经左胸小切口多支冠状动脉搭桥与杂交冠状动脉血运重建的对比研究：近中期临床疗效分析

doi:10.3969/j.issn.1674-8115.2025.12.005

摘要/Abstract

摘要：

目的·比较微创多支冠状动脉旁路移植术（minimally invasive multivessel cardiac surgery-coronary artery bypass grafting，MICS-CABG）与杂交冠状动脉血运重建术（hybrid coronary revascularization， HCR）治疗多支冠状动脉疾病的围术期和近中期临床疗效，探讨其安全性和应用价值。方法·回顾性分析2020年1月至2023年6月在上海交通大学医学院附属瑞金医院心脏外科行微创冠状动脉搭桥术的123例患者的临床资料及随访结果。按照手术方式将患者分为MICS-CABG组（58例）和HCR组（65例）。对比2组基础资料［吸烟史、高血压、糖尿病、慢性阻塞性肺病（chronic obstructive pulmonary diseases，COPD）、脑梗史、心肌梗死史、经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）史、左心室射血分数（left ventricular ejection fraction，LVEF）、病变冠状动脉支数等］、围术期指标［外科手术时间、围术期有无输血、手术有无中转正中开胸、术中有无植入主动脉球囊反搏（intra-aortic balloon pump，IABP）、有无使用体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）、任何原因的二次手术、呼吸机使用时间、重症监护病房（intensive care unit，ICU）停留时间、住院时间、血运重建冠状动脉支数、术后24 h引流量、死亡、术后并发症等］。并于术后1、3、6、12个月及之后每隔6个月进行电话或门诊定期随访，随访主要终点为主要心脑血管事件（major adverse cardiac and cerebral events，MACCE），术后（12±3）个月行冠状动脉影像学检查，对比2组患者近中期MACCE事件及目标治疗血管的通畅情况。结果·MICS-CABG组患者外科手术时间显著长于HCR组（P<0.001），术后呼吸机使用时间更长（P=0.001），且术后早期呼吸衰竭发生率更高（32.76% vs 12.31%，P=0.007），但MICS-CABG组血运重建冠状动脉数更多（P=0.002）。MICS-CABG组患者术后24 h引流量更多（P<0.001），但2组术中术后输血患者比例差异无统计学意义（6.90% vs 1.54%，P=0.145）。除此之外，2组均无转正中开胸、未植入IABP、未使用ECMO，2组围术期心肌梗死、脑卒中、新发心房颤动、死亡、ICU停留时间、住院时间差异也无统计学意义。MICS-CABG组共吻合170支血管桥，其中左前降支（left anterior descending，LAD）桥血管58支，其余靶血管血管桥共计112支。HCR组共吻合65支血管桥（均为LAD），共行PCI完成血运重建冠状动脉90支。术后（12±3）个月影像学检查评估LAD桥血管通畅率，2组差异无统计学意义（93.10% vs 96.92%，P=0.601）；而对于非LAD靶血管血运重建后通畅情况，虽然MICS-CABG组略低于HCR组（91.96% vs 96.67%），但两者差异亦无统计学意义（P=0.190）。MICS-CABG组术后随访（30±22）个月，HCR组术后随访（31±16）个月，MACCE累积发生率均较低（0 vs 1.54%，P=0.325），再次血运重建率差异无统计学意义。结论·MICS-CABG和HCR这2种手术在治疗多支冠状动脉病变的围术期安全性和近中期临床疗效相当，但MICS-CABG手术时间更长、术后呼吸并发症风险更高，而HCR需严格评估PCI指征。临床应根据患者病变特点及心肺功能个体化选择术式。

关键词: 微创小切口, 冠状动脉多支病变, 微创多支冠状动脉旁路移植术, 冠状动脉再血管化杂交技术, 临床疗效

Abstract:

