Sintek C F, Pfeffer T A, Khonsari S
Department of Cardiac Surgery, Southern California Regional Center, Kaiser Permanente Medical Center, Los Angeles 90027.
J Thorac Cardiovasc Surg. 1994 May;107(5):1317-21; discussion 1321-2.
At present no consensus exists regarding the timing of surgical revascularization after acute myocardial infarction. Patients admitted with acute myocardial infarction between January 1990 and April 1993 underwent early cardiac catheterization if they had postinfarction ischemia or positive results on a low-level exercise stress test. If indications for surgical intervention were found at the time of catheterization, patients were operated on within 1 or 2 days or were discharged and returned for the operation within 2 to 3 weeks. During this period, we performed 2175 isolated coronary artery bypass graft procedures; 23 patients were operated on within 24 hours of acute myocardial infarction with an operative mortality of 4.4%, 30 patients underwent surgery between 24 and 72 hours after infarction with no deaths, 193 patients were operated on between 3 and 7 days after infarction with an operative mortality of 2.1%, 284 patients underwent revascularization between 1 week and 1 month after infarction with an operative mortality of 1.4%, and the 1645 patients without a recent infarction had a mortality rate of 1.9%. Multivariate statistical analysis was performed to evaluate mortality with these independent variables: reoperative surgery, sex, age, diabetes, timing of infarction, location of infarction, and type (transmural versus subendocardial). Myocardial infarction at any time interval less than 1 month before the operation was not associated with mortality when adjusted by these other risk factors. In addition, no differences were noted in length of stay, stroke rate, or prevalence of renal failure or pulmonary insufficiency. We conclude that nonemergency surgical revascularization can be done safely at any time interval after acute myocardial infarction, certainly after 72 hours, with no increase in operative mortality and acceptable morbidity.
目前，关于急性心肌梗死后外科血管重建的时机尚无共识。1990年1月至1993年4月期间因急性心肌梗死入院的患者，如果有梗死后缺血或低水平运动负荷试验结果阳性，则接受早期心脏导管插入术。如果在导管插入术时发现手术干预指征，患者在1或2天内接受手术，或出院并在2至3周内返回接受手术。在此期间，我们进行了2175例单纯冠状动脉旁路移植手术；23例患者在急性心肌梗死后24小时内接受手术，手术死亡率为4.4%，30例患者在梗死后24至72小时接受手术，无死亡病例，193例患者在梗死后3至7天接受手术，手术死亡率为2.1%，284例患者在梗死后1周与1个月之间接受血管重建，手术死亡率为1.4%，1645例近期无梗死的患者死亡率为1.9%。采用多变量统计分析来评估这些自变量对死亡率的影响：再次手术、性别、年龄、糖尿病、梗死时间、梗死部位和类型（透壁性与心内膜下）。在根据这些其他危险因素进行调整后，手术前任何小于1个月的时间间隔发生的心肌梗死与死亡率无关。此外，在住院时间、卒中发生率、肾衰竭或肺功能不全患病率方面未发现差异。我们得出结论，急性心肌梗死后的任何时间间隔，当然是在72小时后，均可安全地进行非急诊外科血管重建，手术死亡率不会增加，发病率也可接受。
