合并终末期肾病的冠状动脉粥样硬化性心脏病患者行冠状动脉旁路移植术临床疗效分析
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摘要
目的分析合并终末期肾病(ESRD)的冠状动脉粥样硬化性心脏病(冠心病)患者行冠状动脉旁路移植术(CABG)的早期临床效果及中远期随访结果。方法收集2010年1月至2017年12月首都医科大学附属北京安贞医院30例需透析治疗的ESRD合并冠心病患者的临床资料,术前肌酐(665±262)μmol/L,肾小球滤过率(8±4)ml/(min·1.73 m~2);平均冠状动脉病变支数(3.1±0.8)支。其中行非体外循环CABG 28例、体外循环下CABG+二尖瓣成形或置换各1例。分析患者的手术资料、围术期情况、出院用药并完成术后随访。结果全部患者术后均使用连续肾脏替代透析治疗。平均完成冠状动脉吻合桥数(3.1±0.7)支。主动脉内球囊反搏使用率为33.3%(10/30)。围术期死亡率为10.0%(3/30),死亡原因包括心功能衰竭2例和顽固性心室颤动1例。术后二次开胸止血率为6.7%(2/30)。围术期心房颤动发生率26.7%(8/30),心肌梗死发生率为36.7%(11/30)。出院服用联合抗血小板药物治疗占85.2%(23/27)。术后成功随访25例,随访率为92.6%(25/27);中位随访时间4(1,7)年,全因死亡率为12.0%(3/25),其中心源性猝死1例,肺部疾病导致死亡2例;不良心脑血管事件发生率为20.0%(5/25)。结论合并ESRD的冠心病患者行CABG的围术期风险较高,但中远期随访结果较为满意。
Objective To analyze the early and long-term outcomes of coronary artery bypass grafting(CABG) in coronary atherosclerotic heart disease( CHD) patients with end-stage renal disease( ESRD).Methods Clinical data of 30 ESRD patients who had CABG from January 2010 to December 2017 in Beijing Anzhen Hospital, Capital Medical University were analyzed; the mean creatinine level was(665 ±262) μmol/L;the mean glomerular filtration rate was(8 ± 4) ml/(min · 1. 73 m~2); the mean number of coronary artery lesions was(3.1 ±0.8). Twenty-eight patients had off-pump CABG; 1 patient had on-pump CABG plus mitral valvuloplasty;1 patient had on-pump CABG plus mitral valve replacement. Surgical and perioperative records,discharge medication and follow-up data were analyzed. Results All patients had continuous renal replacement therapy after surgery.The mean number of bypass grafts was(3. 1 ±0. 7). Intra-aortic balloon pump was used in 10 patients(33. 3%).The perioperative mortality rate was 10. 0%(3/30) including heart failure(2 cases) and ventricular fibrillation(1 case). Two patients(6. 7%) had reoperation for hemorrhage. Perioperative atrial fibrillation and myocardial infarction rates were 26. 7%( 8/30) and 36. 7%( 11/30), respectively. Twenty-three patients( 85. 2%) took antiplatelet drugs after discharge. Twenty-five patients(92. 6%) were followed up for 4( 1,7) years; the all-cause mortality rate was 12.0%(3/25) including sudden cardiac death( 1 case) and pulmonary disease(2 cases); the cardiovascular adverse event rate was 20. 0%(5/25). Conclusion CABG procedure has a high risk in CHD patients with ESRD; the mid-and long-term outcomes are good.
