Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44198, USA.
J Thorac Cardiovasc Surg. 2010 Feb;139(2):283-93, 293.e1-7. doi: 10.1016/j.jtcvs.2009.08.055.
The surgical approach to ischemic cardiomyopathy maximizing survival remains a dilemma, with decisions complicated by secondary mitral regurgitation, ventricular remodeling, and heart failure. As a component of decision support, we sought to develop prediction models for comparing survival after coronary artery bypass grafting alone, coronary artery bypass grafting plus mitral valve anuloplasty, coronary artery bypass grafting plus surgical ventricular restoration, and listing for cardiac transplantation.
From 1997 to 2007, 1468 patients with ischemic cardiomyopathy (ejection fraction <30%) underwent coronary artery bypass grafting alone (n = 386), coronary artery bypass grafting plus mitral valve anuloplasty (n = 212), coronary artery bypass grafting plus surgical ventricular restoration (n = 360), or listing for cardiac transplantation (n = 510). Mean follow-up was 3.8 +/- 2.8 years, with 5577 patient-years of data available for analysis. Risk factors were identified for early and late mortality by using 80% training and 20% validation sets. Outcomes were calculated for each applicable strategy to identify which maximized predicted 5-year survival. Models were programmed as a strategic decision-support tool.
One-, 5-, and 9-year survival were as follows, respectively: coronary artery bypass grafting, 92%, 72%, and 53%; coronary artery bypass grafting plus mitral valve anuloplasty, 88%, 57%, and 34%; coronary artery bypass grafting plus surgical ventricular restoration, 94%, 76%, and 55%; and listing for cardiac transplantation, 79%, 66%, and 54%. Risk factors included older age, higher New York Heart Association class, lower ejection fraction, longer interval from myocardial infarction to operation, and numerous comorbidities. Predicted and observed survivals in validation groups were similar (P > .1). Patient-specific simultaneous solutions of applicable models revealed therapy potentially providing maximum survival benefit. Coronary artery bypass grafting alone and listing for cardiac transplantation often maximized 5-year survival; only 15% of patients undergoing coronary artery bypass grafting plus mitral valve anuloplasty were predicted to fare best with this therapy.
Validated prediction models can aid surgeons in recommending personalized treatment plans that maximize short- and long-term survival for ischemic cardiomyopathy.
最大限度地提高生存率仍然是缺血性心肌病的手术方法的难题，由于继发性二尖瓣反流、心室重构和心力衰竭，决策变得复杂。作为决策支持的一个组成部分，我们试图开发预测模型来比较单独进行冠状动脉旁路移植术、冠状动脉旁路移植术加二尖瓣环成形术、冠状动脉旁路移植术加心脏手术修复术和心脏移植的生存率。
1997 年至 2007 年，1468 例缺血性心肌病（射血分数<30%）患者接受了单独冠状动脉旁路移植术（n=386）、冠状动脉旁路移植术加二尖瓣环成形术（n=212）、冠状动脉旁路移植术加心脏手术修复术（n=360）或心脏移植（n=510）。平均随访 3.8+/-2.8 年，有 5577 患者年的数据可用于分析。使用 80%的训练集和 20%的验证集确定了早期和晚期死亡率的危险因素。为每个适用的策略计算了结果，以确定哪些策略能最大限度地提高预测的 5 年生存率。将模型编程为一个战略决策支持工具。
分别为：冠状动脉旁路移植术，92%、72%和 53%；冠状动脉旁路移植术加二尖瓣环成形术，88%、57%和 34%；冠状动脉旁路移植术加心脏手术修复术，94%、76%和 55%；心脏移植，79%、66%和 54%。危险因素包括年龄较大、纽约心脏协会分级较高、射血分数较低、从心肌梗死到手术的时间间隔较长以及多种合并症。验证组中预测和观察到的生存率相似（P>0.1）。适用于每个患者的模型的同时解决方案显示出治疗可能提供最大的生存获益。单独进行冠状动脉旁路移植术和心脏移植通常可以最大限度地提高 5 年生存率；只有 15%的进行冠状动脉旁路移植术加二尖瓣环成形术的患者预计通过这种治疗获得最佳效果。
验证后的预测模型可以帮助外科医生推荐个性化的治疗方案，以最大限度地提高缺血性心肌病的短期和长期生存率。
