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1、LOGO冠心病左心功能低下患者冠状动脉冠心病左心功能低下患者冠状动脉旁路移植术近远期结果分析旁路移植术近远期结果分析2009年年9月月宋云虎宋云虎 中国医学科学院中国医学科学院 阜外心血管病医院阜外心血管病医院 北京协和医学院北京协和医学院 阜外心血管病研究所阜外心血管病研究所研究背景研究背景左左心心室室功功能能功功能能低低下下1、Hamad M, Erwin S,et al. Long-Term Results of Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction. Ann Thora
2、c Surg 2008;85:488 93.2、Faulkner SL, Stoney Ws, et al. Ishemic cardiomyopathy: medcial versus surgical treatment. J Thorac Cardiovasc Surg 1977;74:77.药物治疗药物治疗(5 5年死亡率可达年死亡率可达68%68%)CABGCABG手术治疗手术治疗围术期研究较多,围术期研究较多,死亡率在死亡率在5%左右左右长期随访研究较少长期随访研究较少研究目的研究目的v分析冠心病分析冠心病LVEF40%患者患者CABG手术近远期结果手术近远期结果v分析影响手术及远
3、期结果的相关危分析影响手术及远期结果的相关危险因素险因素66656665例例研究对象研究对象左心室功能不全的患者左心室功能不全的患者(LVEF40%LVEF40%)共)共396396例,例,占占5.94%5.94%阜外心血管病医院阜外心血管病医院19991999年年-2006-2006年行年行CABGCABG的患者的患者手术及远期生存率手术及远期生存率相关危险因素分析相关危险因素分析LVEF40%LVEF40%的的患者患者 围术期危险因素分析pLVEF40%的患者共396例p平均年龄598岁p男性354例,女性42例p297例患者在体外循环下手术(75)p围术期死亡17例(死亡率4.3%) 女
4、,女,42,11%LVEF40%LVEF40%的的患者患者 围术期危险因素分析患者术前情况患者术前情况患者例数患者例数396396例例年龄(年龄(y y)59599 9体重(体重(kgkg)70701010身高(身高(cmcm)1681686 6男男354354(89.4%89.4%)吸烟史吸烟史 n n(% %)254254(64.1%64.1%)高血压病高血压病 n n(% %)206206(52%52%)高脂血症高脂血症 n n(% %)156156(39.4%39.4%)糖尿病糖尿病 n n(% %)102102(25.8%25.8%)外周血管病史外周血管病史 n n(% %)2323
5、(5.8%5.8%)既往介入及手术史既往介入及手术史 n n(% %)9898(24.7%24.7%)既往既往CABG nCABG n(% %)3 3(0.8%0.8%)LVEF40%LVEF40%的的患者患者 围术期危险因素分析患者例数患者例数396例例超声超声LVEFLVEF(% %)35354 4LVEDDLVEDD(mmmm)62627 7病变血管数量病变血管数量 n n(% %)2.62.60.60.6心梗史心梗史 n n(% %)338338(85.4%85.4%)充血性心衰(术前充血性心衰(术前2 2周)周)5454(13.6%13.6%)是否左主干病变是否左主干病变 n n(%
6、 %)8(22%)8(22%)术前正性肌力药物使用术前正性肌力药物使用 n n(% %)8 8(2%2%)术前静脉硝酸酯类药物术前静脉硝酸酯类药物 n n(% %)2222(5.6%5.6%)术前最后一次术前最后一次Cr(molCr(mol/L)/L)1001002424患者术前情况患者术前情况LVEF40%LVEF40%的的患者患者 围术期危险因素分析患者例数患者例数396396例例是否体外循环是否体外循环 n n(% %)297297(75%75%)急诊手术急诊手术 n n(% %)1010(2.5%2.5%)IABPIABP植入植入1313(3.3%3.3%)主动脉阻断时间主动脉阻断时间
7、(minmin)60.260.243.843.8体外循环时间(体外循环时间(minmin)93.493.466.366.3动脉桥远端吻合口数动脉桥远端吻合口数0.90.90.50.5静脉桥远端吻合口数静脉桥远端吻合口数2.32.31.11.1患者手术情况患者手术情况LVEF40%LVEF40%的的患者患者 围术期危险因素分析围术期死亡组与存活组术前基本资料比较围术期死亡组与存活组术前基本资料比较患者情况患者情况围术期死亡组(围术期死亡组(1717例)例) 存活组(存活组(379379例)例) p p值值年龄(年龄(y y)66669 959599 90.0050.005体重(体重(kgkg)6