Objective ·To compare the perioperative and short-to-medium-term clinical outcomes of minimally invasive multivessel cardiac surgery-coronary artery bypass grafting (MICS-CABG) and hybrid coronary revascularization (HCR) in patients with multivessel coronary artery disease (CAD), and to evaluate their safety and clinical applicability. Methods ·A retrospective analysis was conducted on 123 patients who underwent minimally invasive coronary artery bypass surgery at the Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, between January 2020 and June 2023. Patients were divided into the MICS-CABG group (n=58) and the HCR group (n=65) based on the surgical approach. Baseline characteristics [smoking history, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), history of cerebral infarction, myocardial infarction, prior percutaneous coronary intervention (PCI), left ventricular ejection fraction (LVEF), number of diseased coronary vessels] and perioperative outcomes [operation time, perioperative transfusion, conversion to median sternotomy, intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) use, reoperation for any cause, mechanical ventilation duration, intensive care unit (ICU) stay, hospital stay, number of revascularized vessels, 24-hour postoperative drainage volume, mortality, and complications] were compared. Follow-up was conducted at 1, 3, 6, and 12 months postoperatively and every 6 months thereafter, with the primary endpoint being major adverse cardiac and cerebrovascular events (MACCE). Coronary imaging was performed at (12±3) months to assess graft/stent patency. Results ·The MICS-CABG group had a significantly longer operative time (P<0.001), a longer duration of mechanical ventilation (P=0.001), and a higher incidence of early postoperative respiratory failure (32.76% vs 12.31%, P=0.007) compared to the HCR group. However, the MICS-CABG group achieved more complete revascularization (P=0.002). Postoperative 24-hour drainage volume was greater in the MICS-CABG group (P<0.001), but transfusion rates did not differ significantly (6.90% vs 1.54%, P=0.145). Conversion to sternotomy, IABP implantation, and ECMO use were not required in either group. No significant differences were observed in perioperative myocardial infarction, stroke, new-onset atrial fibrillation, mortality, ICU stay, or hospital stay. In the MICS-CABG group, 170 grafts were anastomosed [58 left anterior descending (LAD) grafts and 112 non-LAD grafts], while the HCR group had 65 grafts (all LAD) and 90 PCI-treated vessels. At 1 year, LAD graft patency (93.10% vs 96.92%, P=0.601) and non-LAD target vessel patency (91.96% vs 96.67%, P=0.190) showed no significant differences. The MICS-CABG group patients were followed up for (30±22) months postoperatively, and the HCR group patients were followed up for (31±16) months postoperatively. MACCE rates were low in both groups (MICS-CABG 0 vs HCR 1.54%, P=0.325), with no significant difference in repeat revascularization. Conclusion ·MICS-CABG and HCR demonstrate comparable perioperative safety and short-to-medium-term efficacy in patients with multivessel CAD. While MICS-CABG requires a longer operative time and carries a higher risk of respiratory complications, HCR necessitates stringent PCI eligibility assessment. The choice of procedure should be individualized based on anatomical complexity and cardiopulmonary function.

Key words: minimally invasive cardiac surgery, multiple coronary artery lesions, minimally invasive multivessel cardiac surgery-coronary artery bypass grafting, hybrid coronary revascularization, clinical outcomes

中图分类号:

R654

林子博, 裘佳培, 孙延军, 姚皓弋, 任挺, 赵强. 经左胸小切口多支冠状动脉搭桥与杂交冠状动脉血运重建的对比研究：近中期临床疗效分析[J]. 上海交通大学学报（医学版）, 2025, 45(12): 1598-1605.

LIN Zibo, QIU Jiapei, SUN Yanjun, YAO Haoyi, RENG Ting, ZHAO Qiang. Comparative study of minimally invasive multivessel coronary artery bypass grafting and hybrid coronary revascularization: analysis of short-to-medium-term clinical outcomes[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(12): 1598-1605.

