Chinese Journal of Tissue Engineering Research ›› 2013, Vol. 17 ›› Issue (5): 920-930.doi: 10.3969/j.issn.2095-4344.2013.05.024
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Off-pump coronary artery bypass grafting treats high-risk coronary heart disease
Wang Shi-xiong1, 2, Li Ning-yin1, 2, Zhao Qi-ming1, Gao Bing-ren1
- 1 Second Hospital of Lanzhou University, Lanzhou 73000, Gansu Province, China
2 Second Clinical Medical College of Lanzhou University, Lanzhou 73000, Gansu Province, Chi
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Received:2012-07-16Revised:2012-09-05Online:2013-01-29Published:2013-03-08 -
Contact:Wang Shi-xiong★, Studying for master’s degree, Second Hospital of Lanzhou University, Lanzhou 73000, Gansu Province, China; Second Clinical Medical College of Lanzhou University, Lanzhou 73000, Gansu Province, China wangshi0815@163.com -
About author:Wang Shi-xiong★, Studying for master’s degree, Second Hospital of Lanzhou University, Lanzhou 73000, Gansu Province, China; Second Clinical Medical College of Lanzhou University, Lanzhou 73000, Gansu Province, China wangshi0815@163.com
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Wang Shi-xiong, Li Ning-yin, Zhao Qi-ming, Gao Bing-ren. Off-pump coronary artery bypass grafting treats high-risk coronary heart disease[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(5): 920-930.
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2.1 检索结果分析 根据检索策略和资料收集方法，初检出文献1516篇，去除重复文献155篇，初筛通过阅读题目和摘要，排除主题与本研究不符的文献1324篇，对初筛后的27篇文献仔细阅读全文，进一步排除受试对象与重复发表的文献11篇，最终纳入16个研究[17-32]，共6441例患者，流程图见图1)。"
2.2 纳入研究的基本特征 本研究共纳入16个临床试验[17-32]，其中2个为随机试验[22, 25]，14个为观察性研究[17-21,23-24,26-32]，观察性研究均为高质量的(得分≥6)。见表2。 2.3 Meta分析结果 2.3.1 安全性评价结果比较 术后新发房颤率，脑卒中率，主动脉内球囊反搏使用率，围手术期心肌梗死发生率，术后急性肾功能损伤率，术后呼吸功能不全，伤口感染率。 术后新发房颤发生率：共12个研究报道了术后新发房颤率[17,19-21,23-25,27,29-32]，其中有1个随机对照试验[25]，11个非随机对照试验[17,19-21,23-24,27,29-32]，OPCABG组共纳入2153例患者，心房纤颤总发生率为19.4%；CCABG组共2792例，AF总发生率为23.0%。各研究间无统计学异质性(I2=0%，P=0.55)，故采用固定效应模型合并效应量。研究数据设计亚组Meta分析结果显示：随机对照试验亚组两组差异无显著性意义[OR=0.96, 95%CI (0.63,1.48)，P=0.86]; 非随机对照试验亚组两组差异无显著性意义[OR=0.99，95%CI (0.84,1.77)，P=0.91]。合并分析显示两组差异亦无显著性意义[OR=0.99，95%CI(0.85,1.15)，P=0.87]，见图2，故认为OPCABG与CCABG术后心房纤颤发生率差异无显著性意义。"
