Filsoufi Farzan, Rahmanian Parwis B, Castillo Javier G, Chikwe Joanna, Adams David H
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
Heart Surg Forum. 2007;10(5):E349-56. doi: 10.1532/HSF98.20071067.
The patient population referred for coronary artery bypass grafting (CABG) has become more challenging. The surgical population is aging and patients present with significant preoperative comorbidities. This worsening risk profile has led to the development of operative techniques (off-pump CABG) and perioperative measures (epi-aortic scanning, intensive insulin therapy) to preserve the quality of care following CABG. The aim of this study was to determine the outcome of contemporary CABG following the implementation of the above measures in our practice.
We retrospectively analyzed prospectively collected data of 2725 patients undergoing CABG between 01/1998 and 12/2005 (mean age, 65 +/- 11 years; 843 [31%] female; mean ejection fraction, 45% +/- 14%). Outcome measures included hospital mortality, postoperative complications, and long-term survival and independent predictors of outcome. Subgroup analyses were performed for 2 study periods (1998-2002 versus 2003-2005) where the above measures were implemented and for patients undergoing conventional versus off-pump CABG.
When comparing the 2 study periods, we observed a substantial worsening of the risk profile with an increased EuroSCORE predicted mortality from 6.4% +/- 6.8% to 7.0% +/- 7.8% (P = .028). During the same period, operative mortality decreased from 2.4% to 0.7% (P < .001). This reduction in mortality was also observed in diabetic patients (3.1% versus 1.0%, P = .021) and those with low ejection fraction (4% versus 2.6%, P = not significant). Off-pump procedures were performed with an increasing frequency in high-risk patients in whom we obtained excellent results. Finally, we observed a reduction of postoperative complications including respiratory failure (P = .013), gastrointestinal complications (P = .017), and stroke (P = .094). Independent predictors of mortality included renal failure (OR = 5.7), peripheral vascular disease (OR = 2.9), intra-aortic balloon pump (OR = 4.8), reoperation (OR = 3.3), and hypertension (OR = 2.3).
Despite a worsening case mix, contemporary CABG can be performed with excellent results (operative mortality < 1%). Off-pump CABG performed in very high-risk patients obtains results similar to those of the general CABG population. Diabetes and ejection fraction were not independent predictors of early outcome. In our experience, these excellent outcomes were achieved by adopting an operative approach using modern perioperative management (epi-aortic scanning, intensive insulin therapy) and surgical techniques (off-pump CABG) based on individual patients.
接受冠状动脉旁路移植术（CABG）的患者群体面临的挑战日益增加。手术患者群体老龄化，且患者术前合并症严重。这种风险状况的恶化促使了手术技术（非体外循环冠状动脉旁路移植术）和围手术期措施（主动脉弓扫描、强化胰岛素治疗）的发展，以维持冠状动脉旁路移植术后的医疗质量。本研究的目的是确定在我们的实践中实施上述措施后当代冠状动脉旁路移植术的结果。
我们回顾性分析了1998年1月至2005年12月期间2725例行冠状动脉旁路移植术患者的前瞻性收集数据（平均年龄65±11岁；843例[31%]为女性；平均射血分数45%±14%）。结果指标包括医院死亡率、术后并发症、长期生存率及结果的独立预测因素。对两个研究阶段（1998 - 2002年与2003 - 2005年）进行亚组分析，这两个阶段实施了上述措施，同时对接受传统冠状动脉旁路移植术与非体外循环冠状动脉旁路移植术的患者进行了亚组分析。
比较两个研究阶段时，我们观察到风险状况显著恶化，欧洲心脏手术风险评估系统（EuroSCORE）预测死亡率从6.4%±6.8%增至7.0%±7.8%（P = 0.028）。同期，手术死亡率从2.4%降至0.7%（P < 0.001）。糖尿病患者（3.1%对1.0%，P = 0.021）及射血分数低的患者（4%对2.6%，P无统计学意义）的死亡率也有下降。在高危患者中，非体外循环手术的实施频率增加，且取得了良好效果。最后，我们观察到术后并发症减少，包括呼吸衰竭（P = 0.013）、胃肠道并发症（P = 0.017）和中风（P = 0.094）。死亡率的独立预测因素包括肾衰竭（比值比[OR] = 5.7）、外周血管疾病（OR = 2.9）、主动脉内球囊反搏（OR = 4.8）、再次手术（OR = 3.3）和高血压（OR = 2.3）。
尽管病例组合情况恶化，但当代冠状动脉旁路移植术仍可取得良好效果（手术死亡率<1%）。在极高危患者中实施的非体外循环冠状动脉旁路移植术取得的结果与一般冠状动脉旁路移植术患者相似。糖尿病和射血分数并非早期结果的独立预测因素。根据我们的经验，通过采用基于个体患者的手术方法，运用现代围手术期管理（主动脉弓扫描、强化胰岛素治疗）和手术技术（非体外循环冠状动脉旁路移植术），可取得这些优异结果。
