Division of Cardiac Surgery, Northwestern University, Bluhm Cardiovascular Institute, Chicago, Ill.
Division of Cardiac Surgery, Northwestern University, Bluhm Cardiovascular Institute, Chicago, Ill.
J Thorac Cardiovasc Surg. 2018 Jun;155(6):2358-2367.e1. doi: 10.1016/j.jtcvs.2018.01.069. Epub 2018 Feb 9.
This study compares early and late outcomes in patients undergoing coronary artery bypass grafting with and without preoperative atrial fibrillation in a contemporary, nationally representative Medicare cohort.
In the Medicare-Linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated coronary artery bypass from 2006 to 2013, of whom 37,220 (10.3%) had preoperative atrial fibrillation; 13,161 (35.4%) were treated with surgical ablation and were excluded. Generalized estimating equations were used to compare 30-day mortality and morbidity. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models. Stroke and systemic embolism incidence was modeled using the Fine-Gray model and the CHADS-VASc score was used to analyze stroke risk. Median follow-up was 4 years.
Preoperative atrial fibrillation was associated with a higher adjusted in-hospital mortality (odds ratio [OR], 1.5; P < .0001) and combined major morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection (OR, 1.32; P < .0001). Patients with preoperative atrial fibrillation experienced a higher adjusted long-term risk of all-cause mortality and cumulative risk of stroke and systemic embolism compared to those without atrial fibrillation. At 5 years, the survival probability in the preoperative atrial fibrillation versus no atrial fibrillation groups stratified by CHADS-VASc scores was 74.8% versus 86.3% (score 1-3), 56.5% versus 73.2% (score 4-6), and 41.2% versus 57.2% (score 7-9; all P < .001).
Preoperative atrial fibrillation is independently associated with worse early and late postoperative outcomes. CHADS-VASc stratifies risk, even in those without preoperative atrial fibrillation.
本研究比较了在当代全国代表性的 Medicare 队列中，接受冠状动脉旁路移植术的患者中伴有和不伴有术前心房颤动的患者的早期和晚期结局。
在 Medicare 关联的胸外科医生协会数据库中，2006 年至 2013 年期间有 361138 名患者接受了单纯冠状动脉旁路移植术，其中 37220 名（10.3%）有术前心房颤动；其中 13161 名（35.4%）接受了手术消融治疗，被排除在外。广义估计方程用于比较 30 天死亡率和发病率。使用 Kaplan-Meier 曲线和 Cox 回归模型总结长期生存情况。使用 Fine-Gray 模型对卒中和全身性栓塞发生率进行建模，并使用 CHADS-VASc 评分分析卒中风险。中位随访时间为 4 年。
术前心房颤动与调整后的住院死亡率（优势比 [OR]，1.5；P<0.0001）和包括卒中、肾衰竭、延长通气、再次手术和深部胸骨伤口感染在内的主要合并症发生率较高相关（OR，1.32；P<0.0001）。与无心房颤动的患者相比，术前心房颤动的患者有更高的调整后全因死亡率和卒中及全身性栓塞累积风险。在根据 CHADS-VASc 评分分层的术前心房颤动与无心房颤动组中，5 年时的生存率分别为 74.8%和 86.3%（评分 1-3）、56.5%和 73.2%（评分 4-6）以及 41.2%和 57.2%（评分 7-9；所有 P<0.001）。
术前心房颤动与术后早期和晚期不良结局独立相关。即使在无术前心房颤动的患者中，CHADS-VASc 也可分层风险。
