1、會計學1藥物支架與冠狀動脈搭橋手術治療冠心藥物支架與冠狀動脈搭橋手術治療冠心病多支病變療效對比胡盛壽病多支病變療效對比胡盛壽 背景 真實世界里，藥物支架與冠狀動脈搭橋治療冠心病多支病變的爭論一直未停止。 1956196219741957199620032007 方案 方案CABG- 手術量與死亡率(1997-2007)1537 casesPCI與CAG的手術量(2003-2007)阜外醫院的兩項注冊登記研究 方案u Fuwai Hospital CABG Registry (1999now)u Fuwai Hospital PCI Registry (2002now) Am Heart J,

2、HEART 兩項注冊登記研究包含了患者的詳細信息； 統一的參數標準； 專用的電子化數據收集和報告系統。JTCVS, EJCTS, HEART 研究人群 (2004年5月至 2005年12月) 方案 三支病變的患者 接受了單純搭橋手術或接受至少一枚藥物支架治療的患者 先前接受過再血管化治療 合并左主干病變 發生于24小時內的急性心肌梗死 入選標準排除標準入選3,720 患者: CABG (n=1,886) ; DES (n=1,834)n 定義：死亡:任何原因導致死亡； 心肌梗死: 在隨訪過程中出現異常Q波或再入院時出現的心肌梗死 或因心肌梗死再入院；靶血管血運重建:經血運重建的血管需要再次血管

3、化。 方案n 隨訪 臨床隨訪 電話隨訪 病例記錄 獨立的事件鑒定委員會（內、外科醫生） 藥物支架組平均隨訪33.1個月 搭橋組平均隨訪38.9個月 方案 方案 結果遵照當前的指南行冠狀動脈搭橋及PCI術 結果 結果非調整住院/30 天死亡率： 0.9 % for CABG vs 0.6 % for DES 結果 結果 Table 1中變量經危險度調整后的對比全組傾向配對792對患者Cox 多變量分析 結果靶血管重建 治療后36個月以內未經調整過的靶血管重建率曲線 結果全組傾向配對792對患者配對組的Kaplan-Meier分析 結果全組傾向配對792對患者配對組的Kaplan-Meier分析

4、結果 討論與評論n冠心病多支病變的再血管化: DES vs. Bypass 仍存爭議！終點終點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復合事件復合事件 6.47.90.39MACCE11.219.10.001 3支病變組觀察第12個月Mohr EF TCT 2008; 討論與評論SYNTAX trial的結果 討論與評論n冠心病多支病變的再血管化: DES vs. Bypass 仍存爭議！ 討論與評論 CABG 治療多支病變的優勢? PCI治療 “罪犯” 病變 . CAB

5、G作用于血管包括了 “罪犯”病變和未來可能的“罪犯”病變CABG的優勢即在于此不同Fuwai Database 討論與評論Cleveland Database CABG 治療多支病變的優勢? 搭橋手術數量增多，圍手術期結果改善 阜外外科醫師培訓 討論與評論LIMA前降支搭橋的金標準Tatoulis JTCVS,2004 CABG 治療多支病變的優勢? 3-5年先心病手術3-5年瓣膜手術搭橋手術 行CABG的患者效果更佳（死亡率，心梗率，再血管化率），盡管他們病情更重， 亞組（糖尿病，年齡大于70歲，3支病變，2支病變）分析也提示CABG組有更好遠期安全性及有效性。 討論與評論我們的研究提示p

6、非隨機性p 選擇偏差p 單中心n 研究局限 討論與評論鳴謝n兩個數據庫的所有工作團隊n阜外-牛津中心n統計研究中心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! 結果 結果 Table 1中變量經危險度調整后的對比全組傾向配對792對患者Cox 多變量分析 結果 BackgroundWe therefore compared the long-term safety and efficacy of PCI with DES and C