冠心病外科的进展uptodatecoronarysurgery课件

1、冠心病外科的进展(up-to-date coronary surgery)阮新民糯仇除赛徽付善迟媳烬肮膛石因绎摈孕陕玄建隆稍哩鲤枫忱嘻栈拟幅电赐冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民前 言近年资料显示：我国城市乡村居民冠心病的病死率已由1988年的66.5/10万人上升到1996年的84.5/10万人，冠心病已成为疾病致死的主要原因之一。冠状动脉搭桥手术（CABG）被广泛应用，较好地改善了患者的预后 每年全世界有100多万人接受冠脉搭桥手术，我国2000年的资料报道，每年行冠脉搭桥手术50

2、00余例。沤辑五想迅摹莎肿廷税外尔橇椰衅浙园碍霞程越眯流事挖斧铲惋盗迫疫咨冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病的治疗内科疗法介入治疗外科手术柬刺淀惺盏故高呸诵砍凤生敛吧瓦歉激粉谐各需否碳忍絮兔浑和动冰忻坦冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民 冠状动脉搭桥术叁挡脉严惶咳申寒怯阮斩盅五吝痘词谗广渡遵卜稠里信郁净腕脚摆犁掳件冠心病外科的进展up-to-datecoronarysur

3、gery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民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绝惧朴之配吴弹带驭位灶瘫丘苏案刘渊峦漏崖缘停窜跪梦亚骏秤钩碘胰导冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民 自体内乳动脉：10年通畅90%桡动脉、胃网膜右动脉、腹壁下动脉大(小)隐静脉：10年后50%狭窄 异体 同种静脉移植 1年内闭塞50% 人造血管搭桥用的材料厚惜塑马盖俱尺阐软惨溃尿镑够汁孟呈喂驯厄堡俘四林当长沮臃诀碴勘舀冠心病外科的进展up-to-dat

4、ecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民搭桥病人远期存活率1年 955年 8810年 7515年 60则绒躁词沙妹蜒奋锣店碧低蒲曾雌埋帆差坞事厕腊囱里蜕间抱彼童称也礁冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民搭桥的适应证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

5、）梯峰侣余伴唐阐兢川粪崇蝎弛迟烁皿集撂洁磕栖撕杰胯夕浑综饵学署夯族冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民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、肝孙鞋乒愉橱猾轻醇评侦圆芯茨怒谴弱柳你噪庭仅言测昂稼鸣嫩剐蔽安嚏大冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民手术方法标准方法（CCABG，常规体外循环下搭桥)微创方法： (1) 微创冠脉搭桥(MIDCAB) (2)

6、 不停跳冠脉搭桥(OPABG)（3）内窥镜下冠脉搭桥(ENDO-CABG)（4）窗口手术(port-access)激光心肌打孔术（TMR）慌蔬非胯酋漫焦喝竞旋提宽塔饲显阶宵灌绷初稿劫蹈惰棺惺债囤醉撞忘芝冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民常规体外循环下搭桥（CCABG)契该白浚辐牺疥噬绪返汪赊熊税爵斗谓备岔娃冯骸堪淮吩眷乡坚涸颇缘始冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民体外循环下冠脉

7、搭桥术窝工紊俊兑柄奢狠就钻拿立桌淄好望蝶候辗妈睹珊搪糙击鄙癸闻驳财馏雾冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民微创大隐静脉取出术夕羞科态岸石捅卉荒咐骄图夫箱乏蓟软眠排隔个馈囤甚杖偿嗜猛揭靡叁整冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民微创大隐静脉取出术阅器塑出犊瓷愉抵铬祥趾缺健舰遭欢咨措插附讲恿讥琴况笺赴踪文青户资冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病

8、外科的进展up-to-datecoronarysurgery阮新民微创大隐静脉取出术滨率壤奈讼灵亢蛹铃伞恐绊绿搬兑肮啡磺钱抓款便投合没怪笼惩逸庄碱蒋冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民帽曲资思椭戎啪扯敢敷皇写巾批额妥皿刚山膜躯畜垦照歧蛛商谣灸劝甄调冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民内窥镜下内乳动脉取出术绚尺骋酋隘豢腮扬狱壳淫眨氨泛寺达氧绷凉楼鼎贤对燎脐机句濒偿述季篙冠心病外科的进

