JACC:冠状动脉无保护左主干病变中支架与搭桥手术结果相近

2015-05-30 MedSci MedSci原创

    背景  在以前的随机试验中,研究人员发现,在1年时经皮冠状动脉介入治疗(PCI)不劣于冠状动脉旁路移植术(CABG)对无保护左主干冠状动脉狭窄的治疗。    意义  本研究旨在确定对于治疗无保护左主干冠状动脉狭窄,PCI与CABG的5年治疗结果的比较。    方法  研究人员随机分配600例冠状动脉无

背景  
在以前的随机试验中,研究人员发现,在1年时经皮冠状动脉介入治疗(PCI)不劣于冠状动脉旁路移植术(CABG)对冠状动脉无保护左主干病变的治疗。

意义  
本研究旨在确定对于治疗冠状动脉无保护左主干病变,PCI与CABG的5年治疗结果的比较。

方法  
研究人员随机分配600例冠状动脉无保护左主干病变患者接受西罗莫司洗脱支架的PCI(n =300)或CABG(n=300)。主要终点为主要不良心脑血管事件(MACCE:一个由任何原因引起的死亡,心肌梗死,中风,或复合,缺血驱动的靶血管血运重建)并意向性治疗的基础上进行比较。

结果  
在5年时,在PCI组52例发生MACCE事件,CABG组发生42例(累积发生率分比为17.5%和14.3%;风险比[HR]:1.27;95%可信区间[Cl]:0.84-1.90;P=0.26)。对于任何原因导致的死亡,心肌梗死或中风,以及它们的复合事件在2组间无显著差异(8.4%和9.6%;HR,0.89;95% Cl,0.52-1.52;P=0.66)。PCI组的缺血驱动的靶血管血运重建更频繁地发生,高于CABG组(分别为11.4%和5.5%;HR:2.11;95%Cl:1.16-3.84;P=0.012)。

结论  
在5年的随访过程中,对于接受受西罗莫司洗脱支架的PCI患者和接受CABG的患者的MACCE发生率,该研究没有显示出明显差异。然而,考虑到研究力量有限,该研究结果应谨慎解释。

Jung-Min Ahn, MD∗; Jae-Hyung Roh, MD∗; Young-Hak Kim, MD∗; Duk-Woo Park, MD∗; Sung-Cheol Yun, PhD†; Pil Hyung Lee, MD∗; Mineok Chang, MD∗; Hyun Woo Park, MD∗; Seung-Whan Lee, MD∗; Cheol Whan Lee, MD∗; Seong-Wook Park, MD∗; Suk Jung Choo, MD∗; CheolHyun Chung, MD∗; JaeWon Lee, MD∗; Do-Sun Lim, MD‡; Seung-Woon Rha, MD§; Sang-Gon Lee, MD‖; Hyeon-Cheol Gwon, MD¶; Hyo-Soo Kim, MD#; In-Ho Chae, MD∗∗; Yangsoo Jang, MD††; Myung-Ho Jeong, MD‡‡; Seung-Jea Tahk, MD§§; Ki Bae Seung, MD‖‖; Seung-Jung Park, MD∗,Randomized Trial of Stents Versus Bypass Surgery for Left Main Coronary Artery Disease,JACC,2015.5.16

小知识:无保护左主干病变

无保护左主干病变(unprotected left main disease):指冠状动脉造影左主干狭窄程度大于或者等于50%的病变,同时不存在通畅的血管桥或自身右向左良好侧枝循环。
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有关冠状动脉无保护左主干病变

