张宇超,吴铮,高海,柳景华

• 1:首都医科大学附属北京安贞医院冠心病中心北京市心肺血管疾病研究所

摘要(Abstract)：

目的 探讨冠状动脉慢性完全闭塞（CTO）病变合并左心室收缩功能不全（LVSD）患者接受CTO病变血运重建和最佳药物治疗（OMT）的临床获益，并开发有效的预后工具。方法 本研究连续纳入了2014年1月至2020年12月因CTO病变合并LVSD而住院的患者。根据患者是否接受了成功的CTO病变血运重建及OMT进行两两组合，并比较各组随访期间全因死亡率以及主要不良心脑血管事件（MACCE）的发生风险。采用随机森林、最小绝对收缩和选择算子（LASSO）回归及Cox回归模型构建列线图，以预测患者的远期生存率。结果 本研究共纳入987例患者，其中（CTO血运重建+OMT）组229例（23.20%）、（CTO血运重建+非OMT）组270例（27.36%）、（OMT+非CTO血运重建）组250例（25.33%）、（非OMT+非CTO血运重建）组238例（24.11%）。中位随访64个月，（CTO血运重建+OMT）组患者被观察到全因死亡、MACCE、心血管死亡、心肌梗死、因心力衰竭住院发生率最低。经协变量调整后，（CTO血运重建+OMT）组相比于（非OMT+非CTO血运重建）组与显著更低的全因死亡（AHR 0.60,95%CI 0.39～0.92,P=0.019）、MACCE(AHR 0.56,95%CI 0.41～0.76,P<0.001)、心血管死亡（AHR 0.40,95%CI 0.23～0.72,P=0.002）和因心力衰竭住院（AHR 0.53,95%CI 0.31～0.89,P=0.016）风险相关。基于随机森林、LASSO和Cox回归模型的结果构建了用于预测患者1年、3年和5年生存率的列线图，其C指数分别为0.682、0.731和0.721。对该模型进行了内部验证，校准图显示模型预测的概率与实际发生率之间存在较高的一致性。结论 本研究证实了CTO病变血运重建联合OMT对CTO病变合并LVSD患者的临床获益。本研究提供的列线图可作为预测患者远期生存率的初步工具，有望为临床策略的制订和长期疾病管理提供一定参考。