Objective To analyze the early and long-term outcomes of coronary artery bypass grafting(CABG) in coronary atherosclerotic heart disease( CHD) patients with end-stage renal disease( ESRD).Methods Clinical data of 30 ESRD patients who had CABG from January 2010 to December 2017 in Beijing Anzhen Hospital, Capital Medical University were analyzed; the mean creatinine level was(665 ±262) μmol/L;the mean glomerular filtration rate was(8 ± 4) ml/(min · 1. 73 m~2); the mean number of coronary artery lesions was(3.1 ±0.8). Twenty-eight patients had off-pump CABG; 1 patient had on-pump CABG plus mitral valvuloplasty;1 patient had on-pump CABG plus mitral valve replacement. Surgical and perioperative records,discharge medication and follow-up data were analyzed. Results All patients had continuous renal replacement therapy after surgery.The mean number of bypass grafts was(3. 1 ±0. 7). Intra-aortic balloon pump was used in 10 patients(33. 3%).The perioperative mortality rate was 10. 0%(3/30) including heart failure(2 cases) and ventricular fibrillation(1 case). Two patients(6. 7%) had reoperation for hemorrhage. Perioperative atrial fibrillation and myocardial infarction rates were 26. 7%( 8/30) and 36. 7%( 11/30), respectively. Twenty-three patients( 85. 2%) took antiplatelet drugs after discharge. Twenty-five patients(92. 6%) were followed up for 4( 1,7) years; the all-cause mortality rate was 12.0%(3/25) including sudden cardiac death( 1 case) and pulmonary disease(2 cases); the cardiovascular adverse event rate was 20. 0%(5/25). Conclusion CABG procedure has a high risk in CHD patients with ESRD; the mid-and long-term outcomes are good.
引文
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[15]Gelsomino S,Morocutti G,Masullo G,el al.Open heart surgery in patients with dialysis-dependent renal insufficiency[J].J Card Surg,2001,16(5):400-407.DOI:10.1111/j.1540-8191.2001.tb00541.x.
[16]周明阳,张健群,毛斌,等.冠状动脉旁路移植术患者死亡相关因素分析[J].中国医药,2017,12(3):343-346.DOI:10.3760/cma.j.issn.1673-4777.2017.03.006.Zhou MY,Zhang JQ,Mao B,et al.Analysis of death related factors in patients with coronary artery bypass grafting[J].China Medicine,2017,12(3):343-346.DOI:10.3760/cma.j.issn.1673-4777.2017.03.006.
[17]Sezai A,Nakata K,Hata M,et al.Long-term results of dialysis patients with chronic kidney disease undergoing coronary artery bypass grafting[J].Ann Thorac Cardiovasc Surg,2013,19(6):441-448.DOI:10.5761/atcs.oa.12.02028.
[18]Takami Y,Tajima K,Kato W,et al.Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients[J].Ann Thorac Surg,2012,94(6):1940-1945.DOI:10.1016/j.athoracsur.2012.07.037.
[2]FleissnerF,WarneckeG,CebotariS,et al.Coronary artery bypass grafting in young patients-insights into a distinct entity[J].J Cardiolhorac Surg,2015(10):65.DOI:10.1186/s13019-015-0266-1.
[3]Gelsomino S,Da CP,Frassani R,et al.Coronary artery bypass grafting in patients with dialysis-dependent renal failure:ten-year results[J].Ital Heart J,2001,2(5):379-383.
[4]Hori D,Yamaguchi A,Adachi H.Coronary artery bypass surgery in end-stage renal disease patients[J].Ann Vase Dis,2017,10(2):79-87.DOI:10.3400/avd.ra.17-00024.
[5]Liyanage T,Ninomiya T,Jha V,et al.Worldwide access to treatment for end-stage kidney disease:a systematic review[J].Lancet,2015,385(9981):1975-1982.DOI:10.1016/S0140-6736(14)61601-9.
[6]杨艳,董莘,敖国昆,等.尿毒症与非尿毒症患者胸部CT心血管钙化的对照研究[J].中国医学装备,2015,12(2):62-64.DOI:10.3969/J.ISSN.1672-8270.2015.02.020.Yang Y,Dong X,Ao GK,et al.Comparative study on cardiovascular calcification in chest CT between uremic and non-uremic patients[J].China Medical Equipment,2015,12(2):62-64.DOI:10.3969/J.ISSN.1672-8270.2015.02.020.
