Mickleborough L L, Carson S, Tamariz M, Ivanov J
University of Toronto, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2000 Mar;119(3):550-7. doi: 10.1016/s0022-5223(00)70135-8.
In patients with coronary disease and poor left ventricular function, bypass grafting remains a surgical challenge. This study evaluates experience in 125 consecutive patients with ejection fraction less than 20% (study group).
Preoperative viability studies were not used for patient selection. Clinical data were prospectively collected. The average age of the study subjects was 59 +/- 9 years, and 112 (90%) were male. Most patients (108 [86%]) were in symptom class III or IV. Main indications for surgery included angina in 62 (50%), heart failure and angina in 36 (29%), heart failure in 9 (7%), ventricular arrhythmia in 2 (2%), and critical anatomy in 16 (13%). Significant mitral regurgitation was present in 48 (38%), and distal vessels were poorly visualized in 67 (54%). At surgery, temperature mapping guided an integrated approach to cold cardioplegia. Results in this group were compared with those obtained in case-matched control subjects receiving cardioplegia without temperature mapping (matched for age, sex, functional class, and urgency of operation).
Hospital morbidity (intra-aortic balloon pump support) and mortality rates were significantly lower in the study group versus those of control subjects (15% vs 30%, P =. 004; and 4% vs 11%, P =.03, respectively). In study patients the 5-year actuarial survival was 72%. Among survivors, both anginal class and heart failure class improved significantly. By means of multivariate analysis, survival was adversely affected by older age, class IV symptoms, and poorly visualized distal vessels.
These results support the use of coronary artery bypass grafting in patients with severe left ventricular dysfunction without case selection on the basis of viability studies or visibility of distal vessels. Low hospital morbidity and mortality rates have been achieved when temperature mapping guides cardioplegia. Symptoms are improved in most patients, and long-term survival is encouraging.
在冠心病且左心室功能较差的患者中，冠状动脉搭桥术仍是一项外科挑战。本研究评估了125例连续入选的射血分数低于20%的患者（研究组）的治疗经验。
术前未使用存活心肌研究来选择患者。前瞻性收集临床数据。研究对象的平均年龄为59±9岁，112例（90%）为男性。大多数患者（108例[86%]）处于症状分级III或IV级。手术的主要指征包括62例（50%）心绞痛、36例（29%）心力衰竭合并心绞痛、9例（7%）心力衰竭、2例（2%）室性心律失常以及16例（13%）严重解剖结构异常。48例（38%）存在显著二尖瓣反流，67例（54%）远端血管显影不佳。手术时，温度监测引导采用综合冷停搏方法。将该组结果与未进行温度监测的病例匹配对照组患者（根据年龄、性别、功能分级和手术紧迫性进行匹配）的结果进行比较。
研究组的医院发病率（主动脉内球囊泵支持）和死亡率显著低于对照组（分别为15%对30%，P = 0.004；4%对11%，P = 0.03）。研究患者的5年预期生存率为72%。在存活者中，心绞痛分级和心力衰竭分级均有显著改善。通过多因素分析，年龄较大、IV级症状以及远端血管显影不佳对生存率有不利影响。
这些结果支持在严重左心室功能不全患者中不基于存活心肌研究或远端血管可视性进行病例选择而实施冠状动脉搭桥术。当温度监测引导停搏时，已实现较低的医院发病率和死亡率。大多数患者症状得到改善，长期生存情况令人鼓舞。
