急性心肌梗死近期行非体外循环冠状动脉旁路移植术的临床分析

目的探讨急性心肌梗死(AMI)后患者近期行非体外循环冠状动脉旁路移植术(OPCAB)的临床疗效和围术期处理方法。方法 2006年1月至2010年3月,上海交通大学医学院附属仁济医院连续239例患者在发生AMI后14～27(20.55±3.91)d行OPCAB(AMI组),术前磷酸肌酸激酶同工酶(CK-MB,15.82±6.24)U/L,心肌肌钙蛋白Ⅰ(cTnI,0.07±0.04)ng/ml;将同期406例无心肌梗死史的OPCAB患者作为对照(对照组);比较、分析两组患者的临床资料。结果术后30 d AMI组死亡率为2.51%(6/239),其中死于循环衰竭4例,主动脉内球囊反搏(IABP)导致下肢缺血、坏死1例,肺部感染合并休克1例。AMI组患者术后应用多巴胺明显多于对照组(61.51%vs.37.44%,P=0.001),术中/术后行IABP亦多于对照组,但差异无统计学意义(P>0.05)。AMI组术后引流量及输注红细胞悬液量均多于对照组(385.18±93.22)ml vs.(316.41±70.05)ml,P=0.022;(373.68±69.54)ml vs.(289.78±43.33)ml,P=0.005],但两组二次开胸止血率差异无统计学意义(P>0.05)。两组术后新发心房颤动发生率差异无统计学意义(P>0.05);AMI组急性肾损伤发生率高于对照组(13.81%vs.8.62%,P=0.038)。AMI组术后30 d死亡率高于对照组(2.51%vs.1.48%),但差异无统计学意义(P>0.05)。两组住ICU时间(2.01±0.95)dvs.(1.78±0.98)d]和术后住院时间(10.33±4.16)d vs.(9.89±4.52)d]差异均无统计学意义(P>0.05)。AMI组随访211例(88.28%),随访时间(2.89±1.02)年;失访28例(11.72%)。随访期间死亡25例,其中心源性死亡14例;1年生存率为97.63%,5年生存率88.15%。结论在AMI发生2～4周、待CK-MB和cTnI水平恢复至正常范围后,行OPCAB是相对安全的。

Clinical Analysis of Off-pump Coronary Artery Bypass Grafting Following Acute Myocardial Infarction

Objective To investigate clinical outcomes and perioperative management of off-pump coronary artery bypass grafting(OPCAB) for patients following acute myocardial infarction(AMI).Methods From January 2006 to March 2010,239 consecutive patients underwent OPCAB on the 14-27(20.55±3.91) d following AMI(AMI group)in Renji Hospital,School of Medicine of Shanghai Jiaotong University.Preoperative MB isoenzyme of creatine kinase(CK-MB) level was(15.82±6.24) U/L and cardiac troponin I(cTnI) was(0.07±0.04) ng/ml.Clinical data of 406 patients without myocardial infarction history who underwent OPCAB during the same period were also collected as the control group for comparison.Results The 30-day mortality of AMI group was 2.51%(6/239).The causes of death were circulatory failure in 4 patients,ischemic necrosis of lower extremity caused by intra-aortic balloon pump(IABP) in 1 patient and pneumonia with septic shock in 1 patient.Dopamine usage in AMI group was significantly higher than that of the control group(61.51% vs.37.44%,P=0.001).Intraoperative or postoperative IABP implantation was more common in AMI group,but there was no statistical difference between the two groups(P>0.05).Postoperative drainage and blood transfusion in AMI group were significantly larger than those of the control group(385.18±93.22 ml vs.316.41±70.05 ml,P=0.022;373.68±69.54 ml vs.289.78±43.33 ml,P=0.005,respectively).But there was no statistical difference in re-exploration rate between the two groups(P>0.05).There was no statistical difference in the incidence of postoperative new onset atrial fibrillation between the two groups(P>0.05).Incidence of acute kidney injury of AMI group was significantly higher than that of the control group(13.81% vs.8.62%,P=0.038).Postoperative 30-day mortality of AMI group was higher than that of the control group,but there was no statistical difference between the two groups(2.51% vs.1.48%,P>0.05).There was no statistical difference in ICU stay time and postoperative hospital stay between the two groups(2.01±0.95 d vs.1.78±0.98 d;10.33±4.16 d vs.9.89±4.52 d,respectively,P>0.05).A total of 211 patients(88.28%)in AMI group were followed up for 2.89±1.02 years,and 28 patients(11.72%) were lost during follow-up.Twenty-five patients died during follow-up including 14 cardiac deaths.One-year survival rate was 97.63%,and five-year survival rate was 88.15%.Conclusion It’s comparatively safe to perform OPCAB for patients at 2-4 weeks following AMI when their CK-MB and cTnI levels have returned to normal range.