冠状动脉旁路移植术在射血分数降低型心力衰竭患者中的应用

Coronary artery bypass grafting in patients with heart failure and reduced ejection fraction

目的:通过观察射血分数降低型心力衰竭(HFrEF)患者行冠状动脉旁路移植术(CABG)的围术期风险及远期生存率,比较单纯药物治疗与CABG术对这类患者临床结果的差异,探讨HFrEF患者的最优治疗策略。方法:连续收集2014年1月至2018年12月入院,LVEF<40%合并心力衰竭的症状和体征行CABG术的患者118例及单纯药物治疗的患者45例。住院期间行经胸超声心动图检查测定LVEF和左心室收缩末期容积指数(LVESVI),采用正电子发射断层显像技术(PET)行静息心肌灌注显像及心肌代谢断层显像测定存活心肌占左心室心肌比例。手术组患者除接受指南指导下的药物治疗外均由同一主刀医师行CABG术,单纯药物治疗组患者接受指南指导下的规范化药物治疗。术后平均随访时间(37±12)个月,观察手术组患者手术死亡率,围术期并发症,远期无主要不良心血管事件(MACE)生存率并对比单纯药物治疗组患者与CABG术治疗组患者的远期无MACE事件生存率。结果:全组118例患者围术期死亡8例,死亡率6.8%。死亡原因包括:术后心排4例,感染中毒性休克3例,IABP腿部并发症导致全身代谢紊乱1例。围术期应用主动脉内球囊反搏(IABP)或体外膜式氧合(ECMO)等机械辅助措施的患者分别达到56.8%和8.5%。术中71.2%的患者采用不停跳CABG,全静脉桥血管比例占39.8%。术后平均机械通气时间和ICU时间分别为60 h和84 h。术后对两组患者进行随访,CABG组参与随访103例,药物治疗组参与随访40例,平均随访时间为(37±12)个月。随访期间药物治疗组患者脑卒中,心肌梗死及再次血运重建发生率显著高于CABG组患者(12.5%vs.6.8%,P=0.000,27.5%vs.12.6%,P=0.005,22.5%vs.4.9%,P=0.000)。CABG组患者24个月,36个月,48个月免MACE事件存活率明显高于药物治疗组组患者(96.9%vs.75.6%,86.4%vs.45.5%,44.4%vs.7.2%,P<0.01)。结论:HFrEF患者行CABG术围术期风险较高,需根据患者左心室存活心肌比例及左心室重构情况制定个性化治疗策略。手术治疗与药物治疗相比,手术治疗中远期获益显著,能够有效改善患者预后。

Objective:To explore the optimal treatment strategy for patients with heart failure and reduced ejection fraction(HFrEF).We observed the perioperative risk and free from major adverse cardiovascular events(MACEs)survival rate of coronary artery bypass grafting(CABG)and compared the clinical outcomes of guideline-directed medicine therapy(GDMT)between CABG in HFrEF patients.Methods:CAD patients with symptoms and signs of heart failure and a LVEF<40%were enrolled consecutively from January 2014 to February 2018.There are 118 cases in surgery group and 45 cases in GDMT group.Transthoracic echocardiography was performed to measure LVEF and LVESVI during hospitalization,and the ratio of viable to total myocardium in the left ventricle was determined by myocardial perfusion imaging at rest and myocardial metabolism tomography via positron emission tomography(PET).Patients in surgery group were underwent CABG by the same surgeon,operative mortality,perioperative complications and long-term survival were documented.The patients of medicine therapy group were received GDMT.The average follow-up period was(37±12)months.Survival of free from MACEs was compared between surgery group and medicine therapy group.Results:8 patients died during the perioperative period and the mortality is 6.8%.4 patients died of postoperative low cardiac output syndrome,3 patients died of septic shock and 1 patient died of systemic metabolic disorder due to limb complications of IABP.Mechanical assistance such as IABP or ECMO was used in 56.8%and 8.5%of patients respectively.71.2%of the patients underwent off-pump coronary artery bypass grafting and the proportion of total venous grafts accounted for 39.8%.The mean postoperative mechanical ventilation time and ICU time were 60 hours and 84 hours respectively.103 patients in the CABG group and 40 patients in the drug treatment group were followed up with an average follow-up time of(37±12)months.During follow-up,the incidence of stroke,myocardial infarction and revascularization in the medicine therapy group was significantly higher than that in the CABG group(12.5%vs.6.8%,P=0.000,27.5%vs.12.6%,P=0.005,22.5%vs.4.9%,P=0.000).The survival rate of CABG patients without MACE events at 12,24,and 36 months was significantly higher than those in the drug treatment group(96.9%vs.75.6%,86.4%vs.45.5%,44.4%vs.7.2%,P<0.01).Conclusions:CABG in HFrEF patients has a high perioperative risk,individualized treatment strategies should be developed according to the proportion of left ventricular viable myocardium and left ventricular remodeling.Compared with medicine therapy,surgical treatment has a significant long-term benefit and can effectively improve the prognosis.