冠心病外科的进展up-to-datecoronarysurgery阮新民Stillwatersrundeep.流静水深流静水深,人静心深人静心深Wherethereislife,thereishope。有生命必有希望。有生命必有希望前前 言言l近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民冠心病的病死率已由冠心病的病死率已由冠心病的病死率已由冠心病的病死率已由1988198819881988年的年的年的年的66.5/1066.5/1066.5/1066.5/10万人上升到万人上升到万人上升到万人上升到1996199619961996年的年的年的年的84.5/1084.5/1084.5/1084.5/10万人，冠心病已成为疾病致万人，冠心病已成为疾病致万人，冠心病已成为疾病致万人，冠心病已成为疾病致死的主要原因之一。死的主要原因之一。死的主要原因之一。死的主要原因之一。l冠状动脉搭桥手术（冠状动脉搭桥手术（冠状动脉搭桥手术（冠状动脉搭桥手术（CABGCABGCABGCABG）被广泛）被广泛）被广泛）被广泛应用，较好地改善了患者的预后应用，较好地改善了患者的预后应用，较好地改善了患者的预后应用，较好地改善了患者的预后 每年全世界有每年全世界有每年全世界有每年全世界有100100100100多万人接受冠脉搭桥多万人接受冠脉搭桥多万人接受冠脉搭桥多万人接受冠脉搭桥手术，我国手术，我国手术，我国手术，我国2000200020002000年的资料报道，每年行冠年的资料报道，每年行冠年的资料报道，每年行冠年的资料报道，每年行冠脉搭桥手术脉搭桥手术脉搭桥手术脉搭桥手术5000500050005000余例。余例。余例。余例。冠心病的治疗内科疗法介入治疗外科手术 冠状动脉搭桥术冠脉搭桥的作用消除和减轻心绞痛预防心肌梗死延长生命 自体自体内乳动脉：内乳动脉：1010年通畅年通畅90%90%桡动脉、胃网膜右动脉、腹壁下动脉桡动脉、胃网膜右动脉、腹壁下动脉大大( (小小) )隐静脉：隐静脉：1010年后年后50%50%狭窄狭窄 异体异体 同种静脉移植同种静脉移植 1 1年内闭塞年内闭塞50%50% 人造血管人造血管搭桥用的材料搭桥病人远期存活率1年 955年 8810年 7515年 60搭桥的适应证3支血管病变，特别左室功能受累者(EF50%)左前降支(LAD)及回旋支(Cx)近端显著(70%)狭窄经皮腔内血管PTCA)失败或出现并发症，以及PCI术后再狭窄心肌梗塞后并发症（室间隔穿孔、心室破裂、室壁瘤）搭桥的禁忌证梗阻远端血管腔直径20mmHg，EF20%多脏器功能不全：肾、肝手术方法标准方法（标准方法（CCABGCCABG，常规体外循环下搭桥，常规体外循环下搭桥) )微创方法：微创方法： (1) (1) 微创冠脉搭桥微创冠脉搭桥(MIDCAB)(MIDCAB) (2) (2) 不停跳冠脉搭桥不停跳冠脉搭桥(OPABG)(OPABG)（3 3）内窥镜下冠脉搭桥）内窥镜下冠脉搭桥(ENDO-CABG)(ENDO-CABG)（4 4）窗口手术）窗口手术(port-access)(port-access)激光心肌打孔术（激光心肌打孔术（TMRTMR）常规体外循环下搭桥（CCABG)体外循环下冠脉搭桥术微创大隐静脉取出术微创大隐静脉取出术微创大隐静脉取出术内窥镜下内乳动脉取出术内窥镜下内乳动脉取出术微创冠脉搭桥(MIDCAB)微创冠脉搭桥(MIDCAB)窗口手术(port-access)不停跳冠脉搭桥(OPABG)ROBOTIC-ASSISTED CARDIAC SURGERY: ROBOTIC-ASSISTED CARDIAC SURGERY: HYBRID CORONARY BYPASS PROJECTHYBRID CORONARY BYPASS PROJECTFly by Wire Technology冠脉搭桥的质量控制冠脉搭桥的质量控制冠脉搭桥的质量控制冠脉搭桥的质量控制激光心肌打孔术（TMR）激光心肌打孔术（TMR）激光心肌打孔术（TMR）生物搭桥骨髓干细胞移植细胞生长因子VEGFVEGFFGFFGFRandomized Trial1. RITA trial2. CABRI3. King SB III4. ERACI 5. Hamm CW6. BARI- All balloon PCI vs CABG: similar mortality and MI rate, but freedom from repeat revascularization favor CABGRandomized TrialBare Stent vs CABG 1. SoS trial1. SoS trial2. MASS II 2. MASS II 3. ERACI II3. ERACI II4. ARTS 4. ARTS lower restenosis rate in CABGlower restenosis rate in CABGSoS TrialThe Stent The Stent svsv Surgery Trial Surgery Trial- 1- 1stst Stent vs CABG trial in MVD with preserved LV Stent vs CABG trial in MVD with preserved LV functionfunction Conclusion:Conclusion: 1. 1y mortality in ACS pt : 5.2%(stent) vs 5.6% 1. 1y mortality in ACS pt : 5.2%(stent) vs 5.6% in non-ACS pt : 7.0% ( stent ) vs 8.3% in non-ACS pt : 7.0% ( stent ) vs 8.3% 2. CABG more effective in relieving angina, 2. CABG more effective in relieving angina, increasing physical ability and quality of increasing physical ability and quality of life than stent in 1 year life than stent in 1 year 3. higher repeat revascularization 3. higher repeat revascularization (74/476 pt ) in stent group (74/476 pt ) in stent group Zhang Z, Circulation. 2003;108 Zhang Z, Circulation. 2003;108MASS II Trial Favorite D, circulation 2003;108Favorite D, circulation 2003;108 STENTCABGAngina free79%88%* Peri-op AMI1.5%2.0%AMI8.3%3.0%* Repeat revascularization11.7%*0%30d mortality2.4%3.0%1y mortality4.4%3.9%CostUS $ 130994223US $ 140951053ERACI II Trial Rodriguez A, J Am Coll Cardiol. 2005 Aug 16;46 Rodriguez A, J Am Coll Cardiol. 2005 Aug 16;46 STENTCABGN225225Free from non-fatal AMI97.3%94%5y survival92.8%88.4%Free from MACE65.3%76.4%*Free from repeat revascularization71.5%92.4%*ARTS Trial Serruys PW, Serruys PW, J Am Coll Cardiol. 2005 Aug 16;46 J Am Coll Cardiol. 