应用多支动脉桥经左胸小切口与正中切口行冠状动脉旁路移植术的临床效果比较

Comparison of Clinical Effects Between Left Chest Small Incision and Median Incision Multi-arterial Coronary Artery Bypass Grafting

目的探讨应用多支动脉桥进行左胸小切口微创冠状动脉旁路移植术(minimally invasive cardiac surgery-coronary artery bypass grafting,MICS CABG)的早期临床效果。方法回顾性分析2018年1月~2020年12月我科应用多支动脉桥行单纯非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG)123例,根据患者需求及术者倾向选择正中切口(正中切口组,n=51)或左胸小切口(左胸小切口组,n=72)入路,在患者出院前利用冠状动脉CT或冠状动脉造影进行桥血管评估,术后随访终点指标为主要心脑血管不良事件(major adverse cardiac and cerebrovascular event,MACCE)和再次血运重建。结果左胸小切口组远端吻合口(2.7±0.7)个,正中切口组(3.0±0.8)个,差异无显著性(t=-1.885,P=0.062)。左胸小切口组全动脉化比例较高[91.7%(66/72)vs.41.2%(21/51),χ2=36.762,P=0.000],围术期输血率较低[31.9%(23/72)vs.64.7%(33/51),χ2=12.920,P=0.000]。正中切口组围术期死亡1例。出院前对100例进行桥血管评估,其中左胸小切口组70例,正中切口组30例,复查吻合口共280个,2组桥血管总体通畅率(FitzGibbon A级)差异无显著性[94.2%(179/190)vs.94.4%(85/90),χ2=0.006,P=0.937]。118例随访中位时间24个月(6~36个月),2组MACCE发生率[2.9%(2/70)vs.6.3%(3/48),χ2=0.808,P=0.369]和再次血运重建率[2.9%(2/70)vs.2.1%(1/48),χ2=0.000,P=1.000]差异均无显著性。结论MICS CABG应用多支动脉桥可行,手术策略更倾向于应用全动脉化旁路移植,桥血管通畅率、术后早期随访结果不亚于正中切口手术,且可减少围术期输血。

Objective To evaluate early clinical outcomes of minimally invasive cardiac surgery-coronary artery bypass grafting(MICS CABG)using multi-arteries via left chest small incision.Methods Clinical data of 123 cases of off-pump multi-arterial CABG from January 2018 to December 2020 in our department were retrospectively analyzed.According to the needs of the patient and the tendency of the surgeon,the median incision(median incision group,n=51)or left chest small incision(left chest small incision group,n=72)was applied.Coronary CT or coronary angiography were used to evaluate the bypassing vessels before discharge,and early follow-up was performed after operation.The end point of follow-up was major adverse cardiac and cerebrovascular event(MACCE)and repeated revascularization.Results There were(2.7±0.7)distal anastomoses in the left chest small incision group and(3.0±0.8)in the median incision group,without significant difference(t=-1.885,P=0.062).The left chest small incision group had a higher ratio of total arterial revascularization[91.7%(66/72)vs.41.2%(21/51),χ2=36.762,P=0.000]and less perioperative transfusion[31.9%(23/72)vs.64.7%(33/51),χ2=12.920,P=0.000]than the median incision group.One patient dead in the median incision group due to myocardial infarction.A total of 100 patients underwent coronary CT anteriography before discharge,including 30 in the median incision group and 70 in the left chest small incision group.A total of 280 grafts were reviewed,and there were no significant differences in overall graft patency rate(FitzGibbon grade A)between the two groups[94.2%(179/190)vs.94.4%(85/90),χ2=0.006,P=0.937].A total of 118 patients received follow-ups with a median of 24 months(range,6-36 months),and the incidences of MACCE[2.9%(2/70)vs.6.3%(3/48),χ2=0.808,P=0.369]and repeated revascularization[2.9%(2/70)vs.2.1%(1/48),χ2=0.000,P=1.000]were not significantly different between the two groups.Conclusions MICS CABG using multi-arteries is a feasible alternative.The surgical strategy is more inclined to perform total arterial bypass grafting.The graft patency rate and early follow-up results are all not inferior to median incision surgery,with MICS CABG being associated with less transfusion.