Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, and Translational Research Center, Kyoto University Hospital, Kyoto, Japan.
Ann Thorac Surg. 2011 May;91(5):1393-9. doi: 10.1016/j.athoracsur.2011.01.022. Epub 2011 Mar 10.
Liver cirrhosis is a major risk factor for cardiac surgery using cardiopulmonary bypass. However, percutaneous coronary intervention (PCI) or off-pump coronary artery bypass graft surgery (OPCABG) may be a less invasive alternative strategy.
Among the 9,877 patients undergoing first PCI or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 332 patients diagnosed with liver cirrhosis were entered into the study (age 67.1±9.4 years; 246 male). Liver cirrhosis was diagnosed by liver biopsy or signs of portal hypertension with characteristic morphologic liver and spleen changes.
A total of 233 patients received PCI, 58 conventional on-pump CABG (CCABG), and 41 OPCABG. Median follow-up was 3.3 years. The PCI group included less complex coronary lesions such as triple vessel and left main disease (p<0.01 each). Propensity score adjusted in-hospital mortality after CCABG or OPCABG was higher than that after PCI; however, the differences were not significant (odds ratio [95% confidence interval]: 6.84 [0.52 to 90.8], p=0.14 for CCABG versus PCI; and 1.86 [0.08 to 45.8], p=0.71 for OPCABG versus PCI). Adjusted overall mortality after CCABG or CABG was lower than that after PCI, but the differences were not significant (0.66 [0.31 to 1.40], p=0.28; and 0.64 [0.28 to 1.49], p=0.31, respectively). Approximately two thirds of patients died of noncardiovascular morbidities (malignancies, including hepatocarcinoma, or hepatic decompression).
Because overall noncardiovascular mortality is high among patients with liver cirrhosis, complete revascularization may not be associated with better survival outcomes. Further study is warranted to determine the impact of a coronary revascularization strategy for liver cirrhosis patients.
肝硬化是体外循环心脏手术的一个主要危险因素。然而，经皮冠状动脉介入治疗（PCI）或非体外循环冠状动脉旁路移植术（OPCABG）可能是一种侵袭性较小的替代策略。
在日本 CREDO-Kyoto 注册研究（首次 PCI 和 CABG 患者注册研究）中，纳入了 9877 例首次行 PCI 或 CABG 的患者，其中 332 例患者被诊断为肝硬化（年龄 67.1±9.4 岁，246 例男性）。肝硬化通过肝活检或门静脉高压的迹象诊断，伴有特征性的肝脾形态改变。
共 233 例患者行 PCI，58 例行常规体外循环 CABG（CCABG），41 例行 OPCABG。中位随访时间为 3.3 年。PCI 组的冠状动脉病变较复杂，如三支病变和左主干病变（均 P<0.01）。CCABG 或 OPCABG 后住院死亡率经倾向性评分调整后高于 PCI 后，但差异无统计学意义（比值比[95%置信区间]：CCABG 与 PCI 比较为 6.84[0.52 至 90.8]，P=0.14；OPCABG 与 PCI 比较为 1.86[0.08 至 45.8]，P=0.71）。CCABG 或 CABG 后全因死亡率经调整后低于 PCI 后，但差异无统计学意义（0.66[0.31 至 1.40]，P=0.28；0.64[0.28 至 1.49]，P=0.31）。大约三分之二的患者死于非心血管疾病（恶性肿瘤，包括肝癌或肝失代偿）。
由于肝硬化患者的总体非心血管死亡率较高，完全血运重建可能与生存获益无关。需要进一步研究确定对肝硬化患者的冠状动脉血运重建策略的影响。
