Craver J M, Weintraub W S, Jones E L, Guyton R A, Hatcher C R
Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Ann Surg. 1992 May;215(5):425-33; discussion 433-4. doi: 10.1097/00000658-199205000-00004.
Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.
在1980年9月至1990年12月的十年间，699例患者在择期经皮冠状动脉腔内血管成形术失败后需要进行急诊冠状动脉搭桥术。这占该期间9860例接受12146次择期经皮冠状动脉腔内血管成形术患者的4%。82%的患者因急性难治性心肌缺血需要进行急诊冠状动脉搭桥术。所有患者的医院死亡率为3.1%；难治性心肌缺血患者的死亡率为3.7%，无难治性心肌缺血患者的死亡率为0.8%，p = 0.08。术后Q波心肌梗死的发生率在有难治性心肌缺血的患者中为21%，而在无难治性心肌缺血的患者中为2.4%，p < 0.0001；有难治性心肌缺血的患者中19%需要主动脉内球囊反搏，无难治性心肌缺血的患者中这一比例为0.8%，p < 0.0001。多支血管病变（p = 0.004）、年龄大于65岁（p = 0.005）和难治性心肌缺血（p = 0.08）共同作用导致住院死亡风险最高。随访显示，另有28例晚期死亡，其中23例为心脏原因导致，5年生存率为91%。5年时无晚期死亡和Q波心肌梗死的生存率为61%。在因难治性心肌缺血而进行急诊冠状动脉搭桥术的患者组中，5年时晚期心脏生存率为90%，无缺血患者组为92%，p = 无显著差异。然而，有难治性缺血患者组的无心肌梗死生存率为56%，无缺血患者组为83%，p < 0.0001。多变量分析显示，初次急诊冠状动脉搭桥术时有Q波心肌梗死、年龄大于65岁、心绞痛分级为III或IV级以及既往有冠状动脉搭桥手术的患者晚期事件发生率最高。尽管在最近3年的患者队列中早期急性心肌梗死的发生率持续较高且手术死亡率有所上升（7%），但出色的晚期生存率和较低的后续心脏事件发生率表明，对于经皮冠状动脉腔内血管成形术失败患者，及时、成功的急诊冠状动脉搭桥手术具有持久的有效性。
