Salomon N W, Page U S, Bigelow J C, Krause A H, Okies J E, Metzdorff M T
Division of Cardiovascular and Thoracic Surgery, Good Samaritan Hospital and Medical Center, Portland, Ore.
J Thorac Cardiovasc Surg. 1990 Aug;100(2):250-9; discussion 259-60.
During an 18-year period a consecutive series of 6591 patients underwent primary coronary bypass grafting and 508 patients underwent reoperative bypass. The mean patient age for the reoperative group was identical to that of the primary group, 59.8 years, but the mean age at initial operation for the reoperative group was 55.2 years. Mammary grafts were done at initial operation in 59% of patients who have had one operation versus only 46% of patients who subsequently required reoperation (p less than 0.001). The overall operative mortality rate was 2.0% (134/6591) for primary coronary bypass versus 6.9% (35/508) for reoperations (p less than 0.001). Patients with a reoperative interval of 1 to 10 years had a 6.0% (18/312) mortality rate, compared with 17.6% (13/74) for those in whom the interval between operations was greater than 10 years (p less than 0.01). Ventricular arrhythmias, excessive bleeding, prolonged ventilatory support, intraaortic balloon pump insertion (all p less than 0.05), and perioperative myocardial infarction (p less than 0.001) were all more prevalent after reoperations. Including perioperative mortality, the actuarial survival rate at 5 years was 80% for reoperations versus 90% for primary operations. The corresponding figures at 10 years were 65% and 75%. The probability of undergoing reoperation within 5 and 10 years was 0.034 +/- 0.003 and 0.055 +/- 0.005, respectively. Ten years postoperatively, 36% of patients having the initial operation had recurrent angina whereas 58% of the reoperative group had significant recurrent angina. Ten years after reoperation, 30% of operative survivors were free of heart-related morbidity and mortality compared with 50% of patients having a primary operation. Univariate analysis of factors increasing the probability of reoperation include the absence of a mammary graft and younger age at operation. Patients undergoing a second bypass operation represent a substantially higher risk subgroup than patients undergoing initial operation in terms of perioperative morbidity, mortality, decreased long-term survival, and decreased relief of recurrent cardiac morbidity.
在18年期间，连续6591例患者接受了初次冠状动脉搭桥手术，508例患者接受了再次搭桥手术。再次手术组患者的平均年龄与初次手术组相同，为59.8岁，但再次手术组初次手术时的平均年龄为55.2岁。初次手术时，59%接受过一次手术的患者采用了乳内动脉移植，而随后需要再次手术的患者中这一比例仅为46%（p<0.001）。初次冠状动脉搭桥手术的总体手术死亡率为2.0%（134/6591），再次手术的死亡率为6.9%（35/508）（p<0.001）。再次手术间隔时间为1至10年的患者死亡率为6.0%（18/312），而手术间隔时间大于10年的患者死亡率为17.6%（13/74）（p<0.01）。再次手术后室性心律失常、出血过多、通气支持时间延长、主动脉内球囊反搏置入（均p<0.05）以及围手术期心肌梗死（p<0.001）更为常见。包括围手术期死亡率在内，再次手术5年时的精算生存率为80%，初次手术为90%。10年时相应的数据分别为65%和75%。5年和10年内再次手术的概率分别为0.034±0.003和0.055±0.005。术后10年，初次手术患者中有36%出现复发性心绞痛，而再次手术组中有58%出现明显的复发性心绞痛。再次手术后10年，30%的手术幸存者无心脏相关的发病和死亡，而初次手术患者中这一比例为50%。对增加再次手术概率的因素进行单因素分析，包括未采用乳内动脉移植和手术时年龄较小。就围手术期发病率、死亡率、长期生存率降低以及复发性心脏疾病缓解情况而言，接受二次搭桥手术的患者代表的风险亚组比接受初次手术的患者高得多。
