Hemodynamically significant left main coronary artery stenosis(LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left cir-cumflex a...Hemodynamically significant left main coronary artery stenosis(LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left cir-cumflex artery has no previous patent grafts.Previous randomized studies have demonstrated a significant re-duction in mortality when revascularization by coronary artery bypass graft(CABG) surgery was undertaken compared with medical treatment.Therefore,current practice guidelines do not recommend percutaneous coronary intervention(PCI) for such a lesion because of the proven benefit of surgery and high rates of reste-nosis with the use of bare metal stents.However,with the advent of drug-eluting stents(DES),the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable.Therefore,apart from the current guidelines,PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy.Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.展开更多
Flow fractional reserve(FFR) allows to evaluate the functional significance of coronary artery lesions, through the ratio of the mean coronary artery pressure after the stenosis to the mean aortic pressure duringmaxim...Flow fractional reserve(FFR) allows to evaluate the functional significance of coronary artery lesions, through the ratio of the mean coronary artery pressure after the stenosis to the mean aortic pressure duringmaximum hyperemia. The actual widely accepted cutoff value is 0.80. Below this value a coronary lesion is considered significant and therefore it requires invasive revascularization. Several studies [in particular Fractional Flow Reserve vs Angiography for Multivessel Evaluation 1(FAME-1) and FAME-2] have shown the relationship between FFR measurement and hard end-points(death, myocardial infarction, and urgent revascularization). Consequently, FFR evaluation represents the cornerstone in the decision-making in intermediate coronary lesions. Recent studies paved the way for further applications of FFR evaluation in complex and tricky clinical settings. In this paper, we perform an overview of the data regarding contemporary application of FFR. In particular, we review the use of FFR in: left main intermediate stenoses, serial stenoses, evaluation after stenting, guidance in coronary artery bypass surgery, and acute coronary syndrome. All the data presented in our overview confirm the essential role of FFR assessment in the daily clinical practice. The shift from "operator-dependent" to "FFR-dependent" evaluation in intermediate coronary artery stenosis is of paramount importance in order to improve the prognosis of our patients, through the discrimination of the functional role of every single coronary stenosis.展开更多
Current evidence clearly demonstrates that coronary artery bypass grafting （CABG） remains the ＂gold standard＂ treatment for most patients with multivessel and left main stem disease. This article summarizes the re...Current evidence clearly demonstrates that coronary artery bypass grafting （CABG） remains the ＂gold standard＂ treatment for most patients with multivessel and left main stem disease. This article summarizes the relevant evidence basis demonstrating that CABG, in comparison to stenting, reduces mortality and subsequent myocardial infarction and the need for repeat revascularization. The article also describes the evidence basis to support the use of more arterial grafts during CABG and the current role of off-pump CABG.展开更多
Background The patients with unprotected left main coronary artery （ULMCA） stenosis and chronic total occlusion （CTO） lesions at the left anterior descending （LAD） artery are often recommended for bypass surgery...Background The patients with unprotected left main coronary artery （ULMCA） stenosis and chronic total occlusion （CTO） lesions at the left anterior descending （LAD） artery are often recommended for bypass surgery. However, some of these patients are deemed inoperable or are at high risk for surgery. In this study, we explored strategies and evaluated the efficacy of percutaneous coronary intervention for the treatment of ULMCA stenosis complicated by LAD CTO. Methods From November 2001 to July 2009, 78 patients with ULMCA stenosis and LAD CTO lesions were selectively treated with stenting. Six patients （7.7%） refused surgery due to their young age （S40 years）, and the other 72 patients （92.3%） were unsuitable for surgery. Reasons for poor surgical candidacy included advanced age （〉80 years）, chronic obstructive pulmonary, unsuitable distal target vessels for bypass, EuroSCORE ≥6, and so on. Four different strategies were applied based on the degree of left main stenosis and the ostial diameter and involvement of the left circumflex. Results Total procedural success was achieved in 94.9%, there were no deaths or thromboses. Five patients （6.4%） experienced non-Q-wave myocardial infarction in hospital. At long-term follow-up （（52±28） months）, there were 3 cardiac deaths （3.8%） and 4 （5.1%） nonfatal myocardial infarctions. Angiographic follow-up was performed in 50 patients （64.1%）, and target vessel revascularizations were required in 10 patients （12.8%）, among which 4 nonfatal myocardial infarction patients included. The rate of major adverse cardiac events was 16.7% （13/78）.Conclusions This study indicates that percutaneous intervention can be performed safely in high risk surgical patients with ULMCA and LAD CTO lesions based on individual therapeutic strategies. It may be feasible to apply this technique in selected patients mentioned above.展开更多
