微创单支血管左乳内动脉至左前降支动脉搭桥术比传统胸骨切开术能改善预后：一项单机构回顾性队列研究。

Minimally invasive single-vessel left internal mammary to left anterior descending artery bypass grafting improves outcomes over conventional sternotomy: A single-institution retrospective cohort study.

作者信息

Smith Nathan J, Miles Bryan, Cain Michael T, Joyce Lyle D, Pearson Paul, Joyce David L

机构信息

Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI.

出版信息

J Card Surg. 2019 Sep;34(9):788-795. doi: 10.1111/jocs.14144. Epub 2019 Jul 3.

DOI:10.1111/jocs.14144

PMID:31269282

Abstract

BACKGROUND

Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited.

METHODS

The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity.

RESULTS

A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010).

CONCLUSIONS

Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting.

摘要

背景

冠状动脉旁路移植术（CABG）可通过多种方法进行。微创冠状动脉旁路移植术（MICABG）可能会降低围手术期发病率。先前的结果显示围手术期结局有所改善；然而，其应用一直有限。

方法

回顾了胸外科医师协会（STS）数据库以及一家机构的电子病历，以获取2011年至2018年间进行的单纯左乳内动脉至左前降支动脉（LIMA-LAD）旁路移植手术。根据手术方式对患者进行分组，比较胸骨切开术与非胸骨切开术（微创）。比较患者特征、围手术期变量以及短期和长期结局。主要结局包括死亡率和主要不良心脏事件（MACE）。次要结局为发病率。

结果

共进行了42例MICABG手术和54例传统LIMA-LAD手术，其中95.2%的MICABG手术由两名外科医生完成。MICABG手术更多为择期手术（83.3%对38.9%，P <.001）。STS风险评分预测，根据手术指征，MICABG的死亡率和发病率相当。MICABG与较少的肺部并发症（0.0%对11.1%，P =.033）、院内事件（11.9%对37.0%，P =.005）以及较短的重症监护病房住院时间（34.1小时对66.0小时，P =.022）和总住院时间（3.7天对6.5天，P =.002）相关。未观察到中风、心肌梗死或再次手术情况。MICABG患者的30天死亡率降低（0.0%对10.9%，P =.036），Kaplan-Meier 5年生存率提高（95.2%对77.9%，P =.016），无MACE生存率提高（89.2%对63.9%，P =.010）。