Pocar Marco, Moneta Andrea, Grossi Adalberto, Donatelli Francesco
Università degli Studi di Milano, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.
Ann Thorac Surg. 2007 Feb;83(2):468-74. doi: 10.1016/j.athoracsur.2006.09.029.
Coronary artery bypass grafting (CABG) has been safely extended to ischemic cardiomyopathy and heart failure, but outcome beyond 5 years remains poorly defined.
We retrospectively analyzed 45 consecutive angina-free patients with ischemic left ventricular dysfunction (ejection fraction < or = 0.35) and heart failure (New York Heart Association functional class III to IV) who were selected for CABG between 1988 and 1995. Positron emission tomography was used for preoperative identification of myocardial viability.
The 30-day mortality was 4.4%. At a median follow-up of 117 months (longest observation, 205 months), the probability of survival at 1, 5, 10, and 15 years after CABG was 93.3%, 84%, 65%, and 44%, respectively. At multivariable analysis, a left ventricular end-diastolic pressure (LVEDP) of 25 mm Hg or more predicted a threefold increase of the hazard of death (p = 0.02), whereas a LVEDP of 20 mm Hg or more correlated with the requirement of an intraaortic balloon pump perioperatively (p = 0.04). Other independent predictors of survival were age older than 70 years and peripheral vascular disease. Cardiac events accounted for 88% of late deaths, which were primarily related to sudden death or progressive heart failure. Most patients were in New York Heart Association functional class I to II at late follow-up.
CABG alone yields good long-term outcome in selected angina-free patients with ischemic systolic dysfunction and advanced heart failure. However, associated diastolic impairment, reflected by elevated LVEDP, predicts reduced long-term survival despite myocardial viability.
冠状动脉旁路移植术（CABG）已安全地应用于缺血性心肌病和心力衰竭患者，但5年以上的预后仍不明确。
我们回顾性分析了1988年至1995年间连续入选接受CABG的45例无心绞痛的缺血性左心室功能不全（射血分数≤0.35）和心力衰竭（纽约心脏协会心功能分级III至IV级）患者。术前使用正电子发射断层扫描来识别心肌存活情况。
30天死亡率为4.4%。中位随访117个月（最长观察期205个月），CABG术后1年、5年、10年和15年的生存率分别为93.3%、84%、65%和44%。多变量分析显示，左心室舒张末期压力（LVEDP）≥25 mmHg可预测死亡风险增加两倍（p = 0.02），而LVEDP≥20 mmHg与围手术期主动脉内球囊泵的使用相关（p = 0.04）。其他独立的生存预测因素包括年龄≥70岁和外周血管疾病。心脏事件占晚期死亡的88%，主要与猝死或进行性心力衰竭有关。大多数患者在晚期随访时纽约心脏协会心功能分级为I至II级。
对于选定的无心绞痛、缺血性收缩功能障碍和晚期心力衰竭患者，单纯CABG可产生良好的长期预后。然而，LVEDP升高所反映的相关舒张功能障碍预示着尽管心肌存活，但长期生存率会降低。
