Department of General Surgery, Duke University Medical Center, Durham, NC, USA.
Duke Clinical Research Institute, Durham, NC, USA.
Eur J Cardiothorac Surg. 2018 Oct 1;54(4):710-716. doi: 10.1093/ejcts/ezy114.
Previous studies have demonstrated a 20% mortality rate among patients undergoing isolated coronary artery bypass grafting (CABG) for cardiogenic shock. However, outcomes following CABG for cardiogenic shock in patients who are neurologically unresponsive preoperatively are unknown.
Utilizing the Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2011 and December 2013, patients undergoing urgent or emergent CABG within 7 days of an acute myocardial infarction complicated by cardiogenic shock were identified. Patients were stratified on the basis of whether they had a non-medically induced unresponsive state within 24 h of surgery.
Of the 5259 patients with acute myocardial infarction complicated by cardiogenic shock who underwent CABG during the study period, 243 (4.62%) patients had an unresponsive preoperative neurological state. The unresponsive cohort had a higher 30-day operative mortality than the responsive cohort (33.74% vs 16.91%, P < 0.001). Unresponsive neurological state was associated with increased odds for mortality (adjusted odds ratio 1.81, 95% confidence interval 1.37-2.4; P < 0.001), postoperative stroke (adjusted odds ratio 2.17, 95% confidence interval 1.27-3.73; P = 0.0048) and encephalopathy (adjusted odds ratio 2.08, 95% confidence interval 1.44-3.01; P < 0.001). Among survivors in the unresponsive cohort, 78 (46.15%) were discharged home and 62 (36.69%) were discharged to extended care facilities.
Although cardiac surgery in unresponsive patients in the setting of acute myocardial infarction complicated by cardiogenic shock is associated with considerable neurological disability and mortality, the majority survive to discharge. These findings may help guide patient and family discussions regarding goals of care.
先前的研究表明，在因心原性休克而行单纯冠状动脉旁路移植术（CABG）的患者中，死亡率为 20%。然而，对于术前无神经反应的因心原性休克而行 CABG 的患者，其术后结果尚不清楚。
利用胸外科医师学会成人心脏手术数据库，在 2011 年 7 月至 2013 年 12 月期间，确定了在急性心肌梗死后 7 天内行紧急或急诊 CABG 且伴有心原性休克的患者。根据患者在手术 24 小时内是否有无医疗诱导的无反应状态，对患者进行分层。
在研究期间，5259 例因急性心肌梗死并发心原性休克而行 CABG 的患者中，有 243 例（4.62%）患者术前有无法响应的神经状态。无反应组的 30 天手术死亡率高于有反应组（33.74% vs. 16.91%，P<0.001）。无法响应的神经状态与死亡率增加的几率相关（校正比值比 1.81，95%置信区间 1.37-2.4；P<0.001）、术后中风（校正比值比 2.17，95%置信区间 1.27-3.73；P=0.0048）和脑病（校正比值比 2.08，95%置信区间 1.44-3.01；P<0.001）。在无反应组的幸存者中，有 78 例（46.15%）出院回家，62 例（36.69%）出院到延长护理机构。
尽管在急性心肌梗死并发心原性休克的患者中，心脏手术与相当程度的神经功能障碍和死亡率相关，但大多数患者都能存活下来。这些发现可能有助于指导患者和家属讨论护理目标。
