非体外循环冠状动脉旁路移植治疗高危冠心病的评价

背景：非体外与体外循环冠状动脉旁路移植是治疗冠状动脉粥样硬化性心脏病的外科学方法,但目前尚无二者对高危冠心病患者疗效比较的系统评价。 目的：通过Meta分析评价非体外与体外循环冠状动脉旁路移植对高危冠心病患者围手术期的疗效和安全性差异。 方法：计算机检索PubMed、EMbase、中国期刊全文数据库、中国生物医学文献数据库、维普数据库、万方数据库和Cochrane Library(2012年第8期),并辅以检索相关文献的参考文献,语种限制为中文和英文,检索时间为1993年1月至2012年6月。严格按照纳入和排除标准进行筛选研究。由2位评价员独立对纳入的研究进行质量评价与提取资料并交叉核对,最后将提取的资料用RevMan 5.1软件进行数据处理与分析。 结果与结论：共纳入16个研究包括2个随机对照试验与14个观察性研究;共6 441例患者,其中非体外循环冠状动脉旁路移植组2 948例患者,常规体外循环下冠状动脉旁路移植组3 493例患者。Meta 分析结果显示：非体外循环冠状动脉旁路移植与常规体外循环下冠状动脉旁路移植比较,在围手术期脑卒中、主动脉内球囊反搏使用、再发心肌梗死、呼吸功能不全与死亡率,呼吸机辅助时间、ICU时间、住院时间,输血量及术后引流量方面的差异均有显著性意义,而在房颤、急性肾功能损伤、伤口感染及二次开胸率方面的差异均无显著性意义。结果提示,在围手术期方面与常规体外循环下冠状动脉旁路移植相比,对高危冠心病患者采用非体外循环冠状动脉旁路移植是安全有效的,且具有创伤少,手术死亡率低,术后恢复快,术后并发症少的优点,但是由于纳入文献数量有限且大多为非随机对照试验,因此非体外循环冠状动脉旁路移植并不能取代常规体外循环下冠状动脉旁路移植,其具体疗效与中远期疗效需要进一步通过更高质量、大样本量、多中心的随机双盲对照试验研究及长期的观察才能得出肯定的结论。

Off-pump coronary artery bypass grafting treats high-risk coronary heart disease

BACKGROUND:Off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting are the two surgical methods for the treatment of coronary atherosclerotic heart disease, but there is no systematic review on the comparison of these two methods in the treatment of high-risk coronary heart disease. OBJECTIVE:To assess the effect and safety of off-pump versus on-pump coronary artery bypass grafting in perioperative period of high-risk coronary heart disease through Meta analysis. METHODS:Relevant clinical trials published in English and Chinese from January 1993 to June 2012 were searched in PubMed database, EMbase database, China National Knowledge Infrastructure database, China Biomedicine Literature database, VIP database, Wanfang database and Cochrane Library (Issue 8, 2012). Manual searches of bibliographies were also performed. All the clinical trials were selected and analyzed according to the inclusion and exclusion criteria. Two reviewers independently selected eligible trials, performed quality assessment, and cross-checked each other. Finally, the abstracted relevant data was processed and analyzed with software RevMan 5.1. RESULTS AND CONCLUSION:A total of 16 studies, including two randomized controlled trials and 14 retrospective studies were identified. A total of 6 441 high-risk patients, involving 2 948 in the off-pump coronary artery bypass grafting group and 3 493 in the on-pump coronary artery bypass grafting group were included. The results of Meta-analyses showed the differences of stroke, the intra-aortic balloon counterpulsation using, recurrent myocardial infarction, respiratory dysfunction and mortality incidence in the perioperative period, the ventilation time, the time in intensive care unit, hospitalization time, postoperative drainage and blood transfusion were significant between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting patients. While there were no statistical differences in atrial fibrillation, acute renal injury, wound infection and reoperation rate. Compared with on-pump coronary artery bypass grafting in the perioperative period, using off-pump coronary artery bypass grafting for high-risk patients is safe and effective with the advantages of less trauma, lower operative mortality, rapider postoperative recovery and fewer complications, but because of the limited number of included studies and most is the non-randomized controlled trials, off-pump coronary artery bypass grafting cannot replace on-pump coronary artery bypass grafting. However, the results and long-term efficacy still need to be confirmed by higher-quality, more multi-center, large-sample and randomized double-blind controlled trials in the future．