左主干为左冠状动脉起始部位的主干血管,发自升主动脉根部的左冠状窦,走行于肺动脉和左心房之间,部分被左心耳覆盖,短暂向左前方向移行后发出分支。2/3病人左主干远端分出左前降支和回旋支两个分支血管,1/3病人左主干分出三分叉,发出前降之、回旋支和中间动脉。正常的左主干开口直径5-10mm,长度小于4cm,冠状动脉造影受投照体位和角度的影响,显示左主干平均直径女性3.5mm,男性4.5mm,平均长度13.5mm。冠状动脉左主干直径狭窄≥50%诊断为左主干病变。左主干病变会造成严重的心肌缺血,因而病情非常危重,是猝死的重要原因。在金属裸支架时代,左主干病变是介入支架治疗的禁区。随着介入水平的提高以及介入器械的发展,尤其药物洗脱支架的出现,禁区被打破。大量新的临床证据改写了以往指南中冠脉搭桥手术作为治疗首选的推荐。SYNTAX研究中,左主干的亚组分析显示,介入治疗1年结果与传统外科搭桥相似,甚至有优于外科搭桥的趋势。尤其是简单左主干病变,介入支架治疗和外科搭桥相比心脏事件发生率有更低的趋势。自药物洗脱支架问世以来,多项研究评价了两者的总体疗效,在部分无保护左主干病变患者,药物支架与外科搭桥的结果已经基本相当,最近公布的MAIN-COMPARE注册结果显示,尽管外科搭桥的3年无靶病变血管重建生存率更高,但两者累计生存率及符合终点事件发生率无显著差异。因此,在低、中危的无保护左主干病变患者,药物支架和外科搭桥长期生存率基本相当,介入治疗是其理想的治疗选择,而在高危左主干患者,由于外科搭桥长期生存率更高,应尽量选择外科搭桥。

1 对UPLM狭窄病变CABG与PCI比较的循证医学证据

在裸金属支架年代,根据ARTS、ERACI-Ⅱ、MASS-Ⅱ和SOS四个临床试验CABG与裸金属支架(BMS)置入术治疗多支病变5年随访结果在病人水平的汇萃分析,BMS与CABG比较死亡率和复合安全性终点(死亡、卒中、心肌梗死)相似,BMS患者主要由于再次血管重建术增加导致5年心脑血管不良事件(MACCE)增加(Circulation 2008, 118: 1146-1154)。
最近发表的3773例UPLM狭窄病变支架置入与CABG比较的汇萃分析(J Am Coll Cardiol Intv. 2009, 2:739-747) ,包括了二个随机对照研究SYNTAX和LE MENS和包括MAIN-COMPARE在内的8个注册研究,DES的使用率从35﹪~100﹪,随访时间2~8年,结果显示支架置入与CABG比较直至3年病死率无显著差异(OR 1.11,95﹪CI 0.66~1.86),复合安全性终点(死亡、心肌梗死、卒中)无显著差别(OR,1.16,95﹪CI 0.68~1.98),支架置入组只是再次靶血管重建(TVR)明显增加(OR 3.30,95﹪CI 0.96~11.33)。

但是对TVR发生率的解释需要注意,许多CABG术后的患者未进行再次TVR,尤其左内乳动脉(LIMA)旁络血管通畅时,并不是由于病人不能从再次手术获益,而是由于手术风险太大或手术成功可能性低;事实上,CABG数年后自身血管和大隐静脉旁路血管都可退化至完全闭塞或弥漫性狭窄而难以再次CABG或PCI;据统计,在术后12~18个月30﹪的大隐静脉旁路移植血管(SVG)狭窄或闭塞,5年后50﹪SVG狭窄或闭塞。而在临床试验中观察到的PCI后再次TVR相对升高,至少有部分原因是由于PCI后仍然是进一步血管重建的良好指证。

