两种微创旁路移植手术治疗多支冠状动脉病变效果的对比

Comparison of outcomes of two minimally invasive approaches for multi-vessel coronary revascularization

目的:对比分析研究分期杂交技术(staged-hybrid coronary revascularization,Staged-HCR)与微创双侧胸廓内动脉(bilateral internal thoracic artery,BITA)全动脉旁路移植术治疗多支冠状动脉病变的安全性和有效性。方法:自2014年8月至2017年2月,70名患者接受微创冠状动脉旁路移植术治疗多支冠状动脉血管病变,随机分为两组,其中应用微创直视冠状动脉旁路移植技术(minimally invasive direct coronary artery bypass grafting,MIDCAB)行左侧胸廓内动脉至冠状动脉前降支搭桥、结合经皮冠状动脉介入技术(percutaneous coronary intervention,PCI)治疗非前降支血管病变的Staged-HCR组患者40名;应用微创BITA旁路移植术治疗患者30名。对比两组患者的术前资料、术中血液制品使用情况、机械通气时间、监护室停留时间、术后主要心脑血管不良事件以及术后冠状动脉造影结果,分析两种微创方法治疗冠状动脉多支血管病变的安全性和有效性。结果:两组患者术前资料差异无统计学意义,均按计划接受微创搭桥治疗。在术后机械辅助通气时间[Staged-HCR组(11.2±8.7)h,微创BITA组(18.3±9.1)h,P=0.013]、监护室停留时间[Staged-HCR组(26.29±4.05)h,微创BITA组(44.74±28.75)h,P=0.022]以及累计伤口引流量[Staged-HCR组(695.57±250.46)m L,微创BITA组(1103.26±547.44)m L,P=0.03]方面,Staged-HCR技术更有优势。术后冠状动脉造影显示两种方法均取得较高的移植血管通畅率,两组患者住院期间未发生术后主要心脑血管不良事件。结论:Staged-HCR技术是治疗冠状动脉多支病变的一种微创方法,在治疗存在右冠状动脉主干病变再血管化方面有优势;微创BITA全动脉化旁路移植手术具备更优异的远期通畅率,且适用于不能耐受PCI治疗后双联抗血小板治疗的患者,本研究表明两种方法均安全且有效。

Objective： To compare the safety and effectiveness of two minimally invasive approaches for multi-vessel coronary revascularization. Methods： From August 2014 to February 2017,70 consecutive patients who underwent minimally invasive coronary artery bypass grafting in Peking University Third Hospital were randomly divided into two groups. In one group,40 patients underwent staged-hybrid coronary revascularization（ staged-HCR） treatment; in the other group,30 patients underwent minimally invasive total arterial revascularization with bilateral internal thoracic artery（ BITA）. In staged-HCR group,the patients underwent minimally invasive direct coronary artery bypass grafting（ MIDCAB） and percutaneous coronary intervention（ PCI） procedure for treatment of multi-vessel disease. In BITA group,the patients underwent total arterial coronary artery bypass grafting with composite ＂Y＂BITA graft. Preoperative and postoperative data of the two groups,including postoperative blood usage,mechanical ventilation time,domiciling duration in intensive care unit（ ICU）,major adverse cerebral and cardiovascular event（ MACCE）,and postoperative coronary angiography results were compared,in order to evaluate the safety and effectiveness of these surgical approaches. Results： The preoperative characteristics of 70 patients in the two groups showed no significant difference. All the patients underwent successfully,elective minimally invasive multi-vessel coronary artery bypass grafting as scheduled preoperatively. Postoperative result showed the patients in staged-HCR group took advantages in less postoperative mechanical ventilation time [Staged-HCR group（ 11. 2 ± 8. 7） h vs. BITA group（ 18. 3 ± 9. 1） h,P = 0. 013],shorter domiciling duration in ICU [Staged-HCR group（ 26. 29 ± 4. 05） h vs. BITA group（ 44. 74 ± 28. 75） h,P =0. 022],and less total drainage [Staged-HCR group（ 695. 57 ± 250. 46） m L vs. BITA group（ 1 103. 26 ± 547. 44） m L,P = 0. 03]than the patients in the group of minimally invasive total arterial revascularization with BITA. Postoperative in hospital coronary angiography showed satisfactory graft patency rates in both groups [97. 5% in Staged-HCR group vs. 97. 8% in BITA group]. No MACCE occurred in both groups during hospitalization. Conclusion： Staged-HCR is a feasible method for the treatment of multi-vessel revascularization involving right coronary artery. Minimally coronary revascularization with BITA is associated with superior long-term graft patency and it ＇s recommended for patients who could not tolerate dual-antiplatelet therapy. This study shows that both minimally invasive surgical approaches are safe and effective for treatment of patients with multi-vessel coronary artery disease.