摘要：
目的 比较全动脉化(TAR)和常规非体外循环冠状动脉旁路移植术(OPCAB)在合并左心室功能低下(LVD)冠心病患者中的优劣.方法 2008年1月至2015年3月复旦大学附属中山医院心外科左心室射血分数≤35％行TAR-OPCAB术[取双侧乳内动脉、左侧和(或)右侧桡动脉]患者38例,年龄(60.4±11.6)岁,男32例.选取同期收治的年龄、性别相匹配的常规OPCAB术(取左乳内动脉和大隐静脉)患者38例为对照组.收集整理所有入选患者术前、术中及围手术期临床资料.术后随访36个月,比较两组患者随访结果.结果 两组患者术前临床资料差异均无统计学意义(均P＞0.05).两组乳内动脉应用率、正性肌力药物应用和主动脉内球囊反搏(IABP)辅助方面差异均无统计学意义(均P＞0.05).TAR组与对照组相比,手术时间较长[(278.3±31.2)min比(196.7±19.1)min,P＜0.01],术后24 h胸腔引流量及输血量较多[(895.0±236.2)ml比(585.4±172.5)ml,(656.3±84.4)ml比(433.3±62.9)ml,均P＜0.01].两组患者围手术期死亡率差异无统计学意义(5.3％比7.9％,P=0.64).在心、肾、肺等围手术期并发症方面,两组差异均无统计学意义(均P＞0.05).术后12个月,患者存活率、心因性死亡率、心绞痛再发、心肌梗死、再次血管化治疗率、心功能不全再次住院率、桥血管通畅率、心功能分级及心脏超声数据,两组差异均无统计学意义(均P＞0.05).术后24～36个月,TAR组上述各项指标,除心脏超声数据外均优于对照组(均P＜0.05).结论 对于LVD患者,早期临床疗效两种术式相近,但在中远期临床疗效上,TAR-OPCAB术明显占优.而TAR-OPCAB术缺点在于术后胸腔引流量及血制品使用上明显增多.%Objective To compare the advantages and disadvantages of total arterial revascularization (TAR) and conventional off-pump coronary artery bypass (OPCAB) grafting in patients with left ventricular dysfunction (LVD).Methods Between January 2008 and March 2015,76 patients who were scheduled to undergo selective OPCAB were selected for cardiac surgery in Zhongshan Hospital,Fudan University.The left ventricular ejection fraction of enrolled patients was less than 35％.Among those patients,38 patients in TAR group underwent total arterial OPCAB with bilateral internal mammary artery,left and/or right radial artery,and another 38 patients in control group underwent conventional OPCAB with left internal mammary artery and great saphenous vein.The clinical data of all patients were collected.The follow-up was performed within 36 months.Results There was no significant difference in preoperative clinical data between the two groups (all P＞0.05).Additionally,there was no significant difference in the application rate of internal mammary artery,positive inotropic drugs and intra-aortic balloon pump (IABP)use between the two groups (all P＞0.05).The operation time of TAR group was longer than that of control group [(278.3±31.2) min vs (196.7±19.1) min,P＜0.01].There was no significant difference in perioperative mortality between the two groups (5.3％ vs 7.9％,P=0.64).The volume of operative drainage and blood transfusion in TAR group increased significantly at 24 hours after operation [(895.0±236.2) ml vs (585.4±172.5) ml,(656.3 ±84.4)ml vs (433.3 ±62.9)ml,both P＜0.01].There was no significant difference in perioperative complications such as heart,kidney and lung failure between the two groups (all P＞0.05).At 12 months after operation,there were no significant differences in survival rate,cardiac death rate,angina recurrence,myocardial infarction,re-treatment rate of revascularization,re-hospitalization rate from cardiac insufficiency,graft patency rate,cardiac function and echocardiographic data between the two groups (all P＞0.05).From 24 to 36 months after operation,all the above indexes in TAR group were better than those in control group except for echocardiographic data (all P＜0.05).Conclusions For LVD patients,the early clinical efficacy of the two surgical methods is similar,but for the long-term outcomes,the whole arterial OPCAB operation is obviously superior.However,the shortcomings of total arterial OPCAB are that operative drainage and the use of blood products increased significantly after operation.