Introduction: The aim of our study was to assess the incremental value of Coronary Computed Tomography Angiography (CCTA) added to classical coronary angiography, for complex characterization of coronary lesions and p...Introduction: The aim of our study was to assess the incremental value of Coronary Computed Tomography Angiography (CCTA) added to classical coronary angiography, for complex characterization of coronary lesions and prediction of procedural complexity in patients with significant left main (LM) stenoses. Material and Methods: Thirty-six patients with LM disease were enrolled in the study, and each subject underwent CCTA followed by coronary angiography and percutaneous revascularization. Results: Logistic regression analysis indicated a good correlation between the angiographic-calculated and the CCTA-derived Syntax scores for the whole group (r = 0.87, p < 0.0001) and for the high risk subgroup (r = 0.86, p < 0.0001), but not for the low and intermediate risk (r = 0.38, p = 0.21 and r = 0.62, p = 0.07 respectively). In cases which required complex PCI procedures, both angiographic and CCTA Syntax score were significantly higher than those who did not require complex revascularization procedures (24.5 +/-11.5 vs 32.2 +/-14.6, p = 0.09 for Angio Syntax, 35.3 +/-11.5 vs 25.2 +/-11.3, p = 0.01 for CCTA). In the same time, Ca scoring was significantly higher and plaque volumes were significantly larger in cases requiring complex revascularization procedures (299.5 +/-359.6 vs 917.3 +/-495.4, p = 0.04 for calcium score, 79.7 +/-28.5 vs 108.7 +/-25.3 mm3, p = 0.002 for plaque volumes). Multivariate analysis identified the following CCTA parameters as significant predictors of increased risk for complex intervention in LM lesions: plaque volume (OR 8.00, p = 0.008), Ca scoring (OR 6.37, p = 0.02) and CCTA Syntax score (OR 6.87, p = 0.01). Conclusions: CCTA derived parameters provide incremental information to classical coronary angiography for preoperative assessment of lesion severity in complex left main stenosis. CCTA derived Syntax score significantly correlates with the classical Coronary Angiography Syntax score and identifies the subgroup of patients who will be more exposed to procedural complications during the展开更多
目的评估使用药物洗脱支架（drug-eluting stents,DES）治疗无保护左主干（unprotected left main coronary artery,ULMCA）远端分叉病变的长期预后。方法回顾性入选2005年1月至2009年12月因ULMCA远端分叉病变行DES置入的111例患者。以...目的评估使用药物洗脱支架（drug-eluting stents,DES）治疗无保护左主干（unprotected left main coronary artery,ULMCA）远端分叉病变的长期预后。方法回顾性入选2005年1月至2009年12月因ULMCA远端分叉病变行DES置入的111例患者。以随访过程中发生的主要不良心脑血管事件（major adverse cardiac and cerebrovascular event,MACCE）作为研究终点,包括死亡、非致死性心肌梗死、脑血管意外以及靶病变血运重建（target lesion revascularization,TLR）。结果 111例患者的平均年龄为（65.6±10）岁,其中24例（21.6%）合并糖尿病,35例（31.5%）左主干分叉病变为Medina 1,1,1型,88例（79.3%）接受必要时T支架术。中位随访时间为2.3年,随访过程中34例（30.6%）复查冠状动脉造影。无MACCE事件的生存率为87.4%,无TLR的生存率为94.6%,糖尿病是TLR的独立预测因素（OR 2.62,95%CI 1.12~1.62,P=0.004）。结论使用DES治疗ULMCA远端分叉病变是安全并且有效的。展开更多
文摘Hemodynamically significant left main coronary artery stenosis(LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left cir-cumflex artery has no previous patent grafts.Previous randomized studies have demonstrated a significant re-duction in mortality when revascularization by coronary artery bypass graft(CABG) surgery was undertaken compared with medical treatment.Therefore,current practice guidelines do not recommend percutaneous coronary intervention(PCI) for such a lesion because of the proven benefit of surgery and high rates of reste-nosis with the use of bare metal stents.However,with the advent of drug-eluting stents(DES),the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable.Therefore,apart from the current guidelines,PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy.Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.
文摘Flow fractional reserve(FFR) allows to evaluate the functional significance of coronary artery lesions, through the ratio of the mean coronary artery pressure after the stenosis to the mean aortic pressure duringmaximum hyperemia. The actual widely accepted cutoff value is 0.80. Below this value a coronary lesion is considered significant and therefore it requires invasive revascularization. Several studies [in particular Fractional Flow Reserve vs Angiography for Multivessel Evaluation 1(FAME-1) and FAME-2] have shown the relationship between FFR measurement and hard end-points(death, myocardial infarction, and urgent revascularization). Consequently, FFR evaluation represents the cornerstone in the decision-making in intermediate coronary lesions. Recent studies paved the way for further applications of FFR evaluation in complex and tricky clinical settings. In this paper, we perform an overview of the data regarding contemporary application of FFR. In particular, we review the use of FFR in: left main intermediate stenoses, serial stenoses, evaluation after stenting, guidance in coronary artery bypass surgery, and acute coronary syndrome. All the data presented in our overview confirm the essential role of FFR assessment in the daily clinical practice. The shift from "operator-dependent" to "FFR-dependent" evaluation in intermediate coronary artery stenosis is of paramount importance in order to improve the prognosis of our patients, through the discrimination of the functional role of every single coronary stenosis.
