冠状动脉旁路移植术前存活心肌和术后左心室机械不同步对冠心病患者的预后判断价值

摘要

目的 探讨行冠状动脉旁路移植术(CABG)的冠状动脉粥样硬化性心脏病(简称冠心病)患者术前存活心肌及术后左心室机械不同步对术后心脏不良事件(ACE)的预测价值.方法 前瞻性纳入2012年9月至2016年3月行CABG的冠心病患者49例[男44例、女5例,平均年龄(64±8)岁],术前进行99Tcm-甲氧基异丁基异腈(MIBI) SPECT门控心肌灌注显像(GMPI)和18F-脱氧葡萄糖(FDG) PET心肌代谢显像评估存活心肌,术后4～6个月复查GMPI,运用GMPI相位分析获得左心室机械不同步参数:相位直方图带宽(BW)及相位标准差(SD).以ACE作为终点事件进行术后随访.采用Cox回归模型、Kaplan-Meier法和log-rank检验分析数据.结果 平均随访(3.82±0.80)年,17例(34.7％,17/49)出现ACE.Cox分析显示术前存活心肌节段数[风险比(HR)=0.208,95％ CI:0.068～0.642]、术后BW(HR=1.245,95％ CI:1.099～1.411)是冠心病患者CABG术后发生ACE的独立影响因素(均P＜0.01).Kaplan-Meier生存分析显示存活心肌节段数＜3的患者ACE发生率高于存活心肌节段数≥3者[57.1％(12/21)与17.9％(5/28);X2=21.023,P＜0.01],术后BW≥98°组患者的ACE发生率高于BW＜98°者[14/19与10％ (3/30);x2=38.395,P＜0.01].结论 术前存活心肌数量少、术后严重左心室机械不同步是冠心病CABG术后发生ACE的独立危险因素.冠心病患者CABG术后左心室机械不同步对预后判断及危险再分层具有重要的临床价值.%Objective To investigate the predictive value of preoperative viable myocardium and postoperative left ventricular mechanical dyssynchrony (LVMD) for adverse cardiovascular events(ACE) after coronary artery bypass graft (CABG) in patients with coronary artery disease (CAD) using myocardial perfusion imaging (MPI).Methods From September 2012 to March 2016,49 patients (44 males,5 females,average age:(64±8) years) with CAD were prospectively recruited.All patients underwent 99Tcmmethoxyisobutylisonitrile (MIBI) SPECT gated MPI (GMPI) and 18F-fluorodeoxyglucose (FDG) PET myocardial metabolic imaging to assess myocardial viability preoperatively.GMPI was repeated 4-6 months after CABG to record postoperative LVMD.Phase analysis was used to measure bandwidth (BW) and standard deviation (SD).Regular follow-up was performed,and ACE were taken as the end point.Cox proportional hazard model,Kaplan-Meier method and log-rank test were used to analyze the data.Results The mean duration of follow-up was (3.82±0.80) years,and ACE were present after CABG in 17 CAD patients (34.7％,17/49).Cox multi-analysis revealed that the number of preoperative viable segments (hazard ratio (HR)=0.208,95％ CI:0.068-0.642) and postoperative BW (HR=1.245,95％ CI:1.099-1.411)were independent influencing factors of ACE in CAD patients after CABG (both P＜0.01).Kaplan-Meier survival analysis showed that the incidence of ACE in patients with ＜ 3 viable segments was significantly higher than those with ≥ 3 viable segments (57.1％ (12/21) vs 17.9％ (5/28);x2 =21.023,P＜0.01).The incidence of ACE was significantly higher in the postoperative BW≥98° group than that in the postoperative BW＜98° group (14/19 vs 10％ (3/30);x2 =38.395,P＜0.01).Conclusions Less preoperative viable segments and severe postoperative LVMD are independent risk factors of ACE after CABG in CAD patients.Postoperative LVMD in CAD patients undergoing CABG may have important clinical value in the riskrestratification and prognosis evaluation.