Prifti E, Bonacchi M, Frati G, Giunti G, Proietti P, Leacche M, Massetti M, Babatasi G, Sani G
Divisione di Cardiochirurgia, Policlinico di Careggi, Firenze, Italy.
Cardiovasc Surg. 2001 Dec;9(6):608-14. doi: 10.1016/s0967-2109(01)00092-8.
To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement.
Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2.
Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns).
In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.
在一组严重冠状动脉疾病（ESCAD）患者中，评估体外循环/心脏跳动式冠状动脉旁路移植术（CABG）与传统CABG相比，在早期和中期生存率、发病率以及左心室功能改善方面的效果。
1993年1月至2000年12月期间，78例（第一组）ESCAD患者接受了体外循环/心脏跳动式手术。第一组患者的平均年龄为66.2±6岁（58 - 79岁），纽约心脏协会（NYHA）分级和加拿大心血管学会（CCS）分级分别为3.2±0.6级和3.3±0.4级，心肌存活指数为0.69±0.1（%），左心室射血分数（LVEF）（%）为24.8±4，左心室舒张末期压力（LVEDP）（mmHg）为28.1±5.8，左心室舒张末期内径（LVEDD）（mm）为69.5±6。第二组由78例接受传统CABG的ESCAD患者组成，这些患者是从年龄、性别和LVEF校正后的患者组中随机选择的。第二组患者的平均年龄为65.7±5岁（57 - 78岁），NYHA分级为3.1±0.7级，CCS分级为3.4±0.8级，LVEF（%）为25±5，LVEDP（mmHg）为27.9±4.4，LVEDD（mm）为69.2±7.2。
术后，第一组有5例（7.7%）患者死亡，第二组有7例（11.5%）患者死亡（P>0.1）。第二组患者的体外循环时间更长（P = 0.001），两组患者平均每位患者的远端吻合数量相似（P = 无显著差异）。第二组围手术期心肌梗死（P = 0.039）、低心排综合征（LCOS）（P = 0.002）、超滤需求（P = 0.018）和出血>1000 ml（P = 0.029）的发生率显著更高。第一组没有患者因出血接受手术修正，而第二组有8例（10.3%）患者（P = 0.011）。术后6个月，第一组患者的左心室功能显著改善，表现为LVEF增加至27.2±4（%）（P = 0.001），LVEDP降低至26.4±3（mmHg）（P = 0.029），LVEDD降低至67±4（mm）（P = 0.004），而第二组与术前数据相比LVEDD仅降低至66.8±6（mm）（P = 0.032）。第一组1年、3年和5年的精算生存率分别为90%、82%和71%，第二组分别为89%、83%和74%（P = 无显著差异）。
在可能难以耐受心脏停搏的ESCAD患者中，体外循环/心脏跳动式CABG可能是一种可接受的替代方法，与较低的术后死亡率和发病率相关。这种技术提供了更好的心肌和肾脏保护，且因术中低灌注导致的术后并发症较少。