图/表 6

参考文献 18

[1]	DUGGAN J P, PETERS A S, TRACHIOTIS G D, et al. Epidemiology of coronary artery disease[J]. Surg Clin North Am, 2022, 102(3): 499-516.
[2]	LAWTON J S, TAMIS-HOLLAND J E, BANGALORE S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines[J]. Circulation, 2022, 145(3): e4-e17.
[3]	MONTRIEF T, KOYFMAN A, LONG B. Coronary artery bypass graft surgery complications: a review for emergency clinicians[J]. Am J Emerg Med, 2018, 36(12): 2289-2297.
[4]	SABIK J F, LYTLE B W, BLACKSTONE E H, et al. Comparison of saphenous vein and internal thoracic artery graft patency by coronary system[J]. Ann Thorac Surg, 2005, 79(2): 544-551.
[5]	LINDHOLT J S, SOGAARD R, RASMUSSEN L M, et al. Five-year outcomes of the Danish cardiovascular screening (DANCAVAS) trial[J]. N Engl J Med, 2022, 387(15): 1385-1394.
[6]	MILLER R J H, BONOW R O, GRANSAR H, et al. Percutaneous or surgical revascularization is associated with survival benefit in stable coronary artery disease[J]. Eur Heart J Cardiovasc Imaging, 2020, 21(9): 961-970.
[7]	NOLAN S, FILION K B, ATALLAH R, et al. Hybrid coronary revascularization vs complete coronary artery bypass grafting for multivessel coronary artery disease: a systematic review and meta-analysis[J]. J Invasive Cardiol, 2018, 30(12): E131-E149.
[8]	FITZGIBBON G M, LEACH A J, KEON W J, et al. Coronary bypass graft fate. Angiographic study of 1 179 vein grafts early, one year, and five years after operation[J]. J Thorac Cardiovasc Surg, 1986, 91(5): 773-778.
[9]	ESTEVES V, OLIVEIRA M A P, FEITOSA F S, et al. Late clinical outcomes of myocardial hybrid revascularization versus coronary artery bypass grafting for complex triple-vessel disease: long-term follow-up of the randomized MERGING clinical trial[J]. Catheter Cardiovasc Interv, 2021, 97(2): 259-264.
[10]	PERERA D, CLAYTON T, O'KANE P D, et al. Percutaneous revascularization for ischemic left ventricular dysfunction[J]. N Engl J Med, 2022, 387(15): 1351-1360.
[11]	SABATINE M S, BERGMARK B A, MURPHY S A, et al. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis[J]. Lancet, 2021, 398(10318): 2247-2257.
[12]	SERRUYS P W, ONO M, GARG S, et al. Percutaneous coronary revascularization: JACC historical breakthroughs in perspective[J]. J Am Coll Cardiol, 2021, 78(4): 384-407.
[13]	ALBERT A, ENNKER J, HEGAZY Y, et al. Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgery[J]. J Thorac Cardiovasc Surg, 2018, 156(2): 544-554.e4.
[14]	MOSS E, PUSKAS J D, THOURANI V H, et al. Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke[J]. J Thorac Cardiovasc Surg, 2015, 149(1): 175-180.
[15]	宫一宸, 凌云鹏, 张鲁锋, 等. 左胸小切口多支冠状动脉旁路移植术244例临床分析[J]. 中华外科杂志, 2020, 58(5): 363-364.
	GONG Y C, LING Y P, ZHANG L F, et al. Clinical experience of minimal invasive coronary surgery-coronary artery bypass grafting: a series of 244 cases[J]. Chinese Journal of Surgery, 2020 58(5): 363-364.
[16]	ZHANG Y X, YAN W P, FAN Z Y, et al. Preemptive one lung ventilation enhances lung collapse during thoracoscopic surgery: a randomized controlled trial[J]. Thorac Cancer, 2019, 10(6): 1448-1452.
[17]	周俊辉, 王鹏浩, 奚高原, 等. 非通气侧肺持续中低流量给氧在老年患者胸腔镜肺癌根治术中的应用效果及安全性观察[J]. 山东医药, 2022, 62(11): 33-37.
	ZHOU J H, WANG P H, XI G Y, et al. Application effect and safety observation of continuous medium and low flow oxygen supply to non-ventilated lung in elderly patients with thoracoscopic radical resection of lung cancer[J]. Shandong Medical Journal, 2022, 62(11): 33-37.
[18]	宋正杰, 林栓同, 程静林, 等. 单肺通气的肺损伤机制及其保护性策略研究[J]. 实用临床医药杂志, 2021, 25(2): 101-105, 111.
	SONG Z J, LIN S T, CHENG J L, et al. Study on lung injury mechanism of one-lung ventilation and its protective strategy[J]. Journal of Clinical Medicine in Practice, 2021, 25(2): 101-105, 111.

