Gersh B J, Chesebro J H, Braunwald E, Lambrew C, Passamani E, Solomon R E, Ross A M, Ross R, Terrin M L, Knatterud G L
Mayo Clinic, Rochester, Minnesota.
J Am Coll Cardiol. 1995 Feb;25(2):395-402. doi: 10.1016/0735-1097(94)00387-6.
We examined the results of coronary artery bypass graft surgery after thrombolytic therapy in the Thrombolysis in Myocardial Infarction trial, Phase II (TIMI II) with particular emphasis on patient characteristics, the impact of antecedent percutaneous transluminal coronary angioplasty and morbidity and mortality in certain subgroups.
Coronary bypass surgery is frequently used after thrombolytic therapy, but there is relatively little information with regard to early and late outcomes.
We analyzed 3,339 patients enrolled in the TIMI II trial. Bypass surgery was performed in 390 patients (11.7%): 54 (14%) within 24 h after entry into the trial or within 24 h of coronary angioplasty and 336 (86%) between 24 h and 42 days after entry.
Perioperative mortality rates were, respectively, 16.7% and 3.9% (p < 0.001); perioperative myocardial infarction rates were 5.6% and 6.2%, respectively; and major hemorrhagic events occurred in 74% and 50.9%, respectively (p = 0.002). On multivariate analysis, the only independent predictor of perioperative mortality was bypass surgery within 24 h after entry or after coronary angioplasty. Among patients undergoing bypass surgery within 24 h of entry or after coronary angioplasty, the prevalence of multivessel disease (59.1% vs. 77.8%) and use of the internal thoracic artery (18.5% vs. 62.5%) were lower than in the remaining surgical patients. Among the 322 perioperative survivors, the 1-year mortality rate after discharge was only 2.2% and 1.9%, respectively, in the two groups. Only one patient had a documented recurrent myocardial infarction during the first year.
The increased mortality rate with bypass surgery after thrombolytic therapy, particularly in patients undergoing operation within 24 h of coronary angioplasty or during the involving phase of infarction, must be balanced against the excellent 1-year prognosis and perioperative survivors, who are in general a group at higher risk of death or recurrent infarction. These data provide a basis for comparison for future studies.
我们研究了心肌梗死溶栓试验二期（TIMI II）中溶栓治疗后冠状动脉搭桥手术的结果，特别关注患者特征、先行经皮腔内冠状动脉成形术的影响以及某些亚组中的发病率和死亡率。
溶栓治疗后常进行冠状动脉搭桥手术，但关于早期和晚期结果的信息相对较少。
我们分析了TIMI II试验中纳入的3339例患者。390例患者（11.7%）接受了搭桥手术：54例（14%）在进入试验后24小时内或冠状动脉成形术后24小时内，336例（86%）在进入试验后24小时至42天之间。
围手术期死亡率分别为16.7%和3.9%（p<0.001）；围手术期心肌梗死率分别为5.6%和6.2%；主要出血事件分别发生在74%和50.9%的患者中（p = 0.002）。多因素分析显示，围手术期死亡率的唯一独立预测因素是进入试验后24小时内或冠状动脉成形术后进行搭桥手术。在进入试验后24小时内或冠状动脉成形术后接受搭桥手术的患者中，多支血管病变的患病率（59.1%对77.8%）和胸廓内动脉的使用率（18.5%对62.5%）低于其余手术患者。在322例围手术期存活者中，两组出院后1年死亡率分别仅为2.2%和1.9%。第一年仅有1例患者记录有复发性心肌梗死。
溶栓治疗后搭桥手术死亡率增加，特别是在冠状动脉成形术后24小时内或梗死累及期接受手术的患者中，必须与1年的良好预后和围手术期存活者相权衡，这些存活者总体上是死亡或复发性梗死风险较高的群体。这些数据为未来研究提供了比较基础。
