Weintraub W S, Jones E L, Craver J M, Grosswald R, Guyton R A
Division of Cardiology, Emory University School of Medicine, Atlanta, Ga, USA.
Circulation. 1995 Nov 1;92(9 Suppl):II50-7. doi: 10.1161/01.cir.92.9.50.
Increasingly over the past several years, patients have returned after coronary surgery for reoperative procedures, and the experience has become substantial. In this report, we describe immediate- and long-term outcomes after reoperative coronary artery bypass graft surgery.
The source of data was the clinical database at Emory University. The surgical procedure and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Follow-up was by letter, telephone, or hospital records documenting additional events resulting in readmission. In-hospital correlates of survival were determined by logistic regression, and long-term correlates were determined by Cox model analysis. There were 2030 patients with a mean age of 61 and a mean of 7.8 +/- 4.1 years since the first surgery. The mean ejection fraction was close to 50%, and the majority had three-vessel or left main disease. Urgent or emergency surgery was required in 16.6%. The internal mammary was used in 60.1%. Q-wave myocardial infarctions occurred in just over 5%. Neurological events increased from 1.2% at less than age 50 to 4.1% at more than age 70. The hospital mortality increased from 5.7% at less than age 50 to 10% at more than age 70, with an overall rate of 7.0%. Mortality was 5.7% for elective, 10.9% for urgent, and 16.4% for emergency cases. Angina was noted at follow-up in 41.3%. Urgent or emergency surgery, reduced ejection fraction, hypertension, older age, and female sex were univariate and multivariate correlates of in-hospital death. Diabetes was a univariate correlate only. Five- and 10-year survival rates were 76% and 55%, respectively. Five- and 10-year myocardial infarction-free survival rates were 63% and 40%, respectively. By 12 years, few patients were free of cardiac events. The univariate and multivariate correlates of long-term mortality were older age, reduced ejection fraction, hypertension, diseased vessels, presence of diabetes, congestive failure, and emergency surgery, with a strong trend for female sex. The use of the internal mammary artery was not a correlate for long-term mortality.
Patients undergoing reoperative procedures have higher mortality initially and at long term than patients undergoing a first procedure. Expected mortality based on covariates may help in the decision of whether to perform reoperative coronary artery bypass graft surgery.
在过去几年中，越来越多的患者在冠状动脉手术后返回进行再次手术，并且此类经验已相当丰富。在本报告中，我们描述了再次冠状动脉旁路移植手术后的近期和长期结果。
数据来源是埃默里大学的临床数据库。手术程序和统计方法均为标准方式。数据前瞻性收集并录入计算机化数据库。通过信件、电话或医院记录进行随访，记录导致再次入院的其他事件。通过逻辑回归确定住院期间生存的相关因素，通过Cox模型分析确定长期相关因素。共有2030例患者，平均年龄61岁，自首次手术以来平均间隔7.8±4.1年。平均射血分数接近50%，大多数患者患有三支血管病变或左主干病变。16.6%的患者需要急诊或紧急手术。60.1%的患者使用了乳内动脉。Q波心肌梗死发生率略高于5%。神经系统事件从50岁以下患者的1.2%增加到70岁以上患者的4.1%。住院死亡率从50岁以下患者的5.7%增加到70岁以上患者的10%，总体发生率为7.0%。择期手术死亡率为5.7%，急诊手术为10.9%，紧急手术为16.4%。随访时41.3%的患者有胸痛症状。急诊或紧急手术、射血分数降低、高血压、高龄和女性是住院死亡的单因素和多因素相关因素。糖尿病仅是单因素相关因素。5年和10年生存率分别为76%和55%。5年和10年无心肌梗死生存率分别为63%和40%。到12年时，很少有患者无心脏事件。长期死亡率的单因素和多因素相关因素为高龄、射血分数降低、高血压、病变血管、糖尿病、充血性心力衰竭和急诊手术，女性有强烈趋势。乳内动脉的使用与长期死亡率无关。
接受再次手术的患者在初始和长期的死亡率均高于接受首次手术的患者。基于协变量的预期死亡率可能有助于决定是否进行再次冠状动脉旁路移植手术。