文摘Current evidence clearly demonstrates that coronary artery bypass grafting （CABG） remains the ＂gold standard＂ treatment for most patients with multivessel and left main stem disease. This article summarizes the relevant evidence basis demonstrating that CABG, in comparison to stenting, reduces mortality and subsequent myocardial infarction and the need for repeat revascularization. The article also describes the evidence basis to support the use of more arterial grafts during CABG and the current role of off-pump CABG.
文摘Background The patients with unprotected left main coronary artery （ULMCA） stenosis and chronic total occlusion （CTO） lesions at the left anterior descending （LAD） artery are often recommended for bypass surgery. However, some of these patients are deemed inoperable or are at high risk for surgery. In this study, we explored strategies and evaluated the efficacy of percutaneous coronary intervention for the treatment of ULMCA stenosis complicated by LAD CTO. Methods From November 2001 to July 2009, 78 patients with ULMCA stenosis and LAD CTO lesions were selectively treated with stenting. Six patients （7.7%） refused surgery due to their young age （S40 years）, and the other 72 patients （92.3%） were unsuitable for surgery. Reasons for poor surgical candidacy included advanced age （〉80 years）, chronic obstructive pulmonary, unsuitable distal target vessels for bypass, EuroSCORE ≥6, and so on. Four different strategies were applied based on the degree of left main stenosis and the ostial diameter and involvement of the left circumflex. Results Total procedural success was achieved in 94.9%, there were no deaths or thromboses. Five patients （6.4%） experienced non-Q-wave myocardial infarction in hospital. At long-term follow-up （（52±28） months）, there were 3 cardiac deaths （3.8%） and 4 （5.1%） nonfatal myocardial infarctions. Angiographic follow-up was performed in 50 patients （64.1%）, and target vessel revascularizations were required in 10 patients （12.8%）, among which 4 nonfatal myocardial infarction patients included. The rate of major adverse cardiac events was 16.7% （13/78）.Conclusions This study indicates that percutaneous intervention can be performed safely in high risk surgical patients with ULMCA and LAD CTO lesions based on individual therapeutic strategies. It may be feasible to apply this technique in selected patients mentioned above.
文摘Introduction: The aim of our study was to assess the incremental value of Coronary Computed Tomography Angiography (CCTA) added to classical coronary angiography, for complex characterization of coronary lesions and prediction of procedural complexity in patients with significant left main (LM) stenoses. Material and Methods: Thirty-six patients with LM disease were enrolled in the study, and each subject underwent CCTA followed by coronary angiography and percutaneous revascularization. Results: Logistic regression analysis indicated a good correlation between the angiographic-calculated and the CCTA-derived Syntax scores for the whole group (r = 0.87, p < 0.0001) and for the high risk subgroup (r = 0.86, p < 0.0001), but not for the low and intermediate risk (r = 0.38, p = 0.21 and r = 0.62, p = 0.07 respectively). In cases which required complex PCI procedures, both angiographic and CCTA Syntax score were significantly higher than those who did not require complex revascularization procedures (24.5 +/-11.5 vs 32.2 +/-14.6, p = 0.09 for Angio Syntax, 35.3 +/-11.5 vs 25.2 +/-11.3, p = 0.01 for CCTA). In the same time, Ca scoring was significantly higher and plaque volumes were significantly larger in cases requiring complex revascularization procedures (299.5 +/-359.6 vs 917.3 +/-495.4, p = 0.04 for calcium score, 79.7 +/-28.5 vs 108.7 +/-25.3 mm3, p = 0.002 for plaque volumes). Multivariate analysis identified the following CCTA parameters as significant predictors of increased risk for complex intervention in LM lesions: plaque volume (OR 8.00, p = 0.008), Ca scoring (OR 6.37, p = 0.02) and CCTA Syntax score (OR 6.87, p = 0.01). Conclusions: CCTA derived parameters provide incremental information to classical coronary angiography for preoperative assessment of lesion severity in complex left main stenosis. CCTA derived Syntax score significantly correlates with the classical Coronary Angiography Syntax score and identifies the subgroup of patients who will be more exposed to procedural complications during the
