Battaglia Francesco, Maiani Massimo, Prifti Edvin, Leacche Marzia, Bonacchi Massimo
Cattedra e Scuola di Specializzazione in Cardiochirurgia, Università degli Studi, Firenze.
Ital Heart J Suppl. 2004 Oct;5(10):806-15.
Surgical revascularization employing bilateral internal mammary arteries (IMAs) is an excellent procedure in elective surgery, but its role in urgent/emergent procedures is still debating. This retrospective study evaluates the feasibility, safety and surgical early outcomes of employing double skeletonized IMAs in patients with unstable angina (UA) undergoing urgent/emergent revascularization.
From January 1997 to May 2004, 824 patients (491 males, 333 females, mean age 64 +/- 12 years) underwent urgent revascularization for UA. Bilateral IMAs were employed in 346 (42%) patients (group B) and isolated and/or saphenous vein grafts in the remaining 478 (58%) patients (group M). There were no significant differences in preoperative risk factors between the two groups (mean EuroSCORE value).
Postoperative stay was free from complications in 87% of patients of group B and 91% of group M. In-hospital mortality (group B 5.9%, group M 5.3%, p = NS) and perioperative myocardial infarction (group B 2.2%, group M 1.96%, p = NS), mean coronary care unit stay and total hospital stay were similar in both groups. Actuarial survival at 1, 3, 5 and 7 years was respectively 98.7, 97.5, 96.9 and 96.1% in group B and 99, 93.4, 92.1 and 88.4% in group M (p < 0.05). At a mean follow-up of 6.6 years the event-free survival (p = 0.021) and reoperation-free cardiac survival (p = 0.003) were better in group B. Multivariate analysis identified that age > 65 years (p = 0.01), congestive heart failure (p = 0.001), left ventricular ejection fraction < 35% (p = 0.03), and > 1 ischemic irreversible area (p = 0.02) are negative predictors for reoperation-free cardiac survival. The employment of the left IMA (p = 0.006) and of both IMAs (p = 0.001) were positive predictors for the overall survival and reoperation-free cardiac survival.
Our results show that the use of skeletonized bilateral IMAs is associated with an acceptable risk and a lower incidence of postoperative complications in patients with UA, improving late outcomes in this group of patients.
在择期手术中，采用双侧乳内动脉（IMA）进行外科血管重建是一种很好的手术方式，但其在急诊/紧急手术中的作用仍存在争议。本回顾性研究评估了在接受急诊/紧急血管重建的不稳定型心绞痛（UA）患者中使用双侧骨骼化IMA的可行性、安全性和手术早期结果。
1997年1月至2004年5月，824例患者（491例男性，333例女性，平均年龄64±12岁）因UA接受了紧急血管重建。346例（42%）患者（B组）采用双侧IMA，其余478例（58%）患者（M组）采用孤立和/或大隐静脉移植。两组术前危险因素（平均欧洲心脏手术风险评估系统值）无显著差异。
B组87%的患者和M组91%的患者术后无并发症。两组的院内死亡率（B组5.9%，M组5.3%，p=无统计学意义）、围手术期心肌梗死（B组2.2%，M组1.96%，p=无统计学意义）、平均冠心病监护病房住院时间和总住院时间相似。B组1、3、5和7年的精算生存率分别为98.7%、97.5%、96.9%和96.1%，M组分别为99%、93.4%、92.1%和88.4%（p<0.05）。在平均6.6年的随访中，B组的无事件生存率（p=0.021）和无再次手术的心脏生存率（p=0.003）更好。多因素分析确定年龄>65岁（p=0.01）、充血性心力衰竭（p=0.001）、左心室射血分数<35%（p=0.03）和>1个缺血不可逆区域（p=0.02）是无再次手术的心脏生存的负性预测因素。使用左IMA（p=0.006）和双侧IMA（p=0.001）是总体生存和无再次手术的心脏生存的正性预测因素。
我们的结果表明，在UA患者中使用双侧骨骼化IMA具有可接受的风险和较低的术后并发症发生率，可改善该组患者的远期预后。
