Magee Mitchell J, Jablonski Kathleen A, Stamou Sotiris C, Pfister Albert J, Dewey Todd M, Dullum Mercedes K C, Edgerton James R, Prince Syma L, Acuff Tea E, Corso Paul J, Mack Michael J
Cardiopulmonary Research Science and Technology Institute, Dallas, Texas, USA.
Ann Thorac Surg. 2002 Apr;73(4):1196-202; discussion 1202-3. doi: 10.1016/s0003-4975(01)03587-1.
Coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass (CPB) is currently increasing in clinical practice. Decreased morbidity associated with off-pump (OP) CABG in selected risk groups examined in relatively small, single institution groups has been the focus of most recent studies. The purpose of this study was to determine the independent impact of CPB on early survival in all isolated multivessel CABG patients undergoing surgery in two large institutions with established experience in OPCABG techniques.
A review of two large databases employed by multiple surgeons in the hospitals of two institutions identified 8,758 multivessel CABG procedures performed from January 1998 through July 2000. In all, 8,449 procedures were included in a multivariate logistic regression analysis to determine the relative impact of CPB on mortality independent of known risk factors for mortality. Procedures were also divided into two treatment groups based on the use of CPB: 6,466 had CABG with CPB (CABG-CPB), 1,983 had CABG without CPB (OPCABG). Disparities between groups were identified by univariate analysis of 17 preoperative risk factors and treatment groups were compared by Parsonnet's risk stratification model. Finally, computer-matched groups based on propensity score for institution selection for OPCABG were combined and analyzed by a logistic regression model predicting risk for mortality.
CABG-CPB was associated with increased mortality compared with OPCABG by univariate analysis, 3.5% versus 1.8%, despite a lower predicted risk in the CABG-CPB group. CPB was associated with increased mortality by multiple logistic regression analysis with an odds ratio of 1.79 (95% confidence interval = 1.24 to 2.67). An increased risk of mortality associated with CPB was also determined by logistic regression analysis of the combined computer-matched groups based on OPCABG-selection propensity scores with an odds ratio of 1.9 (95% confidence interval = 1.2 to 3.1).
Elimination of CPB improves early survival in multivessel CABG patients. Rigorous attempts to statistically account for selection bias maintained a clear association between CPB and increased mortality. Larger multiinstitutional studies are needed to confirm these findings and determine the most appropriate application of OPCABG.
目前，非体外循环冠状动脉搭桥术（CABG）在临床实践中的应用正在增加。在相对较小的单机构研究中，特定风险组中与非体外循环（OP）CABG相关的发病率降低一直是近期研究的重点。本研究的目的是确定在两家具有OPCABG技术成熟经验的大型机构中，接受手术的所有孤立多支血管CABG患者中，体外循环（CPB）对早期生存的独立影响。
回顾两家机构医院的多位外科医生使用的两个大型数据库，确定了1998年1月至2000年7月期间进行的8758例多支血管CABG手术。总共8449例手术纳入多因素逻辑回归分析，以确定CPB对死亡率的相对影响，独立于已知的死亡风险因素。手术还根据CPB的使用情况分为两个治疗组：6466例接受体外循环冠状动脉搭桥术（CABG-CPB），1983例接受非体外循环冠状动脉搭桥术（OPCABG）。通过对17个术前风险因素的单因素分析确定组间差异，并通过Parsonnet风险分层模型比较治疗组。最后，基于OPCABG机构选择倾向评分的倾向得分对计算机匹配组进行合并，并通过预测死亡风险的逻辑回归模型进行分析。
单因素分析显示，与OPCABG相比，CABG-CPB的死亡率更高，分别为3.5%和1.8%，尽管CABG-CPB组的预测风险较低。多因素逻辑回归分析显示，CPB与死亡率增加相关，比值比为1.79（95%置信区间=1.24至2.67）。基于OPCABG选择倾向评分的计算机匹配组合并后的逻辑回归分析也确定，CPB与死亡率增加风险相关，比值比为1.9（95%置信区间=1.2至3.1）。
消除CPB可提高多支血管CABG患者的早期生存率。在统计上严格考虑选择偏倚后，CPB与死亡率增加之间仍保持明显关联。需要更大规模的多机构研究来证实这些发现，并确定OPCABG的最合适应用。
