全动脉化冠状动脉旁路移植术的手术策略及临床结果

Surgical strategies and long-term outcomes of total arterial coronary artery bypass grafting: a series of 208 patients

目的探讨全动脉化冠状动脉旁路移植术(CABG)的近期和远期疗效。方法回顾性分析2009年2月至2019年12月上海交通大学医学院附属瑞金医院心脏外科实施的208例全动脉化CABG的冠心病患者的临床资料。男性188例,女性20例,年龄(54.7±10.7)岁(范围:32~79岁)。个体化选择动脉血管移植物并制定手术策略,其中使用左胸廓内动脉207例,右胸廓内动脉38例(双侧胸廓内动脉37例),桡动脉187例(188支),每例患者移植血管(2.6±0.7)支(范围:2~4支)。非体外循环CABG占98.1%(204/208)。将患者分为双侧组(37例,使用双侧胸廓内动脉加或不加桡动脉)和单侧组(171例,仅使用一侧胸廓内动脉和桡动脉)进行分析。组间比较采用t检验、χ^2检验或Fisher确切概率法。绘制Kaplan-Meier生存曲线并估算远期全因病死率、主要严重心脑血管事件(MACCE)发生率和再次血运重建率。Cox回归分析远期死亡的独立预后因素。结果总体术后30 d病死率为1.4%(3/208),MACCE发生率为1.9%(4/208),出血二次开胸发生率为0.5%(1/208),深部胸部切口感染发生率为1.4%(3/208),围手术期无心肌梗死和再次血运重建。双侧组与单侧组患者术前基线数据无差异,总体术后30 d病死率,MACCE、出血、深部胸骨切口感染发生率均无差异(P值均>0.05)。术后随访(5.4±2.8)年(范围:0.2~10.9年),1、5和10年全因病死率分别为2.3%、3.4%和6.9%,MACCE发生率分别为3.9%、11.2%和28.5%,再次血运重建率分别为0.4%、3.7%和11.9%。年龄>65岁是远期死亡的独立预后因素(HR=1.125,95%CI:1.050~1.205,P<0.01)。结论选择合适的患者、制定个体化手术方案,全动脉化CABG是安全、可行的,可降低远期病死率和再次血运重建风险。

Objective To examine the short and long-term clinical outcomes of total arterial coronary artery bypass grafting.Methods Clinic data of 208 patients with left main and multiple vessel coronary artery disease and undertaken total arterial coronary artery bypass grafting from February 2009 to December 2019 in Department of Cardiac Surgery,Rui Jin Hospital,Shanghai Jiao Tong University School of Medicine were analyzed retrospectively.There were 188 males and 20 females with an age of(54.7±10.7)years(range:32 to 79 years).The harvest of arterial conduits and grafting strategies were depended upon the individual patient characteristics and surgeon′s experience.Left internal thoracic artery(LITA)was applied in 207 cases,right internal thoracic artery(RITA)in 38 cases(bilateral internal thoracic artery(BITA)in 37 cases),and radial artery(RA)in 187 cases(188 grafts).The graft number per case was 2.6±0.7(range:2 to 4).Surgical procedures was completed with off-pump technique in 98.1%patients(204/208).Subgroup analysis was carried out between subgroup BITA(n=37)and subgroup SITA(single ITA+RA)(n=171).The t test,χ^2 test or Fisher exact test were used to compare the clinic characteristics between the two subgroups.The Kaplan-Meier curve was used to estimate the rate of late mortality,major adverse cardiac cerebrovascular event(MACCE),and target vessel revascularization(TVR).A Cox proportional hazards model was used to identify the independent prognosis factors of late mortality.Results The overall mortality within 30 days postoperatively was 1.4%(3/208).The incidences of perioperative MACCE,re-operation for bleeding and deep sternal wound infection(DSWI)were 1.9%(4/208),0.5%(1/208)and 1.4%(3/208),respectively.Perioperative myocardial infarction and TVR were not observed.There was no significant difference of 30-day mortality,MACCE,bleeding and DSWI between subgroup BITA and SITA+RA(all P>0.05).In a follow-up period of(5.4±2.8)years(range:0.2 to 10.9 years),the incidence of all-cause mortality at 1-,5-and 10-year was 2.3%,3.4%and 6.9%,respectively.The incidence of MACCE was 3.9%,11.2%and 28.5%,respectively.The rate of TVR was 0.4%,3.7%and 11.9%,respectively.Age>65 was an independent prognosis factor of late mortality(HR=1.125,95%CI:1.050 to 1.205,P<0.01).Conclusions Total arterial coronary bypass grafting is safe and achievable with proper patient selection and surgical strategies.It significantly decreases the risks of late mortality and repeated revascularization.