急性心肌梗死患者在进行外科心肌血运重建术前的预防性主动脉内球囊反搏。

Prophylactic intra-aortic balloon counterpulsation before surgical myocardial revascularization in patients with acute myocardial infarction.

作者信息

Grieshaber Philippe, Schneider Tobias, Oster Lukas, Orhan Coskun, Roth Peter, Niemann Bernd, Böning Andreas

机构信息

1 Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany.

2 Department of Anesthesiology, Sana Hospital Berlin-Lichtenberg, Berlin, Germany.

出版信息

Perfusion. 2018 Jul;33(5):390-400. doi: 10.1177/0267659118760384. Epub 2018 Feb 18.

DOI:10.1177/0267659118760384

PMID:29457560

Abstract

INTRODUCTION

Prophylactic intra-aortic balloon counterpulsation (pIABC) is recommended for high-risk patients undergoing coronary artery bypass grafting (CABG) surgery. Criteria for high-risk patients benefiting from pIABC are unclear. This study aimed to specifically describe the effect of pIABC on outcomes of patients with acute myocardial infarction (AMI) undergoing CABG.

METHODS

In 178 of 484 AMI patients (non-ST-segment elevation myocardial infarction [NSTEMI] or ST-segment elevation myocardial infarction [STEMI] ≤5 days before surgery) without cardiogenic shock who underwent CABG between 2008 and 2013, pIABC was initiated preoperatively. After propensity score matching, the outcomes of 400 patients were analyzed (pIABC: 150; Control: 250).

RESULTS

After propensity score matching, baseline and operative characteristics were balanced between the groups except for a higher rate of patients with a left ventricular ejection fraction (LVEF)≤30% in the pIABC group (26% vs. Control: 13%; p=0.032). Seven point two percent (7.2%) of the control patients received an IABP intraoperatively or postoperatively. Postoperative extracorporeal life support (ECLS) was only needed in the control group (1.2% vs. 0%; p=0.01). Postoperative plasma curves of troponin I, creatine kinase (CK) and creatine kinase isoform MB (CK-MB) levels were reduced in the pIABC group compared with the control group. In-hospital mortality was reduced in the pIABC group (3.3% vs. control: 6.4%; p=0.18). After multivariate adjustment for other preoperative risk factors, pIABC was significantly protective concerning in-hospital mortality (HR 0.56; 95%-CI 0.023-0.74; p=0.021). Mortality (pIABC vs. control) was more affected in patients with preoperative LVEF≤30% (2/36 (5.6%) vs. 6/31 (19%); heart rate (HR) 0.25; 95%-CI 0.046-1.3; p=0.13) compared with LVEF>30% (3/114 (2.6%) vs. 10/219 (4.6%); HR 0.56; 95%-CI 0.15-2.1; p=0.55). Long-term survival did not differ between the groups.

CONCLUSIONS

pIABC in CABG for AMI is associated with reduced perioperative cardiac injury and in-hospital mortality. Long-term survival is not affected.

摘要

引言

对于接受冠状动脉旁路移植术（CABG）的高危患者，推荐预防性主动脉内球囊反搏（pIABC）。受益于pIABC的高危患者标准尚不清楚。本研究旨在具体描述pIABC对接受CABG的急性心肌梗死（AMI）患者预后的影响。

方法

在2008年至2013年间接受CABG且无心源性休克的484例AMI患者（非ST段抬高型心肌梗死[NSTEMI]或术前5天内的ST段抬高型心肌梗死[STEMI]）中的178例，术前启动pIABC。经过倾向评分匹配后，分析了400例患者的预后（pIABC组：150例；对照组：250例）。

结果

经过倾向评分匹配后，除pIABC组左心室射血分数（LVEF）≤30%的患者比例较高外（26% vs. 对照组：13%；p = 0.032），两组间基线和手术特征达到平衡。7.2%的对照组患者在术中或术后接受了主动脉内球囊反搏（IABP）。术后体外生命支持（ECLS）仅在对照组中需要（1.2% vs. 0%；p = 0.01）。与对照组相比，pIABC组术后肌钙蛋白I、肌酸激酶（CK）和肌酸激酶同工酶MB（CK-MB）水平的血浆曲线降低。pIABC组的住院死亡率降低（3.3% vs. 对照组：6.4%；p = 0.18）。在对其他术前危险因素进行多变量调整后，pIABC对住院死亡率具有显著的保护作用（风险比[HR] 0.56；95%可信区间[CI] 0.023 - 0.74；p = 0.021）。术前LVEF≤30%的患者死亡率（pIABC组 vs. 对照组）受影响更大（2/36 [5.6%] vs. 6/31 [19%]；心率[HR] 0.25；95%CI 0.046 - 1.3；p = 0.13），而LVEF>30%的患者死亡率（3/114 [2.6%] vs. 10/219 [4.6%]；HR 0.56；95%CI 0.15 - 2.1；p = 0.55）。两组间长期生存率无差异。