[7]Chiu YW,Jiwakanon S,Lukowsky L,et al.An update on the comparisons of mortality outcomes of hemodialysis and peritoneal dialysis patients[J].Semin Nephrol,2011,31(2):152-158.DOI:10.1016/j.semnephrol.2011.01.004.
[8]赵雪东,张玉姣,郑文,等.冠状动脉粥样硬化性心脏病合并中重度肾功能不全患者接受不同再血管化治疗的预后比较[J].中国医药,2017,12(5):677-681.DOI:10.3760/cma.j.issn.1673-4777.2017.05.009.Zhao XD,Zhang YJ,Zheng W,et al.Outcomes of different revascularization therapies treating coronary atherosclerotic heart disease complicated with moderate to severe renal dysfunction[J].China Medicine,2017,12(5):677-681.DOI:10.3760/cma.j.issn.1673-4777.2017.05.009.
[9]Herzog CA,Ma JZ,Collins AJ.Comparative survival of dialysis patients in the United States after coronary angioplasty,coronaryartery stenting,and coronary artery bypass surgery and impact of diabetes[J].Circulation,2002,106(17):2207-2211.DOI:10.1161/01.CIR.0000035248.71165.EB.
[10]SoS Investigators.Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease(the Stent or Surgery trial):a randomised controlled trial[J].Lancet,2002,360(9338):965-970.DOI:10.1016/S0140-6736(02)11078-6.
[11]李扬,屈正,张兆光.体外循环与非体外循环冠状动脉旁路移植术早期疗效分析[J].心脏杂志,2011,23(4):487-492.DOI:10.13191/j.chj.2011.04.73.lig.039.Li Y,Qu Z,Zhang ZG.Analysis of early outcomes of on-pump coronary artery bypass grafting and off-pump coronary artery bypass grafting[J].Heart Journal,2011,23(4):487-492.DOI:10.13191/j.chj.2011.04.73.lig.039.
[12]Liu JY,Birkmeyer NJ,Sanders JH,et al.Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery.Northern New England Cardiovascular Disease Study Group[J].Circulation,2000,102(24):2973-2977.DOI:10.1161/01.CIR.102.24.2973.
[13]Powell KL,Smith JM,Woods SE,et al.Coronary artery bypass grafting in patients with dialysis-dependent end stage renal disease:a prospective,nested case-control study[J].J Card Surg,2004,19(5):449452.DOI:10.1111/j.0886-0440.2004.05001.x.
[14]Shahian DM,O'Brien SM,Sheng S,et al.Predictors of longterm survival after coronary artery bypass grafting surgery:results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database(the ASCERT study)[J].Circulation,2012,125(12):1491-1500.DOI:10.1161/CIRCULATIONAHA.111.066902.
[15]Gelsomino S,Morocutti G,Masullo G,el al.Open heart surgery in patients with dialysis-dependent renal insufficiency[J].J Card Surg,2001,16(5):400-407.DOI:10.1111/j.1540-8191.2001.tb00541.x.
[16]周明阳,张健群,毛斌,等.冠状动脉旁路移植术患者死亡相关因素分析[J].中国医药,2017,12(3):343-346.DOI:10.3760/cma.j.issn.1673-4777.2017.03.006.Zhou MY,Zhang JQ,Mao B,et al.Analysis of death related factors in patients with coronary artery bypass grafting[J].China Medicine,2017,12(3):343-346.DOI:10.3760/cma.j.issn.1673-4777.2017.03.006.
[17]Sezai A,Nakata K,Hata M,et al.Long-term results of dialysis patients with chronic kidney disease undergoing coronary artery bypass grafting[J].Ann Thorac Cardiovasc Surg,2013,19(6):441-448.DOI:10.5761/atcs.oa.12.02028.
[18]Takami Y,Tajima K,Kato W,et al.Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients[J].Ann Thorac Surg,2012,94(6):1940-1945.DOI:10.1016/j.athoracsur.2012.07.037.