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北京大学学报（医学版） ›› 2020, Vol. 52 ›› Issue (5): 863-869. doi: 10.19723/j.issn.1671-167X.2020.05.011

• 论著 • 上一篇    下一篇

经左胸前外侧微创冠脉搭桥治疗冠心病多支病变

许志锋1,2,凌云鹏2,∆(),崔仲奇2,赵鸿2,宫一辰2,傅元豪2,杨航2,万峰2   

  1. 1.北京大学深圳医院心血管外科,广东深圳 518036
    2.北京大学第三医院心脏外科,北京 100083
  • 收稿日期:2018-03-07 出版日期:2020-10-18 发布日期:2020-10-15
  • 通讯作者: 凌云鹏 E-mail:micsling@163.com

Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: Early outcome and short-mid-term follow up results

Zhi-feng XU1,2,Yun-peng LING2,∆(),Zhong-qi CUI2,hong ZHAO2,Yi-chen GONG2,Yuan-hao FU2,Hang YANG2,Feng WAN2   

  1. 1. Department of Cardiac Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong, China
    2. Department of Cardiac Surgery, Peking University Third Hospital, Beijing 100191, China
  • Received:2018-03-07 Online:2020-10-18 Published:2020-10-15
  • Contact: Yun-peng LING E-mail:micsling@163.com

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摘要：

目的:评估经左胸前外侧微创冠脉搭桥术(minimally invasive cardiac surgery coronary artery bypass grafting, MICS CABG)治疗冠心病多支病变的可行性、安全性及近中期临床疗效。方法:选择2015年11月—2017年11月在北京大学第三医院完成的经左胸前外侧微创冠脉搭桥术患者作为实验组(MICS CABG组),同期收集接受常规正中开胸非体外循环冠脉搭桥手术(off-pump coronary aortic bypass grafting, OPCABG)患者,应用倾向性评分匹配法,按照年龄、性别、左心室射血分数、体重指数、冠脉血管病变程度以及是否存在吸烟、糖尿病、高血压病、高脂血症、肾功能不全、脑血管意外史、慢性阻塞性肺病史与接受MICS CABG的患者进行1 ∶1配对作为对照组(OPCABG组)。比较两组患者住院临床资料及近中期随访结果。结果:MICS CABG组共入选85例患者,其中男性68例(80.0%),女性17例(20%),平均年龄(63.8±8.7)岁;OPCABG病例451例,经倾向性评分匹配出85例作为对照组(OPCABG组),匹配后两组基线水平一致(P均>0.05)。MICS CABG 组平均搭桥(2.35±0.83)支/例,对照组平均(2.48±0.72)支/例(P=0.284),MICS CABG组无中转正中开胸者,两组均无中转体外循环手术。MICS CABG组与对照组相比,其术后主要不良心脑血管事件(major adverse cardiacand cerebrovascular events, MACCE)发生率[1.17%(1/85) vs. 3.52%(3/85)]、二次手术率[2.34%(2/85) vs. 3.52%(3/85)]、术后新发心房纤颤率[4.70%(4/85) vs. 3.52%(3/85)]及新发肾功能不全率[1.17%(1/85) vs. 0%(0/85)]差异无统计学意义(均P>0.05)。MICS CABG组手术时间较OPCABG组长[(282.8±55.8) min vs. (246.8±56.9) min, P<0.05],但术后呼吸机使用时间[(16.9±7.8) h vs. (29.6±15.9) h]、术后监护病房住院时间[(29.3±20.8) h vs. (51.5±48.3) h]及住院时间[(18.3±3.2) d vs. (25.7±4.2) d]均较短(均P<0.05)。术后冠脉造影检查,MICS CABG组总体桥血管通畅率(A+B级)为 96.5%。术后随访1年,两组患者MACCE累积发生率差异无统计学意义[1.18%(1/85) vs. 3.61%(3/83), P>0.05]。结论:经左胸前外侧小切口微创冠状动脉搭桥手术安全可行,近中期随访结果良好,MICS CABG出院更早,恢复更快。

关键词: 左胸前外侧小切口, 微创, 非体外循环冠状动脉旁路移植术, 冠脉多支病变, 疗效结果

Abstract:

Objective: To explore the feasibility, safety and mid-term outcome of minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) surgery. Methods: Data of patients who underwent MICS CABG between November 2015 and November 2017 in Peking University Third Hospital were retrospectively analyzed. Results were compared with the patients who underwent off-pump coronary aortic bypass grafting (OPCABG) surgery over the same period. The two groups were matched in propensity score matching method according to age, gender, left ventricular ejection fraction, body mass index, severity of coronary artery disease, smoking, diabetes mellitus, hypertension, hyperlipidemia, renal insufficiency, history of cerebrovascular accident, and history of chronic obstructive pulmonary disease (COPD). Results: There were 85 patients in MICS CABG group, including 68 males (80.0%) and 17 females (20%), with an average age of (63.8±8.7) years; 451 patients were enrolled in OPCABG group, and 85 patients were matched by propensity score as control group (OPCABG group). There was no significant difference in general clinical characteristics (P>0.05). The average grafts of MICS CABG and OPCABG were 2.35±0.83 and 2.48±0.72 respectively (P=0.284). No conversion to thoracotomy in MICS CABG group or cardiopulmonary bypass in neither group occurred. There was no significant difference in the major adverse cardiovascular events (MACCEs, 1.17% vs. 3.52%), reoperation (2.34 vs. 3.52%), new-onset atrial fibrillation rate (4.70% vs. 3.52%) or new-onset renal insufficiency rate (1.17% vs. 0%) between MICS CABG group and OPCABG group (P>0.05). The operation time in MICS CABG group was longer than that in OPCABG group [(282.8±55.8) min vs. (246.8±56.9) min, P<0.05], while the time of ventilator supporting(16.9 h vs. 29.6 h), hospitalization in ICU [(29.3±20.8) h vs. (51.5±48.3) h] and total hospitalization [(18.3±3.2) d vs. (25.7±4.2) d] in MICS CABG group were shorter than those in OPCABG group (P<0.05). The total patency rate (A+B levels) of MICS CABG was 96.5% after surgery. There was no significant difference in MACCEs rate between the two groups [1.18%(1/85) vs. 3.61%(3/83), P>0.05] in 1-year follow up. Conclusion: The MICS CABG surgery is a safe and feasible procedure with good clinical results in early and mid-term follow-up.

