机器人冠状动脉旁路移植术微创术式选择影响因素研究

Clinical factors influencing surgical approach selection of robotic-enhanced minimally invasivecoronary artery bypass grafting

目的研究影响全机器人不停跳冠状动脉旁路移植术（TECAB）与小切口不停跳冠状动脉旁路移植术（MIDCAB）两种微创术式选择的临床因素。方法2007年2月至2013年1月根据统一纳入排除标准选择合适患者，共202例，其中男性142例，女性60例；年龄33～80岁，平均（59±10）岁。患者全部按照TECAB进行常规术前准备，术中根据病情需要选择TECAB或转化为MIDCAB完成手术。本组共90例患者行TECAB（TECAB组），112例患者行MIDCAB（MIDCAB组）。单因素分析比较两组患者术前资料及围术期相关指标，采用Logistic多因素回归分析探讨机器人微创术式选择的预测因素。结果本组患者全部顺利接受手术治疗，未发生死亡、严重并发症或转化为正中开胸。术后早中期冠状动脉CT显示桥血管通畅率满意。平均手术时间（160±64）min，桥血流平均流速（27±18）mffmin。单因素分析比较TECAB组与MIDCAB组术前资料显示，性别比（3．5比1．8，t=4．350，P=0．037）、体重[（69±11）kg比（72±11）kg，t=-1．979，P=0．049]，冠状动脉92支病变率（43．3％比60．7％，t=6．051，P：0．014）以及学习曲线早期手术率（4．4％比14．3％，t=5．418，P=0．02）差异均有统计学意义。多因素Logistic回归分析显示冠状动脉92支病变（HR=1．964，95％CI：1．049～3．680，P=0．035）以及学习曲线早期病例（HR=4．538，95％CI：1．219～16．891．P=0．024）为术式转化的独立影响因素。结论机器人微创冠状动脉旁路移植术安全有效，冠状动脉≥2支病变及学习曲线早期病例是机器人微创术式选择的独立影响因素。

Objective To investigate clinical factors that influence the selection of minimally approach between minimally invasive direct coronary artery bypass （MIDCAB） and totally endoscopic coronary artery bypass （TECAB）. Methods From February 2007 to January 2013, patients were selected under uniform criteria. A total of 202 patients including 142 male and 60 female patients with age range from 33 to 80 years and average age of （59± 10 ） years were included and were all routinely prepared for TECAB. Either TECAB or MIDCAB was performed based on the intraoperative condition. There were 90 patients who underwent TECAB （TECAB group） and 112 patients who received MIDCAB surgery （MIDCAB group）. Univariate analysis was used to compare preoperative, intraoperative and early postoperative parameters. Logistic multivariate regression analysis was used to discuss independent influencing factors of minimally invasive approach selection. Results All of the patients successfully received TECAB or MIDCAB surgery without morlality, severe complications or conversion to sternotomy. The early and midterm follow up of graft patency （by computed tomography angiography） was satisfactory. The mean operative time was （160 ± 64） minutes, mean graft flow was （27 ±- 18） ml/min. Univariate analysis showed that sex ratio （3.5 vs. 1.8, t=4.350, P=0.037）, weight [（69 ＋ll）kgvs. （72±11）kg, t= -1.979, P=0.0491, multivessel coronary disease （43.3% vs. 60. 7% , t =6. 051 , P =0. 014） , and learning curve case （4. 4% vs. 14. 3% , t =5.418, P = 0.02） were significant predietors of conversion to MIDCAB. By multivariate analysis, multivessel coronary disease （ HR = 1. 964, 95% CI： 1. 049-3. 680, P = 0. 035） and learning curve case （HR = 4. 538, 95% CI： 1. 219-16. 891, P = 0. 024 ） were independent influencing factors of MIDCABapproach. Conclusions Robotic-assisted minimally invasive coronary artery bypass grafting can be performed safely and effectively either by TECAB or MIDCAB. Multivessel coronary disease and early learning curve cases are independent influencing factors of minimally invasive approach selection.