Fattouch Khalil, Guccione Francesco, Dioguardi Pietro, Sampognaro Roberta, Corrado Egle, Caruso Marco, Ruvolo Giovanni
Unit of Cardiac Surgery, University of Palermo, Palermo, Italy.
J Thorac Cardiovasc Surg. 2009 Mar;137(3):650-6; discussion 656-7. doi: 10.1016/j.jtcvs.2008.11.033.
Conventional cardioplegic arrest coronary artery bypass grafting after ST-segment elevation myocardial infarction is associated with high mortality and morbidity. The benefits of off-pump surgery have been suggested. This study randomly evaluated the impact of the off-pump technique on clinical results.
Between February 2002 and October 2007, 128 patients with ST-segment elevation myocardial infarction who underwent myocardial revascularization within 48 hours from the onset of symptoms were randomly assigned to 2 groups: on-pump group (66 patients/51.5%) and off-pump group (63 patients/48.5%). The primary end point was the incidence of in-hospital death and outcomes (low cardiac output syndrome, prolonged mechanical and pharmacologic cardiac support, prolonged mechanical ventilation support, and postoperative length of stay in intensive care unit and hospital). The secondary end point was the evaluation of myocardial infarct size measured by the perioperative serum release of cardiac troponin I and the improvement of contractile cardiac function evaluated by the wall motion score index.
Overall in-hospital mortality was 4.6%. In-hospital mortality was 7.7% (5 patients) in the on-pump group and 1.6% (1 patient) in the off-pump group (P = .04). Statistically significant differences were found between the 2 groups concerning the incidence of low cardiac output syndrome (P = .001), time of inotrope drugs support (P = .001), time of mechanical ventilation (P = .006), reoperation for bleeding (P = .04), intensive care unit stay (P = .01), and in-hospital stay (P = .02). Statistically significant differences also were found between the 2 groups concerning the incidence of in-hospital death in patients who were admitted to surgery in cardiac shock (P = .0018) and patients who underwent surgery within 6 hours from the onset of symptoms (P = .0026). The procedure in 1 patient (1.6%) in the off-pump group was converted to the on-pump beating heart technique. The serum levels of cardiac troponin I were high in the on-pump group during the first 48 hours after surgery. Myocardial function was better in the off-pump group. There were no cardiac-related late deaths, and patients had no recurrent cardiac events.
Off-pump surgery reduced early mortality and morbidity in patients with ST-segment elevation myocardial infarction in respect to the conventional procedure. Off-pump surgery showed better results than on-pump surgery in patients who underwent surgery within 6 hours from the onset of symptoms and in patients with cardiogenic shock.
ST段抬高型心肌梗死后传统的心脏停搏冠状动脉搭桥术与高死亡率和高发病率相关。非体外循环手术的益处已被提及。本研究随机评估了非体外循环技术对临床结果的影响。
在2002年2月至2007年10月期间，128例症状发作后48小时内接受心肌血运重建的ST段抬高型心肌梗死患者被随机分为两组：体外循环组（66例患者/51.5%）和非体外循环组（63例患者/48.5%）。主要终点是院内死亡发生率及结局（低心排血量综合征、延长的机械和药物心脏支持、延长的机械通气支持以及术后重症监护病房和住院时间）。次要终点是通过围手术期心肌肌钙蛋白I的血清释放量评估心肌梗死面积以及通过室壁运动评分指数评估心脏收缩功能的改善情况。
总体院内死亡率为4.6%。体外循环组院内死亡率为7.7%（5例患者），非体外循环组为1.6%（1例患者）（P = 0.04）。两组在低心排血量综合征发生率（P = 0.001）、血管活性药物支持时间（P = 0.001）、机械通气时间（P = 0.006）、因出血再次手术（P = 0.04）、重症监护病房住院时间（P = 0.01）和住院时间（P = 0.02）方面存在统计学显著差异。两组在心脏休克患者（P = 0.0018）以及症状发作后6小时内接受手术的患者（P = 0.0026）的院内死亡发生率方面也存在统计学显著差异。非体外循环组有1例患者（1.6%）的手术转为体外循环心脏跳动技术。体外循环组术后最初48小时内心肌肌钙蛋白I血清水平较高。非体外循环组心肌功能更好。没有与心脏相关的晚期死亡，患者也没有复发性心脏事件。
与传统手术相比，非体外循环手术降低了ST段抬高型心肌梗死患者的早期死亡率和发病率。在症状发作后6小时内接受手术的患者以及心源性休克患者中，非体外循环手术的结果优于体外循环手术。
