Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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The Comparison Study of Early and Midterm Clinical Outcome of Off-Pump versus On-Pump Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction (LVEF${\le}35{\%}$)

심한 좌심실 부전을 갖는 환자에서 시행한 Off-Pump CABG와 On-Pump CABG의 중단기 성적비교

  • Youn Young Nam (Department of Thoracic and Cardiovascular Surgery, Yong Dong Severance Hospital, College of Medicine, Yonsei University) ;
  • Lee Kyo Joon (Department of Thoracic and Cardiovascular Surgery, Yong Dong Severance Hospital, College of Medicine, Yonsei University) ;
  • Bae Mi Kyung (Department of Thoracic and Cardiovascular Surgery, Yong Dong Severance Hospital, College of Medicine, Yonsei University) ;
  • Shim Yeon Hee (Department of Anesthesia and Pain Medicine, Yong Dong Severance Hospital, College of Medicine, Yonsei University) ;
  • Yoo Kyung-Jong (Department of Thoracic and Cardiovascular Surgery, Yong Dong Severance Hospital, College of Medicine, Yonsei University)
  • 윤영남 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 이교준 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 배미경 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 심영희 (연세대학교 의과대학 영동세브란스병원 마취통증의학교실) ;
  • 유경종 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실)
  • Published : 2006.03.01
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Abstract

Background: Off-pump coronary artery bypass grafting (OPCAB) has been proven to result in less morbidity. The patients who have left ventricular dysfunction may have benefits by avoiding the adverse effects of the cardiopulmonary bypass. The present study compared early and midterm outcomes of off-pump versus on-pump coronary artery bypass grafting (On pump CABG) in patients with severe left ventricular dysfunction. Material and Method: Ninety hundred forth six patients underwent isolated coronary artery bypass grafting by one surgeon between January 2001 and Febrary 2005.. Data were collected in 100 patients who had left ventricular ejection fraction (L VEF) less than $35\%$ (68 OPCAB; 32 On pump CABG). Mean age of patients were 62.9$\pm$9.0 years in OPCAS group and 63.8$\pm$8.0 years in On pump CABG group. We compared the preoperative risk factors and evaluated early and midterm outcomes. Result: In OPCAB and On pump CABG group, mean number of used grafts per patient were 2.75$\pm$0.72, 2.78$\pm$0.55 and mean number of distal anastomoses were 3.00$\pm$0.79, 3.16$\pm$0.72 respectively. There was one perioperative death in OPCAB group ($1.5\%$). The operation time, ventilation time, ICU stay time, CK-MB on the first postoperative day, and occurrence rate of complications were significantly low in OPCAB group. Mean follow-up time was 26.6$\pm$12.8 months (4${\~}$54 months). Mean LVEF of OPCAB and On pump CABG group improved significantly from $27.1\pm4.5\%$ to $40.7\pm13.0\%$ and $26.9\pm5.4\%$ to $33.3\pm13.7\%$. The 4-year actuarial survival rate of OPCAB and On pump CABG group were $92.2\%,\;88.3\%$ and the 4-year freedom rates from cardiac death were $97.7\%,\;96.4\%$ respectively. There were no significant differences between two groups in 4 year freedom rate from cardiac event and angina. Conclusion: OPCAS improves myocardial function and favors early and mid-term outcomes in patients with severe left ventricular dysfunction compared to On pump CABG group. Therefore, OPCAB is a preferable operative strategy even in patients with severe left ventricular dysfunction.