关键词(KeyWords)： 慢性完全闭塞;冠状动脉血运重建;左心室收缩功能不全;诺曼图;最佳药物治疗

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 张宇超,吴铮,高海,柳景华

参考文献(References)：

• [1] Felker GM,Shaw LK,O'Connor CM.A standardized definition of ischemic cardiomyopathy for use in clinical research[J].J Am Coll Cardiol,2002,39(2):210-218.DOI:10.1016/s0735-1097(01)01738-7.
• [2]Ahmad Y,Petrie MC,Jolicoeur EM,et al.PCI in patientswith heart failure:current evidence,impact of complete revascularization,and contemporary techniques to improve outcomes[J].J Soc Cardiovasc Angiogr Interv,2022,1(2):100020.DOI:10.1016/j.jscai.2022.100020.
• [3] Pastena P,Frye JT,Ho C,et al.Ischemic cardiomyopathy:epidemiology,pathophysiology,outcomes,and therapeutic options[J].Heart Fail Rev,2024,29(1):287-299.DOI:10.1007/s10741-023-10377-4.
• [4]Farsky PS,White J,Al-Khalidi HR,et al.Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy[J].J Thorac Cardiovasc Surg,2022,164(6):1890-1899.e1894.DOI:10.1016/j.jtcvs.2020.12.094.
• [5]Velazquez EJ,Lee KL,Jones RH,et al.Coronary-artery bypass surgery in patients with ischemic cardiomyopathy[J].N Engl J Med,2016,374(16):1511-1520.DOI:10.1056/NEJMoa1602001.
• [6] Perera D,Clayton T,O'Kane PD,et al.Percutaneous revascularization for ischemic left ventricular dy sfunction[J].N Engl J Med,2022,387(15):1351-1360.DOI:10.1056/NEJMoa2206606.
• [7]Ybarra LF,Rinfret S.Why and how should we treat chronic total occlusion?evolution of state-of-the-art methods and future directions[J].Can J Cardiol,2022,38(10 Suppl1):S42-S53.DOI:10.1016/j.cjca.2020.10.005.
• [8]Wu X,Cai J,Zhang Q,et al.Assessing the clinical influence of chronic total occlusions(CTOs)revascularization and the impact of vascularization completeness on patients with left ventricular(LV)systolic dysfunction[J].Comput Intell Neurosci,2022,2022:9128206.DOI:10.1155/2022/9128206.
• [9]Iannaccone M,Nombela-Franco L,Gallone G,et al.Impact of successful chronic coronary total occlusion recanalization on recurrence of ventricular arrhythmias in implantable cardioverter-defibrillator recipients for ischemic cardiomyopathy(VACTO PCI Study)[J].Cardiovasc Revasc Med,2022,43:104-111.DOI:10.1016/j.carrev.2022.03.029.
• [10]van Veelen A,Elias J,van Dongen IM,et al.Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions:a systematic review and meta-analysis of randomised trials[J].Neth Heart J,2020,29(1):30-41.DOI:10.1007/s12471-020-01503-0.
• [11]Kook H,Yang JH,Cho JY,et al.Differential clinical impact of chronic total occlusion revascularization based on left ventricular systolic function[J].Clin Res Cardiol,2020,110(2):237-248.DOI:10.1007/s00392-020-01738-2.
• [12] Toma A,St??hli BE,Gick M,et al.Comparison of benefit of successful percutaneous coronary intervention for chronic total occlusion in patients with versus without reduced(≤40%)left ventricular ejection fraction[J].Am J Cardiol,2017,120(10):1780-1786.DOI:10.1016/j.amjcard.2017.07.088.
• [13] Albaeni A,Chatila KF,Thakker RA,et al.In-hospital outcomes of chronic total occlusion percutaneous coronary interventions in heart failure patients[J].Curr Probl Cardiol,2023,48(2):101458.DOI:10.1016/j.cpcardiol.2022.10145 8.
• [14]Simsek B,Kostantinis S,Karacsonyi J,et al.Outcomes of chronic total occlusion percutaneous coronary intervention in patients with reduced left ventricular ejection fraction[J].Catheter Cardiovasc Interv,2022,99(4):1059-1064.DOI:10.1002/ccd.30097.
• [15]张宇超,吴铮,王韶屏,等.优化左心室收缩功能不全合并冠状动脉慢性完全闭塞患者介入治疗结局的研究进展[J].中国介入心脏病学杂志,2024,32(7):396-404.DOI:10.3969/j.issn.1004-8812.2024.07.005.
• [16]Strauss BH,Knudtson ML,Cheema AN,et al.Canadian multicenter chronic total occlusion registry:ten-year follow-up results of chronic total occlusion revascularization[J].Circ Cardiovasc Interv,2021,14(12):e010546.DOI:10.1161/CIRCINTERVENTIONS.121.010546.
• [17] Ybarra LF,Rinfret S,Brilakis ES,et al.Definitions and clinical trial design principles for coronary artery chronic total occlusion therapies:CTO-ARC consensus recommendations[J].Circulation,2021,143(5):479-500.DOI:10.1161/CIRCULATIONAHA.120.046754.
• [18]Heidenreich PA,Bozkurt B,Aguilar D,et al.2022 AHA/ACC/HFSA guideline for the management of heart failure:a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J].Circulation,2022,145(18):e895-e1032.DOI:10.1161/CIR.0000000000001063.
• [19]Lansky AJ,MesséSR,Brickman AM,et al.Proposed standardized neurological endpoints for cardiovascular clinical trials:an Academic Research Consortium Initiative[J].Eur Heart J,2018,39(19):1687-1697.DOI:10.1093/eurheartj/ehx037.
