He G W, Acuff T E, Ryan W H, Bowman R T, Douthit M B, Mack M J
Cardiothoracic Surgery Associates of North Texas, Medical City Dallas Hospital.
J Thorac Cardiovasc Surg. 1994 Jul;108(1):73-81.
Coronary artery bypass grafting has been performed for elderly patients (> or = 70 years) with increasing frequency. From January 1986 through June 1993, 1399 elderly patients underwent isolated coronary bypass grafting. Of these patients, 823 had saphenous vein grafts alone and 576 had internal mammary artery grafting, including unilateral (n = 546) and bilateral (n = 28). Overall operative mortality was 8.86%. Operative mortality for unilateral internal mammary artery grafting (6.41%) was lower than for saphenous vein grafting only (9.96%, p = 0.021) and bilateral internal mammary artery grafting (21.43%, 6/28, p = 0.018). Fewer patients undergoing internal mammary artery grafting had postoperative complications (low cardiac output, intraaortic balloon pumping, and neurologic complications) than patients having saphenous vein grafting only. To determine risk factors for mortality and the influence of internal mammary artery grafting on the outcome, we analyzed 55 variables (27 preoperative, 15 intraoperative, and 13 postoperative) by univariate analysis. Significant variables (age, gender, height, weight, surface area, diabetes, obesity, body mass index, history of congestive heart failure, myocardial infarction, or arrhythmia, functional class, left ventricular ejection fraction, stenosis of the left anterior descending or right coronary artery, emergency operation, reoperation, number of grafts, perfusion time, and bilateral or right internal mammary artery grafting) were included in a stepwise multiple logistic regression analysis. The logistic regression demonstrates that those preoperative (history of congestive heart failure or myocardial infarction, low ejection fraction, female gender, and old age), intraoperative (long cardiopulmonary bypass time, emergency operation, reoperation, and use of right internal mammary artery grafting), and postoperative (postoperative complications) variables are independently associated with higher mortality. This study reveals the high-risk groups in elderly patients undergoing coronary bypass and suggests that a left internal mammary artery graft in combination with saphenous vein grafting may achieve a lower operative mortality and morbidity than other procedures in selected elderly patients undergoing coronary artery bypass grafting.
冠状动脉旁路移植术在老年患者（≥70岁）中的实施频率日益增加。从1986年1月至1993年6月，1399例老年患者接受了单纯冠状动脉旁路移植术。在这些患者中，823例仅采用大隐静脉移植，576例采用乳内动脉移植，包括单侧（n = 546）和双侧（n = 28）。总体手术死亡率为8.86%。单侧乳内动脉移植的手术死亡率（6.41%）低于仅采用大隐静脉移植的死亡率（9.96%，p = 0.021）和双侧乳内动脉移植的死亡率（21.43%，6/28，p = 0.018）。与仅接受大隐静脉移植的患者相比，接受乳内动脉移植的患者术后并发症（低心排血量、主动脉内球囊反搏和神经系统并发症）更少。为了确定死亡的危险因素以及乳内动脉移植对预后的影响，我们通过单因素分析对55个变量（27个术前变量、15个术中变量和13个术后变量）进行了分析。将显著变量（年龄、性别、身高、体重、体表面积、糖尿病、肥胖、体重指数、充血性心力衰竭病史、心肌梗死病史或心律失常病史、心功能分级、左心室射血分数、左前降支或右冠状动脉狭窄、急诊手术、再次手术、移植血管数量、灌注时间以及双侧或右侧乳内动脉移植）纳入逐步多元逻辑回归分析。逻辑回归表明，那些术前（充血性心力衰竭或心肌梗死病史、低射血分数、女性性别和高龄）、术中（体外循环时间长、急诊手术、再次手术以及使用右侧乳内动脉移植）和术后（术后并发症）变量与较高的死亡率独立相关。本研究揭示了接受冠状动脉旁路移植术的老年患者中的高危群体，并表明在选定的接受冠状动脉旁路移植术的老年患者中，左乳内动脉移植联合大隐静脉移植可能比其他手术方式具有更低的手术死亡率和发病率。
