Lu John C Y, Grayson Antony D, Pullan D Mark
Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom.
Ann Thorac Surg. 2005 Jul;80(1):136-42. doi: 10.1016/j.athoracsur.2005.02.001.
Recent publications have shown coronary surgery is safe and effective in patients with critical left main stem stenosis when using off-pump coronary surgery techniques. However, these studies were small and did not adjust for differences in case mix.
Between April 1997 and March 2003, 1,197 consecutive patients with critical left main stem stenosis (> 50%) underwent coronary surgery. Two hundred and fifty-nine (21.6%) of these patients had off-pump coronary surgery, while 938 (78.4%) received on-pump coronary surgery. Multivariate logistic regression and Cox proportional hazards analysis were used to assess the effect of off-pump coronary surgery on outcomes, while adjusting for patient characteristics (treatment selection bias). Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving off-pump coronary surgery and was included along with the comparison variable in the multivariable analyses of outcome.
After adjusting for the propensity score, the requirement for inotropic support (22.4% versus 35.3%; p < 0.001) or a prolonged length of stay (5.3% versus 9.3%; p = 0.034) were significantly reduced after receiving off-pump coronary surgery. There was a trend to suggest that off-pump patients had a lower incidence of stroke and chest infection. The adjusted freedom from death in off-pump patients at 2 years was 94.6% compared with 93.6% for on-pump patients (p = 0.54).
After risk adjustment, patients with critical left main stem stenosis can undergo off-pump coronary surgery safely, with results comparable with on-pump coronary surgery.
近期发表的文献表明，在使用非体外循环冠状动脉手术技术时，冠状动脉手术对于严重左主干狭窄患者是安全有效的。然而，这些研究规模较小，且未对病例组合差异进行调整。
在1997年4月至2003年3月期间，1197例连续的严重左主干狭窄（>50%）患者接受了冠状动脉手术。其中259例（21.6%）患者接受了非体外循环冠状动脉手术，而938例（78.4%）患者接受了体外循环冠状动脉手术。使用多因素逻辑回归和Cox比例风险分析来评估非体外循环冠状动脉手术对预后的影响，同时对患者特征（治疗选择偏倚）进行调整。通过根据核心患者特征构建倾向评分来控制治疗选择偏倚。倾向评分是接受非体外循环冠状动脉手术的概率，并在多变量预后分析中与比较变量一起纳入。
在调整倾向评分后，接受非体外循环冠状动脉手术后，对血管活性药物支持的需求（22.4%对35.3%；p<0.001）或住院时间延长（5.3%对9.3%；p=0.034）显著降低。有趋势表明非体外循环患者中风和肺部感染的发生率较低。非体外循环患者2年时经调整的无死亡生存率为94.6%，而体外循环患者为93.6%（p=0.54）。
经过风险调整后，严重左主干狭窄患者可以安全地接受非体外循环冠状动脉手术，其结果与体外循环冠状动脉手术相当。
