Comparison of the results between off-pump coronary artery bypass and conventional coronary artery bypass
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摘要:
目的探讨停跳冠脉搭桥术（CCAB）和不停跳冠脉搭桥术（OPCAB）的优缺点，并对术后3年的随访结果进行比较分析。 方法总结分析了近8年来我中心的单纯冠脉搭桥手术病例临床资料，包括心脏停跳下单纯冠脉搭桥术88例和心脏不停跳冠脉搭桥术145例，主要比较分析术前常见的危险因素，术中平均远端吻合口数、手术时间，术后机械通气时间、IUC时间、术后住院天数、血管活性药物应用、术后IABP的使用、术后常见并发症及死亡率等，并对术后3年随访情况进行了分析，内容包括症状、心电图、心功能及死亡率等。 结果术前危险因素中，除年龄和糖尿病外其余两组之间无明显差别，OPCAB与CCAB相比较，平均远端血管吻合口数明显减少（3.1±0.9 vs 3.5±0.9，P<0.001）而手术时间、术后机械通气时间、术后ICU时间和术后住院天数则显著缩短；术后主要并发症（如低心排、IABP使用、肾功能不全）明显减少；术后多巴胺和肾上腺素用量显著减少，而硝酸甘油和硝普钠用量二者无明显差别；术后输血量显著减少，而引流量无明显差别；住院死亡率无明显差别（1.4% vs 3.4%，P=0.287）。术后3年随访显示OPCAB组EF值显著比CCAB组高（66.1%±7.6% vs 62.0%±10.2%，P=0.043），出现心衰症状的概率OPCAB组也明显高于CCAB组（10.9% vs 28.6%，P=0.012）。 结论（1）OPCAB术在术后恢复和术后主要并发症发生减少方面均明显优于CCAB术。虽然OPCAB手术操作较为困难，但其近期优越性是显而易见的；（2）从术后3年的短期随访来看，OPCAB组的心衰症状明显少于CCAB组，反映心功能的指标EF值也显著高于CCAB组。 Abstract:Objective To explore and analyze the advantage of off-pump coronary artery bypass (OPCAB) compared with conventional coronary artery bypass (CCAB). Methods 88 cases of CCAB and 145 cases of OPCAB were collected from Nov. 1999 to Dec. 2006, and the clinical data were summarized and analyzed retrospectively. Results The preoperation risk factors were no significance between CCAB group and OPCAB group except for diabetes. There were more mean graft numbers in CCAB group than in OPCAB group. But operation time, intubation time, ICU stay time, postoperative stay time, low cardiac output, IABP use time and renal dysfunction in OPCAB group were obviously less than in CCAB group, no significance in hospital death between the two groups. Three years postoperative follow-up result indicated that heart function improved obviously and EF value was higher in OPCAB group than in CCAB group. Conclusion There was apparently advantage in postoperation recovery and reduction of postoperation complications in OPCAB compared with CCAB, and OPCAB is a hopeful surgical method for coronary artery disease. -
表 1 CCAB和OPCAB两组术前一般资料和高危因素的比较
Table 1. The preoperative data in CCAB group and OPCAB group
CCAB OPCAB P 例数 88 145 男 75 107 女 13 38 年龄（岁） 62.7±9.4 65.2±8.6 0.011 术前EF(%) 58.1±14.9 62.2±13.8 0.055 术前不稳定性心绞痛(例) 82(93.2%) 134(92.4%) 0.827 术前急性心梗(例) 20(22.7%) 30(20.7%) 0.749 术前陈旧性心梗(例) 25(28.4%) 36(24.8%) 0.575 左主干病变(例) 28(31.8%) 36(24.8%) 0.117 病变血管数 2.8±0.4 2.7±0.5 0.516 糖尿病史(例) 24(27.3%) 22(15.2%) 0.03 术前脑血管病变(例) 7(8.0%) 14(9.7%) 1 高血压病史(例) 50(56.8%) 94(64.8%) 0.926 高血脂(例) 38(43.2%) 74(51.0%) 0.91 术前肾功能损伤(Cr>132 mmol/L)(例) 8(9.1%) 12(8.3%) 1 
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表 2 CCAB和OPCAB两组术后资料的比较
Table 2. The postoperative data comparison between CCAB group and OPCAB group
CCAB OPCAB P 平均远端吻合口数(个) 3.5±0.9 3.1±0.9 0.000 左桡动脉远端吻合口(个) 13(14.8%) 28(19.3%) 1 LIMA远端吻合口(个) 77(87.5%) 122(84.1%) 0.968 RIMA远端吻合口(个) 2(2.3%) 0.000 SVG远端吻合口(个) 193(2.3±1.0) 301(2.0±0.8) 0.001 合并远端吻合口(个) 285 451 0.000 手术时间(h) 6.7±2.1 5.4±0.9 术后机械通气时间(h) 21.7±23.2 7.8±4.7 0.000 术后ICU时间(d) 5.8±4.5 2.9±2.2 0.000 术后住院天数(d) 22.2±12.1 15.7±6.1 0.001 低心排(例) 12(13.6%) 3(2.1%) 0.000 IABP使用(例) 11(12.5%) 1(0.7%) 0.000 术后肾功能不全(例) 20(22.7%) 16(11.0%) 0.013 术后心绞痛(例) 3(3.4%) 1(0.7%) 0.13 围术期心梗(例) 1(1.1%) 2(1.4%) 0.876 术后多巴胺用量(mg) 682.7±1082.0 65.5±232.4 0.000 术后肾上腺素用量(mg) 6.3±32.2 0.1±0.9 0.011 术后硝酸甘油用量(mg) 206.5±238.8 331.0±512.4 0.234 术后硝普钠用量(mg) 57.0±102.7 87.8±159.3 0.117 术后红细胞用量(mL) 645.1±881.5 236.2±295.2 0.004 术后血浆用量(mL) 886.6±894.1 466.0±590.9 0.01 术后引流量(mL) 1095.7±993.9 842.9±698.9 0.247 术后心律失常(例) 41(46.6%) 48(33.1%) 0.027 术后脑血管病变(例) 7(8.0%) 4(2.8%) 0.062 肺部感染(例) 14(15.9%) 13(9.0%) 0.097 住院死亡(例)(率) 3(3.4%) 2(1.4%) 0.287 术后1 年EF(%) 51.3±15.2 64.9±12.0 0.045 术后1 年心功能改善率(%) 93.9 96.5 0.35
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表 3 OPCAB组和CCAB组术后第3 年随访资料比较
Table 3. The comparison of 3 years follow-up data between CCAB group and OPCAB group
OPCAB组 CCAB组 P 随访病例数(随访率) 92(63.5%) 35(39.8%) 胸闷、心绞痛等症状(例) 17(18.5%) 12(34.3%) 0.057 心衰症状(例) 10(10.9%) 9(28.6%) 0.012 ECG新出现的ST-T改变或心律失常(例) 35(38.0%) 12(34.3%) 0.084 ECG及心肌酶学检查示心梗改变(例) 0 2(5.7%) EF值(%) 66.1±7.6 62.0±10.2 0.043 左室舒张期大小(mm) 45.3±4.3 47.1±6.6 0.166 冠脉CT或血管桥造影复查桥血管(根) 34 8 冠脉CT或血管桥造影显示闭塞的桥(闭塞率) 10(29.4%) 1(12.5%) 0.838 再次PCI处理(例) 2(2.2%) 0 因心脏事件死亡(例) 0 0 因心脏以外事件死亡(例) 0 0
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