Emmert Maximilian Y, Salzberg Sacha P, Theusinger Oliver M, Rodriguez Hector, Sündermann Simon H, Plass Andre, Starck Christoph T, Seifert Burkhardt, Baulig Werner, Hoerstrup Simon P, Jacobs Stephan, Grünenfelder Jürg, Falk Volkmar
Department of Cardiovascular Surgery, University Hospital Zurich, Raemi Street 100, 8091, Zurich, Switzerland.
Heart Vessels. 2012 May;27(3):258-64. doi: 10.1007/s00380-011-0146-0. Epub 2011 May 17.
Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF ≤35% underwent myocardial-revascularization. Patients received either OPCAB (n = 256) or ONCABG (n = 222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR) = 1.05; p = 0.93) and MACCE (13.7 vs. 17.6%; PS-OR = 1.22; p = 0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR = 0.39; p = 0.26), low cardiac output (2.3 vs. 4.7%; PS-OR = 0.75; p = 0.72) and stroke (2.3 vs. 2.7%; PS-OR = 0.69; p = 0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR = 0.54; p = 0.059) including renal dysfunction (PAOR = 0.77; 95% CI 0.31-1.9; p = 0.57), bleeding (PAOR = 0.42; 95% CI 0.14-1.20; p = 0.10) and respiratory failure (PAOR = 0.39; 95% CI 0.05-3.29; p = 0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR = 0.75; p = 0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularization.
射血分数严重降低是心脏手术后预后较差的一个既定风险因素。我们比较了射血分数严重受损患者的非体外循环冠状动脉旁路移植术（OPCAB）和体外循环冠状动脉旁路移植术（ONCABG）的预后。2004年至2009年，478例射血分数降低至≤35%的患者接受了心肌血运重建。患者接受OPCAB（n = 256）或ONCABG（n = 222）。倾向评分（PS）包括50个术前风险因素，用于平衡两组之间的特征。进行PS调整的逻辑回归分析以评估死亡率和主要不良心脏和脑血管事件（MACCE）。应用了包括呼吸衰竭、肾衰竭、再次开胸等主要非心脏并发症的复合终点。当远端吻合口数量大于病变血管数量时，假定为完全血运重建（CR）。死亡率（2.3%对4.1%；PS调整比值比（PS-OR）= 1.05；p = 0.93）和MACCE（13.7%对17.6%；PS-OR = 1.22；p = 0.50）包括心肌梗死（1.4%对4.9%；PS-OR = 0.39；p = 0.26）、低心排血量（2.3%对4.7%；PS-OR = 0.75；p = 0.72）和中风（2.3%对2.7%；PS-OR = 0.69；p = 0.66）方面无差异。OPCAB患者出现非心脏复合终点的频率有降低趋势（12.1%对22.1%；PS-OR = 0.54；p = 0.059），包括肾功能不全（PAOR = 0.77；95%可信区间0.31 - 1.9；p = 0.57）、出血（PAOR = 0.42；95%可信区间0.14 - 1.20；p = 0.10）和呼吸衰竭（PAOR = 0.39；95%可信区间0.05 - 3.29；p = 0.39）。完全血运重建率相似（92.2%对92.8%；PS-OR = 0.75；p = 0.50）。射血分数严重降低患者的OPCAB是安全可行的。在非心脏并发症方面甚至可能使这些患者受益，且不会以不完全血运重建为代价。
