Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom.
Cardiothoracic Surgery at Weill Cornell Medical Center, New York, NY.
J Thorac Cardiovasc Surg. 2021 Aug;162(2):591-599.e8. doi: 10.1016/j.jtcvs.2020.02.035. Epub 2020 Feb 19.
We performed a post hoc analysis of the Arterial Revascularization Trial to compare 10-year outcomes after off-pump versus on-pump surgery.
Among 3102 patients enrolled, 1252 (40% of total) and 1699 patients received off-pump and on-pump surgery (151 patients were excluded because of other reasons); 2792 patients (95%) completed 10-year follow-up. Propensity matching and mixed-effect Cox model were used to compare long-term outcomes. Interaction term analysis was used to determine whether bilateral internal thoracic artery grafting was a significant effect modifier.
One thousand seventy-eight matched pairs were selected for comparison. A total of 27 patients (2.5%) in the off-pump group required conversion to on-pump surgery. The off-pump and on-pump groups received a similar number of grafts (3.2 ± 0.89 vs 3.1 ± 0.8; P = .88). At 10 years, when compared with on-pump, there was no significant difference in death (adjusted hazard ratio for off-pump, 1.1; 95% confidence interval, 0.84-1.4; P = .54) or the composite of death, myocardial infarction, stroke, and repeat revascularization (adjusted hazard ratio, 0.92; 95% confidence interval, 0.72-1.2; P = .47). However, off-pump surgery performed by low volume off-pump surgeons was associated with a significantly lower number of grafts, increased conversion rates, and increased cardiovascular death (hazard ratio, 2.39; 95% confidence interval, 1.28-4.47; P = .006) when compared with on-pump surgery performed by on-pump-only surgeons.
The findings showed that in the Arterial Revascularization Trial, off-pump and on-pump techniques achieved comparable long-term outcomes. However, when off-pump surgery was performed by low-volume surgeons, it was associated with a lower number of grafts, increased conversion, and a higher risk of cardiovascular death.
我们对动脉重建试验进行了事后分析，比较了非体外循环与体外循环手术后 10 年的结果。
在纳入的 3102 例患者中，1252 例（占总数的 40%）和 1699 例患者接受了非体外循环和体外循环手术（151 例因其他原因被排除在外）；2792 例（95%）完成了 10 年随访。采用倾向性匹配和混合效应 Cox 模型比较长期结果。交互项分析用于确定双侧内乳动脉移植是否是一个显著的效应修饰因子。
选择了 1078 对匹配的患者进行比较。非体外循环组中共有 27 例（2.5%）需要转为体外循环手术。非体外循环组和体外循环组接受的移植数量相似（3.2±0.89 与 3.1±0.8；P=0.88）。10 年时，与体外循环相比，非体外循环组的死亡（校正后的非体外循环危险比，1.1；95%置信区间，0.84-1.4；P=0.54）或死亡、心肌梗死、卒中和再次血运重建的复合终点（校正后的危险比，0.92；95%置信区间，0.72-1.2；P=0.47）差异均无统计学意义。然而，与体外循环组相比，低容量非体外循环外科医生进行的非体外循环手术与较低的移植数量、更高的转换率和更高的心血管死亡相关（危险比，2.39；95%置信区间，1.28-4.47；P=0.006）。
研究结果表明，在动脉重建试验中，非体外循环和体外循环技术取得了相似的长期结果。然而，当非体外循环手术由低容量外科医生进行时，与较低的移植数量、更高的转换率和更高的心血管死亡风险相关。