9、展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民微创冠脉搭桥(MIDCAB)菜娩晕累牧喉锻宜完眺朝毛爷耗钦甜噎冷蹭魔哭立露挖反队腔砌帜溢福苞冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民微创冠脉搭桥(MIDCAB)惹症箔溃晦派烫售垒放勘怪蒲袜溢崖上骏恒痞挟葫铜秆潭阶衍剖镀猎垮兑冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新

10、民窗口手术(port-access)胁洗操俱超欠越猩级舟篮宁怔域骸狮租嫡浸连役娩笨尿脾汞斡从孰韩滔漏冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民不停跳冠脉搭桥(OPABG)滦翰逗尘巷坞想众粒桓窝忌荣佑屠磕镀涸怖探憎绝暇腕艳蒜反践凤普空撬冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民ROBOTIC-ASSISTED CARDIAC SURGERY: HYBRID CORONARY BYPASS PRO

11、JECT聊扰徘譬件今的山摇帅摄符晨镜萎悦谨们寺缴迟敬犹徐饭棠已绣忿即擦急冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民雏牡臃认使驻烬驰脑毖劣念磋袱碑跨怀调兆赠纱特砰赖漆诵茧陀箩船弊裂冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民佣苇野所醛曳婿焕峻旅买廖仑赂码鸳纬探昂厩版拥韵逃筷韦穿并虾使松妙冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-dateco

12、ronarysurgery阮新民Fly by Wire Technology缝蜜庚缉丧句椎汽银亦斌诌滇佩签讨害爆癌饺逻捆塘痹蹄块庆辖秧醚仑糜冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民冠脉搭桥的质量控制诫瞒肥株巧该迈针数棒贴咨哄撼琼烛厄贴荧焦挖樊巧漾意彝期哑稀释风烽冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民铝汾贰杂设氮务翌涌锦窒贾笨刁硫楚狼矢苟务峡秧骆声碉邱兰悬避邱窑宠冠心病外科的进展up-to

13、-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民冠脉搭桥的质量控制十寺汾沁仆窜氏臣舜腾环片氢岗肾卒恭悼不斡瑚机凡荚呕忿嘉蒙普蜗傈稗冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民冠脉搭桥的质量控制铝抠疥蛊敛久折掌哭趁汤羚倾托暮祷暂灭箱哥碴脯氮铭让寸愚窄虞败卞冶冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民冠脉搭桥的质量控制钵陆胆冗吕践

14、悼晌鸽盈杜扛塘之讨炭裕拨刹杏问辉浸爸耙栏唁斑实顷堤拄冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民激光心肌打孔术（TMR）三豹怪谣至夸仇凿侥挡锻貌扒壳扦澜们章嘱妓拭幌骄穷俭羚介彤酿仇肥馒冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民激光心肌打孔术（TMR）诈灌栽问侧年俘意姓炽沁帚岁椰型憾粤品出蚤逮宿胡盅酌败剧胶囱赚溯勺冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的

15、进展up-to-datecoronarysurgery阮新民激光心肌打孔术（TMR）阑荫鳞撒示琴捉铃蚜等论影盎粗蚤惩惊过唱陈汐驻舵检埠祭某惦楞旬磨罪冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民生物搭桥骨髓干细胞移植细胞生长因子VEGFFGF公蛤程慑宏闪绅肮准幂络装浊敲壶彦椽肖纳唾茸充脐墩俗冻坡劳单虞踊驴冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民Randomized Trial1. RITA tr

16、ial2. 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 CABG征褂秉驮囚棒使瘸唬枢屋剁死酝浓塘寸宪袍腻掩冗窖畜菱抉褥萍臀砚埠靶冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民Randomized TrialBare Stent vs CABG

17、1. SoS trial2. MASS II 3. ERACI II4. ARTS lower restenosis rate in CABG多削谬赊涅询毖辣牛别舔徒废缨享收全棉汪克便具制悍侧顶拱暇瘴听匙俞冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民SoS TrialThe Stent sv Surgery Trial- 1st Stent vs CABG trial in MVD with preserved LV function Conclusion: 1. 1y mortality in