• [20]Thygesen K,Alpert JS,Jaffe AS,et al.Fourth universal definition of myocardial infarction(2018)[J].Circulation,2018,138(20):e618-e651.DOI:10.1161/cir.0000000000000617.
• [21] Garcia-Garcia HM,McFadden EP,Farb A,et al.Standardized end point definitions for coronary intervention trials:the academic research consortium-2 consensus document[J].Eur Heart J,2018,39(23):2192-2207.DOI:10.1093/eurheartj/ehy223.
• [22]Gold DA,Sandesara PB,Jain V,et al.Long-term outcomes in patients with chronic total occlusion[J].Am J Cardiol,2024,214:59-65.DOI:10.1016/j.amjcard.2023.12.052.
• [23] Guo L,Meng S,Lv H,et al.Long-term outcomes of successful recanalization compared with optimal medical therapy for coronary chronic total occlusions in patients with and without left ventricular systolic dysfunction[J].Front Cardiovasc Med,2021,8:654730.DOI:10.3389/fcvm.2021.654730.
• [24]Cabac-Pogorevici I,Muk B,Rustamova Y,et al.Ischaemic cardiomyopathy.Pathophysiological insights,diagnostic management and the roles of revascularisation and device treatment.Gaps and dilemmas in the era of advanced technology[J].Eur J Heart Fail,2020,22(5):789-799.DOI:10.1002/ejhf.1747.
• [25]Brophy TJ,Warsavage TJ,Hebbe AL,et al.Percutaneous coronary intervention in patients with stable coronary artery disease and left ventricular systolic dysfunction:insights from the VA CART program[J].Am Heart J,2021,235:149-157.DOI:10.1016/j.ahj.2021.02.002.
• [26]DeVore AD,Yow E,Krucoff MW,et al.Percutaneous coronary intervention outcomes in patients with stable coronary disease and left ventricular systolic dysfunction[J].ESC Heart Fail,2019,6(6):1233-1242.DOI:10.1002/ehf2.12510.
• [27]Velagaleti RS,Vetter J,Parker R,et al.Change in left ventricular ej ection fraction with coronary artery revascularizationand subsequent risk for adverse cardiovascular outcomes[J].Circ Cardiovasc Interv,2022,15(4):e011284.DOI:10.1161/CIRCIN TERVENTIONS.121.011284.
• [28] Moroni F,Gertz Z,Azzalini L.Relief of ischemia in ischemic cardiomyopathy[J].Curr Cardiol Rep,2021,23(7):80.DOI:10.1007/s11886-021-01520-4.
• [29]Greene SJ,Butler J,Albert NM,et al.Medical therapy for heart failure with reduced ejection fraction:the CHAMP-HF registry[J].J Am Coll Cardiol,2018,72(4):351-366.DOI:10.1016/j.jacc.2018.04.070.
• [30] Serruys PW,Ono M,Garg S,et al.Percutaneous coronary revascularization:JACC historical breakthroughs in perspective[J].J Am Coll Cardiol,2021,78(4):384-407.DOI:10.1016/j.jacc.2021.05.024.
• [31] Ito H,Masuda J,Kurita T,et al.Effect of left ventricular ejection fraction on the prognostic impact of chronic total occlusion in a non-infarct-related artery in patients with acute myocardial infarction[J].Int J Cardiol Heart Vasc,2021,33:100738.DOI:10.1016/j.ij cha.2021.100738.
• [32]王凯阳,宁怡,闵轩,等.冠状动脉慢性完全闭塞病变不同治疗方式疗效评价的网状Meta分析[J].中国介入心脏病学杂志,2023,31(1):51-62.DOI:10.3969/j.issn.1004-8812.2023.01.009.
• [33] Cardona M,Martín V,Prat-Gonzalez S,et al.Benefits of chronic total coronary occlusion percutaneous intervention in patients with heart failure and reduced ejection fraction:insights from a cardiovascular magnetic resonance study[J].J Cardiovasc Magn Reson,2016,18(1):78.DOI:10.1186/s12968-016-0287-5.
• [34] Galassi AR,Boukhris M,Toma A,et al.Percutaneous coronary intervention of chronic total occlusions in patients with low left ventricular ejection fraction[J].JACC Cardiovasc Interv,2017,10(21):2158-2170.DOI:10.1016/j.jcin.2017.06.058.
• [35]Roth C,Goliasch G,Aschauer S,et al.Impact of treatment strategies on long-term outcome of CTO patients[J].Eur J Intern Med,2020,77:97-104.DOI:10.1016/j.ejim.2020.03.008.
• [36]Sachdeva R,Agrawal M,Flynn SE,et al.The myocardium supplied by a chronic total occlusion is a persistently ischemic zone[J].Catheter Cardiovasc Interv,2014,83(1):9-16.DOI:10.1002/ccd.25001.
• [37]Ryan M,Morgan H,Petrie MC,et al.Coronary revascularisation in patients with ischaemic cardiomyopathy[J].Heart,2021,107(8):612-618.DOI:10.1136/heartjnl-2020-316856.
• [38]Glikson M,Nielsen JC,Kronborg MB,et al.2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy[J].Eur Heart J,2021,42(35):3427-3520.DOI:10.1093/eurheartj/ehab 364.
• [39]Acerbo V,Cesaro A,Scherillo G,et al.Understanding the role of coronary artery revascularization in patients with left ventricular dysfunction and multivessel disease[J].Heart Fail Rev,2023,28(6):1325-1334.DOI:10.1007/s10741-023-10335-0.
• [40]Ishida K,Martin-Yuste V,Prat S,et al.Prognosis of patients with reduced left ventricular ejection fraction and chronic total occlusion according to treatment applied[J].Cardiovasc Revasc Med,2021,27:22-27.DOI:10.1016/j.carrev.2020.06.006.