全动脉化冠状动脉旁路移植术治疗心房颤动患者。

Total arterial revascularization coronary artery bypass surgery in patients with atrial fibrillation.

机构信息

Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Center of Postgraduate Medical Education, Warszawa, Poland.

Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland.

出版信息

Kardiol Pol. 2022;80(11):1119-1126. doi: 10.33963/KP.a2022.0200. Epub 2022 Aug 29.

DOI:10.33963/KP.a2022.0200

PMID:36036747

Abstract

BACKGROUND

Atrial fibrillation (AF) is a relatively common comorbidity among patients referred for coronary artery bypass grafting (CABG) and is associated with poorer prognosis. However, little is known about how surgical technique influences survival in this population.

AIM

The current analysis aimed to determine whether total arterial revascularization (TAR) is associated with improved long-term outcomes in patients with preoperative AF.

METHODS

We analyzed patients' data from the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. The registry, to date, involves five tertiary high-volume centers in Poland. Between 2006 and 2019, 4746 patients presented with preoperative AF and multivessel coronary artery disease and underwent CABG. We identified cases of TAR and used propensity score matching to determine non-TAR controls. Median follow-up was 4.1 years (interquartile range [IQR], 1.9-6.8 years).

RESULTS

Propensity matching resulted in 295 pairs of TAR vs. non-TAR. The mean (standard deviation [SD]) number of distal anastomoses was 2.5 (0.6) vs. 2.5 (0.6) (P = 0.94) respectively. Operative and 30-day mortality was not different between TAR and non-TAR patients (hazard ratio [HR] and 95% confidence intervals [CIs], 0.17 (0.02-1.38); P = 0.12 and 0.74 [0.40-1.35]; P = 0.33, respectively). By contrast, TAR was associated with nearly 30% improved late survival: HR, 0.72 (0.55-0.93); P = 0.01. This benefit was sustained in subgroup analyses, yet most pronounced in low-risk patients ( < 70 years old; EuroSCORE II < 2; no diabetes) and when off-pump CABG was performed.

CONCLUSIONS

TAR in patients with preoperative AF is safe and associated with improved survival, with particular survival benefits in younger low-risk patients undergoing off-pump CABG.

摘要

背景

心房颤动（AF）是冠状动脉旁路移植术（CABG）患者中较为常见的合并症，与预后较差相关。然而，关于手术技术如何影响该人群的生存情况知之甚少。

目的

本分析旨在确定术前存在 AF 的患者中，全动脉血运重建（TAR）是否与长期预后改善相关。

方法

我们分析了来自 HEIST（心房颤动和室上性心动过速中的心脏手术）注册研究的患者数据。该注册研究目前包括波兰五个三级高容量中心。2006 年至 2019 年，4746 例术前存在 AF 和多支冠状动脉疾病并接受 CABG 的患者入组。我们确定了 TAR 病例，并使用倾向评分匹配确定非 TAR 对照组。中位随访时间为 4.1 年（四分位距[IQR]，1.9-6.8 年）。

结果

倾向评分匹配后得到 295 对 TAR 与非 TAR。平均（标准差[SD]）远端吻合数量分别为 2.5（0.6）和 2.5（0.6）（P = 0.94）。TAR 和非 TAR 患者的手术和 30 天死亡率无差异（风险比[HR]和 95%置信区间[CI]，0.17（0.02-1.38）；P = 0.12 和 0.74[0.40-1.35]；P = 0.33）。相比之下，TAR 与近 30%的晚期生存改善相关：HR，0.72（0.55-0.93）；P = 0.01。亚组分析结果一致，在低危患者（<70 岁；EuroSCORE II<2；无糖尿病）和非体外循环 CABG 时获益最为显著。