배경: 심장박동 상태에서 시행하는 관상동맥우회술(Off pump coronary artery bypass grafting, OPCAB) 은 심폐체외순환 하에서 시행하는 관상동맥우회술(On pump coronary artery bypass grafting, On pump CABG)에 비해 합병증이 다소 적은 것으로 보고되고 있다. 저자들은 좌심실 기능이 저하된 환자들에서 OPCAB과 On pump CABG의 단기 및 중기 성적을 평가하여 OPCAB의 유용성을 확인하였다. 대상 및 방법: 2001년 1월부터 2005년 2월까지 동반수술을 시행 받지 않고 관상동맥우회술만을 시행 받은 946명 중 좌심실 박출계수가 $35\%$ 이하인 100명을 대상으로 하였다(OPCAB군 : On pump CABG군 =68명: 32명). 평균 연령은 두 군이 OPCAB군과 On pump CABG군이 각각 62.9$\pm$9.0세와 63.8 $\pm$ 8.0로 두 군의 차이가 없었다. 두 군의 수술 전 위험요인을 분석하고, 수술 결과 및 추적결과를 평가 및 비교하였다. 결과: OPCAB군은 평균 2.75$\pm$0.72개, On pump CABG군은 2.78$\pm$0.55개의 도관을 획득하여, 각각 3.00$\pm$0.79개, 3.16$\pm$0.72개의 원위문합을 시행하였다. 수술 후 사망은 OPCAB군에서만 1명 ($1.5\%$) 발생하였으나 두 군간의 통계적 유의성은 없었다. 수술시간, 수술 후 1일째 CK-MB, 수술 후 기계 환기 시간, 중환자실 체류기간, 합병증 발생률이 통계적으로 유의하게 OPCAB군에서 더 낮았다. 평균 추적 기간은 26.6$\pm$12.8개월(4${\~}$54개월)이었으며, 추적 기간 중 좌심실 박출계수는 OPCAB군과 On pump CABG군이 각각 $27.1\pm4.5\%$와 $26.9\pm5.4\%$에서 $40.7\pm13.0\%$와 $33.3\pm13.7\%$로 통계적으로 유의하게 각각 증가하였다. 4년 생존율은 OPCAB군과 On pump CABG군이 각각 $92.2\%,\;88.3\%$, 심장관련 사망에 있어서 4년 freedom rate은 각각 $97.7\%,\;96.4\%$로 두 군간의 차이는 없었으며, 심장관련 합병증과 협심증 발생의 freedom rate도 두 군간의 차이는 없었다. 결론: 좌심실 기능이 저하된 환자들에서 심장박동 상태에서 시행하는 관상동맥우회술은 심장기능을 향상시키고 On pump CABG군에 비해 우수한 수술결과를 보였다. 특히 On pump CABG군에 비해 우수한 단기 성적을 보였으나 중기성적은 차이가 없었다. 따라서 좌심실 기능이 저하된 환자들에 있어서 심장박동 상태에서 시행하는 관상동맥우회술은 안전하고 효과적으로 사용될 수 있는 수술방법이라고 생각한다.

