糖尿病和非糖尿病患者全动脉化心肌血运重建与传统冠状动脉搭桥术的长期结局：一项倾向匹配分析
Long-Term Outcome of Total Arterial Myocardial Revascularization Versus Conventional Coronary Artery Bypass in Diabetic and Non-Diabetic Patients: A Propensity-Match Analysis.
作者信息
Di Bacco Lorenzo, Repossini Alberto, Muneretto Claudio, Torkan Lawrence, Bisleri Gianluigi
机构信息
Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
出版信息
Cardiovasc Revasc Med. 2020 May;21(5):580-587. doi: 10.1016/j.carrev.2019.09.018. Epub 2019 Oct 22.
OBJECTIVE
Despite the improved survival in patients with multi-vessel coronary disease compared to conventional myocardial revascularization associated with the use of multiple arterial grafting for myocardial revascularization, it has been adopted in the minority of centers. We sought to evaluate the long-term outcome of patients with and without diabetes undergoing total arterial versus conventional myocardial revascularization.
METHODS
Among 1000 consecutive patients undergoing CABG, we performed a propensity-match analysis to compare patients with multi-vessel disease receiving total arterial (G1 = 618 pts) versus conventional myocardial revascularization (LIMA-LAD plus vein grafts, G2 = 382 pts). The primary end-point was survival free from all-cause and cardiac-related mortality, while the secondary end-point was the occurrence of major cardiac and cerebrovascular accidents.
RESULTS
Hospital mortality was similar (G1: 0 pts. vs G2: 1 pts., 0.3%, p = .91). At a median follow-up of 101 months (range 11-185 months), total arterial grafting was associated with significantly improved survival free from overall (G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%; p < .001) and cardiac mortality (general population: G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%, p = .043; diabetics:G1 = 84.7 ± 2.1 vs G2: 79.3 ± 3.4; p = .035) as well as occurrence of MACCEs (general population:G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%; p > .001; diabetics:G1 = 77 ± 6 vs G2 = 53 ± 5.8; p < .001). Cox regression analysis identified diabetes (HR = 1.94, CI 95% = 1.12-2.93; p < .001) and the use of veins (HR = 1.81, CI 95% = 1.32-2.65; p < .001) as independent predictors for all-cause mortality; among diabetics, vein grafts was the strongest predictor of MACCEs (HR = 2.41, CI 95% = 1.27-4.59; p = .007) and cardiac mortality (HR = 3.24, CI 95% = 1.69-6.23; p < .001).
CONCLUSIONS
Long-term survival following total arterial CABG is remarkably improved compared to conventional grafting with vein grafts especially in diabetic patients.
目的
尽管与采用多条动脉移植物进行心肌血运重建的传统心肌血运重建相比，多支冠状动脉疾病患者的生存率有所提高，但这种方法仅在少数中心被采用。我们试图评估接受全动脉与传统心肌血运重建的糖尿病患者和非糖尿病患者的长期预后。
方法
在1000例连续接受冠状动脉旁路移植术（CABG）的患者中，我们进行了倾向匹配分析，以比较接受全动脉血运重建（G1 = 618例）与传统心肌血运重建（左内乳动脉-左前降支加静脉移植物，G2 = 382例）的多支血管疾病患者。主要终点是无全因和心脏相关死亡率的生存情况，次要终点是主要心脏和脑血管意外的发生情况。
结果
医院死亡率相似（G1：0例 vs G2：1例，0.3%，p = 0.91）。在中位随访101个月（范围11 - 185个月）时，全动脉移植与总体生存率（G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%；p < 0.001）和心脏死亡率（普通人群：G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%，p = 0.043；糖尿病患者：G1 = 84.7 ± 2.1 vs G2：79.3 ± 3.4；p = 0.035）以及主要不良心血管和脑血管事件（MACCEs）的发生率（普通人群：G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%；p > 0.001；糖尿病患者：G1 = 77 ± 6 vs G2 = 53 ± 5.8；p < 0.001）的显著改善相关。Cox回归分析确定糖尿病（HR = 1.94，95%CI = 1.12 - 2.93；p < 0.001）和静脉使用（HR = 1.81，95%CI = 1.32 - 2.65；p < 0.001）是全因死亡率的独立预测因素；在糖尿病患者中，静脉移植物是MACCEs（HR = 2.41，95%CI = 1.27 - 4.59；p = 0.007）和心脏死亡率（HR = 3.24，95%CI = 1.69 - 6.23；p < 0.001）的最强预测因素。
结论
与使用静脉移植物的传统移植相比，全动脉CABG后的长期生存率显著提高，尤其是在糖尿病患者中。
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