Schmuziger M, Christenson J T, Maurice J, Mosimann E, Simonet F, Velebit V
Cardiovascular Unit, Hôpital de la Tour, Geneva, Switzerland.
Cardiovasc Surg. 1994 Oct;2(5):623-9.
A consecutive series of 2645 patients underwent primary coronary bypass grafting while 458 patients underwent reoperative bypass during a 9-year period. The mean age (61 years), sex distribution (83% men) and preoperative risk factors were identical in the two groups. Significantly more patients belonged to New York Heart Association (NYHA) class 4 and were clinically unstable in the reoperative group (P < 0.001). The internal mammary artery was used in 43% of the single operation group but in only 23% of patients who subsequently required reoperation (P < 0.001). In reoperations 61% of the patients had an internal mammary artery graft (P < 0.001). The overall operative mortality rate for single operation was 2.3% (62/2645) versus 9.2% (42/458) for reoperations. Patients with a reoperative interval of more than 1 year had a 8.4% mortality rate, compared with 28% in those reoperated on 1 year or less after the initial operation (P < 0.01). Preoperative myocardial infarction, intra-aortic balloon pump insertion, prolonged ventilatory support and ventricular arrhythmias were all prevalent after reoperations (all P > 0.001), while postoperative myocardial infarctions and re-sternotomy for bleeding did not differ between the groups. Emergency operation, preoperative NYHA class 3-4 and poor left ventricular function were predictors of perioperative mortality in both groups. Left main stem stenosis was an added factor in the reoperative group. After reoperation 93% of the hospital survivors were alive at 5 years after surgery; the cardiac event-free rate was 59% and > 90% of the patients showed improvement of their NYHA class during the follow-up. Reoperative coronary artery bypass grafting is effective, but has an increased operative mortality and morbidity, especially in patients with unstable angina, left main stem stenosis and poor preoperative left ventricular function.
在9年期间，连续2645例患者接受了初次冠状动脉搭桥手术，同时458例患者接受了再次搭桥手术。两组患者的平均年龄（61岁）、性别分布（83%为男性）和术前危险因素相同。再次手术组中属于纽约心脏协会（NYHA）4级且临床不稳定的患者明显更多（P<0.001）。单手术组43%的患者使用了乳内动脉，而随后需要再次手术的患者中只有23%使用了乳内动脉（P<0.001）。在再次手术中，61%的患者有乳内动脉移植（P<0.001）。单手术的总体手术死亡率为2.3%（62/2645），而再次手术为9.2%（42/458）。再次手术间隔超过1年的患者死亡率为8.4%，而初次手术后1年或更短时间内接受再次手术的患者死亡率为28%（P<0.01）。再次手术后，术前心肌梗死、主动脉内球囊泵置入、长时间通气支持和室性心律失常都很常见（均P>0.001），而两组之间术后心肌梗死和因出血再次开胸手术并无差异。急诊手术、术前NYHA 3 - 4级和左心室功能差是两组围手术期死亡率的预测因素。左主干狭窄是再次手术组的一个附加因素。再次手术后，93%的医院幸存者在术后5年存活；无心脏事件发生率为59%，超过90%的患者在随访期间NYHA分级有所改善。再次冠状动脉搭桥手术是有效的，但手术死亡率和发病率增加，尤其是在不稳定型心绞痛、左主干狭窄和术前左心室功能差的患者中。
