术前应用低分子肝素对非体外循环冠状动脉旁路移植术后早期疗效的影响

Impact of Preoperative Use of Low-molecular-weight Heparin on Early Outcomes of Off-pump Coronary Artery Bypass Grafting

目的探讨术前应用低分子肝素(low molecular weight heparin,LMWH)对行非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)患者术后早期疗效的影响。方法回顾性分析2011年4月1日至2012年9月30日中国医科大学附属第一医院809例行单纯OPCAB患者的临床资料,根据术前是否应用LMWH分为两组,LMWH组:386例,男290例,女96例;年龄49～81岁;术前停用抗血小板药物后均常规给予低分子肝素(低分子肝素钠或低分子肝素钙,4 000 U每日2次,皮下注射)抗凝治疗,直至手术前一天早晨。对照组:423例,男321例,女102例;年龄46～78岁;直接停用抗血小板药物,而不应用LMWH或其它抗凝药物。比较两组患者的死亡率、围术期心肌梗死发生率、手术时间、失血量、输血量、术后急性肾功能不全发生率等。结果 LMWH组患者术中失血量[(296±94)ml vs.(249±81)ml,P=0.03]、术后胸腔引流量[(526±159)ml vs.(410±125)ml,P=0.02]、输红细胞量[(2.6±1.1)U vs.(1.4±0.9)U,P=0.04]以及手术时间[(172±34)min vs(.154±41)min,P=0.04]均显著大于对照组,而两组间手术死亡率(1.0%vs.1.2%,P=1.00)、围术期心肌梗死发生率(4.4%vs.3.8%,P=0.55)差异无统计学意义。结论对于稳定的缺血性心脏病,术前不用LMWH可缩短手术时间、减少失血量和输血量,并不增加手术死亡率以及围术期心肌梗死的发生率。

Objective To investigate the impact of preoperative use of low-molecular-weight heparin （LMWH） on early outcomes of off-pump coronary artery bypass grafting （OPCAB）. Methods Clinical data of 809 patients undergoing isolated OPCAB from April 1 st, 2011 to September 30th, 2012 in the First Affiliated Hospital of China Medical University were retrospectively analyzed. All the patients were divided into LMWH group and control group according to preoperative use of LMWH or not. In LMWH group, there were 386 patients including 290 male and 96 female patients with their age of 49-81 years, who routinely received anticoagulation therapy with LMWH （LMWH sodium or LMWH calcium, 4 000 U twice a day, subcutaneous injection） after discontinuation of anti-platelet therapy until the day before surgery. In the control group, there were 423 patients including 321 male and 102 female patients with their age of 46-78 years, who didn＇t receive LMWH or any other anticoagulant after discontinuation of anti-platelet therapy. Postoperative mortality, incidence ofperio- perative myocardial infarction （MI）, operation time, amount of blood loss and transfusion, and incidence of postoperative acute renal injury were compared between the 2 groups. Results Intraoperative blood loss （296-4- 94 ml vs. 249_ 81 ml, P=0.03 ）, postoperative thoracic drainage （526_ 159 ml vs. 410 ~ 125 ml, P=0.02 ）, blood transfusion （2.6-4- 1.1 U vs. 1.4-4- 0.9 U, P=-0.04） and operation time （ 172-4- 34 min vs. 154-4- 41 min, P=-0.04） of LMWH group were significantly larger or longer than those of the control group. There was no statistical difference in postoperative mortality （ 1.0% vs. 1.2%, P= 1.00）or incidence ofperioperative MI （4.4% vs. 3.8%,P=0.55）between the 2 groups. Conclusion For OPCAB patients with stable ischemic heart disease, preoperative management without use of LMWH can decrease operation time and amount of blood loss and transfusion without increasing postoperative mortality or incidence of perioperative MI.