杂交冠状动脉血运重建术与双侧或单根内乳动脉旁路移植术治疗冠心病的比较。
Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts.
机构信息
Divisions of Cardiothoracic Surgery and Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta Ga.
Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
出版信息
J Thorac Cardiovasc Surg. 2016 Apr;151(4):1081-9. doi: 10.1016/j.jtcvs.2015.10.061. Epub 2015 Oct 26.
OBJECTIVE
Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery (LIMA)-left anterior descending artery (LAD) bypass with percutaneous intervention of non-LAD vessels. The purpose of this study was to compare outcomes of HCR to conventional coronary artery bypass graft (CABG) surgery with single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting.
METHODS
Between October 2003 and September 2013, 306 consecutive patients who underwent HCR were compared with 8254 patients who underwent CABG with SIMA (7381; 89.4%) or BIMA (873; 10.6%) at a US academic center. The primary outcome was a composite of 30-day death, myocardial infarction, and stroke (major cerebrovascular and cardiac event [MACCE]). In addition to multiple logistic and linear regression analysis, a propensity score-matched analysis was used to compare HCR with SIMA and with BIMA.
RESULTS
The Society of Thoracic Surgeons-predicted risk of mortality was 1.6% for HCR, 2.1% for SIMA, and 1.1% for BIMA (P < .001). Factors associated with HCR use were older age, lower body mass index, history of percutaneous coronary intervention, and 2-vessel disease. In propensity-matched groups, 30-day MACCE rates were comparable (3.3% for HCR vs 1.3% for BIMA [odds ratio (OR), 2.50; P = .12] and vs 3.6% for SIMA [OR, 1.00; P = 1.00]). In-hospital complications were lower after HCR versus SIMA or BIMA (OR, 0.59; P = .033 and OR, 0.55; P = .015, respectively), as was the need for blood transfusion (OR, 0.44; P < .001 and OR, 0.57; P < .001). HCR was associated with shorter hospital stay compared with SIMA (OR, 1.28; P = .038) or BIMA (OR, 1.40; P = .006). No survival difference between matched groups was found at midterm follow-up (HCR vs SIMA: hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.32-1.38; P = .66; HCR vs BIMA: HR, 1.05; 95% CI, 0.48-2.29; P = .91).
CONCLUSIONS
HCR may represent a safe, less invasive alternative to conventional CABG in carefully selected patients, with similar short-term and midterm outcomes as CABG performed with either SIMA or BIMA grafting.
目的
杂交冠状动脉血运重建（HCR）将微创左内乳动脉（LIMA）-左前降支（LAD）旁路与非 LAD 血管的经皮介入相结合。本研究旨在比较 HCR 与常规冠状动脉旁路移植术（CABG）联合单支内乳动脉（SIMA）或双侧内乳动脉（BIMA）移植的结果。
方法
2003 年 10 月至 2013 年 9 月，在美国一所学术中心，306 例连续接受 HCR 的患者与 8254 例接受 CABG 联合 SIMA（7381 例；89.4%）或 BIMA（873 例；10.6%）的患者进行了比较。主要结局是 30 天内死亡、心肌梗死和卒中等主要脑血管和心脏事件（MACCE）的复合结局。除了多变量逻辑和线性回归分析外，还使用倾向评分匹配分析来比较 HCR 与 SIMA 和 BIMA。
结果
HCR 的胸外科医生协会预测死亡率为 1.6%，SIMA 为 2.1%，BIMA 为 1.1%（P<.001）。与 HCR 应用相关的因素包括年龄较大、体重指数较低、经皮冠状动脉介入治疗史和 2 支血管疾病。在倾向评分匹配的组中，30 天 MACCE 发生率相似（HCR 为 3.3%，BIMA 为 1.3%[比值比（OR），2.50；P=.12]，SIMA 为 3.6%[OR，1.00；P=1.00]）。与 SIMA 或 BIMA 相比，HCR 术后院内并发症发生率较低（OR，0.59；P=.033 和 OR，0.55；P=.015），输血需求也较低（OR，0.44；P<.001 和 OR，0.57；P<.001）。与 SIMA 或 BIMA 相比，HCR 与较短的住院时间相关（OR，1.28；P=.038 和 OR，1.40；P=.006）。在中期随访中，未发现匹配组之间的生存差异（HCR 与 SIMA：风险比[HR]，0.66；95%置信区间[CI]，0.32-1.38；P=.66；HCR 与 BIMA：HR，1.05；95%CI，0.48-2.29；P=.91）。
结论
在仔细选择的患者中，HCR 可能是一种安全、微创的替代常规 CABG 的方法，其短期和中期结果与 SIMA 或 BIMA 移植的 CABG 相似。
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