Dominici Carmelo, Salsano Antonio, Nenna Antonio, Spadaccio Cristiano, Mariscalco Giovanni, Santini Francesco, Chello Massimo
Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
Department of Cardiac Surgery, University of Genoa, Genoa, Italy.
J Card Surg. 2020 Aug;35(8):1958-1978. doi: 10.1111/jocs.14780. Epub 2020 Jul 9.
Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature.
A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study.
Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39).
OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.
高危患者外科心肌血运重建的手术技术仍是一个有争议的话题。体外循环冠状动脉旁路移植术（CABG）联合心脏停搏和非体外循环CABG都有其内在局限性。多年来一直有人提出体外循环心脏不停跳CABG（OPBHC）的混合方法，但结果相互矛盾。本系统评价和荟萃分析旨在总结当代文献。
通过主要电子数据库进行文献检索。系统评价共提供了279篇文章，本研究纳入了其中17项研究。
与体外循环CABG相比，OPBHC患者术前风险更高，但早期死亡率降低（风险比[RR]，0.59，95%可信区间[CI]，0.36 - 0.97），术后中风减少（RR，0.60，95%CI，0.39 - 0.91）。此外，还观察到术后主动脉内球囊泵使用减少（RR，0.56，95%CI，0.31 - 1.01）和心肌梗死减少（RR，0.48，95%CI，0.22 - 1.07）的有趣趋势。OPBHC和非体外循环CABG之间的基线特征和术后并发症相似，但可用数据有限。OPBHC中血管重建不完全的风险低于非体外循环CABG（RR，0.53，95%CI，0.33 - 0.87），但高于传统体外循环CABG（RR，1.71，95%CI，1.23 - 2.39）。
OPBHC是一种在高危患者中进行外科血运重建的有效技术，可防止血流动力学恶化并保证足够的终末器官灌注。在那些更可能出现心脏停搏或心脏操作并发症的情况下，OPBHC是体外循环和非体外循环CABG的替代技术。基于这些原因，OPBHC可能对近期心肌梗死或左心室功能不全的患者有用。