Item	MICS-CABG group (n=58)	HCR group (n=65)	t/χ² value	P value
Gender (male)/n(%)	48 (82.76)	56 (86.15)	0.249	0.603
Age/year	67.2±7.1	67.0±12.9	0.105	0.917
BMI/(kg·m^-2)	25.2±3.1	25.1±2.3	0.205	0.838
Hypertension/n(%)	44 (75.86)	49 (75.38)	0.003	0.189
Diabetes/n(%)	18 (31.03)	17 (26.15)	0.359	0.549
History of smoking/n(%)	42 (72.41)	49 (75.38)	0.141	0.708
History of cerebrovascular disease/n(%)	21 (36.21)	22 (33.85)	0.075	0.784
COPD/n(%)	8 (13.79)	11 (16.92)	0.232	0.632
History of myocardial infarction/n(%)	28 (47.28)	18 (27.69)	5.537	0.019
History of PCI/n(%)	25 (43.10)	18 (27.69)	3.208	0.074
Creatinine/(μmol·L^-1)	79.6±18.3	81.8±14.2	-0.760	0.449
LVDD/mm	49.8±4.6	51.6±5.8	-1.913	0.059
LVEF/%	63.2±5.8	61.7±7.1	1.287	0.201
Number of coronary artery lesions/n	2.7±0.5	2.6±0.4	1.249	0.215
2/n(%)	16 (27.58)	40 (61.54)	14.286	<0.001
3/n(%)	42 (72.42)	25 (38.46)	14.286	<0.001

Item	MICS-CABG group (n=58)	HCR group (n=65)	t/χ² value	P value
Gender (male)/n(%)	48 (82.76)	56 (86.15)	0.249	0.603
Age/year	67.2±7.1	67.0±12.9	0.105	0.917
BMI/(kg·m^-2)	25.2±3.1	25.1±2.3	0.205	0.838
Hypertension/n(%)	44 (75.86)	49 (75.38)	0.003	0.189
Diabetes/n(%)	18 (31.03)	17 (26.15)	0.359	0.549
History of smoking/n(%)	42 (72.41)	49 (75.38)	0.141	0.708
History of cerebrovascular disease/n(%)	21 (36.21)	22 (33.85)	0.075	0.784
COPD/n(%)	8 (13.79)	11 (16.92)	0.232	0.632
History of myocardial infarction/n(%)	28 (47.28)	18 (27.69)	5.537	0.019
History of PCI/n(%)	25 (43.10)	18 (27.69)	3.208	0.074
Creatinine/(μmol·L^-1)	79.6±18.3	81.8±14.2	-0.760	0.449
LVDD/mm	49.8±4.6	51.6±5.8	-1.913	0.059
LVEF/%	63.2±5.8	61.7±7.1	1.287	0.201
Number of coronary artery lesions/n	2.7±0.5	2.6±0.4	1.249	0.215
2/n(%)	16 (27.58)	40 (61.54)	14.286	<0.001
3/n(%)	42 (72.42)	25 (38.46)	14.286	<0.001

