Langenburg S E, Buchanan S A, Blackbourne L H, Scheri R P, Sinclair K N, Martinez J, Spotnitz W D, Tribble C G, Kron I L
Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
Ann Thorac Surg. 1995 Nov;60(5):1193-6; discussion 1196-7. doi: 10.1016/0003-4975(95)00755-A.
The success of coronary revascularization for ischemic cardiomyopathy (left ventricular ejection fraction of 0.25 or less) has been unpredictable. We and others have demonstrated that the hospital operative mortality rate for these operations has been surprisingly low, particularly if evidence of ischemia is present. We subsequently liberalized our selection criteria based on our hypothesis that coronary artery bypass grafting is safe in this subset of patients regardless of the status of their distal coronary vasculature.
To examine this hypothesis, we studied retrospectively our patients undergoing coronary artery bypass grafting from 1983 to 1993. Ninety-six patients with ejection fractions of 0.25 or lower underwent this operation, with 88 hospital survivors (mortality 8%). All of the patients had clinical symptoms of heart failure. The male to female ratio was 4.6:1. The average age was 63.1 +/- 0.9 years (mean +/- standard error of the mean). Patients were excluded if they had valvular heart disease other than mild to moderate mitral regurgitation, required resection of a ventricular aneurysm, or required an emergency operation for acute coronary occlusion. Possible predictors of death were examined retrospectively. The catheterization films were reviewed retrospectively by a cardiovascular surgeon who was blinded to patient outcome and was never involved in the clinical management of any of the patients. Vessel quality was described as good, fair, or poor.
Increased age and poor vessel quality were the only significant predictors of poor outcome. Sex, presence or absence of angina, preoperative angina, preoperative ejection fraction, preoperative arrhythmia disorder, aortic cross-clamp time, and the number of bypass grafts had no significant effect on outcome in the perioperative period.
These results demonstrate that poor vessel quality and older age are predictors of poor outcome in patients with low ejection fractions undergoing myocardial revascularization. We conclude that poor distal coronary vasculature is a contraindication to coronary artery bypass grafting in patients with an ejection fraction of 0.25 or less, even if angina is present.
缺血性心肌病（左心室射血分数为0.25或更低）患者冠状动脉血运重建的成功率一直难以预测。我们及其他研究者已证明，此类手术的医院手术死亡率出奇地低，尤其是存在缺血证据时。随后，基于我们的假设，即无论远端冠状动脉血管状态如何，冠状动脉旁路移植术在此类患者亚组中都是安全的，我们放宽了选择标准。
为检验这一假设，我们回顾性研究了1983年至1993年间接受冠状动脉旁路移植术的患者。96例射血分数为0.25或更低的患者接受了该手术，88例患者存活出院（死亡率8%）。所有患者均有心力衰竭的临床症状。男女比例为4.6:1。平均年龄为63.1±0.9岁（均值±均值的标准误差）。若患者有除轻度至中度二尖瓣反流以外的瓣膜性心脏病、需要切除室壁瘤或因急性冠状动脉闭塞需要急诊手术，则被排除。对死亡的可能预测因素进行了回顾性研究。由一位对患者结局不知情且从未参与过任何患者临床管理的心血管外科医生对心导管造影影片进行回顾性审查。血管质量被描述为良好、一般或较差。
年龄增加和血管质量差是预后不良的唯一显著预测因素。性别、是否存在心绞痛、术前心绞痛、术前射血分数、术前心律失常、主动脉阻断时间和旁路移植血管数量在围手术期对结局均无显著影响。
这些结果表明，血管质量差和年龄较大是射血分数低的患者进行心肌血运重建时预后不良的预测因素。我们得出结论，即使存在心绞痛，远端冠状动脉血管质量差也是射血分数为0.25或更低的患者进行冠状动脉旁路移植术的禁忌证。
