Pompilio G, Antona C, Cannata A, Lotto A, Alamanni F, Gelpi G, Tartara P, Biglioli P
Cattedra di Cardiochirurgia, Università degli Studi di Milano.
G Ital Cardiol. 1999 Mar;29(3):246-54.
This study was conducted to assess the impact of coronary bypass surgery (CABG) without cardiopulmonary bypass (CPB) on high-risk patients.
From February 1997 to July 1998, 71 patients considered at high-risk underwent a CABG off-pump. Using the "Higgins score", eleven preoperative risk factors were identified and stratified in this group of patients. Among 1271 patients who underwent CABG with CPB in the same period, using a computer-based matched comparison, a second identical group of patients was selected according to the 11 risk variables and the number with coronary disease, so that complete preoperative matching included the year of operation, score index and coronary target. Moreover, among seven other preoperative variables that were not included in the matching comparison, the two groups differed only in mean age (64 +/- 10.9 vs 61.6 +/- 7.3 in groups off and on-pump, respectively, p < 0.05). Postoperative outcome and complications and blood requirement were compared. Myocardial cell injury and left ventricular performance were also assessed in the two groups.
The global incidence of neurologic complications in the off-pump group was significantly lower (9.8 vs 0%, in on and off-pump groups, respectively; p = 0.02). Patients undergoing CABG off-pump required blood far less often (% of transfused patients: 26.7% for the patients with CPB and 11.2% for the patients without CPB; p = 0.032). Three patients from the on-pump group (4.2%) had a perioperative myocardial infarction (AMI), versus 0% of the off-pump cases (p = ns). Postoperative atrial fibrillation accounted for 14.1% in off-pump patients and 30.9% in on-pump patients (p = 0.027). One patient in both groups (1.4%) suffered from postoperative heart failure. Mean ventilation time and ICU stay did not differ significantly between the two groups. However, hospital discharge occurred earlier in the off-pump group (9.3 +/- 3 vs 12.6 +/- 8, p = 0.007). In-hospital death occurred in one case from the on-pump group (1.4%) versus 0% of patients operated off-pump. CPK-MB release in patients without perioperative AMI was significantly lower in off-pump patients 6 and 12 hours after the operation (36.6 +/- 17 IU/l vs 69.8 +/- 23 IU/l after 6 hours, p < 0.05; and 36.7 +/- 19 IU/l vs 67.3 +/- 26 IU/l after 12 hours, p < 0.05, in off and on-pump groups, respectively) and LVSWI turned out to be better in off-pump patients 6 hours postoperatively (34.2 +/- 2 gm/m2 vs 27.2 +/- 3 gm/m2, p < 0.01).
CABG without CPB seems to be a promising technique for high-risk patients. It offers better neurologic and cardiac protection, shortens postoperative hospital stay and reduces the need for blood transfusion.
本研究旨在评估非体外循环冠状动脉搭桥术（CABG）对高危患者的影响。
1997年2月至1998年7月，71例高危患者接受了非体外循环冠状动脉搭桥术。使用“希金斯评分”，在这组患者中确定并分层了11个术前危险因素。在同期接受体外循环冠状动脉搭桥术的1271例患者中，通过基于计算机的匹配比较，根据11个风险变量和冠心病患者数量选择了第二组相同的患者，以便术前完全匹配包括手术年份、评分指数和冠状动脉靶点。此外，在匹配比较中未包括的其他七个术前变量中，两组仅在平均年龄上有所不同（非体外循环组为64±10.9岁，体外循环组为61.6±7.3岁，p<0.05）。比较术后结果、并发症和血液需求量。还评估了两组的心肌细胞损伤和左心室功能。
非体外循环组神经并发症的总体发生率显著较低（体外循环组和非体外循环组分别为9.8%和0%；p=0.02）。接受非体外循环冠状动脉搭桥术的患者输血频率远较低（输血患者百分比：体外循环患者为26.7%，非体外循环患者为11.2%；p=0.032）。体外循环组有3例患者（4.2%）发生围手术期心肌梗死（AMI），而非体外循环组为0%（p=无显著性差异）。非体外循环患者术后房颤发生率为14.1%，体外循环患者为30.9%（p=0.027）。两组各有1例患者（1.4%）发生术后心力衰竭。两组的平均通气时间和ICU住院时间无显著差异。然而，非体外循环组出院更早（9.3±3天对12.6±8天；p=0.007）。体外循环组有1例患者（1.4%）院内死亡，而非体外循环手术患者为0%。术后6小时和12小时，非围手术期AMI患者的肌酸磷酸激酶同工酶（CPK-MB）释放量在非体外循环患者中显著较低（术后6小时分别为36.6±17IU/L对69.8±23IU/L，p<0.05；术后12小时分别为36.7±19IU/L对67.3±26IU/L，p<0.05），非体外循环患者术后6小时的左心室每搏功指数（LVSWI）更好（34.2±2g·m/m²对27.2±3g·m/m²，p<0.01）。
非体外循环冠状动脉搭桥术似乎是一种适用于高危患者的有前景的技术。它提供了更好的神经和心脏保护，缩短了术后住院时间并减少了输血需求。
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