SYNTAX研究,对1800例左主干和3支血管病变患者CABG与应用TAXUS支架的PCI进行了随机对照研究,其中2/3为3支病变,1/3为左主干病变,1年随访时全因死亡在支架置入和CABG组间无显著差异(4.3﹪ vs 3.5﹪,p=0.37),脑卒中CABG组明显高于支架置入组(2.2﹪ vs 0.6﹪,p=0.003),心肌梗死在支架置入与CABG组间无显著差异(4.8﹪ vs 3.2﹪,p=0.11),复合安全性终点(死亡、卒中、心肌梗死)无显著差异(7.6﹪ vs 7.7﹪,p=0.98),但再次血管重建支架置入组明显高于CABG组(13.7﹪ vs 5.9﹪,p=0.001),致使主要终点MACCE发生率支架置入组明显高于CABG(17.8﹪ vs 12.1﹪,p=0.002),未达到试验设计的非劣效比较的标准。该研究根据冠状动脉病变复杂性提出了SYNTAX积分,病变复杂程度轻者积分≤22,中度复杂者积分23~32,病变严重复杂者积分≥33。分析表明,在CABG患者SYNTAX积分对12个月MACCE无显著影响,而支架置入患者则SYNTAX积分≥33者其MACCE发生率明显高于轻(≤22)、中度(23~32)复杂病变者。左主干病变亚组分析显示,全因死亡在支架置入与CABG两组间无显著差别(4.4﹪ vs 4.2﹪,p=0.88),脑卒中CABG组明显高于支架置入组(2.7﹪ vs 0.3﹪,p=0.009),心肌梗死发生率两组无显著差别(4.3﹪ vs 4.1﹪,p=0.97),但再次血管重建术在支架置入组明显高于CABG组(12.0﹪ vs 6.7﹪,p=0.02)。左主干亚组2年随机结果分析显示,MACCE及死亡、脑卒中和心肌梗死复合终点在支架置入与CABG两组间均无显著差别(分别为22.9﹪ vs 19.3﹪,p=0.27,和10.2﹪ vs 11.8﹪,p=0.48),再次血管重建支架置入组明显高于CABG组(17.3﹪ vs 10.4﹪,p=0.01)。按病变复杂程度(SYNTAX积分)分,MACCE在低积分(0~22)组(15.5﹪ vs 18.8﹪,p=0.45)和中等积分(23~32)组(22.4﹪ vs 22.4﹪,p=0.91)支架置入与CABG之间无显著差别;但在高积分(≥33)组则支架置入显著高于CABG(29.7﹪ vs 17.8﹪,p=0.02),病死率在支架置入组也显著高于CABG组(10.4﹪ vs 4.1﹪,p=0.04)。虽然左主干亚组分析的结果只能提出假设,但至少可以看出,对UPLM病变PCI的结果与病变复杂程度有明显相关,对轻、中度复杂程度(SYNTAX积分﹤32)者至少2年内支架置入可达到与CABG类似的结果,但对严重复杂病变(SYNTAX积分≥33)者,CABG的效果明显优于支架置入。
除病变复杂程度以外,以前的研究还表明,年龄、左室EF及肾功能等也是决定UPLM狭窄患者预后的重要因素。
根据当前的循证医学证据,支架置入术仅在部分患者可作为CABG的替代治疗,因此,必须严格选择适应证。

2 对UPLM狭窄病变如何制定临床决策

将循证医学的证据适当地应用于具体病人,为病人制定最适宜的治疗策略,才是循证医学的精髓。

对UPLM狭窄患者究竟应该选择CABG还是支架置入应该考虑下述诸因素:
2.1 病变复杂程度(SYNTAX积分的高低)
SYNTAX积分属低、中度者(<32分),可考虑支架置入,≥33分者应首选CABG。
2.2 对UPLM狭窄病变合并多支病变者是否能达到完全性血管重建
对冠状动脉右优势型患者,如果完全闭塞的右冠状动脉有重要功能意义(非梗死相关动脉)而PCI不能再通者,应选择CABG;对左优势型冠状动脉的UPLM狭窄病变支架置入也需十分慎重。
2.3 左主干病变是否有严重钙化
有严重钙化者多考虑CABG。
2.4 患者是否为需要胰岛素治疗的糖尿病伴UPLM合并3支病变
若是,应多考虑CABG。
2.5 患者左心功能如何
左室EF降低对CABG及PCI均是高危因素,但EF降低合并多支病变者应首先改虑CABG。若考虑支架置入应预先置入主动脉内球囊反搏(IABP)予以保护。
2.6 患者是否可耐受至少1年的双重抗血小板治疗
术前必须认真评价患者是否能耐受长期的双重抗血小板治疗,若患者有出血倾向、消化性溃疡、消化道出血史,或抗血小板药过敏、不能耐受等情况,则是支架置入的禁忌,应选择CABG。
2.7 患者是否有合并疾患而不适宜CABG
如患者有慢性阻塞性肺疾病(COPD)等禁忌手术的合并疾患,对病变适宜者可行支架置入。
2.8 术者的技术水平
一些研究表明,术者的经验及技术水平与患者预后相关,UPLM狭窄的PCI治疗应在治疗病例较多的中心由有经验的术者进行。
2.9 在合理的情况下尊重患者意愿和选择

3 CABG或支架置入适应证选择的考虑

3.1 孤立的UPLM开口部或体部狭窄是支架置入适应证,这些病变支架置入方法简单,血管腔大,支架内血栓并发症少,远期再狭窄少,选择支架置入是合理的。
3.2 比较简单的UPLM分叉部狭窄,SYNTAX积分为低或中度<32分)者,可考虑支架置入。
3.3 复杂的UPLM分叉部狭窄合并复杂多支病变,SYNTAX积分≥33分者应考虑CABG。
3.4 UPLM狭窄合并多支病变,对重要血管不能达到完全性血管重建者,如合并有重要功能意义的右冠状动脉(右优势的非梗死相关动脉)的慢性完全闭塞(CTO),PCI不能再通者,则不应进行   UPLM狭窄的PCI治疗,而应CABG。
3.5 左室EF显著降低合并多支病变者,应首选CABG。
3.6 选择适应征时应遵循的基本原则
若患者有CABG高风险倾向于支架置入治疗;若病变复杂程度高,如弥漫狭窄、严重钙化等PCI难以达到理想效果或预计不能耐受长期双重抗血小板治疗时,应选择CABG。

