急性心肌梗死近期行非体外循环冠状动脉旁路移植术的临床分析

Clinical Analysis of Off-pump Coronary Artery Bypass Grafting Following Acute Myocardial Infarction

目的探讨急性心肌梗死(AMI)后患者近期行非体外循环冠状动脉旁路移植术(OPCAB)的临床疗效和围术期处理方法。方法 2006年1月至2010年3月,上海交通大学医学院附属仁济医院连续239例患者在发生AMI后14～27(20.55±3.91)d行OPCAB(AMI组),术前磷酸肌酸激酶同工酶(CK-MB,15.82±6.24)U/L,心肌肌钙蛋白Ⅰ(cTnI,0.07±0.04)ng/ml;将同期406例无心肌梗死史的OPCAB患者作为对照(对照组);比较、分析两组患者的临床资料。结果术后30 d AMI组死亡率为2.51%(6/239),其中死于循环衰竭4例,主动脉内球囊反搏(IABP)导致下肢缺血、坏死1例,肺部感染合并休克1例。AMI组患者术后应用多巴胺明显多于对照组(61.51%vs.37.44%,P=0.001),术中/术后行IABP亦多于对照组,但差异无统计学意义(P>0.05)。AMI组术后引流量及输注红细胞悬液量均多于对照组[(385.18±93.22)ml vs.(316.41±70.05)ml,P=0.022;(373.68±69.54)ml vs.(289.78±43.33)ml,P=0.005],但两组二次开胸止血率差异无统计学意义(P>0.05)。两组术后新发心房颤动发生率差异无统计学意义(P>0.05);AMI组急性肾损伤发生率高于对照组(13.81%vs.8.62%,P=0.038)。AMI组术后30 d死亡率高于对照组(2.51%vs.1.48%),但差异无统计学意义(P>0.05)。两组住ICU时间[(2.01±0.95)dvs.(1.78±0.98)d]和术后住院时间[(10.33±4.16)d vs.(9.89±4.52)d]差异均无统计学意义(P>0.05)。AMI组随访211例(88.28%),随访时间(2.89±1.02)年;失访28例(11.72%)。随访期间死亡25例,其中心源性死亡14例;1年生存率为97.63%,5年生存率88.15%。结论在AMI发生2～4周、待CK-MB和cTnI水平恢复至正常范围后,行OPCAB是相对安全的。

Objective To investigate clinical outcomes and perioperative management of off-pump coronary artery bypass grafting（OPCAB） for patients following acute myocardial infarction（AMI）.Methods From January 2006 to March 2010,239 consecutive patients underwent OPCAB on the 14-27（20.55±3.91） d following AMI（AMI group）in Renji Hospital,School of Medicine of Shanghai Jiaotong University.Preoperative MB isoenzyme of creatine kinase（CK-MB） level was（15.82±6.24） U/L and cardiac troponin I（cTnI） was（0.07±0.04） ng/ml.Clinical data of 406 patients without myocardial infarction history who underwent OPCAB during the same period were also collected as the control group for comparison.Results The 30-day mortality of AMI group was 2.51%（6/239）.The causes of death were circulatory failure in 4 patients,ischemic necrosis of lower extremity caused by intra-aortic balloon pump（IABP） in 1 patient and pneumonia with septic shock in 1 patient.Dopamine usage in AMI group was significantly higher than that of the control group（61.51% vs.37.44%,P=0.001）.Intraoperative or postoperative IABP implantation was more common in AMI group,but there was no statistical difference between the two groups（P0.05）.Postoperative drainage and blood transfusion in AMI group were significantly larger than those of the control group（385.18±93.22 ml vs.316.41±70.05 ml,P=0.022;373.68±69.54 ml vs.289.78±43.33 ml,P=0.005,respectively）.But there was no statistical difference in re-exploration rate between the two groups（P0.05）.There was no statistical difference in the incidence of postoperative new onset atrial fibrillation between the two groups（P0.05）.Incidence of acute kidney injury of AMI group was significantly higher than that of the control group（13.81% vs.8.62%,P=0.038）.Postoperative 30-day mortality of AMI group was higher than that of the control group,but there was no statistical difference between the two groups（2.51% vs.1.48%,P0.05）.There was no statistical difference in ICU stay time and postoperative hospital stay between the two groups（2.01±0.95 d vs.1.78±0.98 d;10.33±4.16 d vs.9.89±4.52 d,respectively,P0.05）.A total of 211 patients（88.28%）in AMI group were followed up for 2.89±1.02 years,and 28 patients（11.72%） were lost during follow-up.Twenty-five patients died during follow-up including 14 cardiac deaths.One-year survival rate was 97.63%,and five-year survival rate was 88.15%.Conclusion It＇s comparatively safe to perform OPCAB for patients at 2-4 weeks following AMI when their CK-MB and cTnI levels have returned to normal range.