Soylu Erdinc, Harling Leanne, Ashrafian Hutan, Athanasiou Thanos
Department of Surgery and Cancer, Imperial College London, London, UK.
Department of Surgery and Cancer, Imperial College London, London, UK
Interact Cardiovasc Thorac Surg. 2014 Aug;19(2):295-301. doi: 10.1093/icvts/ivu116. Epub 2014 May 2.
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 with coronary endarterectomy (OPCAB-CE) is a safe and feasible method of myocardial revascularization in patients presenting with diffuse coronary artery disease. Seventy-one papers were identified by a systematic search, of which nine were judged to best answer the clinical question. All were observational studies. Of these, two were comparative and the remaining seven were case series. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results were tabulated. In total, these 9 studies included 341 patients (225 OPCAB-CE, 116 ONCAB-CE) undergoing coronary endarterectomy in combination with coronary artery bypass grafting. CE was performed either by an open method whereby the atheroma is removed through an arteriotomy made along the length of the stenosis or by a closed method whereby the atheroma is removed by gentle traction through a small arteriotomy made over a proximal area of the plaque. Overall, OPCAB-CE was associated with a low perioperative mortality ranging from zero in smaller case series to 2.8% in the largest study (n = 70). Two comparative studies demonstrate at least equivalent 30-day mortality between OPCAB-CE and ONCAB-CE, although the sample sizes are small. The overall incidence of postoperative myocardial infarction (MI) was 6.1% (11/180) and seems comparable between OPCAB-CE and ONCAB-CE. Notably, both postoperative MI and mortality appeared higher in patients undergoing multiple endarterectomies performed using a closed technique and CE to the right coronary artery was associated with increased postoperative MI. In summary, OPCAB-CE in the setting of diffuse coronary artery disease appears both safe and feasible, yielding comparable results to ONCAB-CE. Where possible, open arteriotomy with on-lay patch angioplasty may improve postoperative outcomes. Large, prospective database studies are now required with explicit sub-group criteria and stratification to number, territory and technique of endarterectomy in order to isolate the patients in whom OPCAB-CE may confer the greatest benefit.
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,对于患有弥漫性冠状动脉疾病的患者,非体外循环冠状动脉搭桥术联合冠状动脉内膜切除术(OPCAB-CE)是否是一种安全可行的心肌血运重建方法。通过系统检索确定了71篇论文,其中9篇被判定为能最佳回答临床问题。所有均为观察性研究。其中,2篇为比较性研究,其余7篇为病例系列研究。将作者、期刊、日期、出版国家、患者组、研究类型、相关结局和结果制成表格。这9项研究总共纳入了341例接受冠状动脉内膜切除术联合冠状动脉搭桥术的患者(225例行OPCAB-CE,116例行ONCAB-CE)。CE可通过开放方法进行,即通过沿狭窄长度进行的动脉切开术切除动脉粥样硬化斑块,也可通过闭合方法进行,即通过在斑块近端区域进行的小动脉切开术轻柔牵拉来切除动脉粥样硬化斑块。总体而言,OPCAB-CE的围手术期死亡率较低,在较小的病例系列中为零,在最大的研究(n = 70)中为2.8%。两项比较性研究表明,OPCAB-CE和ONCAB-CE之间的30天死亡率至少相当,尽管样本量较小。术后心肌梗死(MI)的总体发生率为6.1%(11/180),OPCAB-CE和ONCAB-CE之间似乎相当。值得注意的是,采用闭合技术进行多次内膜切除术的患者术后MI和死亡率似乎更高,而右冠状动脉的CE与术后MI增加相关。总之,在弥漫性冠状动脉疾病的情况下,OPCAB-CE似乎既安全又可行,与ONCAB-CE的结果相当。在可能的情况下,开放动脉切开术并进行补片血管成形术可能会改善术后结局。现在需要进行大型前瞻性数据库研究,明确亚组标准,并按内膜切除术的数量、区域和技术进行分层,以便确定OPCAB-CE可能带来最大益处的患者。