单纯非体外循环冠状动脉旁路移植术或联合二尖瓣成形术治疗冠心病合并中度缺血性二尖瓣关闭不全的远期效果比较

Comparison of off-pump coronary artery bypass grafting alone or combined with mitral valve plasty for coronary heart disease with moderate ischemic mitral insufficiency

目的比较非体外循环冠状动脉旁路移植术(CABG)和CABG联合二尖瓣成形术(MVP)治疗冠心病合并中度缺血性二尖瓣关闭不全的效果。方法回顾性分析2009年1月至2020年12月在首都医科大学附属北京安贞医院心脏外科诊断为冠心病合并中度二尖瓣关闭不全并接受外科手术的1 050例患者的临床资料。男性733例, 女性317例, 年龄(63.3±9.0)岁(范围:31~83岁)。按照手术方式将患者分为联合组(CABG+MVP)和CABG组(非体外循环CABG), 采用倾向性评分匹配法对两组患者进行1∶4匹配, 匹配后联合组107例, CABG组406例。采用t检验、Mann-WhitneyU检验、χ^(2)检验、Fisher确切概率法或重复测量方差分析比较匹配后两组患者的手术情况及远期结局。结果两组的围手术期病死率和术后并发症发生率无明显差异(P值均>0.05)。联合组较CABG组的手术时间[(5.6±1.2)h比(4.2±1.0)h, t=11.528, P<0.01]、ICU停留时间[M(IQR)][43.0(47.3)h比25.0(33.6)h, Z=2.483, P=0.013]和术后住院时间[8(4)d比7(5)d, Z=2.143, P=0.032]更长, 悬浮红细胞、血小板用量明显增加[2.0(6.5)单位比0(2.0)单位, Z=7.084, P<0.01;0(0.5)单位比0(0)单位, Z=5.210, P<0.01]。463例获得随访, 随访率为93.9%(463/493)。随访时间为32(31)个月(范围:3~105个月)。CABG组和联合手术组的总体生存率和无主要不良心脑血管事件生存率无差异(P=0.196, P=0.305);随访1年、3年超声心动图结果显示, 两组射血分数、左心室舒张末内径无差异(F=0.322, P=0.571;F=0.681, P=0.410), 但联合手术较CABG能更好地改善二尖瓣反流(F=160.222, P<0.01)。结论非体外循环CABG和CABG联合MVP治疗冠心病合并中度二尖瓣关闭不全, 手术全因病死率和主要不良心脑血管事件发生率相似。虽然联合手术较单纯CABG能更好地改善二尖瓣反流, 但联合手术的手术时间、ICU停留时间、术后住院时间更长, 血液制品用量更多。

Objective To compare the efficacy of off-pump coronary artery bypass grafting(CABG)or CABG plus mitral valve plasty(MVP)in patients with coronary heart disease complicated with moderate ischemic mitral insufficiency.Methods The clinical data of 1050 patients with coronary heart disease complicated with moderate ischemic mitral insufficiency who underwent surgical procedures from January 2009 to December 2020 were analyzed retrospectively.There were 733 males and 317 females,aging(63.3±9.0)years(range:31 to 83 years).Patients were divided into CABG+MVP group and CABG group according to surgical methods,and the two groups of patients were matched for 1∶4 by the propensity score matching method.There were 107 patients in the CABG+MVP group and 406 patients in the CABG group after matching.The t test,Mann-Whitney U test,χ^(2) test,Fisher′s exact probability method and repeated measures anova were used to compare the surgical outcomes and overall survival in the two groups.Results There were no significant differences in perioperative death and postoperative complications between the two groups(all P>0.05).Compared with CABG group,CABG+MVP group had longer operation time((5.6±1.2)hours vs.(4.2±1.0)hours,t=11.528,P<0.01),ICU stay(M(IQR))(43.0(47.3)hours vs.25.0(33.6)hours,Z=2.483,P=0.013),and postoperative hospital stay(8(4)days vs.7(5)days,Z=2.143,P=0.032).The amount of erythrocyte and platelet used in CABG+MVP group was significantly increased(2.0(6.5)U vs.0(2.0)U,Z=7.084,P<0.01;0(0.5)U vs.0(0)U,Z=5.210,P<0.01).A total of 463 cases(93.9%)were followed up.Median follow-up was 32(31)months(range:3 to 105 months).There was no significant difference in overall survival and no major adverse cardic and cerebrovascular events survival between CABG group and CABG+MVP group(P=0.196,P=0.305).Echocardiography showed that there was no significant difference in ejection fraction left ventricular end-diastolic diameter between the two groups(F=0.322,P=0.571;F=0.681,P=0.410).However,CABG+MVP improved mitral regurgitation better than CABG(F=160.222,P<0.01).Conclusions For patients with coronary heart disease with moderate ischemic mitral insufficiency,the rates of all-cause mortality and major adverse cardiac and cerebrovascular events are similar between the two surgeries.Although CABG+MVP improves mitral regurgitation better than CABG,it increases the duration of surgery,ICU stay,postoperative hospital stay,and blood transfusion requirement.