目的：

研究表明外科血运重建可以逆转缺血性心肌病（ICM）患者心室重构，但不同手术方式对患者的获益存在争议。本研究拟通过观察体外循环下冠状动脉旁路移植术和非体外循环下冠状动脉旁路移植术治疗缺血性心肌病的短期和中期疗效，探索患者接受不同手术的获益程度，以期为外科治疗缺血性心肌病提供临床参考。

方法：

本研究为一项单中心回顾性临床研究，纳入自2013年01月至2019年10月在泰达国际心血管病医院住院接受外科治疗的221例缺血性心肌病患者，其中114例接受体外循环下冠状动脉旁路移植术（ONCAB），107例接受非体外循环下冠状动脉旁路移植术（OPCAB）。收集所有患者基线资料和临床特征、手术住院资料和术后随访资料，对比分析患者的短期和中期疗效。评价左心功能指标包括左心室射血分数（LVEF）、左心室舒张末期内经（LVEDD）和左心房内径（LAD）；短期和中期主要结果包括死亡、脑卒中、心肌梗死、肾功能衰竭；其他次要结果包括再次血运重建、再次入院、手术切口愈合不良、术后新发心律失常等。

结果：

1. 221例接受冠状动脉旁路移植术的缺血性心肌病患者分为体外循环组和非体外循环组，术后30天内ONCAB组死亡率4.4%，OPCAB组死亡率0.9%。平均随访30.7月时，ONCAB组死亡率13.2%，OPCAB组死亡率6.5%。两组患者术后短期和中期的主要不良事件（死亡、脑卒中、心肌梗死、肾功能衰竭）发生率无组间差异（P＞0.05）。两组患者术后左心功能（LVEF、LVEDD、LAD）比术前均有显著改善（P＜0.05），但组间差异无统计学意义（P＞0.05）。

2. 与ONCAB组相比，OPCAB组手术时间缩短、总住院时间减少且术中血液制品（红细胞、新鲜冰冻血浆、血小板）用量降低（P＜0.05）。

3. 221例ICM患者接受外科心肌血运重建，30天内死亡6例，其余215 例根据患者术后LVEF是否增加10%分为两组，LVEF未改善组103例，LVEF改善组112例。Logistic回归分析显示心肌梗死病史是LVEF未改善的独立危险因素。

结论：

1.外科血运重建可以改善ICM患者术后左心功能，ONCAB与OPCAB在改善患者左心功能及短期、中期生存方面无显著差别，其远期生存益处有无差异仍需进一步验证。

2.与ONCAB相比，OPCAB可缩短手术和住院时间、减少输血需求。

Objective:

Previous studies have shown that surgical revascularization can reverse ventricular remodeling in patients with ischemic cardiomyopathy (ICM). However, the benefits of different surgical methods are controversial. This study observed the short-term and mid-term effects of on-pump coronary artery bypass grafting and off-pump coronary artery bypass grafting in the treatment of ischemic cardiomyopathy, and explored the benefits of different operations, in order to provide clinical clues for surgical treatment of ischemic cardiomyopathy.

Methods:

This single-center retrospective clinical study included 221 patients with ischemic cardiomyopathy who received surgical treatment in TEDA International Cardiovascular Hospital from January 2013 to October 2019. Among them, 114 patients were performed with on-pump coronary artery bypass grafting (ONCAB) and 107 patients were performed with off-pump coronary artery bypass grafting (OPCAB). The baseline data, clinical characteristics, surgical hospitalization data and postoperative follow-up data of all patients were collected, and then the short-term and mid-term effects of the patients were compared and analyzed. The evaluation of left ventricular function included left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD) and left atrial diameter (LAD). The short-term and mid-term primary outcome was a composite outcome of death, myocardial infarction, stroke and renal failure while secondary outcomes included repeated revascularization, rehospitalization, poor wound healing and postoperative arrhythmia.

Results:

1. 221 patients with ischemic cardiomyopathy who underwent coronary artery bypass grafting were divided into ONCAB group and OPCAB group. The mortality rate within 30 days was 4.4% in the ONCAB group and 0.9% in the OPCAB group. At an average follow-up of 30.7 months, ONCAB mortality was 13.2% and OPCAB mortality was 6.5%. There was no significant difference between the incidences of short-term and mid-term major adverse events (death, myocardial infarction, stroke and renal failure) of the two groups. The left ventricular function (LVEF, LVEDD and LAD) of the two groups was significantly improved after operation (P＜0.05), but there was no significant difference between the two groups (P > 0.05).

2. Compared with the ONCAB group, the operation time, the total hospital stay and the dosage of blood products in the OPCAB group were lower than those in the OPCAB group (P＜0.05).

3. 221 patients with ICM were performed with surgical myocardial revascularization and 6 patients died within 30 days. The remaining 215 patients were divided into two groups: a LVEF improved group (LVEF increased≥10%，N=103) and a LVEF non-improved group (LVEF increased＜10%，N=112). Logistic regression analysis showed that the history of myocardial infarction was an independent risk factor for no improvement in LVEF.

Conclusion:

1. Surgical revascularization can improve left ventricular function in patients with ICM, but there is no significant difference between ONCAB and OPCAB in improving left ventricular function and short-term and mid-term survival. However, the long-term survival still remains to be further verified.

2. OPCAB can reduce the operation time, hospital stay and the need for blood transfusion compared with ONCAB.