4 UPLM狭窄支架置入术的技术要求
对UPLM 狭窄病变行支架置入术必须达到完美的结果,以保证近、远期疗效。

4.1 开口部狭窄
必须选择最佳体位,在透视下能充分显示开口部切线位,一般以后前位(稍向左前或右前)头位偏转角度最好,置入支架时必须充分覆盖开口部并突出至升主动脉内1㎜,然后将球囊拉回一部分在开口部扩张,将突出的支架“ 熨平 ”。

4.2 体部狭窄
支架应覆盖到开口部,若体部较短时,支架可伸向前降支(前降支的血管直径要足够大)

4.3 分叉部狭窄
4.3.1 尽可能选用单支架置入(Cross-over)技术
对廻旋支开口无显著狭窄,廻旋支较小时尤为适用。单支架置入后若廻旋支开口受累,必要时可临时植入支架(provisional stenting);

4.3.2 双支架置入技术
当左主干分义病变累及前降支及廻旋支开口,廻旋支血管较大、廻旋支开口狭窄病变较严重且累及其近端血管时,一般需用双支架置入。当廻旋支及前降支夹角≥70°时可采用“T”支架技术,SYNTAX研究表明T支架技术优于其它技术(减少再次血管重建);当夹角<70°时可采用Mini-Crush技术。当前降支、廻旋支血管直径近似,夹角较小,且与左主干直径也近似时,可用“裙裤 ”(Culotte)技术。当前降支、廻旋支开口及近端均被累及、血管直径较小而左主干直径较粗大时,可用对吻支架技术(Kissing stenting),但对吻支架技术将在左主干内造成金属嵴(carina),其安全性及远期疗效尚待评价。
无论用何种技术,只要是置入双支架,用对吻球囊(Kissing balloon)技术进行后扩张对保证近、远期疗效都是必须的。

4.4 对UPLM狭窄合并多支血管病变的支架置入术必要时可分期进行,如UPLM狭窄合并右冠状动脉CTO,可先行将CTO病变再通,数天后再行UPLM狭窄病变支架置入术,可增加安全性。

4.5 血管内超声(IVUS)的应用
IVUS对左主干病变支架置入术有重要指导价值,有研究表明IVUS指导下的左主干支架置入术可取得更好的近、远期效果,因此,对左主干病变的介入治疗,应尽量在IVUS指导下进行。在支架置入前IVUS检查可精确测量血管直径,并可确定病变性质、病变狭窄程度、病变长度、钙化严重程度及分叉部累及情况,从而协助制订策略、选择最适直径和长度的支架。支架植入后IVUS可确定支架扩张及贴壁情况,病变是否被充分覆盖,及支架边缘是否有血管夹层、撕裂等,从而达到完美的支架置入效果。

