Christenson J T, Bloch A, Maurice J, Simonet F, Velebit V, Schmuziger M
Cardiovascular Surgery Unit, Hôpital de la Tour, Meyrin-Geneva, Switzerland.
Coron Artery Dis. 1995 May;6(5):423-8. doi: 10.1097/00019501-199505000-00010.
This study aimed to investigate whether patients with very low left ventricular ejection fractions (LVEF) should be accepted for reoperative coronary artery bypass grafting (CABG).
Between January 1990 and December 1993, 1681 patients underwent primary CABG and 308 (15.5%) reoperative CABG. One hundred and eight patients (5.4%) had an LVEF < or = 25%, 91 patients for primary CAGB (group I) and 17 for CABG (group II). The mean age of the patients was 62 years. Sex distribution and preoperative risk factors did not differ. Urgent operations were more frequently necessary in group II (P < 0.01). Mitral regurgitation was present in 49% of the group I patients and 18% of the group II patients (P < 0.05). Pulmonary artery hypertension was observed in 24% of group I patients, but in only 6% in group II patients. The mean LVEF was 21% and left ventricular end-diastolic pressure 18 mmHg, without between-group differences. All patients had significant two- or three-vessel disease (stenosis > or = 70%). An average of 4.5 grafts per patient were performed. Mitral valve surgery was not performed in any of the patients.
The postoperative mortality was significantly higher in reoperative CABG patients (group II; 23.5%) than in group I patients (12.1%; P < 0.05), whereas the incidence of non-fatal myocardial infarction did not differ. The incidence of postoperative complications did not differ between the groups, except for transient renal failure, more frequently encountered in group II (P < 0.05). After an average follow-up of 18 months, the New York Heart Association (NYHA) class and the LVEF were significantly improved in both groups (NYHA class from 3.5 to 1.8 and LVEF from 21% to 45%; P < 0.001). The mitral regurgitation had improved or completely disappeared at the end of follow-up in all patients in both groups.
Our results suggest that patients with left ventricular ejection fraction < or = 25%, angina and significant two- or three-vessel coronary artery disease should not categorically be refused for reoperative CABG. Careful patient selection is necessary because of an increased operative risk.
本研究旨在调查左心室射血分数（LVEF）极低的患者是否应接受再次冠状动脉旁路移植术（CABG）。
1990年1月至1993年12月期间，1681例患者接受了初次CABG，308例（15.5%）接受了再次CABG。108例患者（5.4%）的LVEF≤25%，其中91例为初次CABG患者（I组），17例为再次CABG患者（II组）。患者的平均年龄为62岁。性别分布和术前危险因素无差异。II组更频繁地需要急诊手术（P<0.01）。I组49%的患者存在二尖瓣反流，II组为18%（P<0.05）。I组24%的患者观察到肺动脉高压，而II组仅为6%。平均LVEF为21%，左心室舒张末期压力为18mmHg，两组之间无差异。所有患者均患有严重的双支或三支血管疾病（狭窄≥70%）。每位患者平均进行4.5次移植。所有患者均未进行二尖瓣手术。
再次CABG患者（II组；23.5%）的术后死亡率显著高于I组患者（12.1%；P<0.05），而非致命性心肌梗死的发生率无差异。除了II组更频繁出现的短暂性肾衰竭外，两组术后并发症的发生率无差异（P<0.05）。平均随访18个月后，两组的纽约心脏协会（NYHA）分级和LVEF均显著改善（NYHA分级从3.5改善至1.8，LVEF从21%提高至45%；P<0.001）。随访结束时，两组所有患者的二尖瓣反流均有所改善或完全消失。
我们的结果表明，左心室射血分数≤25%、心绞痛且患有严重双支或三支冠状动脉疾病的患者不应被绝对拒绝接受再次CABG。由于手术风险增加，需要仔细选择患者。