脑卒中发生率：共15个研究报道了围手术期脑卒中发生率[17-29, 31-32]，其中有2个随机对照试验[22, 25]，13个非随机对照试验[17-21,23-24,26-29,31-32]。OPCABG组共纳入2908例患者，脑卒中总发生率2.2%；CCABG组共纳入3 447例患者，脑卒中总发生率3.0%。各研究间无统计学异质性(I2=0%，P=0.48)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义[OR=0.93，95%CI(0.33，2.61)，P=0.89]；非随机对照试验亚组两组比较差异有显著性意义[OR=0.49，95%CI (0.34,0.71)， P=0.000 1]。合并分析显示两组比较差异有显著性意义[OR=0.53，95%CI(0.38，0.74)，P=0.000 3]，见图3，故认为OPCABG围手术期脑卒中发生率比CCABG低。"
"
主动脉内球囊反搏使用率：共8个研究报道了主动脉内球囊反搏使用率[17-18,20-21,23,25,30,32]，其中有1个随机对照试验[25]，7个非随机对照试验[17-18, 20-21,23 ,30,32]，OPCAB组共纳入1369例患者，主动脉内球囊反搏总使用率为5.6%；CCABG组共1 057例，主动脉内球囊反搏总使用率8.5%。各研究间无统计学异质性(I2=34%，P=0.16)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义[OR=1.08，95%CI(0.36，3.29)，P=0.89]；非随机对照试验亚组两组差异有显著性意义[OR=0.53，95%CI(0.37，0.75)，P=0.000 4]。合并分析显示两组差异有显著性意义[OR=0.57，95%CI(0.41,0.79)，P=0.000 8]，见图4，故认为OPCAB围手术期主动脉内球囊反搏使用率比CCABG低。"
再发心肌梗死率：共12个研究报道了围手术期再发心肌梗死率[17,19,21,22,25-29,31-32]，其中有2个随机对照试验[22,25]，10个非随机对照试验[17,19,21 ,26-29,31-32]。OPCAB组共纳入2373例患者，总发生率2.1%；CCABG组纳入2 998例患者，总发生率3.5%。各研究间无统计学异质性(I2=0%，P=0.65)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义[OR=0.56，95%CI(0.28，1.15)，P=0.11]；非随机对照试验亚组两组差异有显著性意义[OR=0.61，95%CI(0.39，0.94)，P=0.03]。合并分析显示两组差异有显著性意义[OR=0.58，95%CI (0.41，0.86)，P=0.006]，见图5，故认为OPCABG围手术期再发心肌梗死率比CCABG低。"
术后急性肾功能损伤率：共12个研究报道了急性肾功能损伤[17,19-23,25,26,29-32]，其中有2个随机对照试验[22,25]，10个非随机对照试验[17,19-21,23, 26,29-32]，OPCABG组共纳入1993例患者，总发生率10.8%；CCABG组共2 432例，总发生率8.5%。各研究间有统计学异质性(I2=45%，P=0.04)，分析异质性的来源，进行亚组分析。随机对照试验亚组的各研究间无统计学异质性(I2=7%，P=0.30)，故采用固定效应模型合并效应量，Meta分析两组间差异无显著性意义[OR=0.78，95%CI(0.45，1.35)，P=0.37]。非随机对照试验亚组的各研究间有统计学异质性(I2=52%，P=0.03)，故采用随机效应模型合并效应量。Meta分析两组间差异无显著性意义[OR=0.76，95%CI (0.47，1.23)，P=0.26]，见图6。故认为OPCABG与CCABG围手术期急性肾功能损伤发生率差异无显著性意义。"
呼吸功能不全发生率：共11个研究报道了呼吸功能不全发生率[17,19,21-25, 29-32]，其中有2个随机对照试验[22,25]，9个非随机对照试验[17,19,21,23-24,29-32]。OPCAB组共纳入1701例患者，总发生率5.8%；CCABG组共2345例，总发生率7.5%。各研究间无统计学异质性(I2=2%，P=0.42)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义[OR=0.98，95%CI(0.49，1.99)，P=0.98]；非随机对照试验亚组两组差异有显著性意义[OR=0.48，95%CI(0.35，0.65)，P < 0.000 01]。合并分析显示两组差异有显著性意义[OR=0.54，95%CI(0.40，0.71)，P < 0.000 1]，见图7，故认为OPCABG围手术期急性呼吸功能不全发生率低于CCABG组。 伤口感染率：共3个研究报道了伤口感染率[19,20,31]，都为非随机对照试验。OPCABG组共纳入755例患者，CCABG组共340例。各研究间无统计学异质性(I2=0%，P=0.89)，故采用固定效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[OR=0.65，95%CI(0.28，1.52)，P=0.32]，见图8，故认为OPCABG与CCABG围手术期伤口感染率差异无显著性意义。"
