Nakae Masaro, Kainuma Satoshi, Toda Koichi, Yoshioka Daisuke, Kawamura Takuji, Kawamura Ai, Kashiyama Noriyuki, Komukai Sho, Kitamura Tetsuhisa, Hirayama Atsushi, Shimomura Yoshimitsu, Taniguchi Kazuhiro, Miyagawa Shigeru
Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
JTCVS Open. 2022 Nov 15;13:163-175. doi: 10.1016/j.xjon.2022.10.012. eCollection 2023 Mar.
The study objectives were to determine the incidence, predictors, and clinical impact of ventricular arrhythmias after coronary artery bypass grafting and to evaluate the impact of implantable cardioverter defibrillators on the survival of patients with ventricular arrhythmias.
We enrolled 498 patients with a left ventricular ejection fraction of 40% or less who underwent coronary artery bypass grafting between 1993 and 2015. Clinical follow-up was completed in 94.0% of patients, with a median follow-up of 58.4 months.
Overall, 212 patients (43%) died, mainly of heart failure (n = 54, 10.8%) or sudden cardiac death (n = 40, 8.0%). The sudden cardiac death rate was highest during the first 6 months, with a monthly rate of 0.37%. Overall, 99 patients (20%) developed postoperative ventricular arrhythmias, and implantable cardioverter defibrillator was implanted in 55 patients. Previous ventricular arrhythmias (hazard ratio, 3.22; 95% confidence interval, 1.98-5.24; < .001), left ventricular end-systolic dimension (hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; < .001), and myocardial infarction in the left anterior descending artery territory (hazard ratio, 1.73; 95% confidence interval, 1.10-2.73; = .02) were independent predictors of postoperative ventricular arrhythmias. Notably, the 5-year survival of patients with ventricular arrhythmias who received an implantable cardioverter defibrillator was significantly higher than that of patients with ventricular arrhythmias who did not receive it (76.1% vs 22.7%, < .001) and was comparable to that of patients without ventricular arrhythmias (76.1% vs 73.6%, = .98).
Sudden cardiac death affects a significant proportion of patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, most frequently within 6 months postoperatively. To prevent sudden cardiac death, earlier implantable cardioverter defibrillator implantation should be indicated for high-risk patients with scars in the left anterior descending artery territory and excessive left ventricular remodeling.
本研究的目的是确定冠状动脉旁路移植术后室性心律失常的发生率、预测因素和临床影响，并评估植入式心脏复律除颤器对室性心律失常患者生存的影响。
我们纳入了498例左心室射血分数为40%或更低且在1993年至2015年间接受冠状动脉旁路移植术的患者。94.0%的患者完成了临床随访，中位随访时间为58.4个月。
总体而言，212例患者（43%）死亡，主要死于心力衰竭（n = 54，10.8%）或心源性猝死（n = 40，8.0%）。心源性猝死率在最初6个月内最高，每月发生率为0.37%。总体而言，99例患者（20%）发生了术后室性心律失常，55例患者植入了植入式心脏复律除颤器。既往室性心律失常（风险比，3.22；95%置信区间，1.98 - 5.24；P <.001）、左心室收缩末期内径（风险比，1.07；95%置信区间，1.04 - 1.10；P <.001）以及左前降支区域心肌梗死（风险比，1.73；95%置信区间，1.10 - 2.73；P = 0.02）是术后室性心律失常的独立预测因素。值得注意的是，接受植入式心脏复律除颤器的室性心律失常患者的5年生存率显著高于未接受该装置的室性心律失常患者（76.1%对22.7%，P <.001），且与无室性心律失常患者的生存率相当（76.1%对73.6%，P = 0.98）。
心源性猝死影响了相当一部分接受冠状动脉旁路移植术的缺血性心肌病患者，最常见于术后6个月内。为预防心源性猝死，对于左前降支区域有瘢痕且左心室重塑过度的高危患者，应尽早植入植入式心脏复律除颤器。
