冠状动脉旁路移植术联合与不联合升主动脉操作：一项网状 Meta 分析。
Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis.
机构信息
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia.
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Baird Institute of Applied Heart and Lung Surgical Research, Sydney, New South Wales, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
出版信息
J Am Coll Cardiol. 2017 Feb 28;69(8):924-936. doi: 10.1016/j.jacc.2016.11.071.
BACKGROUND
Coronary artery bypass grafting (CABG) remains the standard of treatment for 3-vessel and left main coronary disease, but is associated with an increased risk of post-operative stroke compared to percutaneous coronary intervention. It has been suggested that CABG techniques that eliminate cardiopulmonary bypass and reduce aortic manipulation may reduce the incidence of post-operative stroke.
OBJECTIVES
A network meta-analysis was performed to compare post-operative outcomes between all CABG techniques, including anaortic off-pump CABG (anOPCABG), off-pump with the clampless Heartstring device (OPCABG-HS), off-pump with a partial clamp (OPCABG-PC), and traditional on-pump CABG with aortic cross-clamping.
METHODS
A systematic search of 6 electronic databases was performed to identify all publications reporting the outcomes of the included operations. Studies reporting the primary endpoint, 30-day post-operative stroke rate, were included in a Bayesian network meta-analysis.
RESULTS
There were 13 included studies with 37,720 patients. At baseline, anOPCABG patients had higher previous stroke than did the OPCABG-PC (7.4% vs. 6.5%; p = 0.02) and CABG (7.4% vs. 3.2%; p = 0.001) patients. AnOPCABG was the most effective treatment for decreasing the risk of post-operative stroke (-78% vs. CABG, 95% confidence interval [CI]: 0.14 to 0.33; -66% vs. OPCABG-PC, 95% CI: 0.22 to 0.52; -52% vs. OPCABG-HS, 95% CI: 0.27 to 0.86), mortality (-50% vs. CABG, 95% CI: 0.35 to 0.70; -40% vs. OPCABG-HS, 95% CI: 0.38 to 0.94), renal failure (-53% vs. CABG, 95% CI: 0.31 to 0.68), bleeding complications (-48% vs. OPCABG-HS, 95% CI: 0.31 to 0.87; -36% vs. CABG, 95% CI: 0.42 to 0.95), atrial fibrillation (-34% vs. OPCABG-HS, 95% CI: 0.49 to 0.89; -29% vs. CABG, 95% CI: 0.55 to 0.87; -20% vs. OPCABG-PC, 95% CI: 0.68 to 0.97), and shortening the length of intensive care unit stay (-13.3 h; 95% CI: -19.32 to -7.26; p < 0.0001).
CONCLUSIONS
Avoidance of aortic manipulation in anOPCABG may decrease the risk of post-operative stroke, especially in patients with higher stroke risk. In addition, the elimination of cardiopulmonary bypass may reduce the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay.
背景
冠状动脉旁路移植术（CABG）仍然是治疗 3 支血管和左主干病变的标准治疗方法，但与经皮冠状动脉介入治疗相比，术后中风的风险增加。有人提出，消除体外循环和减少主动脉操作的 CABG 技术可能会降低术后中风的发生率。
目的
进行网状荟萃分析，比较所有 CABG 技术的术后结果，包括非体外循环旁路移植术（anOPCABG）、无夹钳 Heartstring 装置的非体外循环旁路移植术（OPCABG-HS）、部分夹钳的非体外循环旁路移植术（OPCABG-PC）和传统带主动脉夹闭的体外循环旁路移植术。
方法
系统检索 6 个电子数据库，以确定所有报告纳入手术结果的出版物。报告主要终点，即术后 30 天内中风发生率的研究被纳入贝叶斯网状荟萃分析。
结果
共有 13 项研究纳入了 37720 名患者。基线时，anOPCABG 患者的既往中风发生率高于 OPCABG-PC 患者（7.4% vs. 6.5%；p=0.02）和 CABG 患者（7.4% vs. 3.2%；p=0.001）。anOPCABG 是降低术后中风风险最有效的治疗方法（与 CABG 相比，降低 78%，95%置信区间[CI]：0.14 至 0.33；与 OPCABG-PC 相比，降低 66%，95% CI：0.22 至 0.52；与 OPCABG-HS 相比，降低 52%，95% CI：0.27 至 0.86），死亡率（与 CABG 相比，降低 50%，95% CI：0.35 至 0.70；与 OPCABG-HS 相比，降低 40%，95% CI：0.38 至 0.94），肾功能衰竭（与 CABG 相比，降低 53%，95% CI：0.31 至 0.68），出血并发症（与 OPCABG-HS 相比，降低 48%，95% CI：0.31 至 0.87；与 CABG 相比，降低 36%，95% CI：0.42 至 0.95），心房颤动（与 OPCABG-HS 相比，降低 34%，95% CI：0.49 至 0.89；与 CABG 相比，降低 29%，95% CI：0.55 至 0.87；与 OPCABG-PC 相比，降低 20%，95% CI：0.68 至 0.97），并缩短重症监护病房停留时间（-13.3 小时；95% CI：-19.32 至 -7.26；p<0.0001）。
结论
anOPCABG 避免主动脉操作可能降低术后中风的风险，尤其是在中风风险较高的患者中。此外，消除体外循环可能降低短期死亡率、肾功能衰竭、心房颤动、出血和重症监护病房停留时间的风险。
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