Jegaden O, Bontemps L, de Gevigney G, Eker A, Montagna P, Chatel C, Itti R, Mikaeloff P
Cl. Bernard University, INSERM 121, Cardiovascular Hospital, Lyons, France.
Eur J Cardiothorac Surg. 1998 Oct;14(4):353-9. doi: 10.1016/s1010-7940(98)00219-x.
To assess the prognostic factors of myocardial recovery expected after coronary bypass surgery and the impact of surgical technique used, a prospective non-randomized study including a 1-year postoperative evaluation of left ventricular function was performed in patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF) < 0.40).
From 1993 to 1996, 110 patients (mean age 61+/-11 years) were included in the study. The mean LVEF was 31+/-6%. All patients had preoperative radionuclide investigations based on the combination of stress/reinjection thallium single photon emission computed tomography (SPECT) and planar evaluation of LVEF; 88% of patients had reversible ischemic thallium defects. Two surgical technique were used: 53 patients received the left internal mammary artery with associated sequential vein graft, and 57 patients received only arterial grafts, internal mammary and gastroepiploic arteries. The mean number of distal anastomoses was 3.2+/-0.8 and 54% of patients had complete revascularization. At 1 year, all survivors had clinical evaluation and the same radionuclide investigations.
The early mortality was 2.7%. At 1 year, 100 patients were surviving; on average, NYHA class decreased 1.9+/-0.8 to 1.4+/-0.6 (P < 0.01) and CCS class from 2.8+/-0.6 to 1+/-0.3 (P < 0.01). The mean LVEF increase from 31+/-9 to 34+/-10% (P < 0.01) and the mean LV end-diastolic volume decreased from 317+/-112 to 285+/-108 ml (n.s.). The postoperative improvement in LV function was higher in patients in NYHA class 3 or 4 before surgery (P < 0.05), when associated sequential vein graft had been used (P < 0.01), and in patients with low preoperative LVEF (P < 0.01). The postoperative LVEF improvement observed was significantly correlated with the improvement in left ventricular end-diastolic (LVED) volume and the improvement in redistribution/reinjection thallium uptake. Multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial function recovery, with a significant positive impact of the vein use.
This study confirms the excellent clinical results of coronary artery bypass grafting (CABG) in patients with coronary artery disease and LV dysfunction; improvement in LV function can be documented objectively and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one internal mammary artery (IMA) and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.
为评估冠状动脉搭桥手术后预期的心肌恢复的预后因素以及所采用手术技术的影响，对左心室功能不全（左心室射血分数（LVEF）<0.40）患者进行了一项前瞻性非随机研究，包括术后1年的左心室功能评估。
1993年至1996年，110例患者（平均年龄61±11岁）纳入研究。平均LVEF为31±6%。所有患者术前行放射性核素检查，基于负荷/再注射铊单光子发射计算机断层扫描（SPECT）与LVEF平面评估相结合；88%的患者有可逆性缺血性铊缺损。采用了两种手术技术：53例患者接受左乳内动脉及相关序贯静脉移植，57例患者仅接受动脉移植，即乳内动脉和胃网膜动脉。平均远端吻合口数量为3.2±0.8，54%的患者实现了完全血运重建。1年时，所有存活者进行了临床评估及相同的放射性核素检查。
早期死亡率为2.7%。1年时，100例患者存活；平均而言，纽约心脏协会（NYHA）分级从1.9±0.8降至1.4±0.6（P<0.01），加拿大心血管学会（CCS）分级从2.8±0.6降至1±0.3（P<0.01）。平均LVEF从31±9增加至34±10%（P<0.01），左心室舒张末期容积平均从317±112降至285±108 ml（无统计学差异）。术前NYHA 3或4级患者术后左心室功能改善更高（P<0.05），使用相关序贯静脉移植时更高（P<0.01），术前LVEF低的患者更高（P<0.01）。观察到的术后LVEF改善与左心室舒张末期（LVED）容积改善及再分布/再注射铊摄取改善显著相关。多因素分析表明，所采用的手术技术和术前LVEF是术后心肌功能恢复的独立预后因素，静脉使用有显著的积极影响。
本研究证实了冠状动脉搭桥术（CABG）在冠心病合并左心室功能不全患者中的优异临床效果；左心室功能改善可客观记录，且与冬眠心肌再灌注相关。然而，动脉移植的广泛应用未能实现使用一根乳内动脉（IMA）及相关序贯静脉移植所观察到的显著心肌恢复；这似乎与患者的术前选择有关，但已证明动脉移植有直接负面影响，因此对于严重左心室功能不全患者需谨慎。
