Vasques Francesco, Rainio Antti, Heikkinen Jouni, Mikkola Reija, Lahtinen Jarmo, Kettunen Ulla, Juvonen Tatu, Biancari Fausto
Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.
Heart Vessels. 2013 Jan;28(1):46-56. doi: 10.1007/s00380-011-0200-y. Epub 2011 Nov 9.
Patients aged ≥80 years are at high risk of adverse events after coronary artery bypass grafting. This study was performed to evaluate whether off-pump coronary artery bypass surgery (OPCAB) is superior to conventional surgery (CCAB) in these high-risk patients. The outcome of 185 patients aged ≥80 years who underwent OPCAB or CCAB at our institution was reviewed and a meta-analysis on this issue was performed. Similar immediate postoperative results were observed after OPCAB and CCAB at our institution, despite significantly different operative risk (mean logistic EuroSCORE, OPCAB 20.3% vs CCAB 13.4%, P = 0.003). Among 56 propensity score matched pairs a trend toward lower postoperative stroke (0%, 95% CI 0-0 vs 3.6%, 95% CI 0-10.0, P = 0.50) was observed after OPCAB. No significant differences were observed in the other outcome end points. Five-year survival was 81.0% after OPCAB and 78.1% after CCAB (P = 0.239). Pooled analysis of eight studies including 3416 patients showed a significantly higher risk of postoperative stroke after CCAB (pooled rates: 4.2%, 95% confidence interval (95% CI) 2.4-7.1 vs 1.5%, 95% CI 0.9-2.5, risk ratio (RR) 2.15, 95% CI 1.17-3.96, P = 0.01). A trend toward higher immediate postoperative mortality was observed after CCAB (15 studies including 4409 patients, pooled rates: 6.5%, 95% CI 5.2-8.0 vs 5.6%, 95% CI 4.2-7.4, RR 1.29, 95% CI 0.86-1.93, P = 0.21). Generic inverse variance analysis showed similar intermediate survival after CCAB and OPCAB (RR 1.31, 95% CI 0.85-2.01, P = 0.22). At 2 years, survival was 82.8% (95% CI 76.4-89.2) after CCAB and 88.3% (95% CI 82.9-93.7) after OPCAB. Current results indicate that OPCAB compared with CCAB in patients aged ≥80 years is associated with significantly lower postoperative stroke and with a trend toward better early survival. However, suboptimal quality of the available studies, particularly the lack of comparability of the study groups, prevents conclusive results on this controversial issue.
80岁及以上的患者在冠状动脉搭桥术后发生不良事件的风险很高。本研究旨在评估非体外循环冠状动脉搭桥手术（OPCAB）在这些高危患者中是否优于传统手术（CCAB）。回顾了在我们机构接受OPCAB或CCAB的185例80岁及以上患者的结果，并对该问题进行了荟萃分析。尽管手术风险存在显著差异（平均逻辑欧洲心脏手术风险评估系统评分，OPCAB为20.3%，CCAB为13.4%，P = 0.003），但在我们机构，OPCAB和CCAB术后的近期结果相似。在56对倾向评分匹配的患者中，观察到OPCAB术后有降低术后中风的趋势（0%，95%可信区间0 - 0 vs 3.6%，95%可信区间0 - 10.0，P = 0.50）。在其他结局终点未观察到显著差异。OPCAB术后五年生存率为81.0%，CCAB术后为78.1%（P = 0.239）。对包括3416例患者的八项研究进行的汇总分析显示，CCAB术后发生中风的风险显著更高（汇总发生率：4.2%，95%可信区间（95%CI）2.4 - 7.1 vs 1.5%，95%CI 0.9 - 2.5，风险比（RR）2.15，95%CI 1.17 - 3.96，P = 0.01）。观察到CCAB术后有术后即刻死亡率升高的趋势（15项研究包括4409例患者，汇总发生率：6.5%，95%CI 5.2 - 8.0 vs 5.6%，95%CI 4.2 - 7.4，RR 1.29，95%CI 0.86 - 1.93，P = 0.21）。通用逆方差分析显示CCAB和OPCAB术后的中期生存率相似（RR 1.31，95%CI 0.85 - 2.01，P = 0.22）。在2年时，CCAB术后生存率为82.8%（95%CI 76.4 - 89.2），OPCAB术后为88.3%（95%CI 82.9 - 93.7）。目前的结果表明，在80岁及以上的患者中，与CCAB相比，OPCAB术后中风显著降低，且有早期生存更好的趋势。然而，现有研究质量欠佳，尤其是研究组缺乏可比性，使得在这个有争议的问题上无法得出确凿的结果。