Keywords

References

  1. Trachiotis GD, Weintraub WS, Johnston TS, et al. Coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Ann Thorac Surg 1998;66:1632-9 https://doi.org/10.1016/S0003-4975(98)00773-5
  2. Bouchart F, Tabley A, Litzler PY, et al. Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long-term follow-up in 141 patients. Eur J Cardiothorac Surg 2001;20:1157-62 https://doi.org/10.1016/S1010-7940(01)00982-4
  3. O'Connor GT, Plume SK, Olmstead EM, et al. Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group. Circulation 1992;85:2110-8 https://doi.org/10.1161/01.CIR.85.6.2110
  4. Ferguson TB Jr, Hammill BG, Peterson ED, DeLong ER, Grover FL, and the STS National Database Committee. A decad e of change-risk profiles and outcomes for isolated coronary artery bypass graft ing procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute . Society of Thoracic Surgeons. Ann Thorac Surg 2002;73:480-9 https://doi.org/10.1016/S0003-4975(02)03503-8
  5. Moshkovitz Y, Stemik L, Paz Y, et al. Primary coronary artery bypass graft ing without cardiopulmonary bypass in impaired left ventricular function . Ann Thorac Surg 1997;63 (6 Suppl):S44-7 https://doi.org/10.1016/S0003-4975(97)00432-3
  6. Nashef SAM, Roques F, Michel P, Gauducheau E, Lerneshow S, Salamon R, for the EuroSCORE Study Group. European system for cardiac operatic risk evaluation EuroSCORE. Eur J Cardiothorac Surg 1999;16:9-13 https://doi.org/10.1016/S1010-7940(99)00134-7
  7. Yau T, Fedak P, Weisel R, Teng C, Ivanov J. Predictors of operative risk for coronary bypass grafing operations in patients with left ventricular dysfunction. J Thorac Cardio vase Surg 1999;118:1006-13 https://doi.org/10.1016/S0022-5223(99)70094-2
  8. Veenhuyzen G, Singh S, McAreavey D, Shelton B, Exner D. Prior coronary artery bypass surgery and risk of death among patients with ischemic left ventricular dysfunction. Circulation 2001;104:1489-93 https://doi.org/10.1161/hc3801.096335
  9. Wos S, Bachowski R, Ceglarek W, Domaradzki W, Matuszewski M, Kucewicz E. Coronary artery bypass grafting without cardiopulmonary bypass : initial experience of 50 cases . Eur J Cardiothorac Surg 1998;14(Suppl 1):38-42 https://doi.org/10.1016/S1010-7940(98)00102-X
  10. Nathoe HM, van Dijk D, Jansen EW, et al. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med 2003;348:394-402 https://doi.org/10.1056/NEJMoa021775
  11. AI-Ruzzeh S, Athanasiou T, George S, et al. Is the use of cardiopulmonary bypass for multi vessel coronary artery bypass surgery an independent predi ctor of operative mortality in patients with ischemic left ventricular dysfunction? Ann Thorac Surg 2003;76:444-52 https://doi.org/10.1016/S0003-4975(03)00348-5
  12. Shennib H, Endo M, Benhamed O, Morin JF. Surgical revascularization in patients with poor left ventricular function : on- or off-pump- Ann Thorac Surg 2002;74:S1344-7 https://doi.org/10.1016/S0003-4975(02)03966-8
  13. Ohata T, Kaneko M, Kuratani T, Ueda H, Shimamura K. Using the Euroscore to assess changes in the risk profiles of the patients undergoing coronary artery bypass grafting before and after the introduction of less invasiv e coronary surgery. Ann Thorac Surg 2005;80:131-5 https://doi.org/10.1016/j.athoracsur.2005.02.031
  14. Arom KV, Favin TF, Emery RW, et al. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 2000;70:1021-5 https://doi.org/10.1016/S0003-4975(00)01761-6
  15. Narayan P, Rogers CA, Lim KH, Capoun R, Angelini GD. Early and midterm clinical outcome in patients with severe left ventricular dysfun ction undergoing coronary artery surgery . Ann Thorac Surg 2003;76:793-9 https://doi.org/10.1016/S0003-4975(03)00664-7
  16. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of arterial coronary bypass graft on lO-year survival and other cardiac events . N Engl J Med 1986;314:1-6 https://doi.org/10.1056/NEJM198601023140101
  17. Lytle BW, Loop FD. Superiority of bilateral internal thoraci c artery grafting: it 's been a long time comin'. Circulation 2001;104:2152-4 https://doi.org/10.1161/hc2601.092124
  18. Pevni D, Kramer A, Paz Y, et al. Composite arterial grafting with double skeletonized internal thoracic arteries. Eur J Cardiothorac Surg 2001;20:299-304 https://doi.org/10.1016/S1010-7940(01)00832-6
  19. Stevens LM, Carrier M, Perrault LP, et al. Single versus bilateral internal thoraci c artery grafts with concomitant saphenous vein grafts for multi vessel coronary artery bypass grafting: effects on mortality and event-free survival. J Thorac Cardiovasc Surg 2004;127:1408-15 https://doi.org/10.1016/j.jtcvs.2003.10.006
  20. Ura M, Sakata R, Nakayama Y, Arai Y, Saito T. Long-term results of bilateral internal thora cic arte ry grafting. Ann Thorac Surg 2000;70:1991-6 https://doi.org/10.1016/S0003-4975(00)01697-0