左主干病变冠脉搭桥患者围术期及中长期临床效果分析

Early, middle and long-term clinical outcomes of coronary artery bypass grafting for left main coronary stenosis

目的 评价冠状动脉左主干狭窄（LMS）行冠状动脉搭桥术（CABG）围术期及中长期疗效,并分析术前应用他汀类药物对围术期疗效的影响.方法 回顾性分析1998年1月至2008年3月北京安贞医院收治626例LMS行CABG围术期疗效资料及中长期随访结果,按患者在入院前是否服用他汀类药物（持续2周以上）将LMS患者分为服用他汀类药物组（A组,n=322例）,未服用他汀类药物组（B组,n=304例）;根据手术性质分为两组：非急诊手术组（n=456例）,急症手术组（n=170例）.结果 住院死亡27例（4.31%）,其中A组住院死亡6例（1.90%）;B组住院死亡21例（6.91%）,x2检验x2=9.642,P=0.002.非急诊手术组住院死亡9例（1.97%）;急诊手术组住院死亡18例（10.6%）,x2检验,x2=22.267,P=0.000.术前应用他汀类药物可降低围术期全因病死率（1.90%vs 6.91%,P=0.002）、房性心律失常的发生率（14.69%vs19.61%,x2=5.780,P=0.016）、致残性中风的发生率（2.50%vs4.58%,x2=3.94,P=0.047）.围术期生存599例患者中,完整随访565例,随访率为94.3%,随访时间1～98（56±26）个月,总随访时间为2610患者年,随访期间发生心脏事件为29例次（4.63%）,其中死亡为12例,再发心肌梗死事件17例.43例（7.18%）心绞痛复发,余者心绞痛症状均消失.单因素分析发现急诊手术、术前C反应蛋白增高、肌钙蛋白增高、LMS复杂病变（累及左主干分叉）、术前需要IABP支持、术前有心跳骤停史、既往心梗史、术前未应用他汀类药物为早期死亡危险因子;而既往心梗史、LMS复杂病变（累及左主干分叉）、术前需要IABP支持、术前有心跳骤停史、术前未应用他汀类药物为晚期死亡的危险因子.多因素Binary Logistic回归分析发现,术前C反应蛋白和肌钙蛋白增高、急诊手术、术前需要IABP支持、术前未应用他汀类药物是早期死亡的独立危险因子;而术前需要IABP支持、术前未应用他汀类药物、复杂病变（累及左主干分叉）、术前心脏骤停史为晚期死亡的独立危险因子.常规体外循环下CABG、OPCAB是手术风险差异无统计学意义.结论 LMS病变行CABG手术病死率相对较高,但术前应用他汀类药物对LMS病变的CABG可有效提高围术期生存率、降低不良事件发生率.

Objective To evaluate the early, middle and long-term clinical outcomes of coronary artery bypass grafting （CABG） for a special subset of left main coronary stenosis （LMS）. Methods A total of 626 LMS patients, recruited at our hospital between January 1998 and March 2008, were classified them into the statin therapy group （ Group A, n = 322） or the non-statin therapy group （ Group B, n = 304） according to whether or not taking statins pre-operatively. Then their clinical data were retrospectively analyzed. Results The inhospital mortality was 4. 31% （ n = 27 ）. And the mortality was 1.90% （ n = 6） for Group A and 6. 91% for Group B （n =21 ） （χ2 test, χ2=9. 642, P =0. 002）. Preoperative statin therapy could lower the all-cause mortality rate （1.90% vs 6.91%, P = 0.002）, the prevalence of new atrial fibrillation or flutter （ 14. 69% vs 19, 61% , P = 0. 016, χ2 = 5. 780） and disabling stroke （ 2. 50% vs 4. 58% , P =0. 047, χ2 = 3.94）. Among 599 CABG survivors, 565 eases （94. 3% ） were actually followed up with a mean duration of 55.5±26. 1 months （range =98 ）. During the follow-up period, there were 29 （4. 63% ） cardiac events, including 12 deaths and 17 myocardial infarctions, There were 43 （7. 18% ） eases with relapsing angina pectoris. The univariate analysis showed that emergency procedure, abnormal C-reactive protein （CRP）, abnormal troponin I（TnI）, complicated LMS pathology, preoperative IABP （intra-aortic balloon pump） support, preoperative cardiac arrest, preoperative history of myocardium infarction and no preoperative statin therapy were the risk factors for perioperative death while complicated LMS pathology, preoperative IABP support, preoperative cardiac arrest, preoperative myocardium infaretion and no preoperative statin therapy were the risk factor for late cardiac events. The multivariate binary logistic regression showed that emergency procedure, preoperative IABP support, no preoperative statin therapy and preoperative IABP support were independent predictors for peri-operative death. And preoperative IABP support, preoperative cardiac arrest, no preoperative statin therapy and complicated LMS pathology were independent predictors for late cardiac events. There was no statistical significance in inhospital mortality between on pump CABG and OPCAB （off pump coronary artery bypass）. Conclusion The CABG procedure for LMS carries a relative high mortality. However preoperative statin therapy may offer such protective effects as lowering the all-cause mortality rate and reducing the prevalenee of new atrial fibrillation or flutter and disabling stroke.