心肌梗死病史对同期行外科主动脉瓣置换术和冠状动脉旁路移植术患者预后的影响

Impact of myocardial infarction history on the prognosis of patients undergoing concomitant surgical aortic valve replacement and coronary artery bypass grafting

目的 分析有心肌梗死(MI)病史的主动脉瓣狭窄合并冠心病患者同期行外科主动脉瓣置换术(SAVR)和冠状动脉旁路移植术(CABG)的手术及随访情况,探讨MI病史对患者预后的影响。方法 2018年1月—2023年7月阜外华中心血管病医院诊治同期行SAVR和CABG的主动脉瓣狭窄合并冠心病患者225例,根据有无MI病史分为MI组74例和非MI组151例。采用1∶1倾向性评分匹配,协变量包括性别、年龄、体质量指数、吸烟史、基础疾病等临床资料,匹配后比较2组冠状动脉病变血管数量和部位、欧洲心血管手术危险因素评分(EuroSCORE)等MI病史相关指标,术后24、48 h血清心肌损伤标志物,手术情况及术后并发症发生情况。随访3~67个月,比较2组术后3个月时左室射血分数、左心室舒张末期内径及死亡、再入院发生率。结果 经1∶1倾向性评分匹配后,MI组和非MI组各69例,2组年龄、体质量指数及男性、吸烟、高血压、糖尿病、高脂血症、心房颤动、脑血管疾病、慢性阻塞性肺疾病、肾功能不全比率比较差异均无统计学意义(P>0.05)。MI组3支病变血管、左回旋支病变比率(62.3%、68.1%)及EuroSCORE评分[(7.1±2.0)分]均高于非MI组[34.8%、47.8%、(5.6±2.0)分](P<0.05),心绞痛、经皮冠状动脉介入治疗比率及NYHA心功能分级、左室射血分数、左心室舒张末期内径与非MI组比较差异均无统计学意义(P>0.05)。MI组术后24 h血清N末端脑钠肽前体水平[2 016.0(1 210.0,4 023.8)ng/L]高于非MI组[1 315.5(856.6,2 272.8)ng/L](Z=-2.603,P=0.009),术后48 h血清N末端脑钠肽前体及术后24、48 h血清肌钙蛋白T、肌红蛋白、肌酸激酶同工酶水平与非MI组比较差异均无统计学意义(P>0.05)。MI组搭桥数量[(2.8±1.2)支]多于非MI组[(2.3±1.2)支](t=2.707,P=0.008),体外循环时间[(209.3±98.5)min]、手术时间[(441.5±115.5)min]、机械通气时间[39.0(21.5, 73.0)h]、ICU停留时间[4.0(2.5, 6.0)d]均长于非MI组[(175.5±57.5)min、(401.1±93.5)min、28.0(16.0,59.5)h、3.0(2.0,4.5)d](P<0.05),主动脉阻断时间、术后住院时间及完全血运重建、主动脉内球囊反搏、体外膜肺氧合、使用正性肌力药比率与非MI组比较差异均无统计学意义(P>0.05)。2组术后新发MI、低心排血量综合征、心房颤动、心室颤动、急性肾损伤、消化道出血、切口愈合不良、院内死亡发生率比较差异均无统计学意义(P>0.05)。2组术后3个月时左室射血分数、左心室舒张末期内径及死亡、再入院发生率比较差异均无统计学意义(P>0.05)。结论 对同期行SAVR和CABG的主动脉瓣狭窄合并冠心病患者,MI病史可能延长手术时间及术后监护时间,但不增加术后心肌损伤、严重并发症和近中期死亡的发生风险。

Objective To analyze the surgery and follow-up results of patients with aortic stenosis and coronary heart disease with a history of myocardial infarction(MI)after concomitant surgical aortic valve replacement(SAVR)and coronary artery bypass grafting(CABG),and to explore the impact of MI history on the prognosis.Methods A total of225 patients with aortic stenosis and coronary artery disease underwent concomitant SAVR and CABG from January,2018to July,2023 in Fuwai Central China Cardiovascular Hospital,and were divided into MI group(n=74)and non-MI group(n=151)according to the history of MI.The patients were matched by 1:1 propensity score,and the covariates included baseline data such as gender,age,body mass index,smoking habits,and underlying diseases.After matching,the number and location of coronary artery lesions,MI history related indices such as the European system for cardiac operative risk evaluation(EuroScore),serum myocardial injury markers 24 and 48 h postoperatively,surgical condition and postoperative complication were compared between two groups.The patients were followed up for 3 to 67 months,and the left ventricular ejection fraction(LVEF),left ventricular end-diastolic dimension(LVEDD),mortality and rate of readmission 3 months postoperatively were compared between two groups.Results After 1:1 propensity score matching,69 patients in each of MI and non-MI groups were matched,and no statistically significant differences were found in the age,body mass index,and rates of males,smoking,hypertension,diabetes,hyperlipidemia,atrial fibrillation,cerebrovascular disease,chronic obstructive pulmonary disease,and renal insufficiency between two groups(P>0.05).The rates of triple-vessel lesion and left circumflex artery lesion,and EuroScore score were higher in MI group(62.3%,68.1%,7.1±2.0)than those in non-MI group(34.8%,47.8%,5.6±2.0)(P<0.05),and there were no significant differences in the rates of angina pectoris and percutaneous coronary intervention,NYHA cardiac function classification,LVEF,and LVEDD between two groups(P>0.05).The serum N-terminal pro-brain natriuretic peptide level 24 h postoperatively was higher in MI group[2016.0(1210.0,4023.8)ng/L]than that in non-MI group[1315.5(856.6,2272.8)ng/L](Z=-2,603,P=0.009),and there were no significant differences in the serum N-terminal pro-brain natriuretic peptide 48 h postoperatively,and in the serum troponin T,myoglobin and creatine kinase isoenzyme levels 24 and 48 h postoperatively between two groups(P>0.05).The number of bypass was larger in MI group[(2.8±1.2)branches]than that in non-MI group[(2.3±1.2)branches](t=2.707,P=0.008),the cardiopulmonary bypass time,operative time,length of mechanical ventilation and length of ICU stay were longer in MI group[(209.3±98.5)min,(441.5±115.5)min,39.0(21.5,73.0)h,4.0(2.5,6.0)d]than those in non-MI group[(175.5±57.5)min,(401.1±93.5)min,28.0(16.0,59.5)h,3.0(2.0,4.5)d](P<0.05),and there were no significant differences in the time of aortic cross-clamping,length of postoperative hospital stay,and the rates of complete revascularization,intra-aortic balloon pump,extracorporeal membrane oxygenation,and use of positive inotropic agents between two groups(P>0.05).There were no significant differences in the incidence of newly-onset MI,low cardiac output syndrome,atrial fibrillation,ventricular fibrillation,acute kidney injury,gastrointestinal bleeding,poor wound healing,and in-hospital death between two groups(P>0.05).There were no significant differences in the LVEF,LVEDD,mortality and readmission rate between two groups 3 months postoperatively(P>0.05).Conclusion For patients with aortic stenosis and coronary artery disease undergoing concomitant SAVR and CABG,MI history may prolong the operative time and length of ICU stay,but does not increase the risks of postoperative myocardial injury,serious complications,or near-to mid-term mortality.