Arom K V, Emery R W, Petersen R J, Bero J W
Minneapolis Heart Institute, Minnesota, USA.
Ann Thorac Surg. 1997 Jun;63(6):1619-24. doi: 10.1016/s0003-4975(97)00359-7.
This study examined the efficacy and safety of retrograde cardioplegia in comparison with an antegrade/retrograde approach.
Between January 1, 1991, and December 31, 1995, 7,032 coronary artery bypass procedures, alone or in combination with valve replacement/repair, were performed using either retrograde cardioplegia (R) or an antegrade/retrograde (AR) approach. There were 4,224 patients in the R group and 2,808 in the AR group. These included elective, urgent, emergent/salvage, first operative, and redo cases.
All preoperative, intraoperative, and postoperative variables listed in The Society of Thoracic Surgeons National Cardiac Surgery Database were used to compare the two groups using univariate analysis. The pump time was longer in the AR group, with fewer grafts per patient. The R group had higher predicted risk (3.2% versus 3.0%; p = 0.04), more postoperative atrial fibrillation (34% versus 31%; p = 0.006), and longer postoperative length of stay (8.8 versus 8.0 days; p < 0.001). Using The Society of Thoracic Surgeons National Cardiac Surgery Database predicted risk group model, a subgroup of 221 coronary artery bypass grafting patients in the retrograde (s-R) and 132 coronary artery bypass grafting patients in the antegrade/retrograde (s-AR) group fell into a greater incidence of predicted mortality group (> or = 10%). The s-R subgroup had more patients in New York Heart Association functional class IV. Univariate analysis revealed higher postoperative atrial fibrillation (51% versus 41%; p = 0.05) and longer postoperative length of stay (12.8 versus 10.8 days; p = 0.03) in the s-R subgroup versus the s-AR subgroup.
The results appear to favor neither approach. Preoperatively, both retrograde groups (R and s-R) had higher preoperative predicted risk, but operative mortality or complications were not significantly increased when compared with the AR and s-AR groups. Retrograde cardioplegia alone was shown to be effective in the R and s-R groups, but atrial fibrillation developed in more patients, which could have contributed to longer length of stay in these groups. Antegrade/retrograde cardioplegia offers good immediate outcome but the delivery method can be cumbersome and confusing during the adjustments of flow clamps for antegrade/retrograde delivery and may contribute to prolonged pump times. From this retrospective, nonrandomized review, it appears that retrograde cardioplegia alone provides as good myocardial protection and safety as an antegrade/retrograde approach in either the low-risk or high-risk patient.
本研究比较了逆行性心脏停搏与顺行/逆行联合方法的疗效和安全性。
在1991年1月1日至1995年12月31日期间，7032例冠状动脉搭桥手术单独或与瓣膜置换/修复联合进行，采用逆行性心脏停搏（R）或顺行/逆行（AR）方法。R组有4224例患者，AR组有2808例患者。这些包括择期、急诊、紧急/挽救性、首次手术和再次手术病例。
使用胸外科医师协会国家心脏手术数据库中列出的所有术前、术中和术后变量，通过单因素分析比较两组。AR组的体外循环时间更长，每位患者的移植血管更少。R组的预测风险更高（3.2%对3.0%；p = 0.04），术后房颤更多（34%对31%；p = 0.006），术后住院时间更长（8.8天对8.0天；p < 0.001）。使用胸外科医师协会国家心脏手术数据库预测风险组模型，逆行组（s - R）中的221例冠状动脉搭桥患者亚组和顺行/逆行组（s - AR）中的132例冠状动脉搭桥患者亚组的预测死亡率组（≥10%）发生率更高。s - R亚组中纽约心脏协会功能分级为IV级的患者更多。单因素分析显示，与s - AR亚组相比，s - R亚组术后房颤发生率更高（51%对41%；p = 0.05），术后住院时间更长（12.8天对10.8天；p = 0.03）。
结果似乎对两种方法均无明显偏好。术前，两个逆行组（R和s - R）的术前预测风险均较高，但与AR组和s - AR组相比，手术死亡率或并发症并未显著增加。单独使用逆行性心脏停搏在R组和s - R组中显示有效，但更多患者发生房颤，这可能导致这些组的住院时间延长。顺行/逆行联合心脏停搏可提供良好的即时效果，但在调整顺行/逆行输送的流量夹时，输送方法可能繁琐且容易混淆，可能导致体外循环时间延长。从这项回顾性、非随机的综述来看，在低风险或高风险患者中，单独使用逆行性心脏停搏在心肌保护和安全性方面与顺行/逆行联合方法相当。
