CAJ | 학술논문

[目的] 分析急性ST抬高型心肌梗死(STEMI)后行外科血运重建治疗缺血性心脏病左心功能不全的不同手术时机对早期结果的影响.方法回顾性分析2003年1月至2012年7月住院的225例有明确STEMI病史的缺血性心脏病合并左心功能不全(射血分数≤50％)患者的临床资料,其中男性186例,女性39例.根据心肌梗死后实施外科血运重建的时间将其分为早期组(＜21 d)、中期组(21 ～90 d)和晚期组(＞90 d).收集患者人口学资料、欧洲心脏手术风险评估系统Ⅱ危险因素以及各项围手术期指标,以30 d死亡及严重并发症作为主要终点事件评价术后早期结果,以术前术后超声心动图测量的左心室舒张末期内径(LVEDD)及射血分数评价左心室形态及功能变化.结果三组实际手术病死率为3.4％、0、2.3％,组间差异无统计学意义(x2 =2.137,P=0.330).三组低心排血量发生率分别为13.8％、3.1％、2.3％,组间差异有统计学意义(x2=8.344,P=0.015).三组患者术前射血分数分别为42％ ±6％、41％±6％、42％±6％,术后分别为46％±7％、45±10％、45％±9％,各组术后较术前均明显提高(t=-3.378～-2.339,P值均＜0.05).三组患者术前LVEDD值分别为(51 ±6)mm、(54±6)mm、(55 ±6)mm,术后分别为(49 7)mm、(47 ±8)mm、(49±9)mm,中期组与晚期组术后LVEDD较术前均明显减小(t=5.634、5.885,P=0.000),早期组手术前后差异无统计学意义(t=1.524,P=0.133).结论 STEMI后左心功能不全患者在不同时期实施外科血运重建均可有效改变左心室重构进程并改善左心功能,手术时机应根据患者病情、手术技术及围手术期管理水平综合决定,心肌梗死3周后手术对该类患者更为安全.
[목적] 분석급성ST태고형심기경사(STEMI)후행외과혈운중건치료결혈성심장병좌심공능불전적불동수술시궤대조기결과적영향.방법 회고성분석2003년1월지2012년7월주원적225례유명학STEMI병사적결혈성심장병합병좌심공능불전(사혈분수≤50％)환자적림상자료,기중남성186례,녀성39례.근거심기경사후실시외과혈운중건적시간장기분위조기조(＜21 d)、중기조(21 ～90 d)화만기조(＞90 d).수집환자인구학자료、구주심장수술풍험평고계통Ⅱ위험인소이급각항위수술기지표,이30 d사망급엄중병발증작위주요종점사건평개술후조기결과,이술전술후초성심동도측량적좌심실서장말기내경(LVEDD)급사혈분수평개좌심실형태급공능변화.결과 삼조실제수술병사솔위3.4％、0、2.3％,조간차이무통계학의의(x2 =2.137,P=0.330).삼조저심배혈량발생솔분별위13.8％、3.1％、2.3％,조간차이유통계학의의(x2=8.344,P=0.015).삼조환자술전사혈분수분별위42％ ±6％、41％±6％、42％±6％,술후분별위46％±7％、45±10％、45％±9％,각조술후교술전균명현제고(t=-3.378～-2.339,P치균＜0.05).삼조환자술전LVEDD치분별위(51 ±6)mm、(54±6)mm、(55 ±6)mm,술후분별위(49 7)mm、(47 ±8)mm、(49±9)mm,중기조여만기조술후LVEDD교술전균명현감소(t=5.634、5.885,P=0.000),조기조수술전후차이무통계학의의(t=1.524,P=0.133).결론 STEMI후좌심공능불전환자재불동시기실시외과혈운중건균가유효개변좌심실중구진정병개선좌심공능,수술시궤응근거환자병정、수술기술급위수술기관리수평종합결정,심기경사3주후수술대해류환자경위안전.
Objective To analysis the influence of surgical revascularization on different timing after ST-elevation myocardial infarction (STEMI) on patients with coronary artery disease and left ventricular dysfunction.Methods Clinical data of 225 patients admitted from January 2003 to July 2012 with history of STEMI and left ventricular dysfunction (ejection faraction ＜ 50％) who underwent isolated coronary artery bypass grafting was retrospectively reviewed.There were 186 male and 39 female patients.According to the timing of surgical revascularization after STEMI,the patients were divided into early revascularization group (ER group,＜ 21 days),mid-term revascularization group (MR group,21 to 90 days) and late revascularization group (LR group,＞ 90 days).There were 20 male and 9 female patients in ER group with mean age of (63 ± 10) years,48 male and 16 female in MR group with mean age of (63 ± 8) years,118 male and 14 female in LR group with mean age of (62 ± 10) years,respectively.Thirty-day postoperative mortality and major complications were determined as the endpoints to evaluate the early results of operation.Results The 30-day post-operative mortality were 3.4％,0 and 2.3％ among three groups respectively and there was no statistic difference between groups (x2 =2.137,P =0.330).Low cardiac output syndrome mortality were 13.8％,3.1％ and 2.3％ among three groups respectively and there was statistic difference between groups (x2 =8.344,P =0.015).The ejection fractions was significantly improved in all the three groups from 42％ ±6％,41％ ±6％ and 42％ ±6％ preoperatively to 46％ ±7％,45％ ± 10％ and 45％ ± 9％ postoperatively (t =-3.378 to-2.339,all P ＜ 0.05).The left ventricular end diastolic dimension were significantly reduced in MR group and LR group from (54 ± 6) mm and (55 ± 6) mm preoperatively to (47 ± 8) mm and (49 ± 9) mm postoperatively (t =5.634,5.885 ; P =0.000).There was no significant change in ER group pre-and postoperatively ((51 ±6) mm vs.(49 ±7) mm,t =1.524,P =0.133).Conclusions The patients with coronary artery disease and left ventricular dysfunction can benefit from surgical revascularization on different timing after STEMI,presenting as the reverse of left ventricle remodeling and the improvement of left ventricle function.The short-term results are mainly determined by the patients' condition,surgical technique and the level of perioperative management.It is recommended for this patient cohort to accept surgical revascularization three weeks after STEMI.