多支与单支动脉桥非体外冠状动脉旁路移植术的中远期疗效——倾向性评分匹配对比研究

Clinical results of multi-artery-graft and single-artery-graft off-pump coronary artery bypass grafting: a propensity score matching follow-up study

目的·利用倾向性评分匹配平衡多支与单支动脉桥非体外冠状动脉旁路移植术(OPCABG)的混杂因素,评价两者在处理左主干及多支冠状动脉病变中的效果。方法·纳入2012年1月至2016年9月在上海交通大学医学院附属瑞金医院行单纯OPCAB术的左主干及多支病变患者共1 578例,对2组患者进行倾向性评分匹配得到风险调整后的临床结果,通过Kaplan-Meier曲线分析2组免于主要不良心脑血管事件(MACCE)与免于因心脏疾患再次入院的生存情况,最后通过Cox回归模型分析MACCE发生的独立危险因素。结果·平均随访时间为28个月(7~55个月)。经倾向性评分匹配后,2组患者在各项院内短期临床终点上差异均无统计学意义。在中远期随访结果中,多支动脉桥组的因心脏疾患再次入院率(2.7%vs 12.7%,P=0.023)、CCS分级(1.2±0.4 vs 1.4±0.6,P=0.020)及术后1年桥血管通畅率(95.8%vs 85.9%,P=0.025)均显著优于对照组,而其余终点均无显著性差异。多支动脉桥组免于因心脏疾患再次入院的生存情况显著改善(P=0.028)。性别为女性是中远期MACCE的独立危险因素(95%CI为0.117~0.906,P=0.032)。结论·使用多支动脉桥OPCABG处理左主干及多支冠状动脉病变是一种安全的手术方式,改善术后桥血管通畅率,具有一定的中远期临床获益;女性患者术后的随访应得到进一步的重视。

Objective·To explore the difference between multi-artery-graft off-pump coronary artery bypass grafting （OPCABG） and single-artery-graft OPCABG on left main coronary artery or multivessel disease with propensity score matching. Methods·A total of 1578 patients with left main coronary artery or multivessel disease underwent isolated OPCABG were selected in Ruijin Hospital from January 2012 to September 2016. The propensity score methodology was used to obtain risk-adjusted outcome. Kaplan-Meier analysis was applied for estimation of freedom from major adverse cardiac and cerebrovascular events （MACCE） and readmission for heart disease. Independent predictor of MACCE were assessed by Cox regression analysis. Results·The average follow-up time was 28 months （7-55 months）. There was no statistical difference in short-term clinical endpoints in hospital. In the follow-up results, multi-artery-graft OPCABG patients had statistical improvement in readmission for heart disease （2.7% vs 12.7%, P=0.023）, CCS class （1.2±0.4 vs 1.4±0.6, P=0.020） and patency rate of grafts in 1 year after operation （95.8% vs 85.9%, P=0.025）, compared with single-artery-graft OPCABG. There was no statistical difference in other endpoints. There was statistical improvement for multi-artery-graft OPCABG patients in freedom from readmission for heart disease （P=0.028）. Female was an independent predictor of MACCE （95% CI 0.117-0.906, P=0.032）. Conclusion·Multi-artery-graft OPCABG appears to be safe and with good patency of grafts and clinical outcomes in treating left main coronary artery or multivessel disease. The follow up of female patients should be paid more attention.