常规非体外循环冠状动脉旁路移植术在左主干病变高危患者中是安全可行的。
Routine off-pump coronary artery bypass grafting is safe and feasible in high-risk patients with left main disease.
机构信息
Department of Cardiac and Vascular Surgery, University Hospital Zurich, and Biostatistics Unit, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland.
出版信息
Ann Thorac Surg. 2010 Apr;89(4):1125-30. doi: 10.1016/j.athoracsur.2009.12.059.
BACKGROUND
Coronary artery bypass graft surgery (CABG) remains the method of choice for patients with left main disease (LMD). The precise role of off-pump coronary artery bypass graft surgery (OPCABG) remains unclear in this setting. We report the safety and feasibility of a routine OPCABG approach to patients with LMD.
METHODS
From 2002 to 2007, 983 patients underwent myocardial revascularization at our institution. We compared 343 OPCABG patients with LMD (group A) to 640 OPCABG patients without LMD (group B). The relationship between the presence of LMD and outcome in OPCABG procedures was statistically assessed. A composite endpoint (30-day mortality, postoperative renal failure, intensive care unit length of stay [>2 days], neurologic complications, use of intra-aortic balloon pump, and conversion to cardiopulmonary bypass) was also used. In addition, completeness of revascularization was compared in both groups.
RESULTS
Group A had a lower mortality rate (1.7% versus 2.2%; p=0.81), and no differences were noted in conversion to cardiopulmonary bypass (6.7% versus 5.3%; p=0.39), intra-aortic balloon pump use (0.3% versus 1.4%; p=0.18), and occurrence of composite endpoint (30.9% versus 30.8%; p=0.99). The number of arterial grafts per patient was significantly higher among patients in group A (1.77+/-0.95 versus 1.66+/-0.95; p=0.029) owing to the more frequent use of the right internal mammary artery (49.6% versus 42.3%; p=0.031), whereas the total number of distal anastomoses (3.72+/-0.90 versus 3.62+/-1.01; p=0.28) and complete revascularization (94% versus 95%; p=0.55) were similar. Logistic regression confirmed that LMD is no risk factor for the occurrence of our composite endpoint (odds ratio 1.00; 95% confidence interval: 0.75 to 1.33; p=0.99).
CONCLUSIONS
A modern OPCABG approach offers low mortality, excellent clinical outcomes, and does not come at the price of less complete revascularization in these high-risk patients.
背景
冠状动脉旁路移植术（CABG）仍然是左主干疾病（LMD）患者的首选方法。非体外循环冠状动脉旁路移植术（OPCABG）在这种情况下的确切作用仍不清楚。我们报告了对 LMD 患者常规采用 OPCABG 方法的安全性和可行性。
方法
2002 年至 2007 年，我院共对 983 例患者进行了心肌血运重建。我们比较了 343 例 LMD（A 组）和 640 例无 LMD 的 OPCABG 患者（B 组）。统计学评估了 LMD 的存在与 OPCABG 手术结果之间的关系。还使用了复合终点（30 天死亡率、术后肾功能衰竭、重症监护病房住院时间[>2 天]、神经并发症、使用主动脉内球囊泵和转为心肺旁路）。此外，还比较了两组的血运重建完整性。
结果
A 组死亡率较低（1.7%比 2.2%；p=0.81），转换为心肺旁路的比例无差异（6.7%比 5.3%；p=0.39），使用主动脉内球囊泵的比例（0.3%比 1.4%；p=0.18）和复合终点的发生率（30.9%比 30.8%；p=0.99）也无差异。A 组每位患者的动脉移植物数量明显更高（1.77+/-0.95 比 1.66+/-0.95；p=0.029），这归因于右侧内乳动脉的更频繁使用（49.6%比 42.3%；p=0.031），而远端吻合数量（3.72+/-0.90 比 3.62+/-1.01；p=0.28）和完全血运重建（94%比 95%；p=0.55）相似。逻辑回归证实 LMD 不是发生我们复合终点的危险因素（比值比 1.00；95%置信区间：0.75 至 1.33；p=0.99）。
结论
现代 OPCABG 方法可降低死亡率，提供良好的临床结果，并且不会降低高危患者的血运重建完整性。
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