Nardi Paolo, Pellegrino Antonio, Scafuri Antonio, Colella Dionisio, Bassano Carlo, Polisca Patrizio, Chiariello Luigi
Department of Cardiac Surgery, Policlinico Tor Vergata, Tor Vergata University of Rome, Rome, Italy.
Ann Thorac Surg. 2009 May;87(5):1401-7. doi: 10.1016/j.athoracsur.2009.02.062.
Coronary artery bypass grafting (CABG) is a well-accepted therapeutic strategy for patients with multivessel coronary artery disease and left ventricular dysfunction. The aim of the study was to evaluate long-term results after CABG in patients with preoperative left ventricular ejection fraction (LVEF) of 0.35 or less.
Data from 302 consecutive patients (mean age, 62 +/- 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome.
Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% +/- 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% +/- 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 +/- 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 +/- 0.09 versus 0.28 +/- 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% +/- 3%.
Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.
冠状动脉旁路移植术（CABG）是治疗多支冠状动脉疾病和左心室功能不全患者的一种广泛接受的治疗策略。本研究的目的是评估术前左心室射血分数（LVEF）为0.35或更低的患者行CABG后的长期结果。
分析了302例连续接受CABG且LVEF为0.35或更低的患者（平均年龄62±8.7岁）的数据。使用肾上腺素和依诺昔酮，加或不加去甲肾上腺素来增加心脏指数。术后出现低心排综合征时使用主动脉内球囊泵或左心室辅助装置，或两者同时使用。
302例患者中有298例（98.7%）实现了完全血运重建；294例（97.4%）使用了胸廓内动脉。手术死亡率为5.3%；手术死亡率的独立预测因素为急诊CABG（p = 0.005）、室性心律失常病史（p = 0.007）和既往前壁心肌梗死（p = 0.05）。随访时，全因死亡率为30.8%，10年生存率为63%±4%；晚期全因死亡率的独立预测因素为室性心律失常病史（p < 0.0001）、慢性肾功能不全（p = 0.0004）和糖尿病（p = 0.04）。心源性死亡为20.4%，10年无心脏死亡生存率为73%±3.3%；心源性死亡的独立预测因素为室性心律失常病史（p = 0.004）、慢性肾功能不全（p = 0.03）和既往有不止一次前壁心肌梗死（p = 0.004）。在80±44个月的随访中，超声心动图显示LVEF有显著改善（0.43±0.09对0.28±0.06，p < 0.0001）。10年无心肌梗死生存率为87%±3%。
对于LVEF为0.35或更低的患者，CABG术后可预期获得良好的长期结果。完全血运重建和胸廓内动脉移植与高心肌梗死生存率相关。仔细治疗心律失常、糖尿病和肾功能不全对于提高长期生存率是必要的。
