冠心病搭桥术与介入手术的现况比较
 

何国伟

南开大学  医学院 外科学教授
泰达国际心血管病医院   心血管外科 主任医师
香港中文大学         荣誉研究讲座教授
美国俄勒冈医科大学 临床外科学教授

在经皮冠状动脉介入术（PCI）时代，CABG治疗冠心病的实践已经改变。PCI侵入性小，具有良好的早期治疗效果，尤其是药物洗脱支架（DES）的使用，使CABG的手术指证受到很大的影响。但是，与CABG相比，PCI的长期治疗效果，尤其在治疗多支血管病变方面的效果，仍是临床重要问题。本文将对这一重要领域的现状进行介绍。

通过PubMed（美国国家医学图书馆）以及CTSNET（美国胸心外科学网）文献检索，使用关键词 “CABG vs PCI”，PubMed检索出149篇相关文献，而CTSNET检索出266篇。使用关键词 “CABG vs PCI and Drug eluting stenting”，检索出两篇文献。本文选择文献的标准为：1. 高质量的杂志（高影响因子）如N Engl J Med, JAMA,；2. 排除外科杂志； 只选择心内科杂志，如 Circulation, J Am Coll Cardiol, Am Coll Cardiol; 3. 与CABG和PCI 严格相关。

本题目的复杂性将从以下几个方面进行的讨论： 1. 不同医院对使用PCI和CABG的原则； 2. 在专科以及综合医院中再血管化的方法； 3.  作PCI的中心是否具有冠脉搭桥术的条件； 4. CABG中使用的生物移植物以及PCI中使用的非生物材料； 5. CAGB技术方法的不同。

通过这些方面的研究，我们将从以下几点进行总结、评论：

1. 随机分配到PCI组和CABG组的药物治疗无效的顽固性心肌缺血的高危病人，6个月的健康状况相当 [Rumsfeld et al 2003; Baim et al 2004];

2. 经PCI治疗的病人产生不稳定性心绞痛， 再次再血管化， 心血管原因再入院的几率较高 [Fraund et al 2005; Szygula-Jurkiewicz et al 2005];

3. 对多系统疾病病人，初次手术一年后，多支架PCI手术和CABG术对免除死亡，心肌梗塞，或中风可提供类似的保护。PCI术后，再次再血管化率高于CABG，但其差异在支架时代有所缩小[Mercado et al, 2005]。

4. 通过病变血管支数分层分析，2支血管病变的冠心病病人，经外科搭桥术及PCI术后的生存率相当，但对三支血管病变的冠心病病人，搭桥术要比PCI术后生存率高[Malenka et al, 2005];

5. 通过5年的随访发现，ERACI II研究中，再血管化的方法并未影响病人的生存率，但接受搭桥手术的病人免除再次再血管化以及重要的心脏并发事件（main cardiac events）的免除率较高 [Rodriguez et al, 2005]。

6. 一项Cleveland Clinic [Burton et al, 2004] 的研究表明，外科手术能够提高多支血管病变的冠心病及多种高危险因素的病人的生存率；5年以后血管成形术/支架术病人的可能死亡率是经外科手术治疗病人的2.3倍。

7. 类似的是，一项纽约州的50，000例以上的病例研究表明， 对多支血管病变的病人，药物洗脱支架相对于搭桥术在一年时观察到的优点在术后三年时并不明显 [Rodriguez et al, 2007]。

8. 药物洗脱支架对(DIS)对非LAD病变的治疗效果与搭桥术相当；药物洗脱支架优于裸支架, 但并非优于搭桥术; 药物洗脱支架的再狭窄发生率为10~28%;  [Serruys et al, 2005].

9.对比较不同类型危险因素的病人采用药物洗脱支架或塔桥术的长期疗效，需要作进一步研究 [Hannan et al, 2005]。

10. NEJM 最近的研究 [Hannan et al, 2008]表明，药物洗脱支架的18个月死亡率高于搭桥术,并表现在各个分组中；药物洗脱支架的18个月心肌梗塞发生率高于搭桥术 （1：0.67~0.77）；药物洗脱支架的18个月再次手术率远远高于搭桥术 （28%  vs.  5%）。 对多支血管病变的病人，搭桥术的死亡率，心肌梗塞发生率以及再次再血管化的发生率均比药物洗脱支架更低。

11. 最后，对在药物洗脱支架时代，PCI + CABG的联合方法作了讨论并推荐 [Lee et al, 2005; van Domburg RT et al 2005]。

结论

总之，搭桥术和PCI介入术各有优缺点。心内、心外科医生应通力合作，携手努力，根据病人的实际情况和自己的经验，共同为病人制定一项最佳的治疗方案，而介入和搭桥的联合方法更为这一合作提出了新的可能的方向。

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