4.6 FFR测定
FFR测定对造影显示的边缘性狭窄有助于治疗决策的选择。例如,当用Cross-over技术置入单个支架以后,FFR测定有助于决定廻旋支开口部是否 需进一步处理,如果血管造影见廻旋支开口部有狭窄而FFR测定>0.80时,可不干预。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1663888, encodeId=4c93166388855, content=<a href='/topic/show?id=03a35691e2e' target=_blank style='color:#2F92EE;'>#搭桥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56917, encryptionId=03a35691e2e, topicName=搭桥)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=557f25711234, createdName=12498b3em16(暂无昵称), createdTime=Wed Aug 12 23:55:00 CST 2015, time=2015-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853349, encodeId=9e00185334980, content=<a href='/topic/show?id=48351020537' target=_blank style='color:#2F92EE;'>#JACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10205, encryptionId=48351020537, topicName=JACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55ce62, createdName=hbwxf, createdTime=Mon May 02 02:55:00 CST 2016, time=2016-05-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1325039, encodeId=eb1013250391d, content=<a href='/topic/show?id=96c71804b7' target=_blank style='color:#2F92EE;'>#ACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1804, encryptionId=96c71804b7, topicName=ACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623522, encodeId=149e162352269, content=<a href='/topic/show?id=37de5691841' target=_blank style='color:#2F92EE;'>#搭桥手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56918, encryptionId=37de5691841, topicName=搭桥手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f7c320527759, createdName=stfoxst, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25477, encodeId=8f6c254e71b, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=169, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ee0d1618732, createdName=huaxipanxing, createdTime=Sun May 31 20:42:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25466, encodeId=b7f32546677, content=PCI也会这样么?, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:21:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25465, encodeId=4d7b25465e0, content=脑血管不再支持支架了, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:20:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718499, encodeId=8ac01e1849917, content=<a href='/topic/show?id=35534e966a0' target=_blank style='color:#2F92EE;'>#左主干#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47966, encryptionId=35534e966a0, topicName=左主干)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e5fa32580320, createdName=cathymary, createdTime=Tue Aug 11 18:55:00 CST 2015, time=2015-08-11, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1663888, encodeId=4c93166388855, content=<a href='/topic/show?id=03a35691e2e' target=_blank style='color:#2F92EE;'>#搭桥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56917, encryptionId=03a35691e2e, topicName=搭桥)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=557f25711234, createdName=12498b3em16(暂无昵称), createdTime=Wed Aug 12 23:55:00 CST 2015, time=2015-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853349, encodeId=9e00185334980, content=<a href='/topic/show?id=48351020537' target=_blank style='color:#2F92EE;'>#JACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10205, encryptionId=48351020537, topicName=JACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55ce62, createdName=hbwxf, createdTime=Mon May 02 02:55:00 CST 2016, time=2016-05-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1325039, encodeId=eb1013250391d, content=<a href='/topic/show?id=96c71804b7' target=_blank style='color:#2F92EE;'>#ACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1804, encryptionId=96c71804b7, topicName=ACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623522, encodeId=149e162352269, content=<a href='/topic/show?id=37de5691841' target=_blank style='color:#2F92EE;'>#搭桥手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56918, encryptionId=37de5691841, topicName=搭桥手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f7c320527759, createdName=stfoxst, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25477, encodeId=8f6c254e71b, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=169, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ee0d1618732, createdName=huaxipanxing, createdTime=Sun May 31 20:42:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25466, encodeId=b7f32546677, content=PCI也会这样么?, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:21:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25465, encodeId=4d7b25465e0, content=脑血管不再支持支架了, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:20:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718499, encodeId=8ac01e1849917, content=<a href='/topic/show?id=35534e966a0' target=_blank style='color:#2F92EE;'>#左主干#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47966, encryptionId=35534e966a0, topicName=左主干)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e5fa32580320, createdName=cathymary, createdTime=Tue Aug 11 18:55:00 CST 2015, time=2015-08-11, status=1, ipAttribution=)]
    2016-05-02 hbwxf
  3. [GetPortalCommentsPageByObjectIdResponse(id=1663888, encodeId=4c93166388855, content=<a href='/topic/show?id=03a35691e2e' target=_blank style='color:#2F92EE;'>#搭桥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56917, encryptionId=03a35691e2e, topicName=搭桥)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=557f25711234, createdName=12498b3em16(暂无昵称), createdTime=Wed Aug 12 23:55:00 CST 2015, time=2015-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853349, encodeId=9e00185334980, content=<a href='/topic/show?id=48351020537' target=_blank style='color:#2F92EE;'>#JACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10205, encryptionId=48351020537, topicName=JACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55ce62, createdName=hbwxf, createdTime=Mon May 02 02:55:00 CST 2016, time=2016-05-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1325039, encodeId=eb1013250391d, content=<a href='/topic/show?id=96c71804b7' target=_blank style='color:#2F92EE;'>#ACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1804, encryptionId=96c71804b7, topicName=ACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623522, encodeId=149e162352269, content=<a href='/topic/show?id=37de5691841' target=_blank