左主干治疗住院期间结果：DES和BMS 相似
IVUS Guidance Needed for DES Left Main Procedures
In-hospital outcomes similar among left main patients treated with DES and bare-metal stents.

　　最近的系列研究表明IVUS在左主干介入治疗中可能发挥重要作用，一个对比荟萃分析探讨了不同治疗选择对左主干介入治疗死亡率的影响。来自韩国的Park教授报告了左主干MAIN-COMPARE注册研究结果:IVUS指导下的左主干介入治疗能显著减少左主干治疗的死亡率(HR = 0.429; 95% CI, 0.211-0.872)，IVUS指导下的左主干治疗与没有IVUS指导的左主干治疗相比，3年生存率明显提高( 见图1)
 
　　按照注册时间不同，该注册研究也比较了CABG,DES和BMS的治疗效果。三者之间在死亡率上没有明显差异。

　　注册研究中，支架内血栓的发生率为0.5%(570例患者中5例患者发生)，3例发生于BMS,2例发生于DES,（图2）3年支架内无血栓事件生存率DES为99.4%,BMS为98.8%.

　　该注册研究始于2000年1月，共入选775例左主干患者，336例BMS治疗，439例CABG治疗。第二阶段开始于2003年3月，805例患者接受DES治疗，731例患者接受CABG治疗。

　　进一步的荟萃分析

　　Park报告了一项包括3976名患者的荟萃分析以评价左主干介入治疗的安全性与有效性。

　　与CABG相比，BMS和DES能显著减少3年的靶血管重建率。DES也单独显著减少靶血管重建率，DES还减少死亡率57%，其中心源性死亡率减少71%。调整后的死亡率在DES和BMS两组相似。

　　在左主干死亡率影响因素分析中，置入BMS组，Euro 计分≥6(HR = 3.494; 95% CI, 1.489-8.197)是死亡率增加的独立预测因素。而置入DES组，慢性心衰(HR = 2.658; 95% CI, 1.032-6.847)，慢性肾衰(HR = 4.865; 95% CI, 2.102-11.257)，慢性阻塞性肺病(HR = 2.927; 95% CI, 1.004-8.534)和Euro 计分≥6(HR = 3.243; 95% CI, 1.482-7.094) 都是死亡率升高的独立预测因素。

　　（阜外心血管病医院　高立建 陈俊　编译）

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IVUS Guidance Needed for DES Left Main Procedures
In-hospital outcomes similar among left main patients treated with DES and bare-metal stents.

Recent registry results shed light on the role IVUS can play in DES intervention in left main coronary disease, and a further meta-analysis of comparative trials explores how treatment choices can affect mortality.

IVUS guidance during DES treatment was associated with a significant reduction in mortality (HR = 0.429; 95% CI, 0.211-0.872) in the MAIN-COMPARE registry, according to Seung-Jung Park, MD, professor of medicine at the University of Ulsan College of Medicine in Seoul, Korea.

Three-year survival among patients receiving IVUS-guided therapy was significantly higher compared with patients treated without IVUS guidance (Figure 1).

The registry compared CABG to stenting with either bare-metal stents or DES, depending on the year of enrollment.

There was no difference in all-cause mortality between bare-metal stents, DES, or CABG.

Stent thrombosis, by any of the definitions endorsed by the Academic Research Consortium, occurred in 0.9% (5 of 570 patients). Three cases occurred with bare-metal stents and two occurred with DES (Figure 2).

 Stent thrombosis-free survival at 3 years was 99.4% among patients treated with DES and 98.8% among patients treated with bare-metal stents.

The MAIN-COMPARE registry began in January 2000 and enrolled 775 patients with left main CAD who had been treated with bare-metal stents (n = 336) or CABG (n = 439). In phase II, which began in March 2003, treatment strategies shifted from bare-metal stents to DES; 805 patients were treated with DES and 731 patients were treated with CABG.

Further meta-analysis

Park presented a meta-analysis of 3,976 patients to determine overall safety and efficacy associated with left main intervention.

Bare-metal stents and DES were associated with a significant reduction in TVR at 3 years compared with CABG.
DES implantation alone also was associated with a significant reduction in TVR compared with CABG.

Treatment with DES was associated with a 57% reduction in adjusted mortality (P = .027) primarily driven by a 71% reduction in deaths from cardiovascular causes.

The adjusted mortality rate was similar between DES and bare-metal stents.

A EuroSCORE of at least 6 was an independent predictor of mortality (HR = 3.494; 95% CI, 1.489-8.197) among patients treated with bare-metal stents.

Among patients treated with DES, previous CHF (HR = 2.658; 95% CI, 1.032-6.847), chronic renal failure (HR = 4.865; 95% CI, 2.102-11.257), COPD (HR = 2.927; 95% CI, 1.004-8.534) and a EuroSCORE of at least 6 (HR = 3.243; 95% CI, 1.482-7.094) were all independent predictors of mortality.