No description available.

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13435号 / 論医博第2234号 / 新制||医||1054(附属図書館) / (主査)教授 石見 拓, 教授 佐藤 俊哉, 教授 湊谷 謙司 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13207号 / 論医博第2161号 / 新制||医||1031(附属図書館) / (主査)教授 福原 俊一, 教授 湊谷 謙司, 教授 小池 薫 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

No description available.

Purpose of Review: To review the clinical evidence on the use of percutaneous coronary intervention (PCI) revascularization options in left main (LM) disease in comparison with coronary artery bypass graft (CABG). Coronary artery disease (CAD) involving the LM is associated with high morbidity and mortality. Though CABG remains the gold standard for complex CAD involving the LM artery, recent trials have shown a trend towards non-inferiority of the LM PCI when compared with CABG in certain subset of patients. Recent Findings: Two recent major randomized trials compared the outcomes of PCI versus CABG in the LM and multi-vessel disease with LM involvement. The NOBLE trial included patients with all range of Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) scores and utilized biolimus drug-eluting stent (DES). The trial concluded that MACCE (major adverse cardiac and cerebrovascular event) was significantly higher with PCI (28%) when compared with CABG (18%) but overall stroke and motility were not different. EXCEL trial evaluated the same treatment option in low to intermediate SYNTAX score population with third-generation everolimus DES platform as PCI option. Results showed no significant differences in the composite primary endpoints of death, stroke, and myocardial infarction (MI) at the end of 30 days (22% versus 19.2%, p = 0.13), although repeat revascularization was higher in PCI group (16.9% versus 10%). Summary: Recent evidence suggests that PCI is an acceptable alternative to treat symptomatic LM stenosis in select group of patients. In low to medium SYNTAX score, particularly in patients without diabetes mellitus, PCI remains a viable option. Future trials focusing on evaluating subset of patients who would benefit from one particular revascularization option in comparison with other is warranted.

Introdução – Pouco se publicou na literatura médica a respeito de projeções angiográficas dedicadas às anatomias especiais. Neste cenário, propomos uma projeção angiográfica para a exposição da bifurcação do tronco da artéria coronária esquerda (TCE) quando o conjunto de projeções rotineiras previamente utilizadas foi ineficaz para exibir com clareza essa região. Pacientes e Métodos – 84 pacientes foram submetidos à projeção Lateral Direita (90-120°) associada a Cranial (30-40°). Estudo de reprodutibilidade, realizado com a participação de dois observadores independentes, julgou a eficácia da projeção proposta. O índice kappa, ajustado para a prevalência e viés (PABAK) com IC de 95%, foi utilizado para demonstrar a intensidade da concordância inter e intraobservador: ≤ 0,20 = ruim, 0,21 – 0,40 = fraca, 0,41 – 0,60 = moderada, 0,61 – 0,80 = substancial e 0,81 – 1,0 = quase perfeita. Resultados – A projeção proposta foi eficaz em 79% dos angiografias com concordância de 0,76 (0,6 – 0,9; P ≤ 0,001). A origem e o segmento proximal da artéria coronária descendente anterior foram expostos em 89% com concordância de 0,86 (0,7 – 1,0; P ≤ 0,001), a origem e o segmento proximal da artéria circunflexa foram expostos em 83% com concordância de 0,72 (0,5 – 1,0; p ≤ 0,001) e a origem e o segmento proximal do ramo intermediário, quando presente, foram expostos em 89% com concordância de 0,79 (0,6 – 1,0; p ≤ 0,001). Conclusão – A projeção proposta é eficaz, segura e reproduzível. Em situações especiais, onde projeções rotineiras falham, essa poderá exibir detalhes importantes da anatomia da bifurcação do TCE à cinecoronariografia ou ser a projeção de trabalho durante a intervenção coronariana percutânea. / Objectives – We propose a 90 – 120° right lateral with 30-40° cranial angiographic view to expose the bifurcation of the left main coronary artery (LMCA) when previously used routine projections were inefficient at clearly showing this region. Background – Little has been published in the medical literature regarding angiographic projections dedicated to special anatomies. Methods – A total of 84 patients were subjected to the proposed projections. A reproducibility study, conducted with the participation of two independent observers, judged the effectiveness of the proposed projection. The Prevalence and Bias Adjusted Kappa (PABAK) index, with a 95% confidence interval (CI), was used to demonstrate the intensity of intra- and inter-observer agreement: ≤ 0.20 = poor, 0.21 – 0.40 = slight, 0.41 – 0.60 = moderate, 0.61 – 0.80 = substantial and 0.81 – 1.0 = almost perfect. Results – The proposed projection was efficient in 79% of the angiograms, with agreement of 0.76 (0.6 – 0.9; P ≤ 0.001). The origin and the proximal segment of the anterior descending coronary artery were exposed in 89% of the angiograms, with agreement of 0.86 (0.7 – 1.0; P ≤ 0.001); the origin and the proximal segment of the circumflex artery were exposed in 83% of the angiograms, with agreement of 0.72 (0.5 – 1.0; P ≤ 0.001); and the origin and the proximal segment of the intermediate branch, when present, were exposed in 89% of the angiograms, with agreement of 0.79 (0.6 – 1.0; P ≤ 0.001). Conclusion – The proposed projection is effective, safe and reproducible. In special situations where routine projections fail, this proposed projection can reveal important details of the anatomy of the bifurcation of the LMCA during conventional / Tese (Doutorado)