Key words: Minimally invasive cardiac surgery, Minimally invasive, Off-pump coronary aortic bypass grafting, Multiple coronary artery lesions, Clinical effect

中图分类号: 

  • R654

图1

左胸前外侧微创冠状动脉搭桥手术"

表1

匹配后两组患者临床特征基线资料比较"

Items MICS CABG (n=85) OPCABG (n=85) t/χ2 value P value
General characteristics
Age/years, x-±s 63.8±8.7 63.1±13.2 0.408 0.684
Male, n(%) 68 (80.0) 66 (77.6) 0.141 0.707
BMI/(kg/m2), x-±s 25.5±2.7 25.1±3.3 0.865 0.388
Coronary artery and cardiac function
Coronary artery lesions≥3, n(%) 52 (61.2) 54 (63.3) 0.100 0.752
History of PCI, n(%) 29 (34.1) 21 (24.7) 1.813 0.178
LVDd/mm, x-±s 48.4±8.4 47.9±9.8 0.357 0.772
EF/%, x-±s 52.2±5.7 53.3±8.5 -0.991 0.323
Cardiac-related complications
HBP, n(%) 50 (58.8) 52 (61.2) 0.098 0.754
History of myocardial infarction, n(%) 17 (20.0) 21 (24.7) 0.542 0.461
Congestive heart failure, n(%) 2 (2.3) 1 (1.2) 0.339 1.000
Non-cardiac-related complications
Hypercholesterolemia, n(%) 12 (14.1) 11 (14.0) 0.050 0.823
Diabetes, n(%) 25 (29.4) 33 (38.9) 1.675 0.196
Chronic lung disease, n(%) 0 (0.0) 5 (5.9) 5.152 0.059
History of cerebrovascular disease, n(%) 5 (5.8) 3 (3.8) 0.525 0.720
Peripheral vascular disease, n(%) 1 (1.2) 2 (2.3) 0.330 1.000
Creatinine /(μmol/L), x-±s 66.7±15.2 72.5±22.5 -1.969 0.051

表2

两组患者围手术期情况比较"

Items MICS CABG (n=85) OPCABG (n=85) t/χ2 value P value
Ventilator supporting time after operation/h,(x-±s) 16.9±7.8 29.6±15.9 -6.611 <0.001
Hospitalization in ICU/h,(x-±s) 29.3±20.8 51.5±48.3 -3.892 <0.001
Total hospitalization/d,(x-±s) 18.3±3.2 25.7±4.2 -12.921 <0.001
Blood transfusion during operation, n(%) 26 (30.5) 30 (35.2) 0.426 0.514
IABP during operation, n(%) 1 (1.17) 2 (2.35) 0.330 1.000
Impaired wound healing, n(%) 0 (0) 1 (1.17) 1.006 1.000
Re-exploration for hemorrhage, n(%) 2 (2.34) 3 (3.52) 0.206 1.000
New-onset atrial fibrillation after operation, n(%) 4 (4.70) 3 (3.52) 0.149 1.000
New-onset renal insufficiency after operation, n(%) 1 (1.17) 0 (0.00) 1.006 1.000
MACCE, n(%) 1 (1.17) 2 (2.35) 0.330 1.000
Death, n(%) 0 (0) 1 (1.17) 1.006 1.000
Perioperative myocardial infarction, n(%) 1 (1.17) 1 (1.17) 0.000 1.000
Cerebrovascular complications, n(%) 0 (0) 0 (0) - -
Revascularization, n(%) 0 (0) 0 (0) - -

表3

MICS CABG组患者冠脉造影吻合口通畅情况"

Bypass grafts n O B A A+B
LAD 85 1 (1.18) 2 (2.35) 82 (96.5) 84 (98.8)
D 26 1 (3.85) 0 (0.00) 25 (96.2) 25 (96.2)
RAMUS 4 0 (0.00) 0 (0.00) 4 (100.0) 4 (100.0)
OM, LCX 56 1 (1.79) 4 (7.14) 51 (91.1) 55 (98.2)
PL, PDA 29 4 (13.79) 0 (0.00) 25 (86.2) 25 (86.2)
Total 200 7 (3.50) 6 (3.0) 187 (93.5) 193 (96.5)

图2

两组患者MACCE累积发生率Kaplan-Meier生存曲线图"

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