School of Medicine, University of New South Wales, Sydney, Australia.
The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
J Card Surg. 2022 Dec;37(12):5290-5299. doi: 10.1111/jocs.17149. Epub 2022 Nov 9.
Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies.
A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes.
One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy.
Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.
急性冠状动脉综合征（ACS）患者行冠状动脉旁路移植术（CABG）属于高危手术，而心肌血运重建的最佳策略仍存在争议。本研究比较了体外循环下冠状动脉旁路移植术（ONCAB）、非体外循环下冠状动脉旁路移植术（OPCAB）和非体外循环跳动心脏冠状动脉旁路移植术（OnBHCAB）这三种策略的 30 天死亡率获益。
系统检索了三个电子数据库，以查找比较 ACS 患者行 ONCAB 与 OPCAB 或 OnBHCAB 的研究。主要结局为 30 天死亡率，采用贝叶斯层级网络荟萃分析（NMA）进行比较。应用随机效应一致性模型，进行直接和间接比较，以确定每种策略对术后结局的相对有效性。
共纳入一项随机对照试验和十八项符合纳入标准的观察性研究。分别有 4320 例、5559 例和 1962 例患者接受了 ONCAB、OPCAB 和 OnBHCAB 治疗。NMA 显示，OPCAB 最有可能被评为 30 天死亡率的最佳治疗方法（比值比 [OR]，0.50；95%可信区间 [CrI]，0.23-1.00），其次是 OnBHCAB（OR，0.62；95% CrI，0.20-1.57），但 95% CrI 交叉或包含 1。九项仅评估急性心肌梗死（AMI）患者的亚组 NMA 显示，OPCAB 后 30 天死亡率降低 72%（CrI，0.07-0.83）。两种策略均未发现卒中、肾功能不全或重症监护病房（ICU）住院时间的发生率显著增加。
虽然 ACS 患者没有明确的最佳手术血运重建方法，但 OPCAB 治疗 AMI 时显著的死亡率获益表明，高急症患者可能最受益于避免与体外循环和心脏停搏相关的进一步心肌损伤。
