经心肌激光血运重建术后的生存率与未激光灌注心肌区域的关系。

Kraatz E G, Misfeld M, Jungbluth B, Sievers H H

Clinic of Cardiac Surgery, Medical University of Lübeck, Germany.

Ann Thorac Surg. 2001 Feb;71(2):532-6. doi: 10.1016/s0003-4975(00)02457-7.

BACKGROUND

Transmyocardial laser revascularization for severe diffuse coronary artery disease reduces angina significantly. The effect on survival, however, is questionable, and risk factors are not adequately addressed. Considering that transmyocardial laser revascularization channels do not remain patent for improving direct myocardial blood supply, other variables such as perfusion through open native or grafted vessels in remote non-transmyocardial laser revascularization areas are probably more important for survival. This hypothesis is the subject of the study.

METHODS

Transmyocardial laser revascularization was performed with a CO2 laser system in 63 patients between October 1995 and December 1997. Patients received transmyocardial laser revascularization alone or in combination with coronary artery bypass grafting. The heart was divided into three perfusion zones as determined by the three major coronary arteries. Patients were divided into three groups according to the number of zones that were perfused by either a native coronary artery or a patent bypass graft: group 1 (n = 9), none; group 2 (n = 24), one; and group 3 (n = 30), two. Follow-up was performed at 3, 6, 12, 24, and 36 months and was 100% complete. Mean latest follow-up was 26.2 months, minimal follow-up of survivors was at least 12 months.

RESULTS

Overall mortality was remarkably higher in group 1 (77.8%) compared with group 2 (20.8%, p = 0.005) and group 3 (13.3%, p = 0.001). Hospital mortality was 22.2% in group 1, 0% in group 2, and 3.3% in group 3. Late mortality was also higher in group 1 (55.5% versus 20.8%, and versus 9.9%, respectively). Cardiac deaths were more frequent in group 1 (55.5% versus 12.5% in group 2, p = 0.02, and versus 9.9% in group 3, p = 0.009). The number of perfused myocardial zones showed a significant influence for survival (p = 0.002).

CONCLUSIONS

These data give some directional evidence that survival seems to be beneficially affected by the number of nonlasered perfused myocardial zones through native vessels or grafts in patients undergoing transmyocardial laser revascularization.

背景

经皮心肌激光血运重建术用于治疗严重弥漫性冠状动脉疾病可显著减轻心绞痛。然而，其对生存率的影响尚存在疑问，且危险因素未得到充分探讨。鉴于经皮心肌激光血运重建通道并不能保持通畅以改善直接心肌血供，其他变量，如在非经皮心肌激光血运重建区域通过开放的自身血管或移植血管的灌注，可能对生存率更为重要。本研究旨在探讨这一假设。

方法

1995年10月至1997年12月期间，对63例患者使用二氧化碳激光系统进行经皮心肌激光血运重建术。患者单独接受经皮心肌激光血运重建术或联合冠状动脉旁路移植术。根据三大冠状动脉将心脏分为三个灌注区。根据自身冠状动脉或通畅的旁路移植血管灌注的区域数量，将患者分为三组：第1组（n = 9），无灌注区；第2组（n = 24），一个灌注区；第3组（n = 30），两个灌注区。在3、6、12、24和36个月进行随访，随访率达100%。平均末次随访时间为26.2个月，存活者最短随访时间至少为12个月。

结果

与第2组（20.8%，p = 0.005）和第3组（13.3%，p = 0.001）相比，第1组的总体死亡率显著更高（77.8%）。第1组的医院死亡率为22.2%，第2组为0%，第3组为3.3%。第1组的晚期死亡率也更高（分别为55.5% 对比20.8%和对比9.9%）。第1组的心脏死亡更为频繁（对比第2组的12.5%，p = 0.02；对比第3组的9.9%，p = 0.009）。灌注心肌区域的数量对生存率有显著影响（p = 0.002）。