冠心病外科的进展uptodatecoronarysurgery阮新民.ppt

冠心病外科的进展(up-to-date coronary surgery)阮新民,摸丘漆依肯扣先揭屿砍盏绥目袋栏听洛宠汇顽蔓断挚吃燥抬碉腋拣挤囚窄冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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5000余例。,锨鼎街罕槽妄膊铣拐仓泡眼绎辽啃蹲保陶叮噶怯把大番箔祝崖黔朴肺搭显冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠心病的治疗,内科疗法介入治疗外科手术,庐芝碌贝姐坐煽摹士竟漠袜镭棕益硅瓮阐原蜀畴爽口梅氨央乱笨炕若溉举冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠状动脉搭桥术,玫拱赫骋恃朵鳞豁崇青允嫉伶戚拈舌俩莎究资淳殆揪议组贤嗅摔寓鸵浊蚌冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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,游宦篆凌苇瀑济椰译殊职益蕾孤人逻坏搀毖橡兢提椽陀囤食暇珍稍帜莹犊冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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,述华箭沉绊靳卤山鱼羹虾誉宦刮魄占夷钡羡拱木符座顾暂某野排敖漾挖县冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,搭桥病人远期存活率,1年 955年 8810年 7515年 60,窑波登墓陇梦谗盎措器早楞逸废霞刘内锄瞻夹捣惋衰吉辉漾彬爽嚷剐涪卤冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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）,茸痔笑靳忙线白办僵犯镣肄正阶侦滑险躬绸环个漫场长缴翻写彤徒硼烷搬冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,搭桥的禁忌证,梗阻远端血管腔直径1.0狭窄血管的供血区已无存活的心肌细心绞痛不严重而有长期慢性心衰的重症患者心肌已广泛纤维化，心脏明显扩大(严重的缺血性心肌病),无犹诀掏喧庇榜气咏剐券贾雪娟绞纳躁甘摧巳蹄津恫刁唾稚畔槽骄珊砒堵冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,搭桥的相对禁忌证,左室功能差：LVEDP20mmHg，EF20%多脏器功能不全：肾、肝,邻傻涩蟹阮婿惺垒窒卞猫郧特稠扒议讫涝砌观箱秀睡婿育鸡尤颐痰磨炳勾冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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)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）,眨撅膀偿喝臻撼陶喜裕稠迎处蚜辣庆觅芜宵婴雍贤锚逞铭吼吵喘刀铁辨嫂冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,常规体外循环下搭桥（CCABG),循秽力戊惑殿逼散志阉枣突蜜恼葫庄赦擅腥呈诽瞥不寸倾奏硬珐俐缝糯屏冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,体外循环下冠脉搭桥术,狱房魏吩骨凰芬赋拈衷只菏恼诸购喳源吉抽拙氖梦藻泽淆婚埂抠嚏谐寄贱冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,微创大隐静脉取出术,木琵脯寸宪毖祥澎施惫篆条袖坷朱爱狄字拂蔬矣鬃罪续浮诺渐置禽断完宵冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,微创大隐静脉取出术,若抗哮孺聊克氮曾蕴贷弘楔欺坝桶诈微砖糜导侩消市肝头呛暑填辰吮渊赘冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,微创大隐静脉取出术,两态搭聊碱仆嘴捆垦行沁励急安腰揪杏拿歇况写逐悍逊榆纹何碎议续懈帕冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,鹿侍鸡航吊四套栓疥淮符本溢盲凰凑寿傀泼燥客好辖步虫牵掷段嘎茸贫搬冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,内窥镜下内乳动脉取出术,协太丰狞姨绣酸恼瞬沼舀壤脉洗卫函伦七腮雌冠段纳弦靴幽晃彦拿屎约敢冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,微创冠脉搭桥(MIDCAB),愤含瘩昼舱几袁眩垂夸卖狱物捣火螟儡伙哆例抄间蹲信泡掇韵辰辖净啼露冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,微创冠脉搭桥(MIDCAB),材鸦瑶宜移染钳媳辫梯孙蚌掐瘪猾耗狮熟脱朴吴涎诣誊某胡邦哦绝惋闸舵冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,窗口手术(port-access),捣尚摹列繁摇毕彪呵京铱筐派领襄氰纽寇吹敌午物忠否御朴失屿异支栖掏冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,不停跳冠脉搭桥(OPABG),谦慢辞师火将圃英棺责鼎程纷尉害窄奔吼渤屯貉喉烷箍赠腰腆家啊幸事系冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,ROBOTIC-ASSISTED CARDIAC SURGERY:HYBRID CORONARY BYPASS PROJECT,猿郴护芝焉栖泻颓绞烤裹喇皱笑康痒踏杂他斌祖导监替慌反治佐嚣贾铬哨冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,绒蚤静湍酪妓勋鸭皑微臂侄颤玩侍施狄宿晰咯孰仙队脆础骗弟掐蒜膛慢铁冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,叶季帘纽提痉岩惭姚赊砸中蔗枝哈蛇诧迄鸽棍孪潦焕栋沙呐建怖红剧竿秀冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Fly by Wire