Aldea Gabriel S, Mokadam Nahush A, Melford Rayland, Stewart Douglas, Maynard Charles, Reisman Mark, Goss Richard
Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
Ann Thorac Surg. 2009 Jun;87(6):1828-38. doi: 10.1016/j.athoracsur.2009.03.067.
This study analyzed and quantified perceptions that evolving percutaneous coronary intervention technologies changed referral patterns of patients with coronary artery disease and adversely impacted volumes, risk profiles, and outcomes of patients undergoing coronary artery bypass grafting surgery (CABG).
Washington State's prospective clinical registry was used to analyze volumes, risk profiles, and outcomes of all patients undergoing isolated CABG and percutaneous coronary intervention.
A total of 154,602 revascularization procedures were performed between 1999 and 2007. Total revascularizations procedures (percutaneous coronary intervention plus CABG) increased by 32% (from 14,084 in 1999 to 18,620 in 2007). Compared with 1999, by 2007 CABG volume decreased by 37%, while percutaneous coronary intervention volume increased by 71%. The ratio of percutaneous coronary intervention to CABG increased by 2.7-fold from 1.7:1 to 4.6:1 (p < 0.0001). Three time intervals were compared (1999-2000, 2001-2003, 2004-2007). For patients undergoing CABG, the prevalence of diabetes (28% to 36%), hypertension (66% to 76%), and three-vessel or left main disease (57% to 68%) increased significantly (p < 0.0001 for all). Female sex (28% to 24%), congestive failure (24% to 13%), and smoking (64% to 59%) decreased significantly (p < 0.0001 for all), whereas patients' age, low ejection fraction, and use of intraaortic balloon pump were unchanged. Although mortality (2.4% to 2.2%; p = 0.79), return to the operating room (3.4% to 3.6%; p = 0.41), and need for postoperative hemodialysis (1.2% to 1.0%; p = 0.44) were unchanged, the incidences of stroke (1.9% to 1.3%; p = 0.01), myocardial infarction (1.7% to 0.8%; p < 0.0001), transfusion (40% to 34%; p < 0.0001), and extubation within 6 hours (43% to 60%; p < 0.0001) improved significantly in the past 9 years.
Despite significant reduction in both the volume and ratio of patients referred for surgical revascularization, risk profiles of patients undergoing isolated CABG in Washington State changed only modestly. Coronary artery bypass grafting mortality was not adversely affected, and morbidity was reduced.
本研究分析并量化了以下观点，即不断发展的经皮冠状动脉介入技术改变了冠心病患者的转诊模式，并对接受冠状动脉旁路移植术（CABG）患者的手术量、风险特征及手术结果产生了不利影响。
利用华盛顿州的前瞻性临床登记系统分析所有接受单纯CABG和经皮冠状动脉介入治疗患者的手术量、风险特征及手术结果。
1999年至2007年间共进行了154,602例血运重建手术。血运重建手术总数（经皮冠状动脉介入治疗加CABG）增加了32%（从1999年的14,084例增至2007年的18,620例）。与1999年相比，到2007年CABG手术量减少了37%，而经皮冠状动脉介入治疗手术量增加了71%。经皮冠状动脉介入治疗与CABG的比例从1.7:1增至4.6:1，增长了2.7倍（p < 0.0001）。比较了三个时间段（1999 - 2000年、2001 - 2003年、2004 - 2007年）。接受CABG的患者中，糖尿病患病率（从28%升至36%）、高血压患病率（从66%升至76%）以及三支血管病变或左主干病变患病率（从57%升至68%）显著增加（均p < 0.0001）。女性患者比例（从28%降至24%）、充血性心力衰竭患者比例（从24%降至13%）以及吸烟患者比例（从64%降至59%）显著下降（均p < 0.0001），而患者年龄、低射血分数以及主动脉内球囊泵的使用情况未变。尽管死亡率（从2.4%降至2.2%；p = 0.79）、返回手术室的比例（从3.4%升至3.6%；p = 0.41）以及术后需要血液透析的比例（从1.2%降至1.0%；p = 0.44）未变，但在过去9年中，中风发生率（从1.9%降至1.3%；p = 0.01）、心肌梗死发生率（从1.7%降至0.8%；p < 0.0001）、输血率（从40%降至34%；p < 0.0001）以及6小时内拔管率（从43%升至60%；p < 0.0001）均有显著改善。
尽管接受外科血运重建的患者数量及其比例显著下降，但华盛顿州接受单纯CABG患者的风险特征仅有适度变化。冠状动脉旁路移植术的死亡率未受到不利影响，且发病率有所降低。
