Shapira Oz M, Hunter Curtis T, Anter Elad, Bao Yusheng, DeAndrade Kolleen, Lazar Harold L, Shemin Richard J
Department of Cardiothoracic Surgery, Boston Medical Center, Boston, Massachusetts, USA.
J Card Surg. 2006 May-Jun;21(3):225-32. doi: 10.1111/j.1540-8191.2006.00221.x.
The prevalence of patients with severe left ventricular dysfunction (LVD) referred for coronary artery bypass grafting (CABG) is increasing. The aim of the present study was to assess the outcomes of patients with severe LVD undergoing CABG.
Outcomes of 115 consecutive patients with severe LVD (left ventricular ejection fraction [LVEF]</= 30%, mean 22 +/- 6%) undergoing isolated CABG between 1995 and 2000 were compared to 2335 patients with LVEF >30% (HEF). To further evaluate the LVD patients, they were divided into three subgroups base on LVEF: 0% to 10%, 11% to 20%, and 21% to 30%. Data were collected prospectively and entered into the departmental database of the Society of Thoracic Surgeons.
Patients in the LVD group had increased incidence of diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, prior myocardial infarction (MI), congestive heart failure, and less elective procedures compared to the HEF group. Despite this greater risk profile, operative mortality (LVD 2.6% vs. HEF 1.2%, p = 0.19), the incidence of stroke (2.6% vs. 1.0%, p = 0.13), and perioperative MI (0.9% vs. 0.7%) were not statistically different between the groups. The incidence of respiratory (14.8% vs. 1.9%, p < 0.001), renal (5.2% vs. 1.0%, p < 0.001), and vascular (5.2% vs. 0.5%, p < 0.001) complications was significantly higher in the LVD group, resulting in a longer hospital length of stay (8 +/- 8 vs. 6 +/- 4 days, p < 0.0001). In a multivariate analysis, advanced age was as an independent predictor of hospital mortality. Average follow-up in 108 (94%) LVD patients was 36 +/- 22 months (range 2 to 78 months). Twenty-one patients expired during the follow-up, for nine the causes were cardiac-related. Three- and 5-year survival rates were 91 +/- 3% and 76 +/- 6%, respectively. Independent predictors of mid-term mortality in the LVD group by a multivariate analysis included female gender, renal failure, respiratory complications, and grade I/II mitral regurgitation (MR). At the time of follow-up, 72% of LVD patients were in functional class I/II. There were no statistically significant differences in short- and mid-term outcomes among the LVD subgroups.
CABG in patients with severe LVD can be performed with a low mortality, albeit with higher morbidity and longer length of hospital stay, than patients with LVEF >30%. Low ejection fraction per se was not a predictor of hospital mortality. CABG should be considered a safe and effective therapy for low ejection fraction patients with ischemic heart disease. Mitral valve repair/replacement in the presence of moderate degree of MR should be considered at the time of the initial operation.
因严重左心室功能障碍（LVD）而接受冠状动脉旁路移植术（CABG）的患者比例正在上升。本研究的目的是评估接受CABG的严重LVD患者的预后。
将1995年至2000年间连续115例接受单纯CABG的严重LVD患者（左心室射血分数[LVEF]≤30%，平均22±6%）与2335例LVEF>30%（HEF）的患者进行比较。为进一步评估LVD患者，根据LVEF将他们分为三个亚组：0%至10%、11%至20%和21%至30%。前瞻性收集数据并录入胸外科医师协会的科室数据库。
与HEF组相比，LVD组患者糖尿病、慢性阻塞性肺疾病（COPD）、外周血管疾病、既往心肌梗死（MI）、充血性心力衰竭的发生率更高，择期手术更少。尽管风险更高，但两组间手术死亡率（LVD组为2.6%，HEF组为1.2%，p = 0.19）、中风发生率（2.6%对1.0%，p = 0.13）和围手术期MI发生率（0.9%对0.7%）无统计学差异。LVD组呼吸（14.8%对1.9%，p < 0.001）、肾脏（5.2%对1.0%，p < 0.001）和血管（5.2%对0.5%，p < 0.001）并发症的发生率显著更高，导致住院时间更长（8±8天对6±4天，p < 0.0001）。多因素分析中，高龄是医院死亡率的独立预测因素。108例（94%）LVD患者的平均随访时间为36±22个月（范围2至78个月）。随访期间21例患者死亡，其中9例死因与心脏相关。3年和5年生存率分别为91±3%和76±6%。多因素分析中，LVD组中期死亡率的独立预测因素包括女性、肾衰竭、呼吸并发症和I/II级二尖瓣反流（MR）。随访时，72%的LVD患者心功能分级为I/II级。LVD亚组间短期和中期预后无统计学显著差异。
严重LVD患者行CABG可获得较低的死亡率，尽管与LVEF>30%的患者相比，其发病率更高、住院时间更长。低射血分数本身并非医院死亡率的预测因素。CABG应被视为缺血性心脏病低射血分数患者的一种安全有效的治疗方法。对于存在中度MR的患者，初次手术时应考虑二尖瓣修复/置换。
