合并终末期肾病的冠状动脉粥样硬化性心脏病患者行冠状动脉旁路移植术临床疗效分析

Clinical efficacy of coronary artery bypass grafting in coronary atherosclerotic heart disease patients with end-stage renal disease

目的分析合并终末期肾病(ESRD)的冠状动脉粥样硬化性心脏病(冠心病)患者行冠状动脉旁路移植术(CABG)的早期临床效果及中远期随访结果。方法收集2010年1月至2017年12月首都医科大学附属北京安贞医院30例需透析治疗的ESRD合并冠心病患者的临床资料,术前肌酐(665±262)μmol/L,肾小球滤过率(8±4)ml/(min·1.73 m^2);平均冠状动脉病变支数(3.1±0.8)支。其中行非体外循环CABG 28例、体外循环下CABG+二尖瓣成形或置换各1例。分析患者的手术资料、围术期情况、出院用药并完成术后随访。结果全部患者术后均使用连续肾脏替代透析治疗。平均完成冠状动脉吻合桥数(3.1±0.7)支。主动脉内球囊反搏使用率为33.3%(10/30)。围术期死亡率为10.0%(3/30),死亡原因包括心功能衰竭2例和顽固性心室颤动1例。术后二次开胸止血率为6.7%(2/30)。围术期心房颤动发生率26.7%(8/30),心肌梗死发生率为36.7%(11/30)。出院服用联合抗血小板药物治疗占85.2%(23/27)。术后成功随访25例,随访率为92.6%(25/27);中位随访时间4(1,7)年,全因死亡率为12.0%(3/25),其中心源性猝死1例,肺部疾病导致死亡2例;不良心脑血管事件发生率为20.0%(5/25)。结论合并ESRD的冠心病患者行CABG的围术期风险较高,但中远期随访结果较为满意。

Objective To analyze the early and long-term outcomes of coronary artery bypass grafting （CABG） in coronary atherosclerotic heart disease（CHD） patients with end-stage renal disease（ESRD）. Methods Clinical data of 30 ESRD patients who had CABG from January 2010 to December 2017 in Beijing Anzhen Hospital, Capital Medical University were analyzed; the mean creatinine level was （665±262）μmol/L; the mean glomerular filtration rate was （8±4）ml/（min·1.73 m2）; the mean number of coronary artery lesions was （3.1±0.8）. Twenty-eight patients had off-pump CABG; 1 patient had on-pump CABG plus mitral valvuloplasty; 1 patient had on-pump CABG plus mitral valve replacement. Surgical and perioperative records, discharge medication and follow-up data were analyzed. Results All patients had continuous renal replacement therapy after surgery. The mean number of bypass grafts was （3.1±0.7）. Intra-aortic balloon pump was used in 10 patients（33.3%）. The perioperative mortality rate was 10.0%（3/30） including heart failure（2 cases） and ventricular fibrillation（1 case）. Two patients（6.7%） had reoperation for hemorrhage. Perioperative atrial fibrillation and myocardial infarction rates were 26.7%（8/30） and 36.7%（11/30）, respectively. Twenty-three patients（85.2%） took antiplatelet drugs after discharge. Twenty-five patients（92.6%） were followed up for 4（1，7） years; the all-cause mortality rate was 12.0%（3/25） including sudden cardiac death（1 case） and pulmonary disease（2 cases）; the cardiovascular adverse event rate was 20.0%（5/25）. Conclusion CABG procedure has a high risk in CHD patients with ESRD; the mid- and long-term outcomes are good.