Item	MICS-CABG group (n=58)	HCR group (n=65)	t/z/χ² value	P value
Operation time/min	270.4±72.5	156.8±31.6	11.72	<0.001
Blood transfusion/n(%)	4 (6.90)	1(1.54)	2.12	0.145
Number of coronary arteries in revascularization/n	2.9±0.6	2.6±0.4	3.21	0.002
Drainage volume within 24 h after operation/mL	320 (220, 450)	200 (100, 160)	4.89	<0.001
Ventilator supporting time after operation/h	8.0 (6.0, 16.5)	6.0 (3.0, 8.0)	3.25	0.001
Hospitalizaion in ICU/d	2.0 (1.0, 2.5)	2.0 (1.0, 2.0)	1.70	0.089
Total hospitalization/d	7 (6, 9)	6 (6, 9)	3.14	0.331
Conversion to sternotomy during operation/n(%)	0 (0)	0 (0)	‒	‒
Cardiopulmonary bypass during operation/n(%)	0 (0)	0 (0)	‒	‒
IABP during operation/n(%)	0 (0)	0 (0)	‒	‒
ECMO during operation/n(%)	0 (0)	0 (0)	‒	‒
Reoperation/n(%)	0 (0)	1 (1.54)	1.12	0.462
Postoperative complication/n(%)
Myocardial infarction	0 (0)	0 (0)	‒	‒
Cerebrovascular complications	0 (0)	0 (0)	‒	‒
New-onset atrial fibrillation after operation	6 (1.34)	2 (3.08)	2.74	0.147
Respiratory failure after operation	19 (32.76)	8 (12.31)	7.34	0.007
Reintubation	1 (1.72)	1 (1.54)	1.12	1.000
HFNC	18 (31.03)	7 (10.77)	7.56	0.006
Pulmonary infection	2 (3.45)	1 (1.54)	2.29	0.601
Impaired wound healing	2 (3.45)	1 (1.54)	2.29	0.601
Death	1 (1.72)	1 (1.54)	1.12	1.000

Item	MICS-CABG group (n=58)	HCR group (n=65)	t/z/χ² value	P value
Operation time/min	270.4±72.5	156.8±31.6	11.72	<0.001
Blood transfusion/n(%)	4 (6.90)	1(1.54)	2.12	0.145
Number of coronary arteries in revascularization/n	2.9±0.6	2.6±0.4	3.21	0.002
Drainage volume within 24 h after operation/mL	320 (220, 450)	200 (100, 160)	4.89	<0.001
Ventilator supporting time after operation/h	8.0 (6.0, 16.5)	6.0 (3.0, 8.0)	3.25	0.001
Hospitalizaion in ICU/d	2.0 (1.0, 2.5)	2.0 (1.0, 2.0)	1.70	0.089
Total hospitalization/d	7 (6, 9)	6 (6, 9)	3.14	0.331
Conversion to sternotomy during operation/n(%)	0 (0)	0 (0)	‒	‒
Cardiopulmonary bypass during operation/n(%)	0 (0)	0 (0)	‒	‒
IABP during operation/n(%)	0 (0)	0 (0)	‒	‒
ECMO during operation/n(%)	0 (0)	0 (0)	‒	‒
Reoperation/n(%)	0 (0)	1 (1.54)	1.12	0.462
Postoperative complication/n(%)
Myocardial infarction	0 (0)	0 (0)	‒	‒
Cerebrovascular complications	0 (0)	0 (0)	‒	‒
New-onset atrial fibrillation after operation	6 (1.34)	2 (3.08)	2.74	0.147
Respiratory failure after operation	19 (32.76)	8 (12.31)	7.34	0.007
Reintubation	1 (1.72)	1 (1.54)	1.12	1.000
HFNC	18 (31.03)	7 (10.77)	7.56	0.006
Pulmonary infection	2 (3.45)	1 (1.54)	2.29	0.601
Impaired wound healing	2 (3.45)	1 (1.54)	2.29	0.601
Death	1 (1.72)	1 (1.54)	1.12	1.000

Grade	LAD				non-LAD
Grade	MICS-CABG group (n=58)	HCR group (n=65)	χ² value	P value	MICS-CABG group (n=112)	HCR group (n=90)	χ² value	P value
Grade A/n	50	61			94	83
Grade B/n	4	2			9	4
Grade O/n	4	2			9	3
Grade A+Grade B/n(%)	54 (93.10)	63 (96.92)	0.38	0.601	103 (91.96)	87 (96.67)	1.31	0.190