Christenson J T, Simonet F, Schmuziger M
Cardiovascular Surgery Unit, Hôpital de la Tour, Meyrin-Geneva, Switzerland.
Cardiovasc Surg. 1996 Dec;4(6):801-7. doi: 10.1016/s0967-2109(96)00052-x.
Reoperative (redo) coronary artery bypass grafting is an efficient treatment for patients with progressive coronary artery disease and those with conduit failure. Previous studies have demonstrated that a short time interval between primary and redo coronary artery bypass grafting is associated with a significantly higher mortality rate. In the present report this particular group have been specifically evaluated. Between 1 January 1990 and 1 October 1994, 383 consecutive patients underwent redo coronary artery bypass grafting. Thirty-three patients (8.6%) were operated on at < or = 1 year (group 1) and 350 patients at > 1 year after the primary bypass (group II). The main indications for redo in group I were graft failure (58%), incomplete revascularization (39%) and progress of disease (3%); respective values in group II were 26% 15%, and 23%. In addition, 36% of patients in group II had combinations of complications. Patient characteristics did not differ between groups, except a higher incidence of insulin-dependent diabetes in group I (P < 0.05). There was a higher incidence of left main stem stenosis of > 70% in group I (P < 0.05). Group I patients had a longer aortic cross-clamping time and needed thromboendarterectomy and patching of coronary vessels more often than did those in group II (P < 0.05). The internal mammary artery had been more frequently used at the primary coronary artery bypass grafting in group I (P < 0.01). The overall mortality rate was 8.9%; that in group I was 18% and in group II, 8% (P < 0.05). There was a higher incidence of non-fatal myocardial infarction and a need for prolonged ventilatory support (> 24 h) in group I. Other postoperative complications did not differ. Significant risk factors for mortality in group I were preoperative Canadian Cardiovascular Society class > or = 3, unstable angina, need for urgent operation and left ventricular ejection fraction < 40%, and > or = 70% left main stem stenosis. In group II, the risk factors were: unstable angina, urgent operation, left ventricular ejection fraction < 40%, internal mammary artery not used at primary coronary artery bypass grafting and the need for coronary thromboendarterectomy. The 3-year survival and cardiac event-free survival did not differ between the groups. This study has confirmed that early redo coronary artery bypass grafting (< or = 1 year from primary bypass) is associated with an increased operative risk.
再次冠状动脉搭桥术是治疗进展性冠状动脉疾病患者及血管桥衰竭患者的有效方法。既往研究表明，首次冠状动脉搭桥术与再次冠状动脉搭桥术之间的时间间隔较短与显著较高的死亡率相关。在本报告中，对这一特殊群体进行了专门评估。1990年1月1日至1994年10月1日期间，383例连续患者接受了再次冠状动脉搭桥术。33例患者（8.6%）在首次搭桥术后≤1年接受手术（第1组），350例患者在首次搭桥术后>1年接受手术（第2组）。第1组再次手术的主要指征为血管桥衰竭（58%）、血运重建不完全（39%）和疾病进展（3%）；第2组的相应比例分别为26%、15%和23%。此外，第2组36%的患者有多种并发症合并存在。两组患者的特征无差异，但第1组胰岛素依赖型糖尿病的发生率较高（P<0.05）。第1组左主干狭窄>70%的发生率较高（P<0.05）。第1组患者的主动脉阻断时间较长，比第2组患者更常需要冠状动脉内膜血栓切除术及冠状动脉血管修补术（P<0.05）。第1组在首次冠状动脉搭桥术中更频繁地使用了乳内动脉（P<0.01）。总体死亡率为8.9%；第1组为18%，第2组为8%（P<0.05）。第1组非致命性心肌梗死的发生率较高，且需要延长机械通气支持（>24小时）。其他术后并发症无差异。第1组死亡的显著危险因素为术前加拿大心血管学会分级≥3级、不稳定型心绞痛、急诊手术的必要性以及左心室射血分数<40%，以及左主干狭窄≥70%。在第2组中，危险因素为：不稳定型心绞痛、急诊手术、左心室射血分数<40%、首次冠状动脉搭桥术中未使用乳内动脉以及需要冠状动脉内膜血栓切除术。两组的3年生存率和无心脏事件生存率无差异。本研究证实，早期再次冠状动脉搭桥术（首次搭桥术后≤1年）与手术风险增加相关。
