Wang N, Gundry S R, Van Arsdell G, Razzouk A J, Hill A C, Sjolander M, Cavazos K A, Brewer J M, Vyhmeister E E, Bailey L L
Department of Surgery, Loma Linda University Medical Center, Calif. 92354, USA.
J Thorac Cardiovasc Surg. 1995 Jul;110(1):214-21; discussion 221-3. doi: 10.1016/S0022-5223(05)80028-5.
In recent years, there has been a nationwide trend toward performing percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease. The clinical course of 57 consecutive patients who required emergency first-time coronary artery bypass grafting operations were reviewed to assess for difference in outcome between the 28 patients (49%) with single-vessel disease and the 29 patients (51%) with multivessel disease. The two groups were similar in preoperative characteristics except for a higher proportion of chronic obstructive pulmonary disease in the patients with multivessel disease (p = 0.03). Twice as many patients with multivessel disease were in shock (single-vessel disease = 4 [14%], multivessel disease = 8 [28%], p = not significant) en route to the operating room and significantly more patients with multivessel disease required on-going cardiopulmonary resuscitation (single-vessel disease = 0 [0%], multivessel disease = 5 [17%], p = 0.03). Significantly more coronary artery bypass grafts were placed in the patients with multivessel disease (single-vessel disease = 1.5 +/- 0.6, multivessel disease = 2.9 +/- 0.7, p < 0.01), which required longer aortic clamping time (p = 0.02) and cardiopulmonary bypass time (p < 0.01). There were seven postoperative deaths; all but one occurred in patients with multivessel disease (single-vessel disease = 1 [4%], multivessel disease = 6 [21%], p = 0.05). According to multivariate analysis, incremental risk factors of mortality were preoperative shock (p < 0.01), urgent or emergency percutaneous transluminal coronary angioplasty (p = 0.06), and multivessel disease (p = 0.12). Despite a similar incidence of myocardial infarction (single-vessel disease = 8 [29%], multivessel disease = 12 [41%], p = not significant), patients with multivessel disease had a higher incidence of cardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 11 [38%], p = 0.04) and noncardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 12 [41%], p = 0.02). By multivariate analysis, incremental risk factors of morbidity were preoperative shock (p < 0.01), multivessel disease (p = 0.02), and ejection fraction < 50% (p = 0.07). In the subset of patients with multivessel disease, preoperative shock, ejection fraction < 50, and an age of 60 years or greater were associated with higher morbidity and mortality. In conclusion, the risk of percutaneous transluminal coronary angioplasty failure is considerably higher in patients with multivessel disease. In certain subsets of patients with multivessel disease, coronary artery bypass grafting would be a safer procedure when compared with percutaneous transluminal coronary angioplasty for initial myocardial revascularization.
近年来，全国范围内出现了一种对多支冠状动脉疾病患者进行经皮腔内冠状动脉成形术的趋势。回顾了57例连续需要进行首次急诊冠状动脉搭桥手术患者的临床病程，以评估28例（49%）单支血管疾病患者与29例（51%）多支血管疾病患者在预后方面的差异。两组术前特征相似，但多支血管疾病患者中慢性阻塞性肺疾病的比例较高（p = 0.03）。在前往手术室途中，多支血管疾病患者出现休克的人数是单支血管疾病患者的两倍（单支血管疾病 = 4 [14%]，多支血管疾病 = 8 [28%]，p = 无显著性差异），且多支血管疾病患者中需要持续进行心肺复苏的人数显著更多（单支血管疾病 = 0 [0%]，多支血管疾病 = 5 [17%]，p = 0.03）。多支血管疾病患者植入的冠状动脉搭桥数量显著更多（单支血管疾病 = 1.5 ± 0.6，多支血管疾病 = 2.9 ± 0.7，p < 0.01），这需要更长的主动脉阻断时间（p = 0.02）和体外循环时间（p < 0.01）。术后有7例死亡；除1例之外，均发生在多支血管疾病患者中（单支血管疾病 = 1 [4%]，多支血管疾病 = 6 [21%]，p = 0.05）。根据多因素分析，死亡的增量危险因素为术前休克（p < 0.01）、紧急或急诊经皮腔内冠状动脉成形术（p = 0.06）以及多支血管疾病（p = 0.12）。尽管心肌梗死的发生率相似（单支血管疾病 = 8 [29%]，多支血管疾病 = 12 [41%]，p = 无显著性差异），但多支血管疾病患者的心脏发病率较高（单支血管疾病 = 4 [14%]，多支血管疾病 = 11 [38%]，p = 0.04），非心脏发病率也较高（单支血管疾病 = 4 [14%]，多支血管疾病 = 12 [41%]，p = 0.02）。通过多因素分析，发病的增量危险因素为术前休克（p < 0.01）、多支血管疾病（p = 0.02）以及射血分数 < 50%（p = 0.07）。在多支血管疾病患者亚组中，术前休克、射血分数 < 50以及年龄60岁及以上与更高的发病率和死亡率相关。总之，多支血管疾病患者经皮腔内冠状动脉成形术失败的风险相当高。在某些多支血管疾病患者亚组中，与经皮腔内冠状动脉成形术进行初始心肌血运重建相比，冠状动脉搭桥手术是一种更安全的手术。