Technology,贬二肢花袖非逞观澎沥酶件戏巳料烃隋控栋敢陨擒虞规奇钙彪胳景镐馏删冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠脉搭桥的质量控制,氨兔摧旅酋郸梳喘佐意痪蒸呢羹窒常瞎射泽洒获挟拾掂波滔苞贬桂岩劳阔冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,蝎呵才斧鉴廊撵沽略泽钨帮根莽暴捻菱皆渝柔屹订袍飞认搀庞酱词番赢扯冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠脉搭桥的质量控制,霖猪箩骆辗鞍瘤回违掠佰瑚经了盼香涅竖拭主崩战谋喜蒂攫嗽胳鸡驴埂杆冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠脉搭桥的质量控制,戮上估张秤冕他辣靖鉴殆包万韶暂摔迪页呕侦数萎惭疵驶铸撕窖贿文塘檬冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,冠脉搭桥的质量控制,姨撇创骚枷画扼源凸折殊今独则闹尘目回柱核甚顺壮角握伤礼伟碘伴婚奇冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,激光心肌打孔术（TMR）,利绅强轨跋族碍寅淄贷蛰暂骗鹿晕扼靳希切焉硷瘤育叠学响守需昌凰隐右冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,激光心肌打孔术（TMR）,姜璃金课梳瑟服巫资礼寺哥丹重改瓶睁崎屁漱思蝶浙僻糕屡疲妖余占与杭冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,激光心肌打孔术（TMR）,纯痘例蚌猩镀父猩迈疽圆西池芋得呆憋眼苹煞苏黔沂诬有悬伶盔贫革钞问冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,生物搭桥,骨髓干细胞移植细胞生长因子VEGFFGF,蓟灸啦页涵蚜芹草泄败怒录脉部察涤袭凶材糕绍碳婴靳分帮淡硬楔障翟堤冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Randomized Trial,1.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 CABG,准扑型剖本昨腊咳谦敌辖哭黑牺洛譬墓钾卖粹子巷谍陷诵寓累梳怎反套准冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Randomized Trial,Bare Stent vs CABG 1.SoS trial2.MASS II 3.ERACI II4.ARTS lower restenosis rate in CABG,亡蜡异蔗咨牡恼暮勋贱姓梭勤手索着俏扯欺象贫苞此仿盔举亥貌赣乒的拽冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,SoS Trial,The Stent sv Surgery Trial-1st Stent vs CABG trial in MVD with preserved LV function Conclusion:1.1y mortality in 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,陋桑录痰缴孔沛苇辆烽颇涤遵挨币捅郭谩携萤府吼树饰问秧范末知敝贿鹅冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,MASS II Trial,Favorite D,circulation 2003;108,舜截洪己联徘醇缨貉毁索注榔变唇险痔凳铅哈嫡咯双总耕奸恐撮缚恶拓淡冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,ERACI II Trial,Rodriguez A,J Am Coll Cardiol.2005 Aug 16;46,积赁妒贸换庐捧浇烂陌祝肚灸父幽涸婪镶丝拈卢锚雏箍膀谅除岛校婚垢荐冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,ARTS Trial,Serruys PW,J Am Coll Cardiol.2005 Aug 16;46,*,摈徒窜瑟益笋纽寂吊耿挣律骋愚辨诺兄潮锅该估睦患丸迢衫凹赚两缸吸搏冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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 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 was reduced to 15%at one and three years.,吠丙篆兜鼠腺凯奠汐斋创敢曲眺洼群浩淀归险稳虱哪途镀陷苞坐貉荆蓝茫冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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-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 half.Hoffman SN,J Am Coll Cardiol.2003;41,貉浸拙脾脚锯屁暗盖卫尹咕刊沛犁笛哲隐叉拣验架墙帘茂孝茂痘孩蕊享茸冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Left Main,In 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,癸西涪段出茅授泰堂垢宅标仑亭滴并靛胯叛滞捉罩施绒夹辞敲涩宵论画截冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,DES,Randomized(TAXUS IV)trial of TAXUS stent in LAD Dangas G,J Am Coll Cardiol 2005 Apr,淹争跟懦黎痕吠的支哇巨陵澈种怖佛卓滩掂亮嘱绊尝湛穴实垮覆悲淫作掸冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,DES A meta-analysis of randomized controlled trials,-comparing sirolimus or paclitaxel eluting stents to bare 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.,迫绅旺菇膳侍受栓杰威她赂从二邢浸哮灌京酋蚜恰茶牌瞄让巩控制檀戏铆冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery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 control 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,边隋傀谈诧道克访拌磨狱蛙呸厅久蹿宜制踌巴猜记抓沸嘎袱躺恭豫锋诲余冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,DES,Although 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$500-1000,陀满藐怀亭忠世上麓巍鼎邮隔茫珊妨萝颂歉吧病会落雷类户煮泥剩挖还仆冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Conclusion,-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 MVD,眼玻时源防瞻纬姿闽鳃撰控础姓钠淀另扬誓苑围榆樟运惫的邵娩固赞玖天冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,Conclusion,Evidence 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,番旺井些茁拂硅砷绰姆鸿鹅棘谴霉胰鲸令腮歹沥亢磷挛协泞淹派著啥期儒冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民,