既往纵隔放疗患者冠状动脉旁路移植术中应用胸廓内动脉的安全性：马里兰州全州倾向匹配分析
基于马里兰州心脏外科质量倡议数据库的回顾性队列研究，纳入2011年7月至2023年3月间29 206例使用胸廓内动脉行冠状动脉旁路移植术的患者，其中294例（1%）有纵隔放疗史，经1:10倾向匹配后比较围术期结局。结果显示，既往纵隔放疗与手术死亡和深部胸骨伤口感染复合终点无显著关联（2% vs 3%，p=0.53），次要结局亦无显著差异，提示不应将此类患者排除在动脉血运重建策略之外。
要点
- 既往纵隔放疗患者使用胸廓内动脉行CABG未增加围术期不良事件风险。
- 匹配后主要复合终点（手术死亡+深部胸骨伤口感染）为2% vs 3%，无统计学差异。
- 不应仅因纵隔放疗史而排除患者接受动脉血运重建策略。
核心结论
- 在大样本回顾性队列中，既往纵隔放疗与使用胸廓内动脉行CABG患者的围术期不良事件风险增加无关。
研究设计与样本
- 回顾性队列研究，使用马里兰州心脏外科质量倡议（MCSQI）数据库，纳入29 206例2011年7月1日至2023年3月31日期间使用胸廓内动脉行CABG的患者。
- 将有与无纵隔放疗史的患者按1:10进行倾向匹配（最近邻法）。
主要发现
- 29 206例中294例（1%）有纵隔放疗史。
- 放疗组患者年龄更大（中位数70岁 vs 66岁，p<0.001），女性比例更高（66% vs 25%，p<0.001），慢性肺病患病率更高（31% vs 19%，p<0.001）。
- 倾向匹配后，主要复合终点（手术死亡和深部胸骨伤口感染）无显著差异（2% vs 3%，p=0.53），次要结局亦无显著差异。
临床怎么用
- 对于有纵隔放疗史的冠心病患者，使用胸廓内动脉行CABG未显示安全性担忧，可考虑动脉血运重建策略。
局限性
- 回顾性研究设计可能存在残余混杂。
- 放疗组样本量较小（294例），事件数有限。
- 数据来源于单一州数据库，外推性需谨慎。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: The safety of internal thoracic artery (ITA) grafting in patients undergoing coronary artery bypass grafting (CABG) with prior mediastinal radiation remains controversial due to concerns regarding compromised sternal perfusion and radiation-induced injury. This study evaluated whether prior mediastinal radiation is associated with adverse perioperative outcomes in patients undergoing CABG with ITA grafting. METHODS: We conducted a retrospective cohort study using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. A total of 29 206 patients who underwent CABG with ITA use between 1 July 2011 and 31 March 2023 were analysed. Patients with and without prior mediastinal radiation were propensity-matched (1:10) using the nearest neighbour method. The primary outcome was the composite of operative mortality and deep sternal wound infection (DSWI). Secondary outcomes included other infectious complications, major morbidities, postoperative hospital length of stay, and 30-day readmission. RESULTS: Among 29 206 patients, 294 (1%) had a history of mediastinal radiation. Patients with prior radiation were older (median (IQR) 70 (60-75) vs 66 (59-73) years, p<0.001), more frequently female (66% vs 25%, p<0.001) and had a higher prevalence of chronic lung disease (31% vs 19%, p<0.001). After propensity matching, no significant differences were observed in the primary composite outcome (2% vs 3%, p=0.53) or in secondary outcomes. CONCLUSIONS: In this large retrospective cohort, prior mediastinal radiation was not associated with an increased risk of perioperative adverse events in patients undergoing CABG receiving ITA grafts. These findings demonstrate no evidence of safety concerns with the use of ITA grafting in patients with prior radiation and challenge the practice of excluding these patients from arterial revascularisation strategies.
引用
- Zhou AL, Chinedozi ID, Holmes SD, et al. Safety of internal thoracic artery use in patients with prior mediastinal radiation undergoing coronary artery bypass grafting: a Maryland statewide propensity-matched analysis. Heart. 2026. PMID: 40829862. doi:10.1136/heartjnl-2025-325949
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。