不同时机外科血运重建治疗心肌梗死后左心功能不全的回顾性研究

The effect of surgical revascularization on different timing after ST-elevation myocardial infarction on patients with ischemic heart disease and left ventricular dysfunction

[目的] 分析急性ST抬高型心肌梗死（STEMI）后行外科血运重建治疗缺血性心脏病左心功能不全的不同手术时机对早期结果的影响.方法 回顾性分析2003年1月至2012年7月住院的225例有明确STEMI病史的缺血性心脏病合并左心功能不全（射血分数≤50％）患者的临床资料,其中男性186例,女性39例.根据心肌梗死后实施外科血运重建的时间将其分为早期组（＜21 d）、中期组（21 ～90 d）和晚期组（＞90 d）.收集患者人口学资料、欧洲心脏手术风险评估系统Ⅱ危险因素以及各项围手术期指标,以30 d死亡及严重并发症作为主要终点事件评价术后早期结果,以术前术后超声心动图测量的左心室舒张末期内径（LVEDD）及射血分数评价左心室形态及功能变化.结果 三组实际手术病死率为3.4％、0、2.3％,组间差异无统计学意义（χ^2 =2.137,P=0.330）.三组低心排血量发生率分别为13.8％、3.1％、2.3％,组间差异有统计学意义（χ^2=8.344,P=0.015）.三组患者术前射血分数分别为42％ ±6％、41％±6％、42％±6％,术后分别为46％±7％、45±10％、45％±9％,各组术后较术前均明显提高（t=-3.378～-2.339,P值均＜0.05）.三组患者术前LVEDD值分别为（51 ±6）mm、（54±6）mm、（55 ±6）mm,术后分别为（49 7）mm、（47 ±8）mm、（49±9）mm,中期组与晚期组术后LVEDD较术前均明显减小（t=5.634、5.885,P=0.000）,早期组手术前后差异无统计学意义（t=1.524,P=0.133）.结论 STEMI后左心功能不全患者在不同时期实施外科血运重建均可有效改变左心室重构进程并改善左心功能,手术时机应根据患者病情、手术技术及围手术期管理水平综合决定,心肌梗死3周后手术对该类患者更为安全.

Objective To analysis the influence of surgical revascularization on different timing after ST-elevation myocardial infarction （STEMI） on patients with coronary artery disease and left ventricular dysfunction.Methods Clinical data of 225 patients admitted from January 2003 to July 2012 with history of STEMI and left ventricular dysfunction （ejection faraction 〈 50%） who underwent isolated coronary artery bypass grafting was retrospectively reviewed.There were 186 male and 39 female patients.According to the timing of surgical revascularization after STEMI,the patients were divided into early revascularization group （ER group,〈 21 days）,mid-term revascularization group （MR group,21 to 90 days） and late revascularization group （LR group,〉 90 days）.There were 20 male and 9 female patients in ER group with mean age of （63 ± 10） years,48 male and 16 female in MR group with mean age of （63 ± 8） years,118 male and 14 female in LR group with mean age of （62 ± 10） years,respectively.Thirty-day postoperative mortality and major complications were determined as the endpoints to evaluate the early results of operation.Results The 30-day post-operative mortality were 3.4%,0 and 2.3% among three groups respectively and there was no statistic difference between groups （χ^2 =2.137,P =0.330）.Low cardiac output syndrome mortality were 13.8%,3.1% and 2.3% among three groups respectively and there was statistic difference between groups （χ^2 =8.344,P =0.015）.The ejection fractions was significantly improved in all the three groups from 42% ±6%,41% ±6% and 42% ±6% preoperatively to 46% ±7%,45% ± 10% and 45% ± 9% postoperatively （t =-3.378 to-2.339,all P 〈 0.05）.The left ventricular end diastolic dimension were significantly reduced in MR group and LR group from （54 ± 6） mm and （55 ± 6） mm preoperatively to （47 ± 8） mm and （49 ± 9） mm postoperatively （t =5.634,5.885 ; P =0.000）.There was no significant change in ER group pre-and postoperatively （（51 ±6） mm vs.（49 ±7） mm,t =1.524,P =0.133）.Conclusions The patients with coronary artery disease and left ventricular dysfunction can benefit from surgical revascularization on different timing after STEMI,presenting as the reverse of left ventricle remodeling and the improvement of left ventricle function.The short-term results are mainly determined by the patients＇ condition,surgical technique and the level of perioperative management.It is recommended for this patient cohort to accept surgical revascularization three weeks after STEMI.