非体外循环冠状动脉旁路移植术中转体外循环的预后、原因及危险因素分析

摘要

目的：探讨非体外循环冠状动脉旁路移植术（OPCAB）中转体外循环的预后、中转原因以及导致中转体外循环的危险因素。　　方法：回顾性分析2001年-2012年在北京大学人民医院接受择期单纯OPCAB的2613例患者，术中中转体外循环下手术者62例纳入中转组，非中转组2551例。收集围手术期临床资料，对比两组的基线资料及围手术期预后资料。采用二元Logistic回归分析得出导致中转体外循环的危险因素。　　结果：中转率为2.37%。术中中转体外循环下手术的原因包括血液动力学不稳定42例，靶血管暴露困难6例，恶性心律失常9例，桥血管闭塞在体外循环下重新吻合3例，其他原因2例。比较中转组和非中转组的围手术期资料显示，中转组在术后引流量、呼吸机使用时间、二次开胸止血率、血滤使用率以及围手术期死亡率均高于非中转组。二元Logistic回归分析显示，慢性阻塞性肺疾病、既往冠状动脉旁路移植术、纽约心功能分级≥3级、左心室射血分数≤40%及左主干病变是OPCAB术中中转体外循环手术的危险因素。　　结论：血流动力学不稳定、靶血管暴露困难、恶性心律失常等是OPCAB术中中转体外循环手术的常见原因。OPCAB术中发生中转体外循环事件增加了并发症发生率及死亡率。慢性阻塞性肺疾病、既往冠状动脉旁路移植术、纽约心功能分级≥3级、左心室射血分数≤40%、左主干病变是OPCAB术中中转体外循环手术的危险因素。%Objective:To explore the prognosis and risk factors for conversion from off-pump coronary artery bypass grafting (OPCABG) to coronary bypass grafting (CABG) during surgery. Methods: We retrospectively analyzed 2613 patients with elective OPCAB in our hospital from 2001 to 2012, there were 62 (2.37%) patients converted to CABG during the operation as Conversion group, the rest 2551 patients were set as Non-conversion group. The peril-operative baseline clinical data and prognosis condition were compared between 2 groups. The risk factors causing the in-operative conversion were studied with binary logistic regression analysis. Results: The total conversion rate was 2.37%, including 42 patients of hemodynamic instability, 6 with dififculty of target vessel exposure, 9 with malignant arrhythmia, 3 with graft occlusion and 2 patients with other reasons. Compared with Non-conversion group, the Conversion group had increased post-operative drainage and ventilation time, higher rates of second thoracotomy for stop bleeding and higher peril-operative mortality. Binary logistic regression analysis indicated that chronic obstructive pulmonary disease, previous history of CABG, NYHA class≥3, LVEF≤40%and left main disease were the independent risk factors for in-operative conversion. Conclusion: Conversion from OPCAB to CABG during the operation would be result in signiifcantly higher morbidity and mortality in relevant patients.