老年患者行停跳或非停跳冠状动脉旁路移植术后早期及远期结果

Influence of off-pump coronary artery bypass grafting on early and long-term mortality and morbidity in a consecutive series of elderly patients

目的 观察常规冠状动脉旁路移植术（CCABG）及非停跳冠状动脉旁路移植术（OPCAB）对于老年患者（年龄〉65岁）术后早期及远期的发病率及死亡率的影响。方法收集自1999年1月至2003年12月共1191例年龄〉65岁的冠状动脉旁路移植术（CABG）患者资料，其中行CCABG744例，行OPCAB447例。早期结果观察项目包括院内死亡率及术后发病率，远期结果观察项目包括总死亡率，再血管化，Q波心肌梗死，卒中，再次入院及复合终点事件，并利用Cox回归分析进行评估。结果对于早期结果的单变量分析显示，OPCAB有着明显优越性，在根据患者基线特衙进行调整后，OPCAB仍然具有优越性。Kaplan—Meier生存分析表明OPCAB术后患者主要不良心脑血管事件（MACCEs）及再次人院发生率更高（P〈0．001），而在总死亡率（P=0．193）及再血管化比例（P=0．067）方面较CCABG没有明显增高。对于术后远期结果的Cox回归分析显示，行OPCAB患者卒中发生率更高[风险比（RR）：2．611，95％可信区间（CX）：2．152～3．070]，再次入院率更高（RR：2．000，95％CI：1．747～2．253），MACCEs发生率更高（RR：1．764，95％CI：1．456～2．072）。结论与CCABG比较，OPCAB可使老年患者在术后早期受益，但这些早期获益并不能延续到术后远期，其远期结果可能因血运重建不充分而较CCABG差。

Objective To investigate the influence of off-pump coronary artery bypass grafting on early and longterm mortality and morbidity in a eonsecutive series of elderly patients. Methods From January 1999 to December 2003, clinical data of 1191 consecutive patients aged more than 65 years old, who underwent either a conventional coronary artery bypass grafting （ n = 744 ） or an off-pump coronary artery bypass grafting （ n = 447 ）, were obtained. Age-related early outcomes were in-hospital mortality and postoperative morbidities. Long-term outcomes, including total mortality, repeated revascularization, Q-wave myocardial infarction, stroke, readmission, and the combination of death, Q-wave myocardial infarction, stroke, and repeated revascularization, were evaluated with Cox regression analysis. Results Univariate analysis for early outcomes showed significant benefits from offpump coronary artery bypass grafting. After adjustment for baseline characteristics, there was still a benefit of off-pump coronary artery bypass grafting. Kaplan-Meier survival analyses showed that stroke, major adverse cardiac and eerebrovascular events, and readmission occurred more frequently in the offpump coronary artery bypass grafting group （ P 〈 0. 001 ）. There was a nonsignificant trend to higher total mortality （ P = 0. 193） and higher repeated revascularization rates （P = 0. 067） in the off-pump coronary artery bypass grafting group than in conventional bypass group. Cox regression for long-term outcomes showed that patients in the off-pump coronary artery bypass grafting group had a higher incidence of stroke （ HR 2. 611 , 95% CI 2. 152-3. 070） , readmission （ HR 2. 000, 95% CI 1. 747-2. 253）, and major adverse cardiac and cerebrovascular events （HR 1. 764, 95% CI 1. 456-2. 072）. Conclusions Our data shows that, compared with conventional coronary artery bypass grafting, off-pump coronary artery bypass grafting is associated with favorable early outcomes in the elderly population. However, this early benefits are not sustained in the long term, and off-pump coronary after＇ bypass grafting shows trends toward worse long term results.