非体外循环冠状动脉旁路移植术治疗严重左心室功能障碍患者：一种合理的策略？

Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy?

机构信息

Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany.

Department of Vascular and Endovascular Surgery, Hospital Ludwigsburg, Ludwigsburg, Germany.

出版信息

J Card Surg. 2022 Jan;37(1):7-17. doi: 10.1111/jocs.15259. Epub 2021 Feb 5.

DOI:10.1111/jocs.15259

PMID:33547711

Abstract

BACKGROUND AND AIM

Low ejection fraction (EF) has been identified as a main risk factor for perioperative complications and mortality after coronary artery bypass grafting (CABG). The purpose of this study was to compare the efficacy and early as well as midterm outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) surgery in patients with reduced EF.

METHODS

We performed a retrospective review of patient demographics, preoperative risk factors, operative and postoperative outcomes of patients with left ventricular EF (LV-EF) ≤35%, who underwent CABG at our institution between January 2015 and December 2017. Propensity score and multivariate logistic regression analysis were used to compare risk adjusted outcomes between groups.

RESULTS

Overall, 111 consecutive CABG-patients with LV-EF ≤ 35% underwent either ONCAB (46 patients, 41.4%) or OPCAB surgery (65 patients, 58.6%). There was no difference in early mortality (5% vs. 7.5%, p = .64) between groups. After propensity score matching, OPCAB-patients required significantly less re-sternotomies for bleeding (20% vs. 2.5%, p = .03) and consequently received significantly less blood transfusions (57.5% vs. 32.5%, p = .03). Fewer OPCAB-patients experienced low cardiac output syndrome (22.5% vs. 42.5%, p = .06) and suffered from postoperative delirium (22.5% vs. 42.5%, p = .06). There were no differences in completeness of revascularization between groups (median 1 (1.0-1.33; 1.0-1.33) OPCAB versus median 1 (1-1.33; 0.67-2) ONCAB, p = .95). Survival after 6 months, one year and three years was similar for ONCAB- and OPCAB-patients (ONCAB 92.3%, 89.4%, and 89.4% vs. OPCAB 89.8%, 85.7%, and 82.1%; p = .403). More ONCAB-patients needed a coronary re-intervention during follow-up (8.6% vs. 2.3%, p = .402).

CONCLUSION

OPCAB-surgery is a safe and effective option for patients with reduced EF. Furthermore, it does not come at the expense of less complete revascularization or increased coronary re-intervention during early follow-up.

摘要

背景与目的

射血分数降低（EF）已被确定为冠状动脉旁路移植术（CABG）后围手术期并发症和死亡率的主要危险因素。本研究的目的是比较非体外循环冠状动脉旁路移植术（OPCAB）和常规冠状动脉旁路移植术（ONCAB）在左心室射血分数（LV-EF）≤35%的患者中的疗效以及早期和中期结果。

方法

我们回顾性分析了 2015 年 1 月至 2017 年 12 月期间在我院接受 CABG 的 LV-EF≤35%的患者的人口统计学、术前危险因素、手术和术后结果。使用倾向评分和多变量逻辑回归分析比较组间风险调整结果。

结果

共有 111 例连续的 LV-EF≤35%的 CABG 患者接受了 ONCAB（46 例，41.4%）或 OPCAB 手术（65 例，58.6%）。两组早期死亡率无差异（5%比 7.5%，p=0.64）。在进行倾向评分匹配后，OPCAB 患者因出血需要再次开胸的比例明显较低（20%比 2.5%，p=0.03），因此接受的输血明显较少（57.5%比 32.5%，p=0.03）。OPCAB 组发生低心排综合征的患者明显较少（22.5%比 42.5%，p=0.06），术后谵妄发生率也较低（22.5%比 42.5%，p=0.06）。两组间完全血运重建的比例无差异（中位数 1（1.0-1.33；1.0-1.33）OPCAB 与中位数 1（1-1.33；0.67-2）ONCAB，p=0.95）。ONCAB 组和 OPCAB 组术后 6 个月、1 年和 3 年的生存率相似（ONCAB 92.3%、89.4%和 89.4%与 OPCAB 89.8%、85.7%和 82.1%；p=0.403）。随访期间，ONCAB 组需要再次冠状动脉介入治疗的患者更多（8.6%比 2.3%，p=0.402）。