Abraham R, Karamanoukian H L, Jajkowski M R, von Fricken K, D'Ancona G, Bergsland J, Salerno T A
State University of New York at Buffalo, Department of Cardiothoracic Surgery, Kaleida Health-Buffalo General Hospital, Buffalo, New York 14203, USA.
Heart Surg Forum. 2001;4(2):135-40.
The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques.
The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups.
Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients.
Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.
糖尿病对冠状动脉循环的不良影响以及糖尿病患者心血管事件的较高发生率已有充分记载[约翰逊，1982年]。心肌保护、血运重建技术和麻醉管理的改进对糖尿病患者冠状动脉旁路移植术（CABG）的结果产生了有利影响。尽管如此，糖尿病患者更有可能有心肌梗死、充血性心力衰竭、外周血管疾病和高血压病史，并且基线血清肌酐水平显著更高。我们研究的目的是记录、比较和分析有术前糖尿病史的患者在接受非体外循环CABG（OPCAB）和传统体外循环（CPB）CABG时的卒中发生率，以确定非体外循环技术是否能降低这一高风险人群的卒中发生率。
分析了1995年至1999年1227例有术前糖尿病史的患者的记录，其中973例（79.3%）接受传统CPB CABG，254例（20.7%）接受非体外循环CABG。患者的年龄、性别或择期/急诊状态无差异。两组术前危险因素（性别分布、颈动脉疾病、射血分数、CHF、高血压、既往心肌梗死）相同。手术目标是完全血运重建，两组均通过正中胸骨切开术实现。
我们报告的系列研究显示，CPB组的卒中发生率为3.6%，非体外循环组为1.2%。仅这一证据在统计学上无显著意义，但另外两个卒中的高风险标准，再次CABG和钙化主动脉显示，非体外循环组每种情况的比例更高（非体外循环组再次手术的比例为26.4%，CPB组为8.7%，p<0.005；非体外循环组钙化主动脉病例为7.1%，CPB组为2.9%，p<0.004）。鉴于非体外循环组的高风险特征，卒中发生率降低三倍可能具有临床意义。本研究的局限性在于它是回顾性的，事件数量较少，并且两种不同的治疗方法涉及不同的外科医生。
心肌保护、血运重建技术和麻醉管理的改进对糖尿病患者CABG的结果产生了重大有利影响。必须制定新的诊断和治疗策略，以减轻卒中的医学和经济影响。考虑到术前危险因素/卒中预测因素的差异，更大规模的系列研究或更有效的术前风险分析方法很可能显示卒中发生率有统计学显著差异。在出现此类进展之前，使用OPCAB使卒中发生率降低三倍无疑使该技术成为需要冠状动脉血运重建的高风险糖尿病患者的理想选择。
