Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes
Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes
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DOI：
10.1016/j.athoracsur.2018.07.076
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发表时间：
2019-01-01
影响因子：
4.6
通讯作者：
Hattler, Brack
中科院分区：
文献类型：
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作者：
Shroyer, A. Laurie W.;Quin, Jacquelyn A.;Hattler, Brack
背景对于需要进行冠状动脉旁路移植术（CABG）的糖尿病患者，非体外循环或体外循环方法是否有利仍存在争议。这项基于美国的多中心随机对照试验，退伍军人事务部随机化开与关旁路随访研究，比较了糖尿病患者在非体外循环与体外循环手术的5年临床结局。从2002年到2008年，835例药物治疗（即口服降糖药或胰岛素）的糖尿病患者接受了非体外循环（n = 402）或体外循环（n = 433）CABG。5年主要终点包括全因死亡和主要不良心血管事件（MACE;复合终点包括全因死亡、心肌梗死或重复血运重建）。次要5年终点包括心源性死亡和MACE相关成分。在基线风险因素平衡的情况下，使用p值小于或等于0.01来评估结局; p值大于0.01且小于或等于0.15时报告无显著性趋势。5年全因死亡率为20.2%（非泵组）vs 14.1%（泵组）（p = 0.0198）。MACE（32.6%非体外循环方法vs 28.6%体外循环方法，p = 0.216）、重复血运重建（12.4%非体外循环方法vs 11.8%体外循环方法，p = 0.770）和非致死性心肌梗死（12.7%非体外循环方法vs 10.4%体外循环方法，p = 0.299）无差异。非体外循环CABG（9.0%）的心源性死亡倾向于比体外循环CABG（6.25%，p = 0.137）更严重。去除转换的敏感性分析证实了这些发现。在6.1%的绝对差异下，观察到药物治疗的糖尿病患者在体外循环CABG中5年生存率有明显改善的趋势。对于任何5年终点，均未发现非体外循环优势。未来的临床试验现在似乎有必要严格比较糖尿病患者的非体外循环与体外循环的长期结局。爱思唯尔公司出版代表胸外科医师协会
Background. For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients' 5-year clinical outcomes for off-pump versus on-pump procedures.Methods. From 2002 to 2008, 835 medically treated (ie, oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15.Results. Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p = 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p = 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p = 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses that removed conversions confirmed these findings.Conclusions. With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients. Published by Elsevier Inc. on behalf of The Society of Thoracic Surgeons