经左胸前外侧微创冠脉搭桥治疗冠心病多支病变

doi:10.19723/j.issn.1671-167X.2020.05.011

摘要/Abstract

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

许志锋,凌云鹏,崔仲奇,赵鸿,宫一辰,傅元豪,杨航,万峰. 经左胸前外侧微创冠脉搭桥治疗冠心病多支病变[J]. 北京大学学报（医学版）, 2020, 52(5): 863-869.

Zhi-feng XU,Yun-peng LING,Zhong-qi CUI,hong ZHAO,Yi-chen GONG,Yuan-hao FU,Hang YANG,Feng WAN. 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[J]. Journal of Peking University (Health Sciences), 2020, 52(5): 863-869.

图/表 5

图1

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1

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2

表3

图2

参考文献 15

[1]	Yi G, Shine B, Rehman SM, et al. Effect of bilateral internal mammary artery grafts on long-term survival: a meta-analysis approach[J]. Circulation, 2014,130(7):539-545. doi: 10.1161/CIRCULATIONAHA.113.004255
[2]	Ahn M, Park DW, Lee CW, et al. Comparison of stenting versus bypass surgery according to the completeness of revascularization in severe coronary artery disease: patient-level pooled analysis of the SYNTAX, PRECOMBAT, and BEST trials[J]. JACC Cardiovasc Interv, 2017,10(14):1415-1424. doi: 10.1016/j.jcin.2017.04.037 pmid: 28728654
[3]	郑宝荣, 王联群, 刘建实, 等. 探讨Sino SCORE系统对非体外循环下冠状动脉旁路移植术风险评估的价值[J]. 中国循环杂志, 2013,28(5):375-378.
[4]	Kikuchi K, Chen X, Mori M, et al. Perioperative outcomes of off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries under direct vision[J]. Interact Cardiovasc Thorac Surg, 2017,24(5):696-701. doi: 10.1093/icvts/ivw431 pmid: 28329064
[5]	Nambiar P, Kumar S, Mittal CM, et al. Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: will this be the future[J]. J Thorac Cardiovasc Surg, 2017,155(1):190-197. pmid: 29102209
[6]	张希涛, 高杰, 刘岩, 等. 腔镜获取大隐静脉在糖尿病患者心脏不停跳冠状动脉旁路移植术的应用[J]. 中华胸心血管外科杂志, 2016,32(3):159-161.
[7]	Chan V, Lapierre H, Sohmer B, et al. Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy during minimally invasive multivessel coronary artery bypass grafting: a stepwise approach to safety and reproducibility[J]. Semin Thorac Cardiov Surg, 2012,24(1):79-83. doi: 10.1053/j.semtcvs.2011.12.010
[8]	杨威, 凌云鹏, 陈彧. 左胸前外侧小切口冠状动脉旁路移植术学习曲线[J]. 中国微创外科杂志, 2015,15(11):990-994.
[9]	Dijk DV, Nierich AP, Jansen EWL, et al. Early outcome after off-pump vs. on-pump coronary bypass surgery results from a randomized study[J]. Circulation, 2001,104(15):1761-1766. doi: 10.1161/hc4001.097036 pmid: 11591611
[10]	Kim YH, Oh HC, Choi JW, et al. No-touch saphenous vein harvesting may improve further the patency of saphenous vein com-posite grafts: early outcomes and 1-year angiographic results[J]. Ann Thorac Surg, 2017,103(5):1489-1497. doi: 10.1016/j.athoracsur.2016.09.024 pmid: 27916241
[11]	Kikuchi K, Une D, Suzuki K, et al. Off-pump minimally invasive coronary artery bypass grafting with a heart positioner: direct retraction for a better exposure[J]. Innovations, 2015,10(5):183-187.
[12]	Nambiar P, Mittal C. Minimally invasive coronary bypass using internal thoracic arteries via a left minithoracotomy: “the Nambiar Technique”[J]. Innovations, 2013,8(2):420-426.
[13]	杨俊峰, 顾承雄, 韦华, 等. 非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例[J]. 中华外科杂志, 2006,44(22):1529-1531.
[14]	Glineur D, Etienne PY, Kuschner CE, et al. Bilateral internal mammary artery Y construct with multiple sequential grafting improves survival compared to bilateral internal mammary artery with additional vein grafts: 10-year experience at 2 different institutions[J]. Eur J Cardio-Thorac, 2017,51(2):368-375.
[15]	Kikuchi K, Mori M. Less-invasive coronary artery bypass grafting international landscape and progress[J]. Curr Opin Cardiol, 2017,32(6):715-721. doi: 10.1097/HCO.0000000000000461 pmid: 28858911

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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)