高龄冠心病合并心房颤动患者行非体外循环冠状动脉旁路移植术中左心耳处理的回顾性队列研究

目的本文旨在探讨左室射血分数(LVEF)降低的高龄冠心病合并心房颤动(房颤)患者在非体外循环冠状动脉旁路移植术(OPCABG)中同期处理左心耳的手术技巧及效果评价。方法纳入2013~2018年,84例OPCABG LVEF降低(<50%)的高龄(年龄≥70岁)冠心病合并房颤患者在我科行非体外循环冠脉搭桥术。男54例、女30例,年龄70~82岁。将患者分为左心耳闭合组(n=56)和左心耳未闭合组(n=28),左心耳闭合组术后前3个月予以华法林+阿司匹林+氯吡格雷“三联抗栓”,3个月后改为长期服用阿司匹林+氯吡格雷“双联抗血小板”;左心耳未闭合组术后长期予以华法林+阿司匹林+氯吡格雷“三联抗栓”。比较两组患者临床效果。结果全部患者均顺利完成手术。左心耳闭合组应用切割闭合器闭合左心耳44例,应用心耳夹闭合左心耳12例;左心耳闭合时间3~8 min,全组无桥血管及吻合口损伤现象。术后早期死亡2例(2.4%)。术后住院时间6~18 d,两组差异无统计学意义(P=0.115)。出院前复查心脏功能显示两组患者术后LVEF均较术前明显改善,差异有统计学意义(P<0.05)。住院期间无脑卒中及重要脏器出血表现。82例出院患者随访1年时,两组均无脑梗死发生,但左心耳闭合组出血相关并发症发生率明显低于左心耳未闭合组(3.6%vs.18.5%,P=0.036)。结论LVEF降低的高龄冠心病合并房颤患者在OPCABG中同期闭合左心耳可有效降低脑卒中及出血相关并发症的发生风险,且不会增加手术风险,正确合理的手术技巧可以保证手术顺利进行。

The effectiveness of left atrial appendage occlusion during off-pump coronary artery bypass grafting in elderly patients with coronary artery disease and atrial fibrillation:A retrospective cohort study

Objective To investigate the technique and efficacy of left atrial appendage(LAA)occlusion during off-pump coronary artery bypass grafting(OPCABG)in elderly patients with coronary artery disease(CAD)and atrial fibrillation(AF).Methods From 2013 to 2018,84 elderly patients with CAD and AF with reduced left ventricular ejection fraction(LVEF<50%)underwent OPCABG in our department.There were 54 males and 30 females at age of 70-82 years.They were divided into a left atrial appendage(LAA)occlusion group(n=56)and a non-LAA occlusion group(n=28).Postoperative antithrombotic therapy:the LAA occlusion group was given warfarin+aspirin+clopidogrel“triple antithrombotic therapy”for 3 months after operation,then was changed to aspirin+clopidogrel“dual antiplatelet”for long-term antithrombotic;the non-LAA occlusion group was given warfarin+aspirin+clopidogrel“triple antithrombotic”for long-term antithrombotic after operation.The clinical effectiveness of the two groups was compared.Results All patients underwent the surgery successfully.There were 56 patients in the LAA occlusion group,including 44 patients of LAA exclusion and 12 patients of LAA clip.The time of LAA occlusion was 3 to 8 minutes.There was no injury of graft vessels and anastomotic stoma.Early postoperative death occurred in 2 patients(2.4%).There was no statistical difference between the two groups in postoperative hospital stay(P=0.115).Postoperative LVEF of the two groups significantly improved compared with that before operation(P<0.05).There was no stroke or bleeding in important organs during hospitalization.During follow-up of 1 year,no cerebral infarction occurred in both groups,but the incidence of bleeding related complications in the LAA occlusion group was significantly lower than that in the non-LAA occlusion group(3.6%vs.18.5%,P=0.036).Conclusion For elderly patients with CAD and AF with reduced LVEF,LAA occlusion during OPCABG can effectively reduce the risk of stroke and bleeding related complications,and without increasing the risk of surgery.