冠脈閉塞病變：保守？介入治療-周旭晨課件

1、冠脈閉塞病變：保守？介入治療？大連醫(yī)科大學(xué)附屬第一醫(yī)院心內(nèi)科周旭晨CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )冠脈至少有一支血管慢性完全閉塞(時間30天)Puma JA, Sketch Jr MH, Tcheng JE, et al. Percutaneous revascularizationof chronic coronary occlusions: an overview. J Am Coll Cardiol1995;26(1):111.Question是否有臨床癥狀?閉塞的血管是否是優(yōu)勢血管?有側(cè)枝循環(huán)否? 正常人冠脈供血的正

2、常平衡CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )冠心病病人的病態(tài)平衡正常1支病變(CTO) 死亡1+1支病變2支(CTO)病變2+1支病變病態(tài)冠脈血管病變的臨床意義CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )臨床表現(xiàn)1支CTO病變(側(cè)枝循環(huán)好/差)LAD:心絞痛/左心功能不全LCX,RCA優(yōu)勢:無癥狀/不穩(wěn)定心絞痛LCX,RCA非優(yōu)勢:無癥狀/癥狀不典型10年生存率90%CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )1支C

3、TO病變(側(cè)枝循環(huán)良好)常見于:陳舊性下壁心肌梗死陳舊性前壁心肌梗死陳舊性側(cè)壁心肌梗死心電圖遺留定位性病理性Q波無明顯臨床癥狀穩(wěn)態(tài)如能保持,可長期生存CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )1支CTO的危險性1+1支新病變不穩(wěn)定心絞痛/左心功能不全NSTEMISTEMI猝死!5年生存率50%心電圖遺留定位性病理性Q波新出現(xiàn)ST-T變化有明顯臨床癥狀不能保持穩(wěn)態(tài),危險分層很高CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total

4、Coronary Occlusions )CTO的臨床證據(jù)CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions ) CTO 病變非常普遍CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變

5、：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )“一個不能少!”O(jiān)AT試驗(yàn):“少一個能怎地?”目前的爭論CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persist

6、ent occlusion after myocardial infarction. N Engl J Med 2006;355:2395-407.Question Debate開通閉塞血管是否有用？ 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 emphasized that the results of OAT

7、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病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )These results challenge the long-standing belief that opening a blocked artery is always good. Instead, the study sug

8、gests 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. Nabel, MDCTO病變：慢性完全閉塞性病變(Chronic

9、Total Coronary Occlusions )但,臨床實(shí)際出現(xiàn)這樣的結(jié)果怎么辦?下壁OMI,RCA CTO 10年突發(fā)心前區(qū)痛, V2-V6 ST壓低, II,III,aVF ST抬高男, 65歲時心梗,藥物治療75歲時,經(jīng)介入醫(yī)生的手,轉(zhuǎn)危為安FB 3.0/33mm x 2 植入病變血管FB 3.0 x29mm 植入病變血管LADRCALCX冠狀動脈,三足鼎立,桃園三結(jié)義,缺一不可CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )我軍主力部隊(duì)敵軍主力部隊(duì)嚴(yán)重失衡逢戰(zhàn)必敗!CTO病變：慢性完全閉塞性病變(Chronic Total Coronary Occlusions )開通CTO病變的臨床意義心內(nèi)科醫(yī)生的目標(biāo)冠脈0支病變CTO病變：慢性完全閉塞性病變(Chronic Tot