在多支冠状动脉疾病中，移植物数量是否会影响外科医生对于非体外循环冠状动脉搭桥术相对于传统体外循环冠状动脉搭桥术的选择以及患者从中获得的益处？

Does the number of grafts influence surgeon choice and patient benefit of off-pump over conventional on-pump coronary artery revascularization in multivessel coronary artery disease?

作者信息

Lattouf Omar M, Puskas John D, Thourani Vinod H, Noora Joseph, Kilgo Patrick D, Guyton Robert A

机构信息

Joseph B. Whitehead Department of Surgery, Division of Cardiothoracic Surgery, Carlyle Fraser Heart Center, Emory University School of Medicine, Atlanta, Georgia 30308, USA.

出版信息

Ann Thorac Surg. 2007 Nov;84(5):1485-94; discussion 1494-5. doi: 10.1016/j.athoracsur.2007.06.035.

DOI:10.1016/j.athoracsur.2007.06.035

PMID:17954050

Abstract

BACKGROUND

It is not known whether surgeons preferentially assign patients requiring fewer grafts (1 to 3) to off-pump coronary artery bypass graft surgery (OPCABG) and those requiring many grafts (4 to 7) to conventional on-pump coronary artery bypass graft surgery (ONCABG), nor whether risk-adjusted outcomes are similar for OPCABG and ONCABG among patients receiving 1 to 3 and 4 to 7 grafts.

METHODS

Emory Hospitals' prospective database was retrospectively reviewed for 11,413 consecutive, isolated, primary coronary revascularization procedures between January 1997 and May 2005. Patients were divided into four groups: OPCABG 1 to 3 grafts (n = 3,187), OPCABG 4 to 7 grafts (n = 1,305), ONCABG 1 to 3 grafts (n = 3,279), and ONCABG 4 to 7 grafts (n = 3,642). A propensity score for surgery type was estimated from 39 risk factors. Multivariable logistic regression examined independent impact of surgery type and number of vessels grafted on outcomes. Computed interactions determined whether the effect of surgery type on risk-adjusted outcomes was consistent across groups.

RESULTS

Patients requiring 4 to 7 grafts had adjusted odds of receiving ONCABG 2.92 times higher than patients requiring 1 to 3 grafts (p < 0.001). The OPCABG patients had adjusted odds ratios of 0.53 for death (p = 0.007), 0.42 for stroke (p < 0.001), 0.51 for major adverse cardiac events (p < 0.001), and 0.71 for renal failure (p = 0.05) as compared with ONCABG patients. The interaction between OPCABG and number of vessels grafted was not statistically significant.

CONCLUSIONS

This study demonstrates that surgeons tend to perform OPCABG for patients requiring 1 to 3 grafts and ONCABG for those requiring 4 to 7 grafts. Off-pump CABG is associated with reduced adjusted risk of adverse outcomes compared with ONCABG. This benefit is consistent for patients requiring 1 to 3 or 4 to 7 grafts.

摘要

背景

目前尚不清楚外科医生是否会优先将需要较少移植血管（1至3根）的患者分配至非体外循环冠状动脉旁路移植术（OPCABG），而将需要较多移植血管（4至7根）的患者分配至传统体外循环冠状动脉旁路移植术（ONCABG），也不清楚在接受1至3根和4至7根移植血管的患者中，OPCABG和ONCABG的风险调整后结局是否相似。

方法

回顾性分析了埃默里医院前瞻性数据库中1997年1月至2005年5月期间连续进行的11413例孤立性、原发性冠状动脉血运重建手术。患者分为四组：OPCABG 1至3根移植血管组（n = 3187）、OPCABG 4至7根移植血管组（n = 1305）、ONCABG 1至3根移植血管组（n = 3279）和ONCABG 4至7根移植血管组（n = 3642）。根据39个风险因素估算手术类型的倾向评分。多变量逻辑回归分析了手术类型和移植血管数量对结局的独立影响。计算交互作用以确定手术类型对风险调整后结局的影响在各组中是否一致。

结果

需要4至7根移植血管的患者接受ONCABG的调整后比值比是需要1至3根移植血管患者的2.92倍（p < 0.001）。与ONCABG患者相比，OPCABG患者死亡的调整后比值比为0.53（p = 0.007），中风为0.42（p < 0.001），主要不良心脏事件为0.51（p < 0.001），肾衰竭为0.71（p = 0.05）。OPCABG与移植血管数量之间的交互作用无统计学意义。