Tomasco B, Cappiello A, Fiorilli R, Leccese A, Lupino R, Romiti A, Tesler U F
Divisione di Cardiochirurgia, Ospedale San Carlo, Potenza.
G Ital Cardiol. 1995 Mar;25(3):269-80.
A retrospective analysis of 444 patients (Pts) with acute coronary insufficiency (A.C.I.) submitted to coronary artery bypass grafting between January '85 and December '92 was performed in order to identify incremental risk factors associated with perioperative mortality and to evaluate whether prediction of mortality can be accomplished utilizing risk models specifically linked to the severity of myocardial ischemia.
Based on clinical and ECGraphic standpoints three different groups were identified: urgent group, comprehensive of 257 Pts. in whom, because of full medically controlled ischemia, myocardial revascularization could be delayed until to 24-48 hours. Emergency-A group, comprehensive of 127 Pts with recurrent ischemia despite medical therapy, but with no signs of coronary insufficiency at the time of institution of cardiopulmonary bypass (CPB). Emergency-B group, comprehensive of 60 Pts operated on after a mean preoperative ischemic interval of 3.9 +/- 2.4 hours who presented unrelenting signs of ischemia, either persisting since the inception of the clinical picture or lasting for over 30 minutes at the time of institution of CPB; among those, 27 Pts were in cardiogenic shock.
Mortality rate in the three groups was respectively: 7.4%, 13.4%, 31.7%. Multivariate analysis identified the following risk factors of in-hospital mortality: urgent group: aortic cross-clamping time (A.C.C.T.) (p = 0.10) and ejection fraction (E.F.) (p = 0.023). Emergency-A group: A.C.C.T. (p = 0.017), E.F. (p = 0.023) and non-use of blood cardioplegia (B.C.) (p = 0.04). Emergency-B group: cardiogenic shock (p = 0.00), preoperative ischemic interval > 6 hours (p = 0.00), A.C.C.T. (p = 0.018) and non-use of B.C. (p = 0.012).
A useful stratification of Pts with A.C.I. in three different groups, each with its own risk model, can be obtained by means of clinical-ECGraphic criteria alone. Different prognostic weights can be attributed to the variables A.C.C.T., E.F. and non-use of B.C. depending on clinical status. A significant reduction of mortality rate in Pts with cardiogenic shock can be achieved by the utilization of individually-tailored surgical management.
对1985年1月至1992年12月期间接受冠状动脉搭桥术的444例急性冠状动脉供血不足（A.C.I.）患者进行回顾性分析，以确定与围手术期死亡率相关的增量风险因素，并评估是否可以利用与心肌缺血严重程度具体相关的风险模型来预测死亡率。
基于临床和心电图观点，确定了三个不同的组：紧急组，包括257例患者，由于心肌缺血在医学上得到充分控制，心肌血运重建可延迟至24 - 48小时。急诊A组，包括127例尽管接受了药物治疗仍有反复缺血但在体外循环（CPB）开始时无冠状动脉供血不足迹象的患者。急诊B组，包括60例患者，术前平均缺血间隔为3.9 +/- 2.4小时，在CPB开始时出现持续的缺血迹象，这些迹象自临床症状出现以来一直存在或持续超过30分钟；其中27例患者处于心源性休克。
三组的死亡率分别为：7.4%、13.4%、31.7%。多因素分析确定了以下院内死亡的风险因素：紧急组：主动脉阻断时间（A.C.C.T.）（p = 0.10）和射血分数（E.F.）（p = 0.023）。急诊A组：A.C.C.T.（p = 0.017）、E.F.（p = 0.023）和未使用血液停搏液（B.C.）（p = 0.04）。急诊B组：心源性休克（p = 0.00）、术前缺血间隔> 6小时（p = 0.00）、A.C.C.T.（p = 0.018）和未使用B.C.（p = 0.012）。
仅通过临床 - 心电图标准，就可以对A.C.I.患者进行有用的分层，分为三个不同的组，每组都有自己的风险模型。根据临床状态，主动脉阻断时间、射血分数和未使用血液停搏液等变量可赋予不同的预后权重。通过采用个体化的手术管理，可显著降低心源性休克患者的死亡率。
