Yokoyama T, Baumgartner F J, Gheissari A, Capouya E R, Panagiotides G P, Declusin R J
St. Vincent Medical Center, Los Angeles, California, USA.
Ann Thorac Surg. 2000 Nov;70(5):1546-50. doi: 10.1016/s0003-4975(00)01922-6.
Cardiopulmonary bypass (CPB) has pathophysiologic sequelae that may be more severe in high-risk subsets. We wanted to determine whether off-pump coronary bypass (OPCAB) could optimize outcomes.
Our database of 242 OPCAB patients undergoing complete revascularization was compared to a base of 483 CABG patients undergoing CPB. Results were compared for the overall series and in the following high-risk subsets: 80 years of age or older, ventricular dysfunction (ejection fraction (EF) < or = 0.25), prior neurologic event or renal failure, chronic obstructive pulmonary disease (COPD), and reoperation.
In the overall series, OPCAB significantly reduced the incidence of intraoperative transfusion requirements and showed a trend toward reduced morbidity in terms of postoperative neurologic and renal complications, prolonged ventilator requirement greater than 3 days, and bleeding requiring reexploration. Mortality was less in the OPCAB group (0.4% versus 2.7%, p = not significant). Similar results were achieved in the following high-risk subgroups (n = off-pump/on-pump): 80 years of age or older (n = 28/58), EF less than or equal to 25% (n = 13/26), preoperative neurologic event (n = 25/36), preoperative renal failure (n = 27/46), COPD (n = 33/43), and reoperation (n = 28/76). OPCAB decreased the incidence of prolonged ventilation in COPD patients (0/33 [0%] versus 4/43 [9.3%] p = not significant) and decreased the incidence of renal complications in the elderly (1/28 [3.6%] versus 9/58 [15.5%] p = not significant). Off-pump coronary bypass reduced but did not eliminate neurologic events in the elderly (2/28 [7.1%] versus 8/58 [13.8%] p = not significant).
Off-pump coronary bypass significantly reduced the incidence of transfusion requirement compared to the CPB counterparts and had a consistent trend in reducing morbidity and mortality overall and in all high-risk subsets. Neurologic events are not eliminated in OPCAB.
体外循环（CPB）存在病理生理后遗症，在高危亚组中可能更为严重。我们想确定非体外循环冠状动脉搭桥术（OPCAB）是否能优化治疗结果。
将我们数据库中242例行完全血运重建的OPCAB患者与483例行CPB的冠状动脉搭桥术（CABG）患者作为对照。比较了整个系列以及以下高危亚组的结果：80岁及以上、心室功能障碍（射血分数（EF）≤0.25）、既往有神经系统事件或肾衰竭、慢性阻塞性肺疾病（COPD）以及再次手术。
在整个系列中，OPCAB显著降低了术中输血需求的发生率，并且在术后神经系统和肾脏并发症、呼吸机使用时间超过3天以及需要再次探查的出血方面，显示出发病率降低的趋势。OPCAB组的死亡率较低（0.4%对2.7%，p无显著性差异）。在以下高危亚组（非体外循环/体外循环的例数）中也取得了类似结果：80岁及以上（28/58）、EF≤25%（13/26）、术前有神经系统事件（25/36）、术前肾衰竭（27/46）、COPD（33/43）以及再次手术（28/76）。OPCAB降低了COPD患者长时间通气的发生率（0/33 [0%]对4/43 [9.3%]，p无显著性差异），并降低了老年人肾脏并发症的发生率（1/28 [3.6%]对9/58 [15.5%]，p无显著性差异）。非体外循环冠状动脉搭桥术减少了但并未消除老年人的神经系统事件（2/28 [7.1%]对8/58 [13.8%]，p无显著性差异）。
与CPB相比，非体外循环冠状动脉搭桥术显著降低了输血需求的发生率，并且在总体上以及所有高危亚组中都有降低发病率和死亡率的一致趋势。OPCAB并不能消除神经系统事件。
