左侧肋间切口与胸骨中下段切口冠状动脉旁路移植术临床效果的倾向性评分匹配研究

The clinical effects of coronary artery bypass grafting via the left anterior small thoracotomy approach versus the lower-end sternal splitting approach:A propensity score matching study

目的 比较左侧肋间切口(left anterior small thoracotomy,LAST)与胸骨中下段小切口(lower-end sternal splitting,LESS)冠状动脉旁路移植术治疗冠状动脉粥样硬化性心脏病(冠心病)的临床效果。方法 选择2015年10月-2020年12月于天津市胸科医院行LAST不停跳冠状动脉旁路移植术患者作为试验组(LAST组);收集同期接受LESS不停跳冠状动脉旁路移植术患者作为LESS组。应用倾向性评分匹配法,按照1∶1比例,对两组患者进行匹配。比较匹配后两组患者临床基线数据、围术期临床数据、桥血管分布及通畅性。结果 匹配前,LAST组纳入110例,LESS组纳入206例。匹配后两组各纳入110例患者,LAST组男83例、女27例,平均年龄(60.6±8.3)岁;LESS组男80例、女30例,平均年龄(61.0±9.6)岁。匹配后两组患者基线资料差异无统计学意义(P>0.05)。LAST组总住院时间(t=2.255,P=0.025)和呼吸机使用时间(t=-2.229,P=0.027)显著短于LESS组。两组在术后住院时间、ICU停留时间、术后左室射血分数、术后左室舒张末期内径、平均桥血管数、二次插管、二次开胸、术后伤口感染、胸骨并发症、术后心房颤动、术后肺部感染、围术期主要心脑血管不良事件方面差异无统计学意义(P>0.05)。两组靶血管分布在前降支、对角支、后降支区域的差异无统计学意义(P>0.05)。LAST组靶血管在钝缘支、室后支区域显著多于LESS组;LESS组靶血管在右冠区域显著多于LAST组(P<0.05)。术后CT血管造影提示LAST组1例钝缘支静脉桥血管闭塞,两组其余患者桥血管均通畅。结论 LAST与LESS冠状动脉旁路移植术均是安全有效的微创冠状动脉旁路移植术式。LAST冠状动脉旁路移植术可以实现多支血管病变的完全再血管化,且安全可靠,具有创伤小、美观等优点,但手术技术需要一定学习曲线,需要掌握一定手术适应证。

Objective To compare the clinical effects of coronary artery bypass grafting(CABG)via the left anterior small thoracotomy(LAST)versus lower-end sternal splitting(LESS)approach in the treatment of coronary heart disease.Methods The patients who underwent LAST CABG in Tianjin Chest Hospital from October 2015 to December 2020 were allocated to an observation group(LAST group),and the patients who underwent LESS CABG at the same period were allocated to a LESS group.Propensity score matching method was applied with a ratio of 1∶1.The baseline data,perioperative data and grafts data were compared between the two groups after matching.Results Before matching,there were 110 patients in the LAST group,and 206 patients in the LESS group.After matching,there were 110 patients in each group.In the LAST group,there were 83 males and 27 females with an average age of(60.6±8.3)years.In the LESS group,there were 80 males and 30 females with an average age of(61.0±9.6)years.There was no statistical difference in baseline data between the two groups after matching(P>0.05).The hospital stay time(t=2.255,P=0.025)and ventilator using time(t=−2.229,P=0.027)in the LAST group were significantly shorter than those in the LESS group.There were no statistical differences between the two groups in the postoperative hospital stay time,ICU stay time,postoperative left ventricular ejection fraction,postoperative left ventricular end-diastolic diameter,average number of grafts,secondary intubation,secondary thoracotomy,postoperative wound infection,sternal complications,postoperative atrial fibrillation,postoperative pulmonary infection or main adverse cardiovascular and cerebrovascular events(P>0.05).There was no statistical difference in the distribution of target vessels in the anterior descending branch,diagonal branch or posterior descending branch between the two groups(P>0.05).The grafts of the LAST group were significantly more than those of the LESS group in the area of obtuse marginal branch and posterior ventricular branch,and the grafts of the LESS group were significantly more than those of the LAST group in the area of right coronary artery(P<0.05).Post-operative computerized tomography angiography indicated that 1 patient in the LAST group had obtuse marginal branch vein bridge vessel occlusion,and the bridge vessels in the other patients were unobstructed.Conclusion Minimally invasive CABG via both LAST and LESS approaches is safe and effective.LAST approach can achieve complete revascularization for multi-vessel lesions,and it is safe and reliable,with the advantages of less trauma and aesthetic appearance.However,it requires a certain learning curve of surgical techniques and certain surgical indications.