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )临床表现2+1支新病变不稳定心绞痛/左心功能不全NSTEMISTEMI猝死!5年生存率10%心电图遗

5、留定位性病理性Q波新出现ST-T变化临床症状非常不稳定,心源性休克常见造影发现严重问题，难以抢救.CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO的临床证据CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions ) CTO 病变非常普遍CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Tota

6、l Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chroni

7、c Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )“一个不能少!”OAT试验:“少一个能怎地?”目前的争论CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )Hochman JS, Lamas GA, Buller CE, et al.

8、 Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2019;355:2395-407.Question Debate开通闭塞血管是否有用？ Dr Hochman lamented. I tried to get more than 217 sites, but many major medical centers wouldnt participate because they didnt want to leave the artery closed. She e

9、mphasized that the results of OAT do not apply to patients in the acute phase of MI, who are known to benefit from early reperfusion, or those with unstable disease. CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )These results challenge the long-standing belief that opening a blocked artery is a

10、lways good. Instead, the study suggests that late angioplasty is unnecessary in this circumstance. The good news is there have been tremendous advances in drug therapy for heart attack patients. Drug therapy is an important treatment option. National Institutes of Health, NHLBI Director Elizabeth G.

11、 Nabel, MDCTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )但,临床实际出现这样的结果怎么办?下壁OMI,RCA CTO 10年突发心前区痛, V2-V6 ST压低, II,III,aVF ST抬高男, 65岁时心梗,药物治疗75岁时,经介入医生的手,转危为安FB 3.0/33mm x 2 植入病变血管FB 3.0 x29mm 植入病变血管LADRCALCX冠状动脉,三足鼎立,桃园三结义,缺一不可CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )我军主力部队敌军主力部队严重失衡逢战必败!CTO病变：慢性完全闭塞性病变(Chronic Total Coronary Occlusions )开通CTO病变的临床意义心内科医生的目标冠