肋间单一切口直视微创多支OPCABG临床效果:倾向性评分匹配研究

Minimally invasive coronary artery bypass grafting versus off-pump:a propensity-matched study for patients with multi-vessel lesion

目的探讨肋间单一切口微创直视多支不停跳冠状动脉旁路移植术(OPCABG)的围手术期及近期临床治疗效果。方法2017年1月至2019年8月期间北京安贞医院心外科十病房同一术者行多支(两支及以上)OPCABG手术335例,其中男257例,女78例,年龄34~84岁,平均(61.35±8.79)岁。按照手术方法分为微创旁路移植组(微创组,100例)和正中开胸旁路移植组(正中开胸组,235例)。为排除混杂因素,利用倾向性评分匹配法对两组的人口学特征、术前超声心动图、旁路移植数等12项数据进行1:2匹配。匹配后微创组82例,正中开胸组127例。记录患者围手术期和术后1年冠状动脉CTA等临床资料,进行数据分析。结果围手术期正中开胸组死亡2例,心肌梗死2例,卒中1例;微创组心肌梗死1例,无死亡、卒中发生。两组30天主要终点事件(死亡、心肌梗死、卒中)差异无统计学意义(P>0.05)。与正中开胸组比较,微创组术中乳内动脉使用率更高,术中中转体外循环比例更低,差异均有统计学意义(P<0.05)。两组在再次开胸、新发房颤和机械辅助方面差异均无统计学意义(P>0.05)。微创组手术时间长,而围手术期输血、术后24 h胸腔引流量、术后住院时间明显较正中开胸组少,差异均有统计学意义(P<0.05)。术后1年复查冠状动脉CTA结果显示,两组乳内动脉旁路移植血管、静脉旁路移植血管和移植血管总通畅率差异均无统计学意义(P>0.05)。结论经左侧肋间小切口微创多支OPCABG术是一种安全且创伤小的手术方式,围手术期疗效和近期通畅率与传统正中开胸OPCABG类似,术后出血更少,住院时间更短。

Objective To compare the perioperative outcomes and short-term graft patency between patients who underwent multivessel off-pump coronary artery bypass graft(OPCABG)via left intercoastal space or sternotomy.Methods Between January 2017 and August 2019,100 patients who underwent minimal invasive coronary artery bypass graft(MICS CABG)were compared with 235 patients who underwent OPCABG by single surgeon at our institute.Among them,257 cases were male and 78 were female,aged 34 to 84 years,with mean age(61.35±8.79)years old.Due to important differences in patients’characteristics,a propensity score-matched analysis based on 12 covariates was performed to match in a 1∶2 fashion.82 patients(MICS group)were matched with 127 patients(OPCABG group).Surgical and postoperative outcomes were evaluated.Results There was no statistical difference of perioperative mortality,myocardial infarction,and stroke rate(P>0.05).In MICS group,use of internal thoracic artery was higher and conversion to cardiopulmonary bypass was lower(P<0.05),but reoperation,new onset atrial fibrillation,and the use of mechanical device were similar(P>0.05).In addition,operation duration was longer but transfusion rate,postoperative chest tube drainage within 24 hours and postoperative hospital stays were less in the MICS group(P<0.05).LIMA,vein and overall graft patency were similar in the two groups shown by postoperative one-year CTA(P>0.05).Conclusion MICS CABG is safe and feasible for patients with multiple coronary lesions.It has similar in-hospital outcomes and short-term graft patency but less transfusion and faster recovery compared to conventional OPCABG via sternotomy.