单纯不停跳冠状动脉旁路移植术治疗缺血性中度二尖瓣反流的倾向匹配研究

Isolated off-pump coronary artery bypass grafting corrects moderate ischemic mitral regurgitation: a propensity-matched study

目的观察未修复的缺血性中度二尖瓣反流在单纯不停跳冠状动脉旁路移植术后的变化过程及研究其对住院结果及生存率的影响。方法连续收集2013年8月至2017年7月首都医科大学附属北京安贞医院术前有缺血性中度二尖瓣反流择期行不停跳冠状动脉旁路移植术的31例冠状动脉粥样硬化性心脏病患者的临床资料。为了得到组间风险矫正后的结局比较,其中的30例患者(96.8%)用倾向性评分匹配方法与术前无二尖瓣反流且实施了相同手术的60例患者进行匹配。然后进行组间复合住院结局(院内死亡、心肌梗死、脑卒中、主动脉球囊反搏及延迟拔管)及生存率差异的比较。未修复的缺血性中度二尖瓣反流术后随时间的变化利用纵向数据分析方法对这些患者术后的超声资料进行分析。结果 29%、53%及18%的患者术后缺血性二尖瓣的反流程度分别为中度、轻度、微量,且该比例在术后的随访中无明显变化(P=0.88)。虽然左心室舒张末期内径在术后随时间无明显变化(P=0.68),但冠状动脉旁路移植术后左心室射血分数随时间有增长的趋势(P=0.07)。二尖瓣反流组与无二尖瓣反流组复合住院结局及术后4年生存率差异无统计学意义[13.3%(4/30)比15.0%(9/60)、95%比100%](P>0.05)。结论多数术前缺血性中度二尖瓣反流在单纯不停跳冠状动脉旁路移植术后能得到有效且持久的缓解。此外,单纯冠状动脉旁路移植术不增加这些患者住院不良事件的发生,同时也不降低生存率。

Objective To observe the changing process of unrepaired moderate ischemic mitral regurgitation after isolated off-pump coronary artery bypass grafting and to evaluate the impact on in-hospital outcomes and survival.Methods From August 2013 to July 2017,clinical records of 31 consecutive patients with coronaryartery disease and moderate ischemic mitral regurgitation who underwent isolated off-pump coronary artery bypass grafting in Beijing Anzhen Hospital,Capital Medical University were collected.Thirty of them （96.8%） were matched with 60 control patients without mitral regurgitation who had the same procedure using the propensity score matching method to obtain risk-adjusted outcome comparison.Composite in-hospital outcomes （in-hospital death,myocardial infarction,stroke,intra-aortic balloon pump insertion,prolonged ventilation） and survival were analyzed.Changing process of unrepaired mitral regurgitation was analyzed using the longitudinal data analysis of post-bypass echocardiograms from those patients.Results Mitral regurgitation was moderate in 29%,mild in 53% and trace or absent in 18% immediately postoperatively.No significant change was observed in the proportion of each mitral regurgitation severity during follow-up （P =0.88）.Although left ventricular end-diastolic diameter remained unchanged（P =0.68）,there was an increase tendency of left ventricular ejection fraction after surgery （P=0.07）.Composite in-hospital endpoints[13.3% （4/30） vs 15.0% （9/60）] and the 4-year survival rate （95% vs 100%） were similar in patients with or without ischemic mitral regurgitation（P 〉0.05）.Conclusion Moderate ischemic mitral regurgitation can be sustainably relieved by isolated coronary artery bypass grafting in most patients;the in-hospital outcomes and survival are satisfactory.