8、7679 9717110100.80.8身高(身高(cmcm)1681687 716916910100.80.8性别性别0.80.8 男男1515(88.2%88.2%)339339(89.4%89.4%) 女女2 2(11.811.8)4040(10.6%10.6%)吸烟史吸烟史8 8(47.1%47.1%)246246(64.9%64.9%)0.130.13高血压病高血压病6 6(35.3%35.3%)200200(52.8%52.8%)0.150.15高脂血症高脂血症4 4(23.5%23.5%)152152(40.1%40.1%)0.170.17糖尿病糖尿病3 3(17.6%17.6%
9、)9999(26.1%26.1%)0.50.5肺功能障碍肺功能障碍5(29.4%)5(29.4%)5858(15.4%15.4%)0.30.3外周血管病史外周血管病史2 2(11.8%11.8%)2121(5.5%5.5%)0.250.25既往介入及手术史既往介入及手术史5 5(29.4%29.4%)9393(24.5%24.5%)0.160.16既往既往CABGCABG1 1(5.9%5.9%)2 2(0.5%0.5%)LVEF40%LVEF40%的的患者患者 围术期危险因素分析患者情况患者情况围术期死亡组(围术期死亡组(1717例)例)存活组(存活组(379379例)例) p p值值超声超
10、声LVEF35.6435.840.8LVEDD6056270.3病变血管数量病变血管数量2.70.72.60.60.9既往溶栓既往溶栓4(23.5%)72(19%)0.03心梗史心梗史16(94.1%)322(85%)0.25充血性心衰(术前充血性心衰(术前2周)周)4(23.5%)50(13.2%)0.18是否左主干病变是否左主干病变8(47.1%)80(21.1%)0.018术前最后一次术前最后一次Cr(mol/L)1032695230.45术前最后一次术前最后一次Hbg( g/L)13015134160.14术前正性肌力药物使用术前正性肌力药物使用2(11.8%)6(1.6%)0.042
11、术前静脉硝酸酯类药物术前静脉硝酸酯类药物2(11.8%)20(5.3%)0.24围术期死亡组与存活组术前基本资料比较围术期死亡组与存活组术前基本资料比较LVEF40%LVEF40%的的患者患者 围术期危险因素分析患者情况患者情况围术期死亡组(围术期死亡组(1717例)例)存活组(存活组(379379例)例) p p值值动脉桥远端吻合口数动脉桥远端吻合口数0.80.80.60.60.90.90.50.50.390.39静脉桥远端吻合口数静脉桥远端吻合口数2 21.11.12.32.31.11.10.70.7是否体外循环是否体外循环1212(70.6%70.6%)285285(75.2%75.2%
12、)0.420.42是否再次气管插管是否再次气管插管7(41.2%)10(2.6%)0.05急诊手术急诊手术2(11.8%)8(2.1%)0.038术后术后IABP6(35.3%)7(1.8%) 40%远期生存率比较远期生存率比较EF40%EF40%随访时间(年)随访时间(年)生生存存率率p 40%LVEF 40%1 1年年100%100%5 5年年97.6%97.6%LVEF40%LVEF40%的的患者患者 -远期随访结果分析远期随访结果分析COX-Regreesion回归分析结果回归分析结果结果表明:结果表明:l则年龄、术前正性肌力药等是术前独立危险因素。Variables in the V
13、ariables in the Equation(aEquation(a) ) B BSESEWaldWalddfdfSig.Sig.Exp(BExp(B) )95.0% CI for 95.0% CI for Exp(BExp(B) )LowerLowerUpperUpper年龄年龄0.05 0.05 0.02 0.02 6.50 6.50 1 1 0.01 0.01 1.05 1.05 1.01 1.01 1.09 1.09 术前正性肌力药术前正性肌力药1.89 1.89 0.73 0.73 6.65 6.65 1 1 0.01 0.01 6.60 6.60 1.57 1.57 27.71
14、 27.71 随访时间(年)随访时间(年)生生存存率率非低心排组非低心排组低心排组低心排组结果:结果:LVEF40%LVEF40%的的患者患者-术后低心排对远期生存率的影响术后低心排对远期生存率的影响术后低心排对术后远期生存率的分析结果分组分组时间时间生存率生存率术后低心排组1 1年年85.7%85.7%6 6年年53.6%53.6%无低心排组1 1年年98.1%98.1%5 5年年91.8%91.8%6 6年年87.4%87.4%p0.05生生存存率率体外循环体外循环非体外循环非体外循环讨论讨论作者作者年代年代LVEF围术期死亡率围术期死亡率远期生存率远期生存率Isbir et al2002
15、30%5.60%4年为年为73%Ahmed et al200930%5.60%5年为年为69%Nardi et al200935%5.30%10年为年为80%Hamad et al 200840%4.00%8年为年为89.3%本研究本研究2009 50%, n (%)8(22%)8(22%)Dopamine or Dopamine or norepinephrinenorepinephrine n n(% %)8 8(2%2%)Serum creatinine (mean SD, molmol/L)/L)1001002424Preoperative CharacteristicsLVEF 40
