Chaudhry Umar A R, Rao Christopher, Harling Leanne, Athanasiou Thanos
Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK.
Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
Interact Cardiovasc Thorac Surg. 2014 Jul;19(1):149-59. doi: 10.1093/icvts/ivu075. Epub 2014 Mar 21.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass grafting (CABG) surgery offered superior long-term outcomes compared with on-pump CABG surgery. Best evidence papers were considered to be those that had a follow-up period of ≥5 years, had >50 patients in either cohort, did not utilize concomitant interventions nor comprised low-risk, high-risk or sub-population groups. Where potential duplicate data sets from the same institution were likely, the more credible and recently published study was included. Two hundred and fifty-six papers were found as a result of the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The 16 studies comprised 4 prospective randomized controlled trials (RCTs), with the remaining 12 retrospective, of which 8 were propensity-score matched. All 4 RCTs contained fewer than 450 participants. Two studies concluded with a survival advantage towards on-pump CABG: one, a large registry-based study, the Veterans Affairs, with >25 000 patients, and another, a propensity-matched retrospective study involving almost 8000 patients. The remaining 14 studies all provided evidence to suggest comparable long-term survival. In addition, all other long-term outcomes mentioned within these studies including angina recurrence, myocardial infarction heart failure, need for revascularization, stroke, graft patency, cognitive and quality of life showed similar results between the two groups. We conclude that off-pump CABG surgery may have similar or slightly reduced long-term survival compared with on-pump CABG surgery. Other long-term indicators such as cardiovascular or cerebrovascular events or neuro-psychological outcomes were similar between the two groups. Despite these conclusions, the evidence is limited by substantial variability in patient selection and study methods. The CORONARY (coronary artery bypass surgery off- or on-pump revascularization study) trial recently presented results, which showed no significant differences in composite outcomes at 1 year; it will be interesting to observe whether these comparable outcomes are maintained for a much longer time frame.
一篇心脏外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是，与体外循环冠状动脉旁路移植术（CABG）相比，非体外循环冠状动脉旁路移植术是否能提供更优的长期疗效。最佳证据论文被认为是那些随访期≥5年、每组患者超过50例、未采用联合干预措施且不包括低风险、高风险或亚人群组的论文。如果来自同一机构的潜在重复数据集可能存在，则纳入更可信且最新发表的研究。通过报告的检索共找到256篇论文，其中16篇代表回答该临床问题的最佳证据。现将这些论文的作者、期刊、发表日期和国家、所研究的患者组、研究类型、相关结局及结果制成表格。这16项研究包括4项前瞻性随机对照试验（RCT），其余12项为回顾性研究，其中8项为倾向评分匹配研究。所有4项RCT的参与者均少于450人。两项研究得出体外循环CABG具有生存优势的结论：一项是基于大型注册研究的退伍军人事务部研究，患者超过25000例；另一项是涉及近8000例患者的倾向评分匹配回顾性研究。其余14项研究均提供证据表明长期生存率相当。此外，这些研究中提到的所有其他长期结局，包括心绞痛复发、心肌梗死、心力衰竭、血运重建需求、中风、移植血管通畅率、认知和生活质量，两组结果相似。我们得出结论，与体外循环CABG相比，非体外循环CABG手术的长期生存率可能相似或略有降低。两组在心血管或脑血管事件或神经心理结局等其他长期指标方面相似。尽管有这些结论，但证据因患者选择和研究方法的显著差异而受到限制。冠状动脉（非体外循环或体外循环冠状动脉旁路移植血运重建研究）试验最近公布了结果，显示1年时综合结局无显著差异；观察这些相当的结局在更长时间内是否保持将很有意思。
