重度左心室功能不全患者的心肌血运重建：体外循环心脏跳动与非体外循环冠状动脉搭桥术的比较

[Myocardial revascularization among patients with severe left ventricular dysfunction: a comparison between on-pump beating-heart and off-pump coronary artery bypass grafting].

作者信息

Shen J Q, Ji Q, Ding W J, Xia L M, Song K, Wei L, Sun Y X, Wang C S

机构信息

Department of Cardiovascular Surgery, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China.

出版信息

Zhonghua Wai Ke Za Zhi. 2018 Apr 1;56(4):294-298. doi: 10.3760/cma.j.issn.0529-5815.2018.E010.

DOI:10.3760/cma.j.issn.0529-5815.2018.E010

PMID:29562416

Abstract

To evaluate the impacts of an on-pump beating-heart versus an off-pump coronary artery bypass grafting (CABG) technique for surgical revascularization on the early clinical outcomes in patients with a left ventricular ejection fraction (EF) of 35% or less. A total of 216 consecutive patients with an echocardiographic estimated EF of 35% or less who underwent non-emergency, primary, isolated CABG from January 2010 to December 2014 at Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University were included in this study and were divided into either an OBCAB group (patients who received on-pump beating-heart CABG surgery, =88) or an OPCAB group (patients who received off-pump CABG surgery, =128). The early clinical outcomes were investigated and compared. The outcomes were compared between groups by -test, χ test or Fisher's exact test, when appropriate. No significant differences emerged between the two groups in baseline characteristics of the entire cohort except for more patients with diabetes and a larger left ventricular endo-diastolic diameter in the OBCAB group. Patients in the OBCAB group compared to the OPCAB group had a similar in-hospital mortality (3.4% . 4.7%, = 0.741). Mean EF, as measured preoperatively and early postoperatively (before discharge), significantly improved from (31.0±2.8)% to (35.6±2.9)% (=10.61, =0.000) in the OBCAB group and from (31.0±2.9)% to (34.8±3.3)% (=9.68, =0.000) in the OPCAB group, respectively. The improvement of mean LVEF in the OBCAB group was significantly higher than that in the OPCAB group ((4.7±0.2)% . (3.6±0.3)%, =29.53, =0.000). Patients in the OBCAB group compared to the OPCAB group had a significant higher early postoperative EF ((35.6±2.9)% .(34.8±3.3)%, =1.892, =0.034) but shared a similar baseline EF ((31.0±2.8)% . (31.0±2.9)%, =0.012, =0.930). Patients in the OBCAB group compared to the OPCAB group received a greater number of grafts and an increased amount of drainage during the first 24 h (3.7±0.8 . 2.8±0.6, =9.442, =0.000; (715±187) ml . (520±148) ml, =8.544, =0.000, respectively), without evidence of worse in-hospital mortality or major postoperative morbidity. The on-pump beating-heart technique may be an acceptable alternative to the off-pump technique for surgical revascularization in patients with an estimated EF of 35% or less.

摘要

评估体外循环心脏不停跳与非体外循环冠状动脉旁路移植术（CABG）技术用于外科血运重建对左心室射血分数（EF）为35%或更低患者早期临床结局的影响。纳入2010年1月至2014年12月在复旦大学附属中山医院心血管外科接受非急诊、初次、单纯CABG且超声心动图估计EF为35%或更低的216例连续患者，将其分为体外循环心脏不停跳CABG组（接受体外循环心脏不停跳CABG手术的患者，n = 88）或非体外循环CABG组（接受非体外循环CABG手术的患者，n = 128）。对早期临床结局进行调查和比较。在适当情况下，通过t检验、χ²检验或Fisher精确检验对组间结局进行比较。除体外循环心脏不停跳CABG组糖尿病患者更多、左心室舒张末期内径更大外，两组在整个队列的基线特征方面未出现显著差异。与非体外循环CABG组相比，体外循环心脏不停跳CABG组患者院内死亡率相似（3.4%对4.7%，P = 0.741）。体外循环心脏不停跳CABG组术前及术后早期（出院前）测量的平均EF分别从（31.0±2.8）%显著提高至（35.6±2.9）%（t = 10.61，P = 0.000），非体外循环CABG组从（31.0±2.9）%提高至（34.8±3.3）%（t = 9.68，P = 0.000）。体外循环心脏不停跳CABG组平均左心室射血分数的改善显著高于非体外循环CABG组（（4.7±0.2）%对（3.6±0.3）%，t = 29.53，P = 0.000）。与非体外循环CABG组相比，体外循环心脏不停跳CABG组患者术后早期EF显著更高（（35.6±2.9）%对（34.8±3.）%，t = 1.892，P = 0.034），但基线EF相似（（31.0±2.8）%对（31.0±2.9）%，t = 0.012，P = 0.930）。与非体外循环CABG组相比，体外循环心脏不停跳CABG组患者在最初24小时内接受的移植血管数量更多、引流量增加（分别为3.7±0.8对2.8±0.6，t = 9.442，P = 0.000；（715±187）ml对（520±148）ml，t = 8.544，P = 0.000），且无院内死亡率更高或术后主要并发症更严重的证据。对于估计EF为35%或更低的患者，体外循环心脏不停跳技术可能是外科血运重建的非体外循环技术的可接受替代方案。