双侧乳内动脉Y型桥冠状动脉旁路移植术中远期临床疗效分析

Mid-term and Long-term Clinical Outcome Analysis of Bilateral Internal Mammary Artery Composited Y Grafts for Coronary Artery Bypass Grafting

目的评价双侧乳内动脉Y型桥冠状动脉旁路移植术的中远期疗效,分析影响疗效的因素,提高手术的成功率。方法回顾性分析2000年1月至2004年5月165例冠心病患者术前、术后及中远期随访的临床资料,比较心功能变化。采用logistic回归分析影响死亡的危险因素。结果全组共移植血管561支,平均每例移植血管3.4支。围术期无死亡,术后发生并发症16例,包括心绞痛复发、心肌梗死、低心排血量、伤口愈合不良等,均经相应的处理治愈出院。随访160例(97%),随访时间5.6±1.2年。随访期间死亡23例,其中心源性死亡10例,包括再次心肌梗死3例,心力衰竭4例,恶性心律失常3例;非心源性死亡13例,包括胃肠道出血4例,癌症3例,不明原因6例。发生心脏相关并发症25例,包括心绞痛复发18例,心肌梗死4例,再次手术包括冠状动脉介入治疗和冠状动脉旁路移植3例。术后左心室射血分数较术前明显提高(54%±6%vs.43%±12%);术后1年,3年,5年实际生存率分别为98.2%±0.3%,96.2%±0.5%和90.5%±1.9%,免于心脏相关事件发生率分别为95.5%±1.2%,91.3%±2.1%和86.6%±1.5%。单因素分析显示:年龄>65岁、糖尿病、射血分数<30%、心功能分级(NYHA)Ⅲ/Ⅳ级和低心排血量需主动脉内球囊反搏治疗是术后发生主要心血管事件的危险因素。logistic多因素分析结果显示:年龄>65岁(OR=11.6)、糖尿病(OR=21.4)、射血分数<30%(OR=37.5)和心功能分级(NYHA)Ⅲ/Ⅳ级(OR=40.2)是预示晚期死亡的危险因素。结论双侧乳内动脉Y型桥冠状动脉旁路移植术能减少术后心血管相关事件的发生率,提高远期生存率。心功能分级Ⅲ/Ⅳ级、射血分数<30%、糖尿病、年龄>65岁是影响远期疗效的独立危险因素。

Objective To evaluate midterm and long-term clinical outcome of bilateral internal mammary artery composited Y grafts for coronary artery bypass grafting （CABG）, analyze risk factors for late death , and to improve surgical results. Methods Between January 2000 and May 2004, One hundred and sixty-five patients underwent bilateral internal mammary artery grafts for CABG, The clinical data, postoperative complications and survival results were retrospectively reviewed and analyzed. The preoperative and postoperative cardiac function was compared. All factors that may have affected the survival were analyzed by logistic regression, to identify significant variables associated with late death. Results Total 561 anastomosis sites of internal mammary arteries were completed with each patient received an average of 3. 4 grafts. There were no perioperative deaths. There were 16 patients with postoperative complications including recurrent angina, myocardial infarction, low cardiac output syndrome, sternal infection and so on. All patients were treated conservatively without re-operation. One hundred sixty patients（97%） were followed up of 5.6±1.2 years, there were 23 late deaths including 10 patients of cardiac related death in which 3 had recurrent myocardial infarction, 4 heart failure, and 3 arrhythmia; 13 patients of no-cardiac related death in which 4 upper gastrointestinal hemorrhage, 3 cancer and 6 uncertain cause. 25 patients had major cardiac related events including recurrent angina 18, myocardial infarction 4, repeated revascularization 3. Left ventricular ejection fraction was significantly improved as compared with that before operation （54±6% vs. 43%± 12%, P〈0.05）. The 1 - ,3-, 5-year actuarial survival rates and event-free rates were 98. 2% ±0. 3%, 96. 2% ±0. 5%, 90.5%± 1. 9% and 95.5%± 1.2 %, 91.3% ±2.1%, 86.6 % ± 1.5 %, respectively. According to statistical analysis, univariate analyses had proved that advancing age〉 65 years, diabetes, ejection fraction （EF） less than 30%, the New York Heart Association （NYHA） class Ⅲ/Ⅳ, and low cardiac output syndrome required placement of the intraaortic balloon pump were predictors associated with hospital major adverse cardiac events （P〈0. 05）. Those variables entered into the logistic regression model and found to be independent predictors associated with increased late cardiac death included advancing age 〉65 years（OR=11. 6）, diabetes （OR=21.4）, EF less than 30%（OR=37.5） and NYHA class Ⅲ/Ⅳ （OR=40.2）. Conclusion Patients receiving bilateral internal mammary artery composited Y grafts have better long- term survival and reduced cardiac related events. Independent risk factors for late death are NYHA function class Ⅲ/ Ⅳ, EF less than 30%, diabetes and advancing age 〉65 years.