心肌存活与冠状动脉旁路移植术后早期应用主动脉内球囊反搏的关系

Relationship between myocardial viability and early application of intra-aortic balloon pump after coronary artery bypass grafting

目的探讨拟行冠状动脉旁路移植术(coronary artery bypass grafting,CABG)的冠状动脉粥样硬化性心脏病(冠心病)患者术前心肌存活状态与其术后早期应用主动脉内球囊反搏(intra-aortic balloon pump,IABP)治疗之间的关系,为高危患者股动脉术前预置16G单腔导管便于术后新增IABP辅助提供相关临床参考依据。方法回顾性分析泰达国际心血管病医院2015年12月—2020年8月行CABG且术前行正电子发射计算机断层显像(positron emission tomography-computed tomography,PET-CT)心肌灌注-代谢显像的521例冠心病患者的临床资料,其中男414例、女107例,年龄(62.50±8.82)岁。收集术前心肌存活信息和左心室功能参数,包括梗死心肌(灌注-代谢显像匹配心肌)、冬眠心肌(灌注-代谢显像不匹配心肌)、受损心肌(梗死心肌+存活心肌)比例,左心室射血分数,左心室舒张末期容积和左心室收缩末期容积(left ventricular end-systolic volume,LVESV)。根据术后是否新增IABP辅助将患者分为IABP组和非IABP组,比较两组数据并筛选出主要危险因素后进行logistic多因素回归分析,探讨心肌存活与CABG术后新增IABP辅助之间的关系。结果Logistic多因素回归分析结果显示,术前梗死心肌、受损心肌的量化指标和LVESV是CABG术后新增IABP辅助的独立预测因子;受试者工作特征曲线提示梗死心肌比例为9.5%,受损心肌比例为19.5%,及LVESV为114.5 mL是预测应用IABP的阈值。结论术前PET-CT心肌灌注-代谢显像显示的心肌存活状况可预测CABG围术期应用IABP的可能性。除常规麻醉前评估外,麻醉医生可根据术前心肌存活显像的结果对CABG患者进行危险分层评估,对保证CABG高危患者的围术期安全具有重要意义。

Objective To explore the relationship between myocardial viability in patients with coronary artery disease who underwent elective coronary artery bypass grafting(CABG)and early application of intra-aortic balloon pump(IABP)after coronary revascularization,and to provide relevant clinical reference for the pre-implantation of 16G single-lumen catheter in the femoral artery of high-risk patients to facilitate the addition of IABP after operation.Methods This retrospective study included 521 patients(414 males and 107 females,aged 62.50±8.82 years)who underwent positron emission tomography(PET)-computed tomography(CT)perfusion-metabolism imaging prior to CABG surgery in our institution from December 2015 to August 2020.The myocardial viability information and left ventricular functional parameters were measured,including the proportion of non-viable myocardium(perfusionmetabolic imaging match),hibernating myocardium(perfusion-metabolic imaging mismatch)and dysfunctional myocardium(non-viable+viable myocardium),left ventricular ejection fraction,left ventricular end-diastolic volume and left ventricular end-systolic volume(LVESV).The patients were divided into an IABP group and a non-IABP group according to whether they received IABP treatment after revascularization.The clinical data were reviewed and compared to explore significant impact factors between the two groups.And the multivariate logistic regression analysis was performed to investigate the correlation between preoperative myocardial viability and early use of IABP after CABG.Results In multivariate logistic regression analysis,the amount of non-viable,dysfunctional myocardium and LVESV value were identified as the independent predictors for the probability of IABP use in the initial postoperative period.Receiver operating characteristic analysis showed that 9.5%non-viable myocardium,19.5%dysfunctional myocardium,and LVESV of 114.5 mL were the optimal cutoff for predicting early IABP implantation during CABG.Conclusion The myocardial survival status displayed by preoperative PET-CT myocardial perfusion-metabolism imaging can predict the possibility of applying IABP in CABG perioperative period.In addition to routine pre-anesthesia assessment,anesthesiologists can conduct risk stratification assessment for patients with CABG according to the results of preoperative myocardial viability imaging,which is of great significance to ensure the perioperative safety of high-risk patients with CABG.