Gatti Giuseppe, Soso Petar, Dell'Angela Luca, Maschietto Luca, Dreas Lorella, Benussi Bernardo, Luzzati Roberto, Sinagra Gianfranco, Pappalardo Aniello
Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
Eur J Cardiothorac Surg. 2015 Jul;48(1):115-20. doi: 10.1093/ejcts/ezu360. Epub 2014 Sep 19.
Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively.
Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%.
There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 [95% confidence interval (CI): 45.1-66.2], 83.6 (95% CI: 76.6-90.7) and 55.4% (95% CI: 44.7-66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035).
Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.
尽管晚期预后令人鼓舞，但由于胸骨并发症风险增加，双侧胸廓内动脉（BITA）移植用于糖尿病患者心肌血运重建仍存在争议。在本研究中，我们回顾性分析了胰岛素依赖型糖尿病患者常规使用左侧BITA移植的早期和长期预后。
在1999年至2012年期间于作者所在机构连续接受单纯BITA移植的2701例患者中，188例（平均年龄：67±9岁）为胰岛素依赖型糖尿病患者。根据欧洲心脏手术风险评估系统II计算的平均预期手术风险为11±10.8%。
有6例（3.2%）住院死亡。长时间有创通气（17.6%）、多次输血（16.5%）、深部胸骨伤口感染（DSWI，11.7%）和急性肾损伤（10.6%）是最常见的主要术后并发症。慢性肺病（P=0.08）、低心排血量（P=0.039）、多次输血（P=0.034）和纵隔再次探查（P=0.071）是DSWI的危险因素。平均随访时间为5.7±3.6年。10年总体生存率、无心血管和脑血管死亡生存率以及主要不良心血管和脑血管事件的非参数估计分别为57.7[95%置信区间（CI）：45.1 - 66.2]、83.6（95%CI：76.6 - 90.7）和55.4%（95%CI：44.7 - 66.1）。晚期生存率降低的预测因素为高龄（P=0.013）、慢性肺病（P=0.004）、肾功能损害（P=0.009）和左心室功能障碍（P=0.035）。
即使是胰岛素依赖型糖尿病患者，也可常规进行左侧BITA移植。术后并发症发生率增加并未阻止早期低死亡率和良好的长期预后。
