国人非体外循环冠状动脉旁路移植术前阿司匹林治疗策略分析

Should Aspirin Be Discontinued before Off-pump Coronary Artery Bypass Grafting in Chinese Patients?

目的观察国人术前不停用阿司匹林对非体外循环冠状动脉旁路移植术（OPCAB）后早期临床结果的影响。方法回顾性分析北京大学人民医院心外科2011~2012年354例择期行OPCAB术患者的临床资料。2011年132例,术前停用阿司匹林≥5 d,定义为停用组,其中男93例、女39例,年龄36~83（61.70±8.74）岁;2012年222例,术前不停用阿司匹林,定义为不停用组,其中男162例、女60例,年龄37~82（63.26±8.94）岁。比较两组术后总引流量、因出血二次开胸、并发症及住院死亡情况,并比较两组术后4~6 h、12~18 h及24~48 h血清心肌肌钙蛋白I（c Tn I）水平。结果两组术前一般资料差异无统计学意义（P〉0.05）。停用组移植桥血管数少于不停用组[（3.00±0.89）支vs.（3.43±0.93）支,P=0.001]。两组患者术后总引流量[（1 063.75±511.50）ml vs.（1 131.35±460.13）ml,P=0.201]、因出血二次开胸（0例vs.1例,P=1.000）、围术期心肌梗死（2例vs.1例,P=0.647）、术后急性肾功能衰竭（4例vs.7例,P=1.000）、术后脑卒中（1例vs.4例,P=0.726）、术后呼吸机辅助时间[（41.46±85.50）h vs.（52.07±143.59）h,P=0.441]、术后ICU滞留时间[（81.46±116.90）h vs.（79.07±136.43）h,P=0.867]及住院死亡率（0.8%vs.0.9%,P=1.000）差异均无统计学意义。两组间术后4~6 h血清c Tn I水平差异无统计学意义（P=0.506）;术后12~18 h及24~48 h血清c Tn I水平差异有统计学意义（P=0.002,P=0.000）。不停用组术后12~18 h及24~48 h血清c Tn I〉4.0 ng/ml者比例显著低于停用组（5.4%vs.16.7%,P=0.001;5.9%vs.17.4%,P=0.000）。结论 OPCAB术前不停用阿司匹林并不增加术后出血风险,对术后并发症发生率和手术死亡率无显著影响,可以减少OPCAB术后的心肌损伤。

Objective To compare early postoperative outcomes of Chinese patients undergoing off-pump coronary artery bypass grafting（OPCAB） with or without preoperative discontinuation of aspirin. Methods Clinical data of 354 patients who underwent elective OPCAB in Department of Cardiac Surgery, People＇s Hospital of Peking University from 2011 to 2012 were retrospectively analyzed. There were 132 patients during year 2011 who discontinued aspirin more than 5 days before OPCAB and were defined as a discontinuation group, including 93 males and 39 females with their age of 36-83（61.70±8.74） years. There were 222 patients during year 2012 who continued aspirin treatment before OPCAB and were defined as an aspirin group, including 162 males and 60 females with their age of 37-82（63.26±8.94） years. Postoperative chest drainage, incidence of reexploration for bleeding, in-hospital morbidity and mortality were compared between the 2 groups. Serum cardiac troponin I（c Tn I） levels during 4-6 hours, 12-18 hours and 24-48 hours after OPCAB were also compared. Results Preoperative clinical characters were not statistically different between the 2 groups（P〉0.05）. Average number of grafts in the discontinuation group was significantly smaller than that in the aspirin group（3.00±0.89 vs. 3.43±0.93, P=0.001）. There was no significant difference in postoperative chestdrainage（1 063.75±511.50 ml vs. 1 131.35±460.13 ml, P=0.201）, incidence of reexploration for bleeding（0 case vs. 1 case, P=1.000）, perioperative myocardial infarction（2 cases vs. 1 case, P=0.647）, postoperative acute renal failure（4 cases vs. 7 cases, P=1.000）, stroke（1 case vs. 4 cases, P=0.726）, mechanical ventilation time（41.46±85.50 hours vs. 52.07±143.59 hours, P=0.441）, length of ICU stay（81.46±116.90 hours vs. 79.07±136.43 hours, P=0.867）, or in-hospital mortality（0.8% vs. 0.9%, P=1.000）between the 2 groups. Serum c Tn I levels during 4-6 hours after OPCAB were not statistically different between the 2 groups（P=0.506）. Serum c Tn I levels during 12-18 hours and 24-48 hours after OPCAB were statistically different between the 2 groups（P=0.002 and P=0.000）. The percentages of patients with c Tn I level higher than 4.0 ng/ml during 12-18 hours and 24-48 hours after OPCAB in the aspirin group were significantly lower than those in the discontinuation group（5.4% vs. 16.7%, P=0.001;5.9% vs. 17.4%, P=0.000）. Conclusion OPCAB without preoperative discontinuation of aspirin does not increase the risk of postoperative bleeding, in-hospital morbidity or mortality, but can decrease postoperative myocardial injury of Chinese patients undergoing OPCAB.