Patel Nirav C, Patel Nilesh U, Loulmet Didier F, McCabe John C, Subramanian Valavanur A
Section of Cardiothoracic Surgery, Lenox Hill Hospital, 130 E 77th Street, New York, NY 10021, USA.
J Thorac Cardiovasc Surg. 2004 Nov;128(5):655-61. doi: 10.1016/j.jtcvs.2004.04.043.
We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery.
From January 1999 through July 2002, 1678 consecutive isolated coronary artery bypass operations were performed at Lenox Hill Hospital, with the intention to treat all patients with off-pump coronary bypass surgery. Fifty (2.97%) patients required urgent conversion to cardiopulmonary bypass. All the preoperative, intraoperative, and postoperative variables were collected and analyzed in accordance with the New York State Cardiac Surgery Reporting System. Multivariate regression analysis was performed to determine predictors for conversion.
In-hospital mortality and major morbidity were significantly lower in the nonconverted group compared with the converted patients (mortality: 1.47% [n = 24] vs 12% [n = 6], P = .001; stroke: 1.1% [n = 18] vs 6% [n = 3], P = .02; renal failure: 1.23% [n = 20] vs 6% [n = 3], P = .02; deep sternal wound infection: 1.54% [n = 25] vs 8% [n = 4], P = .009; respiratory failure: 3.75% [n = 61] vs 28% [n = 14], P < .0001; nonconverted vs converted patients, respectively). The annual incidence of conversion decreased during the study period. There was a significant reduction in the incidence of conversion after routine use of a cardiac positioning device to performing lateral and inferior wall grafts (4.2% [n = 27] vs 2.3% [n = 23], P = .04). None of the preoperative variables were independent predictors of conversion on multivariate regression analysis.
Because emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery results in significantly higher morbidity and mortality, studies comparing off-pump coronary bypass surgery with conventional coronary artery surgery should include converted patients in the off-pump group. In our experience, emergency conversion is an unpredictable event. The incidence of conversion decreases with increasing experience of surgeons in performing off-pump coronary surgery and use of a cardiac positioning device.
我们试图评估非体外循环冠状动脉搭桥手术中紧急转为体外循环的结果及预测因素。
1999年1月至2002年7月，莱诺克斯山医院连续进行了1678例单纯冠状动脉搭桥手术，旨在对所有患者行非体外循环冠状动脉搭桥手术治疗。50例（2.97%）患者需要紧急转为体外循环。根据纽约州心脏手术报告系统收集并分析所有术前、术中和术后变量。进行多因素回归分析以确定转为体外循环的预测因素。
与转为体外循环的患者相比，未转为体外循环组的住院死亡率和主要并发症显著更低（死亡率：1.47% [n = 24] 对比12% [n = 6]，P = .001；卒中：1.1% [n = 18] 对比6% [n = 3]，P = .02；肾衰竭：1.23% [n = 20] 对比6% [n = 3]，P = .02；深部胸骨伤口感染：1.54% [n = 25] 对比8% [n = 4]，P = .009；呼吸衰竭：3.75% [n = 61] 对比28% [n = 14]，P < .0001；分别为未转为体外循环与转为体外循环的患者）。研究期间转为体外循环的年发生率下降。在常规使用心脏定位装置进行侧壁和下壁移植后，转为体外循环的发生率显著降低（4.2% [n = 27] 对比2.3% [n = 23]，P = .04）。多因素回归分析中，术前变量均不是转为体外循环的独立预测因素。
由于在非体外循环冠状动脉搭桥手术尝试过程中紧急转为体外循环会导致显著更高的发病率和死亡率，比较非体外循环冠状动脉搭桥手术与传统冠状动脉手术的研究应将转为体外循环的患者纳入非体外循环组。根据我们的经验，紧急转为体外循环是不可预测的事件。随着外科医生进行非体外循环冠状动脉手术经验的增加以及心脏定位装置的使用，转为体外循环的发生率降低。
