Ascione Raimondo, Narayan Pradeep, Rogers Chris A, Lim Kelvin H H, Capoun Radek, Angelini Gianni D
Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom.
Ann Thorac Surg. 2003 Sep;76(3):793-9. doi: 10.1016/s0003-4975(03)00664-7.
Patients presenting with severe left ventricular (LV) dysfunction undergoing coronary artery surgery are at increased risk of perioperative morbidity and mortality. The present study investigated early and midterm outcomes in a consecutive series of patients with severe LV dysfunction undergoing coronary surgery at our institution.
Data on 5,195 consecutive patients undergoing coronary artery bypass grafting (CABG) alone (in-hospital mortality 1.35%) from April 1996 to August 2002 were prospectively recorded in the Patient Analysis and Tracking System. Two hundred and fifty patients (median age 65 years [interquartile range, 57 to 70]) with preoperative left ventricular ejection fraction less than 30% (74 off pump; 29.6%) were identified and early and midterm clinical outcomes analyzed. Propensity scores were used to take account of the imbalance in the distribution of prognostic factors between the on-pump and off-pump groups.
Patients undergoing on-pump surgery were less likely to have current congestive heart failure, insulin-dependent diabetes, a history of hypertension, have had gastrointestinal tract surgery or an ulcer, or unstable angina. They had on average lower Parsonnet scores and New York Heart Association and Canadian Cardiovascular Score ratings. However they were more likely to have more extensive coronary artery heart disease and to require more grafts than those undergoing off-pump surgery. After adjustment for consultant team and propensity scores no differences between groups with regard to in-hospital mortality and morbidity were found. The only in-hospital outcome to show a significant difference after adjustment was the need for intraoperative inotropic support, which was higher in the on-pump group (odds ratio 5.1; 95% confidence interval 2.55 to 10.2; p < 0.001)). The median follow-up times for the on- and off-pump groups were 3.4 years and 1.4 years respectively. Three-year survival was higher with on-pump surgery (87% on-pump versus 73% off-pump) but this difference did not reach statistical significance after adjustment for prognostic variables (hazard ratio 0.54, 95% confidence interval 0.22 to 1.26, p = 0.16).
In-hospital mortality and morbidity in patients presenting with severe LV dysfunction is low with comparable results with both on- and off-pump coronary artery surgery. Midterm clinical outcome is encouraging and seems to justify surgical revascularization for this high-risk group of patients.
接受冠状动脉手术的严重左心室(LV)功能不全患者围手术期发病和死亡风险增加。本研究调查了我院连续一系列严重LV功能不全患者接受冠状动脉手术的早期和中期结果。
1996年4月至2002年8月期间,在患者分析与跟踪系统中前瞻性记录了5195例仅接受冠状动脉旁路移植术(CABG)的连续患者的数据(院内死亡率1.35%)。确定了250例术前左心室射血分数低于30%的患者(中位年龄65岁[四分位间距,57至70岁])(74例非体外循环;29.6%),并分析了早期和中期临床结果。使用倾向评分来考虑体外循环和非体外循环组之间预后因素分布的不平衡。
接受体外循环手术的患者目前患有充血性心力衰竭、胰岛素依赖型糖尿病、高血压病史、接受过胃肠道手术或溃疡、或不稳定型心绞痛的可能性较小。他们的Parsonnet评分、纽约心脏协会和加拿大心血管评分平均较低。然而,与接受非体外循环手术的患者相比,他们更有可能患有更广泛的冠状动脉心脏病,并且需要更多的移植血管。在调整顾问团队和倾向评分后,两组在院内死亡率和发病率方面没有差异。调整后唯一显示出显著差异的院内结果是术中需要使用正性肌力支持,体外循环组更高(优势比5.1;95%置信区间2.55至10.2;p<0.001)。体外循环组和非体外循环组的中位随访时间分别为3.4年和1.4年。体外循环手术的三年生存率更高(体外循环组为87%,非体外循环组为73%),但在调整预后变量后,这种差异未达到统计学意义(风险比0.54,95%置信区间0.22至1.26,p = 0.16)。
严重LV功能不全患者的院内死亡率和发病率较低,体外循环和非体外循环冠状动脉手术的结果相当。中期临床结果令人鼓舞,似乎证明了对这一高危患者群体进行手术血运重建的合理性。