Peterson Eric D, Kaul Padma, Kaczmarek Ronald G, Hammill Bradley G, Armstrong Paul W, Bridges Charles R, Ferguson T Bruce
Duke Clinical Research Institute, Durham, North Carolina 27710, USA.
J Am Coll Cardiol. 2003 Nov 5;42(9):1611-6. doi: 10.1016/j.jacc.2003.07.003.
We sought to examine trends in the use and outcomes of transmyocardial revascularization (TMR) in community practice. We also identified important risk factors for TMR and compared outcomes of TMR combined with coronary artery bypass graft surgery (TMR + CABG) versus bypass alone in patients receiving incomplete revascularization.
Although it is approved for use as a stand-alone procedure, there are limited data on the outcomes of (TMR + CABG).
We identified 3,717 patients receiving TMR at 173 U.S. hospitals participating in the Society of Thoracic Surgeons (STS) National Cardiac Database. Baseline characteristics and outcomes in these patients were compared with those from six published randomized TMR trials. Multivariable logistic regression was used to identify clinical risk factors for mortality with TMR. Risk-adjusted mortality was also compared for TMR + CABG relative to CABG only in patients not amenable to complete traditional revascularization.
Between January 1998 and December 2001, the number of STS hospitals performing TMR and total procedural counts increased markedly, driven predominately by more TMR + CABG cases. Overall mortality rates for TMR-alone and TMR + CABG were 6.4% and 4.2%, respectively. Operative risks were significantly higher in those patients with recent myocardial infarction, unstable angina, and depressed ventricular function. Among patients receiving incomplete revascularization, TMR + CABG was not associated with decreased mortality risk compared with CABG alone, adjusted odds ratio 1.11 (95% confidence interval 0.74 to 1.67).
The use of TMR, and in particular, TMR + CABG, is expanding in community practice. Although procedural risks are high, there is room for optimization through improved patient selection and timing of the procedure. Further studies of TMR + CABG are needed given its growing use and unclear benefits.
我们试图研究经心肌血运重建术（TMR）在社区医疗实践中的应用趋势及治疗结果。我们还确定了TMR的重要风险因素，并比较了接受不完全血运重建的患者中TMR联合冠状动脉旁路移植术（TMR+CABG）与单纯旁路移植术的治疗结果。
尽管TMR被批准作为一种独立的手术方法使用，但关于（TMR+CABG）治疗结果的数据有限。
我们在美国胸外科医师协会（STS）国家心脏数据库中，识别出173家美国医院的3717例接受TMR的患者。将这些患者的基线特征和治疗结果与六项已发表的TMR随机试验的结果进行比较。使用多变量逻辑回归来确定TMR术后死亡的临床风险因素。还比较了仅接受冠状动脉旁路移植术（CABG）的患者与接受TMR+CABG且无法进行完全传统血运重建的患者之间的风险调整死亡率。
在1998年1月至2001年12月期间，开展TMR的STS医院数量和手术总数显著增加，主要是由于更多的TMR+CABG病例。单纯TMR和TMR+CABG的总体死亡率分别为6.4%和4.2%。近期发生心肌梗死、不稳定型心绞痛和心室功能低下的患者手术风险明显更高。在接受不完全血运重建的患者中，与单纯CABG相比，TMR+CABG与降低死亡风险无关，调整后的优势比为1.11（95%置信区间0.74至1.67）。
TMR，尤其是TMR+CABG，在社区医疗实践中的应用正在扩大。尽管手术风险很高，但通过改进患者选择和手术时机仍有优化空间。鉴于TMR+CABG的使用日益增加且益处不明，需要对其进行进一步研究。
