不同心肌血运重建方式治疗高龄冠心病三支病变患者的围术期结果

Comparative study on the perioperative results of different myocardial revascularization strategy in the treatment of elderly patients with coronary three-vessel disease

目的比较机器人辅助微创"杂交"冠状动脉血运重建(hybrid coronary revascularization,HCR)、非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass,OPCAB)和经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗累及左前降支(left anterior descending branch,LAD)的高龄冠心病三支病变患者的围术期结果,探讨其手术安全性。方法前瞻性纳入2018年1月至2019年9月在解放军总医院就诊的65岁以上高龄冠心病患者,冠状动脉造影均为累及前降支的三支病变,经术前检查及心血管内外科团队评估,均适合行OPCAB或PCI治疗,根据患者治疗意愿分别给予HCR、OPCAB或PCI治疗。结果共110例患者符合标准纳入研究,HCR组28例,OPCAB组45例,PCI组37例,平均年龄(71.4±5.6)岁。三组患者术前基线资料差异均无统计学意义。HCR组气管插管时间(P=0.039)、术中出血量(P<0.001)、术后输血量(P=0.021)低于OPCAB组。三组患者主要脏器不良事件(main organ adverse events,MOAE,P=0.096)和在院死亡率(P=0.784)差异无统计学意义,PCI组抗生素使用时间明显短于另外两组(P<0.001)。结论 HCR结合了乳内动脉治疗前降支病变远期通畅率高和PCI治疗非前降支病变创伤小且优于大隐静脉桥的优势,与OPCAB和PCI相比,不增加围术期主要脏器不良事件和在院死亡率,对于累及前降支的高龄冠心病三支病变患者是一种安全可靠的微创心肌血运重建技术。

Objective To compare the perioperative results of hybrid coronary revascularization(HCR),off-pump coronary artery bypass(OPCAB)and percutaneous coronary intervention(PCI)in elderly patients with three-vessel coronary artery disease involving left anterior descending(LAD)branch and explores the safety of surgery.Methods We prospectively enrolled patients with coronary heart disease over 65 years who were admitted to General Hospital of People’s Liberation Army from January 2018 to September 2019.Coronary angiography results were all three-vessel lesions involving the anterior descending artery.After preoperative examination and assessment by the cardiovascular team,all patients were suitable for OPCAB or PCI treatment.According to the patient’s preference,HCR,OPCAB or PCI were performed.The preoperative baseline data and perioperative results were collected,and SPSS 22.0 was used for statistical analysis.Results A total of 110 patients met the criteria and were included in the study,28 in the HCR group,45 in the OPCAB group,and 37 in the PCI group,with an average age of 71.4±5.6 years.There was no statistical difference in the preoperative baseline data of patients among the three groups.The intubation time(P=0.039),perioperative drainage volume(P<0.001),blood transfusion(P=0.021)in the HCR group were lower than those in the OPCAB group.There was no statistical difference in the main organ adverse events(MOAE,P=0.096)and inhospital mortality(P=0.784)among the three groups of patients.The use of antibiotics in the PCI group was significantly lowerthan the other two groups(P<0.001).Conclusion HCR combines the advantage of CABG and PCI including proved long-term patency rate with left internal mammary artery-LAD grafting,less trauma and superior long-term patency with PCI in non-LAD territory.Compared with OPCAB and PCI,there is no increase in perioperative major organ adverse events and in-hospital mortality.It is a safe and reliable minimally invasive myocardial revascularization technique for elderly patients with three-vessel coronary artery disease involving the anterior descending artery.