2005 Aug 16;46 *STENTCABGN6006055y mortality8%7.6%5y mortality (DM)13.4%8.3%*Free from stroke & MI18.2%14.9%Repeat revascularization30.3%8.8%*Event free survival 58.3%78.2%*a meta-analysis of 13 randomized trialsl l- 7,964 patients comparing PTCA with CABG- 7,964 patients comparing PTCA with CABGRESULTS: RESULTS: l l1) 1.9% absolute survival advantage favoring CABG over PTCA 1) 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p 0.02), but no significant advantage for all trials at five years (p 0.02), but no significant advantage at one, three, or eight years. at one, three, or eight years. l l2)MVD subgroup analysis- CABG provided significant survival 2)MVD subgroup analysis- CABG provided significant survival advantage at both five and eight years. advantage at both five and eight years. l l3)PTCA group - more repeat revascularizations at all time points 3)PTCA group - more repeat revascularizations at all time points (risk difference RD 24% to 38%, p 0.001); (risk difference RD 24% to 38%, p 0.001); l l4 4） with stents, this RD was reduced to 15% at one and three with stents, this RD was reduced to 15% at one and three years. years. 5 5)DM patients- CABG provided a significant survival )DM patients- CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: CONCLUSIONS: CABG is associated with a lower five-year mortality, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat The addition of stents reduced the need for repeat revascularization by about half.revascularization by about half. Hoffman SN, J Am Coll Cardiol. 2003;41 Hoffman SN, J Am Coll Cardiol. 2003;41Left MainIn hosp- 3% Q-wave MI, 4.5% non-Q-wave MI- 0% mortality, 3% CABGFollow up with CAG in 85% pt in 5 2m- restenosis rate : 31.4%Follow up ( 31 23m) mortality : 16.4%- repeat revascularization : 23.9%, among 1/3 need CABG Takuro Takagi, Circulation 2002;106:698 Takuro Takagi, Circulation 2002;106:698DESRandomized (TAXUS IV) trial of TAXUS stent Randomized (TAXUS IV) trial of TAXUS stent in LAD in LAD Dangas G, J Am Coll Cardiol 2005 Dangas G, J Am Coll Cardiol 2005 AprApr TAXUS stentBare-metal stent1y TVR7.9%18.6%*MACE13.5%21.2%*Need for CABG2.6%6.3%*DES A meta-analysis of randomized controlled trials l l- comparing sirolimus or paclitaxel eluting - comparing sirolimus or paclitaxel eluting stents to bare stents. stents to bare stents. l l1) MACE was highly reduced with DES from 1) MACE was highly reduced with DES from 18.2% to 10.1%, p0.001). - a significant 18.2% to 10.1%, p0.001). - a significant heterogeneity (p0.001) between subgroups heterogeneity (p0.001) between subgroups according to the drug: MACE OR was 0.27 according to the drug: MACE OR was 0.27 (95% CI0.21- 0.36) in the sirolimus (95% CI0.21- 0.36) in the sirolimus (CYPHER) sub-group and 0.72 (95% CI0.59- (CYPHER) sub-group and 0.72 (95% CI0.59- 0.88) in the paclitaxel ( TAXUS)sub-group. 0.88) in the paclitaxel ( TAXUS)sub-group. 2) Restenosis was highly reduced from 30.6% 2) Restenosis was highly reduced from 30.6% with bare stents to 8.7% with DES (p0.001) with bare stents to 8.7% with DES (p0.001) with a similar heterogeneity between sub-with a similar heterogeneity between sub-groups. groups. 3) Mortality was not significantly different 3) Mortality was not significantly different between DES and control group: between DES and control group: 4) Conclusion:4) Conclusion:- confirms the overall benefit of DES on - confirms the overall benefit of DES on restenosis and MACE restenosis and MACE -with significant heterogeneity between -with significant heterogeneity between drugs suggesting higher efficacy of sirolimus-drugs suggesting higher efficacy of sirolimus-eluting stents.eluting stents. Roiron C, Heart 2005. Roiron C, Heart 2005. Oct,10Oct,10DESAlthough lowered restenosis and TVR rate to about in the upper single- digit range for standard lesion, about 16% for complex lesion, but the 1 year mortality still similarUpcoming FREEDOM & CARDIA trial - DES vs CABG with DM & MVD pts. CYPHER stent cost US $ 3000, bare-metal stent $500-1000Conclusion- Stent Vs CABG : favor CABG on mortality, event free survival rate due to higher restenosis rate of Stent groupDES lowered the restenosis rate by half or 1/3 Waiting future trial of DES vs CABG on MVDAlso should consider the huge economic impact of DES on MVDConclusionEvidence base medicine : “ CABG still the best treatment for MVD and LM now”Cardiac Surgeon: What is left for us? - may change from time to timeBut the main point is as a doctor we concern more is “What is the best for the patient?”The patient need to know! - their right