Toda Koichi, Mackenzie Karen, Mehra Mandeep R, DiCorte Charles J, Davis James E, McFadden P Michael, Ochsner John L, White Christopher, Van Meter Clifford H
Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana 07121, USA.
Ann Thorac Surg. 2002 Dec;74(6):2082-7; discussion 2087. doi: 10.1016/s0003-4975(02)04120-6.
We sought to determine the optimal approach to revascularization of patients with severe left ventricular (LV) dysfunction.
We conducted a single-center observational study of 117 consecutive patients who had severe LV dysfunction (15% < OR = LV ejection fraction < OR = 30%) and underwent either coronary artery bypass grafting (CABG, n = 69) or percutaneous revascularization (n = 48) between 1992 and 1997.
The CABG group was younger (62 versus 67 years, p = 0.026), and fewer previous bypasses (7% versus 40%, p < 0.0001) and fewer prior percutaneous revascularizations (16% versus 42%, p = 0.0019) were noted. More vessels were revascularized (3 +/- 0.8 versus 1.5 +/- 0.7, p < 0.0001), and revascularization was more complete by CABG (84% versus 48%, p < 0.0001). Morbidity and mortality at 30 days were similar, and there was no significant difference in 3-year survival (73% versus 67%), although 3-year cardiac event-free survival (52% versus 25%, p = 0.0011) and 3-year target vessel revascularization-free survival (71% versus 41%, p < 0.0001) were significantly better in the CABG group, and LV ejection fraction was significantly improved after CABG. In the subgroup of patients 65 years of age or older and those without proximal left anterior descending coronary artery lesions, significant benefit of CABG in cardiac event-free and target vessel revascularization-free survival disappeared.
We found that in clinically selected patients with severe ventricular dysfunction, CABG compared with percutaneous revascularization achieves more complete revascularization, improved LV function, fewer cardiac events, and fewer target vessel revascularizations, but does not affect mid-term survival. A prospective controlled trial with defined criteria for treatment assignment is warranted to confirm our results regarding the two revascularization strategies in patients with severe LV dysfunction.
我们试图确定重度左心室（LV）功能不全患者血运重建的最佳方法。
我们对117例连续的重度LV功能不全患者（左心室射血分数15%＜或=至30%）进行了一项单中心观察性研究，这些患者在1992年至1997年间接受了冠状动脉旁路移植术（CABG，n = 69）或经皮血运重建术（n = 48）。
CABG组患者更年轻（62岁对67岁，p = 0.026），既往接受过旁路手术的患者更少（7%对40%，p＜0.0001），既往接受过经皮血运重建术的患者也更少（16%对42%，p = 0.0019）。CABG组血运重建的血管更多（3±0.8对1.5±0.7，p＜0.0001），且血运重建更完全（84%对48%，p＜0.0001）。30天的发病率和死亡率相似，3年生存率无显著差异（73%对67%），尽管CABG组的3年无心脏事件生存率（52%对25%，p = 0.0011）和3年无靶血管血运重建生存率（71%对41%，p＜0.0001）显著更高，且CABG后左心室射血分数显著改善。在65岁及以上患者和无左冠状动脉前降支近端病变的患者亚组中，CABG在无心脏事件和无靶血管血运重建生存方面的显著益处消失。
我们发现，在临床选择的重度心室功能不全患者中，与经皮血运重建相比，CABG可实现更完全的血运重建，改善左心室功能，减少心脏事件和靶血管血运重建，但不影响中期生存。有必要进行一项具有明确治疗分配标准的前瞻性对照试验，以证实我们关于重度LV功能不全患者两种血运重建策略的结果。
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