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2.3.2 有效性评价结果比较 围手术期死亡率，呼吸机辅助呼吸时间，ICU时间，住院时间，二次开胸率，术后引流量，输血量。 死亡率：共16个研究报道了死亡率[17-32]。其中有2个随机对照试验[22, 25]，14个非随机对照试验[17-21,23-24,26-32]，OPCAB组共纳入2 948例患者，总发生率3.4%；CCABG组共纳入3493例患者，总发生率5.4%。各研究间无统计学异质性(I2=0%，P=0.79)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义 [OR=0.51，95%CI(0.23,1.12)，P=0.10]；非随机对照试验亚组两组差异有显著性意义[OR=0.62，95%CI (0.48，0.83)，P=0.001]。合并分析显示两组差异有显著性意义[OR=0.62，95%CI(0.48，0.80)，P=0.000 3]，见图9，故认为OPCABG围手术期死亡率比CCABG低。"
二次开胸率：共13个研究报道了二次开胸率[17-20,22-26,29-32]。其中有2个随机对照试验[22,25]，11个非随机对照试验[17-20,23-24,26,29-32]。OPCAB组共纳入1862例患者，CCABG组共纳入2599例患者。各研究间无统计学异质性(I2=0%，P=0.80)，故采用固定效应模型合并效应量。研究数据设计亚组分析结果显示：随机对照试验两组差异无显著性意义[OR=0.88，95%CI (0.44，1.75)，P=0.72]；非随机对照试验亚组两组差异无显著性意义[OR=0.72，95%CI(0.50，1.05)，P=0.09]。合并分析显示两组差异无显著性意义[OR=0.75，95%CI (0.50，1.05)，P=0.09]，见图10，故认为OPCAB与CCABG再次手术率差异无显著性意义。"
呼吸机辅助时间：共8个研究报道了呼吸机辅助时间(h)[17-18,20-21,25,30-32]，其中1个采用了中位数计算[25]， 1个采用min计算[30]，最后纳入6个研究进行Meta分析[17-18, 20-21 ,31, 32]，均为非随机对照试验。OPCABG组共纳入1224例患者，CABG组共808例。各研究间有统计学异质性(I2=91%，P < 0.000 01)，分析异质性的来源，可能与各研究者之间拔除呼吸机时限没有统一标准及监护室条件不一。故采用随机效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[WMD=-6.65，95%CI(-9.24，-4.12)，P < 0.000 01]，见图11。因此认为OPCABG较CCABG减少呼吸辅助通气时间。"
ICU治疗时间：共10个研究报道了在ICU治疗时间 (h)[17-19,21,26-27,29-32]，均为非随机对照试验。OPCABG组共纳入2220例患者，CCABG组共2521例。各研究间有统计学异质性(I2=90%，P < 0.000 01)，分析异质性的来源，可能与各研究者的监护室条件不一致有关。故采用随机效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[WMD=-12.66，95%CI(-18.03， -7.92)，P < 0.000 01]，见图12，故认为OPCABG较CCABG监护时间短，术后恢复较快。"
住院时间：共10个研究报道了住院时间[17,19,21,25-27,29-32]，其中1个研究采用中位数计算[25]，故纳入9个研究进行Meta分析[17,19,21,26-27,29-32]，均为非随机对照试验。OPCABG组共纳入1 902例患者，CCABG组共2 324例。各研究间有统计学异质性(I2=90%，P <0.000 01)。故采用随机效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[WMD=-1.88，95%CI(-3.62，-0. 14)，P < 0.000 01]，见图13，说明OPCABG较CCABG住院时间短，术后恢复快。"
输血量：共4个研究报道了平均输血量[19-21,31]，均为非随机对照试验。OPCABG组共纳入905例患者，CCABG组共480例。各研究间有统计学异质性(I2=99%，P < 0.000 01)。故采用随机效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[WMD=-338.28，95%CI(-552.08，-124. 48)，P=0.002]，见图14，说明OPCABG术后需输血量较CCABG少。"
引流量：共3个研究报道了术后应流量[20-21,31]，均为非随机对照试验。OPCAB组共纳入792例患者，CCABG组共404例。各研究间无统计学异质性(I2=0%，P=0.49)。故采用固定效应模型合并效应量。Meta分析结果显示两组差异有显著性意义[WMD=-254.86，95%CI(-265.40， -224. 31)，P < 0.000 01]，因为说明OPCABG对患者的创伤少，术后引流量较CCABG少，术后恢复快。见图15。"
2.4 发表偏倚 文章纳入16个研究，漏斗图显示16个研究分布数量基本对称，发表偏倚的可能性小，见图16"
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