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1、冠脉闭塞病变：保守？介入治疗？,大连医科大学附属第一医院 心内科 周旭晨,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),冠脉至少有一支血管慢性完全闭塞 (时间30天) Puma JA, Sketch Jr MH, Tcheng JE, et al. Percutaneous revascularization of chronic coronary occlusions: an overview. J Am Coll Cardiol 1995;26(1):111. Question 是否有临床症状? 闭塞的血管是否是优势血管? 有侧枝
2、循环否?,正常人,冠脉供血的正常平衡,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),冠心病病人的病态平衡,正常,1支病变(CTO),死亡,1+1支病变,2支(CTO)病变,2+1支病变,病态,冠脉血管病变的临床意义,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),临床表现 1支CTO病变(侧枝循环好/差) LAD:心绞痛/左心功能不全 LCX,RCA优势:无症状/不稳定心绞痛 LCX,RCA非优势:无症状/症状不典型 10年生存率90%,CTO病变：慢性完全闭塞性病变 (Chr
3、onic Total Coronary Occlusions ),1支CTO病变(侧枝循环良好)常见于: 陈旧性下壁心肌梗死 陈旧性前壁心肌梗死 陈旧性侧壁心肌梗死,心电图遗留定位性病理性Q波 无明显临床症状 稳态如能保持,可长期生存,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),1支CTO的危险性 1+1支新病变 不稳定心绞痛/左心功能不全 NSTEMI STEMI 猝死! 5年生存率50%,心电图遗留定位性病理性Q波 新出现ST-T变化 有明显临床症状 不能保持稳态,危险分层很高,CTO病变：慢性完全闭塞性病变 (Chronic
4、Total Coronary Occlusions ),1支CTO的危险性:冠脉造影常见模式 LAD(CTO)+ RCA(Donated Artery)新病变 Or vise versa： 严重的左心功能受损,A-V Block,心脏骤停 LAD(CTO)+LCX(Donated Artery)新病变 Or vise versa： 严重的左心功能不全, A-V Block,心脏骤停 RCA(CTO)+LCX (Donated Artery)新病变 Or vise versa： 严重的右心功能不全, A-V Block,心脏骤停,CTO病变：慢性完全闭塞性病变 (Chronic Total Co
5、ronary Occlusions ),临床表现 2+1支新病变 不稳定心绞痛/左心功能不全 NSTEMI STEMI 猝死! 5年生存率10%,心电图遗留定位性病理性Q波 新出现ST-T变化 临床症状非常不稳定,心源性休克常见 造影发现严重问题，难以抢救.,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO的临床证据,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CT
6、O 病变非常普遍,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic T
7、otal Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),“一个不能少!”
8、,OAT试验:“少一个能怎地?”,目前的争论,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006;355:2395-407.,Question Debate 开通闭塞血管是否有用？,Dr Hochman lamented. “I tried to get more than 2
9、17 sites, but many major medical centers wouldnt participate because they didnt want to leave the artery closed.“ She emphasized that the results of OAT 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病变：慢性完全闭塞性病变
10、 (Chronic Total Coronary Occlusions ),“These results challenge the long-standing belief that opening a blocked artery is always good. Instead, the study suggests that late angioplasty is unnecessary in this circumstance. The good news is there have been tremendous advances in drug therapy for heart
11、attack patients. Drug therapy is an important treatment option.“,National Institutes of Health, NHLBI Director Elizabeth G. Nabel, MD,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),但,临床实际出现这样的结果怎么办?,下壁OMI,RCA CTO 10年,突发心前区痛, V2-V6 ST压 低, II,III,aVF ST抬高,男, 65岁时心梗,药物治疗,75岁时,经介入医生的手,转危为安,FB 3.0/
12、33mm x 2 植入病变血管,FB 3.0x29mm 植入病变血管,LAD,RCA,LCX,冠状动脉,三足鼎立,桃园三结义,缺一不可,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),我军主力部队,敌军主力部队,严重失衡 逢战必败!,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),开通CTO病变的临床意义,心内科医生的目标 冠脉0支病变,CTO病变：慢性完全闭塞性病变 (Chronic Total Coronary Occlusions ),心内科医生的目标 保持介入的治疗成果,病态平衡,正常稳态,Thank You for Your Attention!,1st Hospital Dalian Medical University,1st Department,2nd Department,