Kucera John, Duggan John, Peters Alex, Trachiotis Gregory
Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA.
Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.
J Cardiothorac Surg. 2025 Mar 21;20(1):158. doi: 10.1186/s13019-025-03408-8.
We evaluated the surgical outcomes in three groups of individuals with diabetes mellitus (DM), end-stage renal disease (ESRD), and on (ONCAB) vs. off-pump (OPCAB) coronary artery bypass grafting (CABG). We also examined the changes in intraoperative decision-making when ultrasound and transit-time flow measurement was utilized in the operating room. This study will aim to identify the utility of HFUS and TTFM in high-risk patient categories.
Data from the multicenter REQUEST (Registry for Quality assessment with ultrasound imaging and TTFM measurement in cardiac bypass surgery) had recently been compiled in three separate papers examining outcomes in patients with DM, ESRD, and on vs. off-pump bypass grafting. Data was extrapolated to determine the impact of HFUS and TTFM in patients with diabetes, ESRD, ONCAB and OPCAB. The primary outcome measured in in the REQUEST study is any change in planned surgical procedure. Secondary end points include rate of changes, coronary targets, completed grafts, and in-hospital morbidity and mortality.
Outcomes were predicated upon patient population surveyed. The REQUEST registry reported 1016 individuals who underwent CABG. For individuals with DM, any surgical change to the coronary target was slightly lower, measured at a change rate of 11.6% vs. 9.5% (OR 0.80, 95% CI 0.53-1.21, P = 0.288). In diabetics, the aortic component of the operation underwent a higher rate of surgical strategy change with TTFM compared to without (10.2% vs. 6.4%, OR 1.67, 95% CI 1.06-2.65; P = 0.026). In patients with ESRD, TTFM increased the rate of strategy changes compared to no TTFM (33.7% vs. 24.3%, 95% CI 1.01-2.48, P = 0.047) and number of revisions per graft (7.0% vs. 3.4%, OR 2.14, 95% CI 1.17-3.71). In the 1016 individuals who underwent CABG, 402 (39.6%) underwent OPCAB and 614 (60.4%) undergoing ONCAB. When TTFM and HFUS were utilized, OPCAB resulted in greater number of strategy changes for aortic portion of the procedure (14.7% vs. 3.4%, OR 4.03, CI 2.32-7.20) without a difference in coronary target or graft revision. In the REQUEST study, in-hospital mortality was published at 0.6%.
TTFM use demonstrates a statistically significant impact on intra-operative decision making and operative strategy changes in patients with concomitant ESRD, DM and who are undergoing OPCAB relative to ONCAB. This difference in OPCAB vs. ONCAB may be related to higher mean graft flows in OPCAB in the setting of a standardized TTFM cutoff for determination of graft quality. This data cumulatively suggests there a role for TTFM in CABG, namely due to its positive impact on outcome and statistically significant impact on intra-operative decision making.
我们评估了三组患有糖尿病（DM）、终末期肾病（ESRD）且接受体外循环冠状动脉搭桥术（ONCAB）与非体外循环冠状动脉搭桥术（OPCAB）的患者的手术结果。我们还研究了在手术室中使用超声和渡越时间流量测量时术中决策的变化。本研究旨在确定高频超声（HFUS）和渡越时间流量测量（TTFM）在高危患者类别中的效用。
多中心REQUEST（心脏搭桥手术中超声成像和TTFM测量质量评估注册研究）的数据最近已汇总在三篇单独的论文中，这些论文研究了糖尿病、终末期肾病患者以及体外循环与非体外循环搭桥术患者的结果。数据经推断以确定HFUS和TTFM对糖尿病、终末期肾病、ONCAB和OPCAB患者的影响。REQUEST研究中测量的主要结局是计划手术程序的任何变化。次要终点包括变化率、冠状动脉靶点、完成的移植血管以及住院期间的发病率和死亡率。
结果取决于所调查的患者群体。REQUEST注册研究报告了1016例接受冠状动脉搭桥术的患者。对于糖尿病患者，冠状动脉靶点的任何手术变化略低，变化率为11.6%对9.5%（OR 0.80，95% CI 0.53 - 1.21，P = 0.288）。在糖尿病患者中，与未使用TTFM相比，使用TTFM时手术的主动脉部分手术策略变化率更高（10.2%对6.4%，OR 1.67，95% CI 1.06 - 2.65；P = 0.026）。在终末期肾病患者中，与未使用TTFM相比，TTFM增加了策略变化率（33.7%对24.3%，95% CI 1.01 - 2.48，P = 0.047）以及每个移植血管的修订次数（7.0%对3.4%，OR 2.14，95% CI 1.17 - 3.71）。在接受冠状动脉搭桥术的1016例患者中，402例（39.6%）接受了OPCAB，614例（60.4%）接受了ONCAB。当使用TTFM和HFUS时，OPCAB导致手术主动脉部分的策略变化数量更多（14.7%对3.4%，OR 4.03，CI 2.32 - 7.20），而冠状动脉靶点或移植血管修订方面没有差异。在REQUEST研究中，住院死亡率公布为0.6%。
使用TTFM对伴有终末期肾病、糖尿病且正在接受OPCAB（相对于ONCAB）的患者的术中决策和手术策略变化具有统计学上的显著影响。OPCAB与ONCAB之间的这种差异可能与在确定移植血管质量的标准化TTFM临界值情况下OPCAB中较高的平均移植血管流量有关。这些数据累积表明TTFM在冠状动脉搭桥术中具有一定作用，即由于其对结局有积极影响且对术中决策有统计学上的显著影响。
