Del Rizzo D F, Boyd W D, Novick R J, McKenzie F N, Desai N D, Menkis A H
London Health Sciences Centre, University of Western Ontario, Canada.
Ann Thorac Surg. 1998 Sep;66(3):1002-7. doi: 10.1016/s0003-4975(98)00660-2.
Myocardial revascularization without cardiopulmonary bypass has been proposed as a potential therapeutic alternative in high-risk patients undergoing coronary artery bypass grafting. To evaluate this possibility we compared 15 high-risk (HR) patients in whom minimally invasive direct coronary artery bypass grafting was used as the method of revascularization with 41 consecutive patients who underwent conventional coronary artery bypass grafting during 1 month.
Patients undergoing myocardial revascularization without cardiopulmonary bypass were significantly older than their low-risk (LR) counterparts (72.2 +/- 11.6 versus 63.3 +/- 9.7 years, p = 0.006). The demographic profile for HR versus LR patients was as follows: female patients, 60.0% versus 26.8%, p = 0.02; diabetes, 20.0% versus 24.4%, p = 0.7; prior stroke, 33.3% versus 7.4%, p = 0.03; chronic obstructive pulmonary disease, 60.0% versus 9.8%, p < 0.0001; peripheral vascular disease, 33.3% versus 12.2%, p = 0.03, congestive heart failure, 26.6% versus 9.8%, p = 0.09; impaired left ventricular (ejection fraction < 0.40), 40.0% versus 17.0%, p = 0.07; urgent operation, 86.6% versus 46.3%, p < 0.0001; and redo operation, 20.0% versus 0%, p = 0.003.
There were no deaths in the HR group and one death in the LR group. The average intensive care unit stay was 1.1 +/- 0.5 days in HR patients versus 1.6 +/- 1.6 days in LR individuals (p = 0.2), and the average hospital stay was 6.1 +/- 1.8 versus 7.3 +/- 4.4 days, respectively (p = 0.3). We used an acuity risk score index developed by the Adult Cardiac Care Network of Ontario to predict outcome in the HR group. The expected intensive care unit stay in HR patients was 4.1 +/- 1.2 days (versus the observed stay of 1.1 +/- 0.5 days, p < 0.0001), and the expected hospital stay was 12.5 +/- 1.5 days (versus the observed stay of 6.1 +/- 1.8 days, p < 0.0001). The expected mortality in the HR group was 6.1% versus 0%, p = 0.3. A cost regression model was used to examine predicted versus actual cost (in Canadian dollars) for the HR patient cohort (based on Ontario Ministry of Health funding). The expected cost for the HR cohort would have been $11,997 per patient. In contrast, the average cost for these 15 patients was $5,997 per patient, an estimated cost saving of 50%.
Myocardial revascularization without cardiopulmonary bypass appears to be a safe and cost-effective therapeutic modality for HR patients requiring myocardial revascularization.
对于接受冠状动脉搭桥术的高危患者，非体外循环下心肌血运重建已被提议作为一种潜在的治疗选择。为评估这种可能性，我们将15例采用微创直接冠状动脉搭桥术进行血运重建的高危（HR）患者与1个月内连续接受传统冠状动脉搭桥术的41例患者进行了比较。
接受非体外循环下心肌血运重建的患者明显比低危（LR）患者年龄大（72.2±11.6岁对63.3±9.7岁，p = 0.006）。HR组与LR组患者的人口统计学特征如下：女性患者，60.0%对26.8%，p = 0.02；糖尿病，20.0%对24.4%，p = 0.7；既往中风，33.3%对7.4%，p = 0.03；慢性阻塞性肺疾病，60.0%对9.8%，p < 0.0001；外周血管疾病，33.3%对12.2%，p = 0.03；充血性心力衰竭，26.6%对9.8%，p = 0.09；左心室功能受损（射血分数<0.40），40.0%对17.0%，p = 0.07；急诊手术，86.6%对46.3%，p < 0.0001；再次手术，20.0%对0%，p = 0.003。
HR组无死亡病例，LR组有1例死亡。HR组患者在重症监护病房的平均停留时间为1.1±0.5天，而LR组为1.6±1.6天（p = 0.2），平均住院时间分别为6.1±1.8天和7.3±4.4天（p = 0.3）。我们使用安大略省成人心脏护理网络制定的急性风险评分指数来预测HR组的结局。HR组患者在重症监护病房的预期停留时间为4.1±1.2天（与观察到的1.1±0.5天相比，p < 0.0001），预期住院时间为12.5±1.5天（与观察到的6.1±1.8天相比，p < 0.0001）。HR组的预期死亡率为6.1%对0%，p = 0.3。使用成本回归模型来检查HR患者队列的预测成本与实际成本（以加元计）（基于安大略省卫生部的资金）。HR队列的预期成本为每位患者11,997加元。相比之下，这15例患者的平均成本为每位患者5,997加元，估计节省成本50%。
对于需要心肌血运重建的HR患者，非体外循环下心肌血运重建似乎是一种安全且具有成本效益的治疗方式。