style='color:#2F92EE;'>#搭桥手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56918, encryptionId=37de5691841, topicName=搭桥手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f7c320527759, createdName=stfoxst, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25477, encodeId=8f6c254e71b, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=169, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ee0d1618732, createdName=huaxipanxing, createdTime=Sun May 31 20:42:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25466, encodeId=b7f32546677, content=PCI也会这样么?, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:21:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25465, encodeId=4d7b25465e0, content=脑血管不再支持支架了, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:20:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718499, encodeId=8ac01e1849917, content=<a href='/topic/show?id=35534e966a0' target=_blank style='color:#2F92EE;'>#左主干#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47966, encryptionId=35534e966a0, topicName=左主干)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e5fa32580320, createdName=cathymary, createdTime=Tue Aug 11 18:55:00 CST 2015, time=2015-08-11, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1663888, encodeId=4c93166388855, content=<a href='/topic/show?id=03a35691e2e' target=_blank style='color:#2F92EE;'>#搭桥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56917, encryptionId=03a35691e2e, topicName=搭桥)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=557f25711234, createdName=12498b3em16(暂无昵称), createdTime=Wed Aug 12 23:55:00 CST 2015, time=2015-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853349, encodeId=9e00185334980, content=<a href='/topic/show?id=48351020537' target=_blank style='color:#2F92EE;'>#JACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10205, encryptionId=48351020537, topicName=JACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55ce62, createdName=hbwxf, createdTime=Mon May 02 02:55:00 CST 2016, time=2016-05-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1325039, encodeId=eb1013250391d, content=<a href='/topic/show?id=96c71804b7' target=_blank style='color:#2F92EE;'>#ACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1804, encryptionId=96c71804b7, topicName=ACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623522, encodeId=149e162352269, content=<a href='/topic/show?id=37de5691841' target=_blank style='color:#2F92EE;'>#搭桥手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56918, encryptionId=37de5691841, topicName=搭桥手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f7c320527759, createdName=stfoxst, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25477, encodeId=8f6c254e71b, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=169, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ee0d1618732, createdName=huaxipanxing, createdTime=Sun May 31 20:42:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25466, encodeId=b7f32546677, content=PCI也会这样么?, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:21:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25465, encodeId=4d7b25465e0, content=脑血管不再支持支架了, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:20:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718499, encodeId=8ac01e1849917, content=<a href='/topic/show?id=35534e966a0' target=_blank style='color:#2F92EE;'>#左主干#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47966, encryptionId=35534e966a0, topicName=左主干)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e5fa32580320, createdName=cathymary, createdTime=Tue Aug 11 18:55:00 CST 2015, time=2015-08-11, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1663888, encodeId=4c93166388855, content=<a href='/topic/show?id=03a35691e2e' target=_blank style='color:#2F92EE;'>#搭桥#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56917, encryptionId=03a35691e2e, topicName=搭桥)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=557f25711234, createdName=12498b3em16(暂无昵称), createdTime=Wed Aug 12 23:55:00 CST 2015, time=2015-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1853349, encodeId=9e00185334980, content=<a href='/topic/show?id=48351020537' target=_blank style='color:#2F92EE;'>#JACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10205, encryptionId=48351020537, topicName=JACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55ce62, createdName=hbwxf, createdTime=Mon May 02 02:55:00 CST 2016, time=2016-05-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1325039, encodeId=eb1013250391d, content=<a href='/topic/show?id=96c71804b7' target=_blank style='color:#2F92EE;'>#ACC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1804, encryptionId=96c71804b7, topicName=ACC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623522, encodeId=149e162352269, content=<a href='/topic/show?id=37de5691841' target=_blank style='color:#2F92EE;'>#搭桥手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56918, encryptionId=37de5691841, topicName=搭桥手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f7c320527759, createdName=stfoxst, createdTime=Mon Jun 01 08:55:00 CST 2015, time=2015-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25477, encodeId=8f6c254e71b, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=169, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ee0d1618732, createdName=huaxipanxing, createdTime=Sun May 31 20:42:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25466, encodeId=b7f32546677, content=PCI也会这样么?, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:21:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=25465, encodeId=4d7b25465e0, content=脑血管不再支持支架了, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=jxsrdw, createdTime=Sun May 31 19:20:00 CST 2015, time=2015-05-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718499, encodeId=8ac01e1849917, content=<a href='/topic/show?id=35534e966a0' target=_blank style='color:#2F92EE;'>#左主干#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47966, encryptionId=35534e966a0, topicName=左主干)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e5fa32580320, createdName=cathymary, createdTime=Tue Aug 11 18:55:00 CST 2015, time=2015-08-11, status=1, ipAttribution=)]
    2015-05-31 huaxipanxing

    看看

    0

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    2015-05-31 jxsrdw

    PCI也会这样么?

    0

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    2015-05-31 jxsrdw

    脑血管不再支持支架了

    0

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