Kiani Soroosh, Brown Alex K, Kurian Dinesh J, Henkin Stanislav, Flynn Mary M, Thirumavalavan Nannan, Desai Pranjal H, Poston Robert S
Division of Cardiothoracic Surgery, University of Arizona School of Medicine, Tucson, AZ 85724-5071, USA.
Innovations (Phila). 2012 May-Jun;7(3):180-6. doi: 10.1097/IMI.0b013e3182614f80.
Several centers have established that off-pump, multivessel coronary artery bypass grafting performed via a small thoracotomy (MVST) is feasible. However, this procedure can be challenging when posterolateral coronary targets need to be grafted. We hypothesized that use of cardiopulmonary bypass via peripheral access (MVST-PA) would improve outcomes compared with a completely off-pump approach (OP-MVST).
This was a prospective observational study of patients undergoing OP-MVST (n = 46) versus MVST-PA (n = 45) using bilateral internal mammary artery grafts onto the left anterior descending coronary artery and circumflex/right coronary artery distribution. Hemostasis was quantified by measuring platelet function (aggregometry), chest tube output, thrombolysis in myocardial infarction bleeding score (%hematocrit change at 24 hours), and transfusion requirements. The rate of mortality and major morbidity at 30 days was defined according to The Society of Thoracic Surgeons criteria. Estimated glomerular filtration rate (normalized to baseline levels) was determined daily until discharge.
The OP-MVST versus MVST-PA groups had similar risk factors at baseline and risks of composite morbidity/mortality at 30 days. However, renal failure was significantly increased after OP-MVST (10.87 vs 0%, P = 0.05), and MVST-PA affected hemostasis as evidenced by inhibition of platelet function (latency to response on aggregometry, 29.9 vs 17.9 seconds; P = 0.04) and higher transfusion requirement (2.31 vs 0.85 units of red blood cells/patient, P = 0.04; 55.6% vs 34.8% transfused; P = 0.059). However, 24-hour chest tube output was similar (645 vs 750 mL; P = 0.53).
In comparison with a completely off-pump strategy, use of cardiopulmonary bypass to assist MVST reduced the risk of renal dysfunction with only modest tradeoffs in other morbidities, for example, altered coagulation and higher transfusion requirements. These data justify further study of the effect of MVST-PA on renal complications.
多个中心已证实，通过小切口开胸进行非体外循环多支冠状动脉旁路移植术（MVST）是可行的。然而，当需要移植后外侧冠状动脉靶点时，该手术可能具有挑战性。我们假设，与完全非体外循环方法（OP-MVST）相比，通过外周通路使用体外循环（MVST-PA）将改善手术结果。
这是一项前瞻性观察性研究，对接受OP-MVST（n = 46）与MVST-PA（n = 45）的患者进行研究，使用双侧乳内动脉移植至左前降支冠状动脉以及回旋支/右冠状动脉分布区域。通过测量血小板功能（凝集测定法）、胸管引流量、心肌梗死溶栓出血评分（24小时时血细胞比容变化百分比）和输血需求来量化止血情况。30天时的死亡率和主要发病率根据胸外科医师协会标准定义。每日测定估计肾小球滤过率（标准化至基线水平）直至出院。
OP-MVST组与MVST-PA组在基线时具有相似的危险因素，30天时的综合发病/死亡率风险也相似。然而，OP-MVST后肾功能衰竭显著增加（10.87%对0%，P = 0.05），并且MVST-PA影响止血，表现为血小板功能受抑制（凝集测定法的反应潜伏期，29.9秒对17.9秒；P = 0.04）以及输血需求更高（每位患者2.31单位对0.85单位红细胞；P = 0.04；输血患者比例55.6%对34.8%；P = 0.059）。然而，24小时胸管引流量相似（645毫升对750毫升；P = 0.53）。
与完全非体外循环策略相比，使用体外循环辅助MVST降低了肾功能不全的风险，在其他发病率方面仅有适度的权衡，例如凝血改变和更高的输血需求。这些数据证明有必要进一步研究MVST-PA对肾脏并发症的影响。