16、% patients perioperative Patients396 cases396 casesCPB nCPB n(% %)297297(75%75%)Emergency CABG, n (%)1010(2.5%2.5%)Intra-aortic balloon pump support n n(% %)1313(3.3%3.3%)Cross-clamp time, minutes60.243.8CPB time(min)93.466.3Mean number of grafts (ITA)0.90.5Number of the vein grafts 2.31.1 Mean numb
17、er of grafts (saphenous)1.40.9operative CharacteristicsLVEF 40% patients perioperative Preoperative CharacteristicsCharacteristicsDiedDied(17 cases17 cases)AliveAlive(379 379 casescases) p p值值age(y)66669 959599 90.0050.005weight(kg)67679 9717110100.80.8height(cm)1681687 716916910100.80.8sex0.80.8 ma
18、le1515(88.2%88.2%)339339(89.4%89.4%) female2 2(11.811.8)4040(10.6%10.6%)Smoking habit, n (%)8 8(47.1%47.1%)246246(64.9%64.9%)0.130.13Hypertension, n (%)6 6(35.3%35.3%)200200(52.8%52.8%)0.150.15Hypercholesterolemia n(%)4 4(23.5%23.5%)152152(40.1%40.1%)0.170.17Diabetes mellitus n(%)3 3(17.6%17.6%)9999
19、(26.1%26.1%)0.50.5Chronic obstructive pulmonary diseasen(%5(29.4%)5(29.4%)5858(15.4%15.4%)0.30.3Peripheral vascular disease2 2(11.8%11.8%)2121(5.5%5.5%)0.250.25PCI or surgery history5 5(29.4%29.4%)9393(24.5%24.5%)0.160.16Repeat CABG, No.1 1(5.9%5.9%)2 2(0.5%0.5%)0.120.12LVEF 40% patients perioperati
20、ve CharacteristicsDiedDied(17 cases17 cases) AliveAlive(379 cases379 cases) p p值值LVEF35.6435.840.8LVEDD6056270.3Number of vessels diseased per patient2.70.72.60.60.9PCI 4(23.5%)72(19%)0.03Previous myocardial infarction, n (%)16(94.1%)322(85%)0.25Congest heart failureCongest heart failure(2 2 weeks b
21、efore surgeryweeks before surgery)4(23.5%)50(13.2%)0.18Left main stem stenosis 50%, n (%)8(47.1%)80(21.1%)0.018Cr(mol/L)1032695230.45Hbg( g/L)13015134160.14Dopamine or Dopamine or norepinephrinenorepinephrine n n(% %)2(11.8%)6(1.6%)0.042 Preoperative Characteristics LVEF 40% patients perioperative C
22、haracteristicsDiedDied(17 cases17 cases)AliveAlive(379 379 casescases) p value p valueMean number of arterial grafts 0.80.80.60.60.90.90.50.50.390.39Mean number of vein Mean number of vein grafts grafts 2 21.11.12.32.31.11.10.70.7CPB1212(70.6%70.6%)285285(75.2%75.2%)0.420.42RE-intubation7(41.2%)10(2
