左心功能不全和左心功能正常的高龄患者非体外循环冠状动脉旁路移植术围手术期结果的比较研究

Perioperative outcomes in off-pump coronary artery bypass grafting patients older than 80 years with left ventricular dysfunction or left ventricular normal: a comparative study based on propensity score matching

目的探讨左心功能不全的高龄患者行非体外循环冠状动脉旁路移植术(OPCAB)的围手术期结果。方法回顾性收集首都医科大学附属北京安贞医院心脏外科2008年6月至2016年7月252例年龄≥80岁的OPCAB患者资料。将射血分数为35%~50%的31例患者作为左心功能不全组(不全组),男性25例,女性6例,年龄(82.0±2.1)岁(范围:80~88岁)。在左心功能正常的患者中采用倾向性评分匹配法按1∶1的比例匹配31例患者作为左心功能正常组(正常组),男性25例,女性6例,年龄(81.9±1.9)岁(范围:80~89岁)。采用t检验、秩和检验、χ^2检验或Fisher确切概率法等比较两组患者的围手术期资料。结果不全组和正常组患者术前血肌酐差异有统计学意义[M(QR):144.6(66.0)μmol/L比94.9(43.2)μmol/L,Z=3.177,P=0.033],其他资料有可比性。不全组出院前血肌酐高于正常组[147.0(59.0)μmol/L比92.0(24.0)μmol/L,Z=-2.685,P=0.007]。不全组围手术期主动脉内球囊反搏(IABP)使用率更高[25.8%(8/31)比3.2%(1/31),P=0.026],总住院时间更长[17(15)d比14(8)d,Z=2.054,P=0.012],术前住院时间更长[7(7)d比5(4)d,Z=-2.457,P=0.014]。两组术后病死率[9.7%(3/31)比3.2%(1/31),P=0.612]和其他并发症发生率差异无统计学意义。结论轻中度左心功能不全的高龄患者术前血肌酐水平更高,OPCAB围手术期IABP使用率增高,术前住院时间及总住院时间延长,但术后病死率及其他并发症发生率与左心功能正常者相似。

Objective To examine the outcome of off-pump coronary artery bypass(OPCAB)in elderly patients with left ventricular dysfunction.Methods From June 2008 to July 2016,252 patients aged over 80 years underwent isolated OPCAB at Department of Cardiovascular Surgery,Beijing Anzhen Hospital,Capital Medical University,these patients′data were collected.The left ventricular dysfunction group(ejection fraction(EF):35%to 50%)was comprised of 31 patients aged(82.0±2.1)years(range:80 to 88 years),including 25 males and 6 females.Through matching one-to-one on propensity scores,31 patients(EF>50%)were included into the left ventricular normal group.Among them,there were 25 males and 6 females,aged(81.9±1.9)years(range:80 to 89 years).Postoperative mortality and complications between the matched groups were compared using the t test,Wilcoxon rank-sum test,χ^2 test or Fisher exact test.Results Between the dysfunction group and normal group,the preoperative serum creatinine was 144.6(66.0)μmol/L vs.94.9(43.2)μmol/L(M(QR),Z=3.177,P=0.033),respectively,while the pre-discharge serum creatinine was 147.0(59.0)μmol/L vs.92.0(24.0)μmol/L(Z=-2.685,P=0.007),respectively.In dysfunction group,the perioperative intra-aortic balloon counterpulsation(IABP)utilization rate was higher(25.8%(8/31)vs.3.2%(1/31),P=0.026),the total hospitalization day was longer(17(15)days vs.14(8)days,Z=2.054,P=0.012),the preoperative hospitalization day was longer too(7(7)days vs.5(4)days,Z=-2.457,P=0.014).However,there was no significant difference in the incidence of postoperative mortality(9.7%(3/31)vs.3.2%(1/31),P=0.612)and other prognostic indicators between the two groups.Conclusions The elderly patients,with light and moderate left ventricular insufficiency,are characterized by the abnormal increase in renal function and the rise of IABP utilization due to hemodynamic disorder in OPCAB perioperative period.Preoperative treatment for cardiac insufficiency may be the cause of prolonged preoperative and total hospital stay.However,there is no significant difference in the postoperative mortality and other complications compared with the patients of normal left ventricular function.