EuroSCORE高危患者行心脏不停跳冠状动脉旁路移植术的获益

Benefits of Off-pump Coronary Artery Bypass Grafting in High-risk Patients with High EuroSCORE

目的对比分析体外循环冠状动脉旁路移植术（CABG）和非体外循环冠状动脉旁路移植术（OPCAB）在治疗根据欧洲心脏手术风险评估系统（EuroSCORE）划分的高风险冠状动脉粥样硬化性心脏病（冠心病）患者的手术获益,并总结其临床经验。方法 2007年6月至2013年7月安徽医科大学附属省立医院心脏外科共收治经冠状动脉造影检查确诊的211例冠心病患者,在初次择期手术的冠心病患者中,将同期伴有瓣膜、左心室或主要血管手术的患者剔除。其中52例患者行CABG,男39例、女13例,年龄（61.5±6.5）岁,159例患者行OPCAB,男104例、女55例,年龄（63.9±7.2）岁。根据EuroSCORE计算每例患者的手术死亡率的预测风险（PROM）分值,PROM≥6的患者进入高风险组。比较OPCAB和CABG患者的手术死亡率、手术时间、术后胸腔引流量与输血量、血管吻合的支数、住重症监护室（ICU）时间、呼吸机辅助时间、术后肾功能不全发生率以及高风险组的30 d心血管事件（心律失常、心源性休克）、术后心绞痛、卒中的发生率。结果 OPCAB组和CABG组患者的左主干病变相似,其中OPCAB组血管吻合的支数（2.75±0.82）支,CABG组血管吻合的支数（2.83±0.58）支,两组差异无统计学意义（P〉0.05）。OPCAB组与CABG组在手术时间[（3.92±0.79）h vs.（6.83±1.53）h]、胸腔引流量[（983.14±802.39）ml vs.（1 620.40±879.32）ml]、输血量[（1 289.30±668.08）ml vs.（2 325.30±491.98）ml]、住ICU时间[（3.90±1.33）d vs.（5.08±1.78）d]、呼吸机辅助时间[（9.63±3.32）h vs.（13.76±3.79）h]差异均有统计学意义（P〈0.05）,OPCAB组30 d死亡率与CABG组差异无统计学意义（1.26%vs.3.85%,P〉0.05）。高风险子组中的患者,30 d卒中发生率CABG相比较OPCAB的比值比（OR）为5.7（95%CI 1.28～25.09,P〈0.05）,30 d心血管事件和术后心绞痛的发生率两组相似。结论 OPCAB与CABG在生存率和血管吻合数方面差异无统计学意义。而相对于CABG,OPCAB在手术时间、胸腔引流量与输血量及住ICU时间、呼吸机辅助时间上都具有优势。在基于EuroSCORE评分的高危患者中,OPCAB相对于CABG更有利于短期卒中预防。

Objective To compare clinical outcomes between coronary artery bypass grafting （CABG） and off- pump coronary artery bypass grafting （OPCAB） for high-risk coronary artery disease （CAD） patients with high European System for Cardiac Operative Risk Evaluation （EuroSCORE）. Methods A total of 211 CAD patients undergoing surgical treatment in the Department of Cardiovascular Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical Uni- versity from June 2007 to July 2013 were enrolled into this study, including 52 patients receiving CABG and 159 patients receiving OPCAB. Predicted risk of operative mortality （PROM） of each patient was calculated by EuroSCORE. Patients with PROM t〉 6 were stratified into high-risk subgroups. Clinical outcomes were compared between CABG and OPCAB patients, as well as incidence of cardiovascular events, angina and stroke within 30 postoperative days in high-risk subgroup patients. Results OPCAB and CABG group patients had similar left main disease. There was no statistical difference in the number of distal anastomosis between OPCAB （2.75±0.82） and CABG group patients （2.83±0.58 ）（P 〉 0.05 ）. Operation time [（3.92± 0.79） hour vs. （6.83 ±1.53 ） hour ], thoracic drainage [ （983.14 ± 802.39） ml vs. （ 1 620.40 ± 879.32） ml], blood transfusion [（ 1 289.30±668.08）ml vs. （2 325.30±491.98）ml], length of ICU stay I（3.90～ 1.33）days vs. （ 5.08 4-1.78 ） days l, and mechanical ventilation time [ （ 9.63 ±3.32 ） h vs. （ 13.76± 3.79 ） h ] of OPCAB group patients were significantly shorter or lower than those of CABG group patients （P 〈 0.05）. There was no statistical difference in 30-day mortality between OPCAB and CABG group patients （ 1.26% vs. 3.85%, P 〉 0.05）. Among high-risk subgroup patients, the odds ratio of stroke within 30 postoperative days in CABG was 5.7 （95%CI 1.28-25.09, P 〈 0.05）compared with OPCAB group patients, and the incidence of cardiovascular events and angina within 30 postoperative days were similar between the 2 subgroups. Conclusions Postoperative mortality and number of distal anastomosis are not significantly different between CABG and OPCAB patients, but OPCAB can significantly reduce operation time, thoracic drainage, blood transfusion, length of ICU stay and mechanical ventilation time compared with CABG. For high-risk patients with high EuroSCORE, OPCAB can better reduce the incidence of postoperative stroke compared with CABG.