Theodore A. Bass教授是佛罗里达大学心血管病学系主任，内科学教授，杰克逊维尔UF-Shands心血管病中心负责人。

International Circulation: Would you like to briefly introduce the new advance in the PCI of left main coronary artery?

《国际循环》：请您简单介绍一下左主干病变经皮冠状动脉介入治疗（PCI）治疗的最新进展。

Prof. Theodore A. Bass: I think it’s a procedure which is still evolving. We are not quite where need to be yet， but we have made great progress. Eventually， most patients， in my opinion， with significant Left Main Coronary stenosis， will be treated with catheter based percutaneous intervention rather than bypass surgery. However， we are not quite there yet. We have learned from recent randomized clinical trials， that left main coronary disease often is accompanied by other vascular disease involving many areas of the coronary anatomy. This is another challenge which we must learn to address successfully enabling us to treat these groups of patients who are often quite complex. Technical challenges exist which will require better stent designs permitting us to successfully treat complex bifurcation lesions which comprise a majority of left main coronary stenosis. The last several years have been very encouraging as both stent technology and our operating skills and experiences have advanced markedly. We’ve come a long way; I think it is currently a relatively safe procedure. The three-year patient clinical outcomes are very encouraging. we’ve now been able to identify a subgroup of patients who have left main disease， who will be very comfortably treated with stents. For example this initial group would include patients who have lesions not involving the distal bifurcation and patients who are clinically stable. There is currently a great deal of data showing that these patients can be treated with left main coronary stenting.

Bass教授：我认为介入技术仍在发展，虽然尚未达到理想水平，但我们已经有了很大的进展。我认为，左主干严重狭窄的大部分患者最终都要进行经皮介入治疗，而不是冠状动脉旁路移植术，但也尚未完全确定。原因在于我们在最近的随机临床试验中发现，冠状动脉左主干病变通常合并有其他血管病变，这就带来另外一个挑战，我们必须学会如何成功处理这些非常复杂的病变。技术上的挑战在于这要求更好的支架设计，以使我们能够成功治疗包括左主干狭窄的复杂的血管分叉病变。过去的几年让人倍受鼓舞，支架技术和我们的手术技巧和经验都有着令人瞩目的重大进步。我们在这方面已经有了很大发展，我认为这一技术是比较安全的。三年临床结果令人满意。而且我们现在也能够把左主干病变患者进行分组，鉴别出最适合支架治疗的患者。例如，病变未累计远端分叉或者临床情况稳定的患者。大量资料显示这些患者适合接受左主干支架治疗。

International Circulation: How do we select coronary artery stent， bare metal stents (BMS) or drug-eluting stents (DES)? What factors should we consider when we make this decision?

《国际循环》：如何选择冠脉内支架，金属裸支架（BMS）还是药物洗脱支架（DES）？在选择时应考虑哪些问题？

Prof. Theodore A. Bass: This is a complicated question. There are advantages and potential limitations when choosing either stent types. Both stent types have improved in design， through recent years. The new generation of DES are clearly more user friendly than in the initial DES stents. At the same time， the BMS are getting very thin， and they’re very deliverable， they provide economic advantages and long term outcomes with these stents might be better than we expect. I think we’re just working out in which patient we need to invest the additional expense of DES deployment including not only the stent cost but also very importantly the additional pharmacological support required when we use drug-eluting stents. Is the patient diabetic? What is the size of the blood vessel? What is the nature of the lesion we are treating? All these questions come into play when we make a decision whether or not to use a bare metal stent or drug-eluting stent. So there is no simple answer. I can tell you in the United States， the use of drug eluting stent， now it’s about 60% of all stents use across the board. It’s a little lower than it used to be， but it’s higher than it was just a couple of weeks ago. We are coming back to it more and more.

Bass教授：这是一个非常复杂的问题。无论选择哪种支架都有优势和潜在的缺陷。近年来，这两种支架在设计方面都有改进。新一代DES较原先的DES支架更加适于应用。同时，BMS也越来越薄，易于投放，其长期效果可能比我们预想的要好。所以我们只需要找出哪些患者需要这笔额外的开销，不只是支架花费，还有用DES必需的药物支持的费用。患者是否有糖尿病，其血管管径大小和病变性质如何，都是在决定应用BMS还是DES时要考虑的问题。所以这一问题没有简单的答案。我能告诉你的是，在美国大概有60%的支架是DES，比过去略有所减少，但这一比例比几周前要高，DES的应用正在逐渐增加。

International Circulation:  How to run the anticoagulation management during the periprocedure of PCI? 

《国际循环》：如何进行PCI围手术期的抗凝治疗？

Prof. Theodore A. Bass: The antithrombotic management of patients receiving left main coronary stents needs to be further clarified.  It most likely will require individual customization depending on each patient’s characteristics. Our great fear in this setting is stent thrombosis which will often be fatal in this group of patients. Stent thrombosis might be due to inadequate or a suboptimal stent deployment predisposing the stent and the vessel to thrombosis. Or perhaps certain patient have platelets which are very active and initiate the coagulation process more easily.  For example， this would be true for patients presenting with an acute heart attack， or patients who are diabetic. These patients may require more intensive antiplatelet therapy than for example more stable patients. We have made great progress understanding which drugs to use to most effectively inhibit platelet activity. We have many new agents， which are currently under investigation. So I think this is a field where we are making great and we are very close to addressing most of these major issues.

Bass教授：接受左主干病变支架治疗的患者其抗凝治疗尚有待进一步明确。这更可能需要根据患者的具体情况给予个体化治疗。在这种情况下，我们最怕的是支架置入后血栓形成，对这类患者来说这常常是致命的。支架血栓形成可能是因为支架展开不充分或者位置不理想导致支架和血管易形成血栓，也有可能是部分患者的血小板活性很强，支架置入激活了其凝血过程，如急性心脏病发作的患者或者糖尿病患者。这部分患者可能较病情更稳定的患者需要更加积极的抗血小板治疗。在哪种药物能更有效地抑制血小板活性方面，我们已经有了很大进展。我们也有很多目前正在研究阶段的新药。所以，我认为，这是我们已经取得重大进展的领域，大部分主要问题有望尽快得以解决。