2019 年第 12 期 第 14 卷

射血分数降低型心力衰竭患者心肌活性与外科血运重建治疗临床结果的关系

Relation between myocardial viability and outcomes of surgical revascularization in patients with heart failure and reduced ejection fraction

作者：曹剑党海明宋跃吴立松刘冬黄琦董然

英文作者：

单位：100029首都医科大学附属北京安贞医院心外科

英文单位：

关键词：冠状动脉粥样硬化性心脏病；心肌活性；冠状动脉旁路移植术；射血分数降低型心力衰竭

英文关键词：

• 摘要：

• 【摘要】目的    探讨心肌活性对射血分数降低型心力衰竭（HFrEF）患者冠状动脉旁路移植术（CABG）围术期风险及中远期无主要不良心血管事件（MACE）生存率的影响。方法    连续入选2014年1月至2018年12月就诊于首都医科大学附属北京安贞医院的左心室射血分数（LVEF）＜40%合并心力衰竭患者118例。CABG术前经胸超声心动图测定LVEF；采用正电子发射计算机断层扫描技术行静息心肌灌注显像及心肌代谢断层显像测定存活心肌占左心室心肌比例，以存活心肌比例≥10%为高心肌活性组（78例），存活心肌比例＜10%为低心肌活性组（40例）。观察2组患者围术期病死率及并发症发生率，以及随访期间无MACE生存率。结果    高心肌活性组患者与低心肌活性组患者相比，术前LVEF、左心室收缩末期和舒张末期容积指数等心功能指标差异均无统计学意义（均P＞0.05）。高心肌活性组既往介入治疗比例高于低心肌活性组［26.9%（21/78）比25.0%（10/40）］（P＝0.05）。全组患者围术期病死率为6.8%（8/118）。低心肌活性组围术期病死率及心房颤动发生率明显高于高心肌活性组［12.5%（5/40）比3.8%（3/78）、35.0%（14/40）比14.1%（11/78）］，差异均有统计学意义（均P<0.05）。低心肌活性组围术期应用主动脉内球囊反搏、体外膜肺氧合比例明显高于高心肌活性组［75.0%（30/40）比47.4%（37/78）、22.5%（9/40）比1.3%（1/78）］，差异均有统计学意义（均P＜0.05）。全组患者平均随访时间为（30±12）个月。高心肌活性组术后12、24、36个月无MACE事件生存率均明显高于低心肌活性组患者(96.9%比88.6%，93.4%比85.5%，79.4%比68.2%，P＝0.004)。结论    心肌活性是影响HFrEF患者CABG围术期死亡率及中远期无MACE生存率的重要因素。

• 【Abstract】Objective    To explore the effect of myocardial viability on perioperative risk and medium to long-term survival rate without major adverse cardiovascular events(MACE) in patients with heart failure and reduced ejection fraction(HFrEF) undergoing coronary artery bypass grafting(CABG). Methods    A total of 118 patients with heart failure and left ventricular ejection fraction(LVEF)＜40% were consecutively enrolled from January 2014 to December 2018 in Beijing Anzhen Hospital, Capital Medical University. LVEF was measured by transthoracic echocardiography before CABG. The ratio of viable myocardium to left ventricle was determined by myocardial perfusion imaging at rest and myocardial metabolism tomography via positron emission tomography. The patients were divided into high myocardial viability group(viable myocardium ratio≥10%, 78 cases) and low myocardial viability group(viable myocardium ratio＜10%, 40 cases). Perioperative complications and mortality were observed. MACE-free survival rate was followed up. Results    There were no significant differences in LVEF, left ventricular end-systolic volume index, left ventricular end-diastolic volume index between patients with or without high myocardial viability before surgery(all P＞0.05)， but high myocardial viability was associated with a high rate of previous intervention treatment［26.9%（21/78） vs 25.0%（10/40）］(P＝0.05). The overall perioperative mortality was 6.8%（8/118）. Compared with patients with high myocardial viability, those with low myocardial viability had higher incidences of perioperative death and atrial fibrillation［12.5%（5/40） vs 3.8%（3/78）, 35.0%（14/40） vs 14.1%（11/78）］, higher use rates of intra-aortic balloon pump and extracorporeal membrane oxygenation［75.0%（30/40） vs 47.4%（37/78）, 22.5%（9/40） vs 1.3%（1/78）］, the differences were statistically significant（all P＜0.05）. The total follow-up time was （30±12）months. The 12-, 24- and 36-month MACE-free survival rates in the high myocardial viability group were significantly higher than those in the low myocardial viability group(96.9% vs 88.6%, 93.4% vs 85.5%, 79.4% vs 68.2%, P＝0.004). Conclusion    Myocardial viability is an important factor that affects perioperative mortality and medium to long-term MACE-free survival in patients with HFrEF undergoing CABG.