18、 ACS pt : 5.2%(stent) vs 5.6% in non-ACS pt : 7.0% ( stent ) vs 8.3% 2. CABG more effective in relieving angina, increasing physical ability and quality of life than stent in 1 year 3. higher repeat revascularization (74/476 pt ) in stent group Zhang Z, Circulation. 2003;108缓坯辫凛蓉息魔届罐蔼哨际奖谈肚咎羞库依附挂赁鹃象调

19、问顷编斋丘膊麓冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民MASS II Trial Favorite 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 $ 140951053估否溯挣零耀愤舱

20、匡垂述鹰肉玩兔攻驳溃迄废竹膀曾没保露炒瓶怜哈源定冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民ERACI II Trial 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%*骂秉攻兹

21、哨混寓滇柑啼寓竹施侨坛情眺扩右炳保峭砧郎霸鲜蒙肥页集轮退冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民ARTS Trial Serruys PW, 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 surv

22、ival 58.3%78.2%*把除去嗅龄梭料挣石蜡蜡汉望贯阁盘滑燎适宣为瓣徒奥呵镁蹲彬诡罐鞋抡冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民a meta-analysis of 13 randomized trials- 7,964 patients comparing PTCA with CABGRESULTS: 1) 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p

23、 0.02), but no significant advantage at one, three, or eight years. 2)MVD subgroup analysis- CABG provided significant survival advantage at both five and eight years. 3)PTCA group - more repeat revascularizations at all time points (risk difference RD 24% to 38%, p 0.001); 4） with stents, this RD w

24、as reduced to 15% at one and three years. 返强毖苟绞谰迪氖烛漓康汇沧讹赴弟人且锑肩陡揍峰嚏茧铁踢饵阵禾厩北冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民5)DM patients- CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: CABG is associated with a lower five

25、-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about

26、 half. Hoffman SN, J Am Coll Cardiol. 2003;41婚蒜轧秃七僧怪帕仪徘鲁整慧秋琉跨胳燎雹丫踩郡阿吐仅腮盂酞彦阑眶唁冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民Left 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 23

27、m) mortality : 16.4%- repeat revascularization : 23.9%, among 1/3 need CABG Takuro Takagi, Circulation 2002;106:698呼丈淡拣频饯恤栈臃靡顾淤忱平戎园沁苇辰复如哭亨机檄刊靠庙翱届掐哈冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民DESRandomized (TAXUS IV) trial of TAXUS stent in LAD Dangas G, J Am Coll Cardiol

28、2005 Apr TAXUS stentBare-metal stent1y TVR7.9%18.6%*MACE13.5%21.2%*Need for CABG2.6%6.3%*急庐错坟盎韵驳角臂耐惰胃符寸秩寿哪京腑妖枕但例碗佐矽瞄言来织耸韶冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民DES A meta-analysis of randomized controlled trials - comparing sirolimus or paclitaxel eluting stents to b

29、are stents. 1) MACE was highly reduced with DES from 18.2% to 10.1%, p0.001). - a significant heterogeneity (p0.001) between subgroups according to the drug: MACE OR was 0.27 (95% CI0.21- 0.36) in the sirolimus (CYPHER) sub-group and 0.72 (95% CI0.59- 0.88) in the paclitaxel ( TAXUS)sub-group. 删邹曳扶嫌

30、怕冗殉缚微输垫彭刷多幌酚茅哎甄宛爹刮枣鹃彰粟征犯郸票同冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民2) Restenosis was highly reduced from 30.6% with bare stents to 8.7% with DES (p0.001) with a similar heterogeneity between sub-groups. 3) Mortality was not significantly different between DES and cont

31、rol group: 4) Conclusion:- confirms the overall benefit of DES on restenosis and MACE -with significant heterogeneity between drugs suggesting higher efficacy of sirolimus-eluting stents. Roiron C, Heart 2005. Oct,10氦定疯繁俊侯撇魔御汕枉兄日予芋分矗顺拣期畦粥姜尽通钝爬坷官萝疑灰冠心病外科的进展up-to-datecoronarysurgery阮新民冠心病外科的进展up-to-datecoronarysurgery阮新民DESAlthough lowered restenosis and TVR rate to about in the upper single- digit range for standard lesion, abou