Al Jaaly Emad, Chaudhry Umar A R, 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. 2015 Apr;20(4):538-45. doi: 10.1093/icvts/ivu425. Epub 2014 Dec 21.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offered superior mortality and morbidity outcomes when compared with conventional on-pump coronary artery bypass grafting (C-ONCAB). Morbidity outcomes consisted of renal failure, stroke (transient or permanent), myocardial infarction, angina, congestive cardiac failure, reintervention and arrhythmias. Best evidence papers investigating BH-ONCAB versus C-ONCAB were considered. Where data were duplicated, the more credible evidence-based and recently published study was included. Two hundred and thirty-one papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. Two were prospective randomized controlled trials and the remaining 10 observational studies, of which one was propensity-matched. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Five of these studies demonstrated significantly improved mortality following BH-ONCAB; however, one study exhibited better survival after C-ONCAB. Notably, this study incorporated BH-ONCAB patients with significantly more haemodynamic instability, thus possibly explaining the worse mortality outcomes. In terms of morbidity, a slightly more mixed picture is drawn. Five studies report morbidity in favour of BH-ONCAB, whereas three studies include individual outcomes favouring C-ONCAB. The remaining studies showed equivalent mortality and morbidity data. In summary, the results presented here suggest that BH-ONCAB may improve survival following coronary artery bypass surgery. A key observation is that the greatest benefits of BH-ONCAB appear to be in studies including patients with considerably higher risk characteristics at the time of surgery (haemodialysis, end-stage coronary artery disease, emergency surgery, low ejection fraction). There are limitations of the current evidence presented. Only two studies were randomized controlled trials. There was variability in sample size, selection criteria and preoperative risk profiles between the studies. The studies span many years, and the outcomes may have been affected by evolving technologies and differing patient profiles between these periods.
一篇心脏外科的最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是，与传统体外循环冠状动脉搭桥术（C-ONCAB）相比，不停跳体外循环冠状动脉搭桥术（BH-ONCAB）在死亡率和发病率方面是否具有更优的结果。发病率结果包括肾衰竭、中风（短暂性或永久性）、心肌梗死、心绞痛、充血性心力衰竭、再次干预和心律失常。考虑了调查BH-ONCAB与C-ONCAB对比的最佳证据论文。若数据重复，则纳入更具可信度的循证且最新发表的研究。通过报告的检索找到231篇论文，其中11篇代表回答该临床问题的最佳证据。2篇为前瞻性随机对照试验，其余10篇为观察性研究，其中1篇为倾向匹配研究。将这些论文的作者、期刊、发表日期和国家、研究的患者组、研究类型、相关结果和结果制成表格。其中5项研究表明BH-ONCAB术后死亡率显著改善；然而，1项研究显示C-ONCAB术后生存率更佳。值得注意的是，该研究纳入的BH-ONCAB患者血流动力学不稳定情况明显更多，因此可能解释了死亡率结果较差的原因。在发病率方面，情况略显复杂。5项研究报告发病率方面BH-ONCAB更具优势，而3项研究包含的个别结果显示C-ONCAB更具优势。其余研究显示死亡率和发病率数据相当。总之，此处呈现的结果表明BH-ONCAB可能改善冠状动脉搭桥手术后的生存率。一个关键观察结果是，BH-ONCAB的最大益处似乎体现在纳入手术时风险特征明显更高的患者（血液透析、终末期冠状动脉疾病、急诊手术、低射血分数）的研究中。目前所呈现的证据存在局限性。仅有2项研究为随机对照试验。各研究之间在样本量、选择标准和术前风险概况方面存在差异。这些研究跨越多年，结果可能受到技术发展以及不同时期患者特征差异的影响。
