冠状动脉再次手术后，左前降支冠状动脉内乳动脉移植的价值。
Value of internal thoracic artery grafting to the left anterior descending coronary artery at coronary reoperation.
机构信息
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
出版信息
J Am Coll Cardiol. 2013 Jan 22;61(3):302-10. doi: 10.1016/j.jacc.2012.09.045.
OBJECTIVES
The study sought to determine if left internal thoracic artery (LITA) grafting of the left anterior descending (LAD) at reoperative coronary artery bypass grafting (CABG) improves patient outcomes.
BACKGROUND
LITA grafting to the LAD is the gold standard for primary CABG, but its value for reoperative CABG is unknown.
METHODS
From January 1985 to January 2007, reoperative CABG was performed in 3,473 patients who did not receive a LITA during their primary CABG and whose anterior myocardium (LAD) was at risk at reoperation: 2,389 had LITA grafting and 1,084 saphenous vein (SV) grafting to the LAD. Propensity matching (908 matched pairs) was used for balanced comparison of outcomes. Follow-up was continued to 20 years post-operatively, with a mean follow-up of 11 ± 8.2 years.
RESULTS
Unadjusted hospital mortality was 2.2% and 6.5% in the LITA and SV groups, respectively (p < 0.001), but 3.1% and 5.6% in propensity-matched groups (p = 0.008). Unadjusted survival at 1, 5, 10, 15, and 20 years was 94%, 82%, 64%, 46%, and 32% for the LITA group, but 88%, 73%, 50%, 32%, and 18% for the SV group (p <.0001), respectively. For propensity-matched groups, both early (p = 0.01) and late survival was greater (p = 0.005) in the LITA group. At 20 years, LITA grafting of the LAD at reoperation resulted in an absolute mortality risk reduction of 6.0% and a hazard ratio of 0.85, with number needed to treat of 16 patients.
CONCLUSIONS
LITA-to-LAD grafting at reoperation is safe and confers a risk-adjusted survival advantage. When appropriate, a LITA should be used to revascularize the LAD at coronary reoperations.
目的
本研究旨在探讨在再次冠状动脉旁路移植术（CABG）中，左内乳动脉（LITA）对左前降支（LAD）的搭桥是否能改善患者的预后。
背景
LITA 桥接至 LAD 是初次 CABG 的金标准，但对于再次 CABG 的价值尚不清楚。
方法
1985 年 1 月至 2007 年 1 月，对 3473 例初次 CABG 时未行 LITA 且再次手术时前壁心肌（LAD）有风险的患者进行再次 CABG 手术：2389 例行 LITA 桥接，1084 例行大隐静脉（SV）桥接至 LAD。采用倾向性匹配（908 对匹配）来平衡比较结局。术后随访至 20 年，平均随访 11 ± 8.2 年。
结果
未校正的住院死亡率分别为 LITA 组 2.2%和 SV 组 6.5%（p < 0.001），但倾向性匹配组分别为 3.1%和 5.6%（p = 0.008）。未校正的 LITA 组 1、5、10、15 和 20 年生存率分别为 94%、82%、64%、46%和 32%，SV 组分别为 88%、73%、50%、32%和 18%（p < 0.0001）。对于倾向性匹配组，LITA 组的早期（p = 0.01）和晚期生存率均更高（p = 0.005）。20 年时，再次手术时 LAD 的 LITA 桥接可使绝对死亡率降低 6.0%，风险比为 0.85，需要治疗的患者人数为 16 人。
结论
再次手术时 LITA 桥接至 LAD 是安全的，并能带来风险调整后的生存优势。在合适的情况下，应使用 LITA 来为再次 CABG 的 LAD 进行血运重建。
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