23、.6%)0.05Emergency CABG, n (%)2(11.8%)8(2.1%)0.038After operative IABP6(35.3%)7(1.8%) 40%EF40%EF40%p 40%LVEF 40%1 1100%100%5 597.6%97.6%Survival rateFollow up(year)LVEFLVEF40% patients -long-term outcomeCOX-RegreesionCONCLUSION:Age and pAge and preoperative usage of intronic agent are risk factors fo
24、r the long term survival.Variables in the Variables in the Equation(aEquation(a) ) B BSESEWaldWalddfdfSig.Sig.Exp(BExp(B) )95.0% CI for 95.0% CI for Exp(BExp(B) )LowerLowerUpperUpperageage0.05 0.05 0.02 0.02 6.50 6.50 1 1 0.01 0.01 1.05 1.05 1.01 1.01 1.09 1.09 Preoperative Preoperative usage of usa
25、ge of intropicintropic agent agent1.89 1.89 0.73 0.73 6.65 6.65 1 1 0.01 0.01 6.60 6.60 1.57 1.57 27.71 27.71 Normal co Low coLow co affect the survival rateTime (y)Time (y)survival rateLow CO 1 185.7%85.7%6 653.6%53.6%Normal CO 1 198.1%98.1%5 591.8%91.8%6 687.4%87.4%p0.05Survival rateOn PumpOff-Dis
26、cussionauthoryearLVEFOperative mortalityLong term survival rateIsbir et al200230%5.60%4 years: 73%Ahmed et al200930%5.60%5 years: 69%Nardi et al200935%5.30%10 years: 80%Hamad et al 200840%4.00%8 years: 89.3%This study200940%4.30%5 years: 89.4%1.Ahmed W A., Tully P J., et al. Survival After Isolated
27、Coronary Artery Bypass Grafting in Patients With Severe Left Ventricular Dysfunction. Ann Thorac Surg 2009;87:1106 112. 2.Isbir. S C, Yildirim T , Akgun S, et al. C oronary artery bypass surgery in patients with severe left ventricular dysfunction. International J of Cardio 2003,90:309316. Results f
28、rom DiscussionTo improve the early results of CABG for CAD with low LVEFvIndependent risk factorsLM lesionPreoperative usage of inotropic agentvIndication for operationCoronary artery fit for graftingSurvived myocardiumVentricular aneurysmvPerioperative myocardial protection and stable DiscussionTo
29、improve the long-term outcome of CABG for CAD with low LVEFvIndependent risk factorsAge Preoperative usage of inotropic agentvSurgical revascularizationEffectiveCConclusionvLow LVEF impact on the early and long-term outcome of CABGLM lesion and preoperative usage of intropic agent are risk factors for early resultsAge and preoperative usage of intropic agent are risk factors for long-term outcomevPreoperative evaluation and perioperative management are important for good THANK YOU!