aterosklerozАтеросклерозAteroscleroz2078-256X2949-3633НИИТПМ-филиал ИЦиГ СО РАН10.52727/2078-256X-2025-21-3-248-271ateroskleroz-1129Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLESАлгоритм выбора тактики коронарного шунтирования пациентов разного пола на основании результатов исследования CROWN-SAGACoronary artery bypass surgery management algorithm in women and men based on the findings of CROWN-SAGA studyhttps://orcid.org/0000-0002-6450-1977ЛилотхиаС. Х.LilothiaS. Kh.

Софья Харишевна Лилотхиа, сердечно-сосудистый хирург

614013, г. Пермь, ул. Маршала Жукова, 35

Sofia Kh. Lilothia, cardiovascular surgeon

35, Marshala Zhukova st., Perm, 614013

sophialilothia@gmail.comhttps://orcid.org/0000-0002-3904-6415КомаровР. Н.KomarovR. N.

Роман Николаевич Комаров, д-р мед. наук, проф., сердечно-сосудистый хирург, директор клиники факультетской хирургии, зав. кафедрой сердечно-сосудистой хирургии и инвазивной кардиологии

119048, г. Москва, ул. Трубецкая, 8, стр. 2

Roman N. Komarov, doctor of medical sciences, professor, cardiovascular surgeon, head of the faculty surgery clinic, head of the department of cardiovascular surgery and invasive cardiology

8, str. 2, Trubetskaya st., Moscow, 119048

Федеральное государственное бюджетное учреждение «Федеральный центр сердечно-сосудистой хирургии им. С.Г. Суханова» Министерства здравоохранения Российской ФедерацииFederal Center for Cardiovascular Surgery named after S.G. SukhanovФедеральное государственное автономное образовательное учреждение высшего образования «Первый Московский государственный медицинский университет им. И.М. Сеченова» Министерства здравоохранения Российской ФедерацииI.M. Sechenov First Moscow State Medical University202529092025213248271Copyright © Лилотхиа С.Х., Комаров Р.Н., 20252025Лилотхиа С.Х., Комаров Р.Н.Lilothia S.K., Komarov R.N.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://ateroskleroz.elpub.ru/jour/article/view/1129

Цель. Оптимизация тактики хирургической реваскуляризации миокарда для пациентов разного пола, основываясь на проведенном сравнительном анализе современных методик коронарной хирургии CROWN-SAGA.Материал и методы. Одноцентровое исследование CROWN-SAGA (Coronary Revascularization Outcomes Within Necessary Sex And Gender Aspects) (NCT06749171) представляло сравнительный анализ влияния предоперационного профиля и различных хирургических методик коронарного шунтирования (КШ) на непосредственные и отдаленные исходы у женщин и мужчин. Первичной конечной точкой был комбинированный исход MACCE (комбинированный исход неблагоприятных сердечно-сосудистых и цереброваскулярных событий), включающий смерть, инфаркт миокарда (ИМ), инсульт или транзиторную ишемическую атаку и повторную реваскуляризацию миокарда в отдаленном послеоперационном периоде. Вторичной конечной точкой была смерть от всех причин в отдаленном периоде.Результаты. Из включенных 400 пациентов (200 женщин и 200 мужчин) в исследования CROWN-SAGA женщины были старше мужчин и отличались менее благоприятным предоперационным профилем. Ближайшие исходы у женщин и мужчин относительно смерти и MACCE были схожи. В отдаленном периоде частота MACCE составила 21,2 % среди женщин и 16,2 % среди мужчин (отношение рисков (HR) = 1,15 [95 % доверительный интервал (ДИ): 0,72; 1,82], p = 0,557), частота летального исхода составила 11,1 % среди женщин и 10,2 % среди мужчин (HR = 0,94 [95 % ДИ: 0,51; 1,72], p = 0,83), женщины характеризовались большим риском развития ИМ (HR = 6,66 [95 % ДИ: 0,83; 53,28], p = 0,038), реваскуляризации миокарда (HR = 4,11 [95 % ДИ: 1,18; 14,32], p = 0,016) и инсульта (HR = 1,24 [95 % ДИ: 0,59; 2,6], p = 0,567). В мужской когорте ONCAB в сравнении с OPCAB показан статистически значимо меньший риск отдаленной смерти (HR = 0,28 [95 % ДИ: 0,09; 0,91], p = 0,03). В женской когорте был более высокий риск возникновения окклюзии шунтов. При сравнении страт операций риски отдаленных MACCE (HR = 1,54 [95 % ДИ: 0,95; 2,49], p = 0,08), смерти (HR = 2,17 [95 % ДИ: 1,14; 4,14], p = 0,016) и возникновения окклюзии шунтов оказались выше в страте All Off-pumps (OPCAB, NTA, MICSCAB) в сравнении с ONCAB. Для женщин предиктором отдаленных MACCE и летального исхода оказалось использование композитных графтов, для мужчин — фракция выброса ≤ 40 %, возраст > 70 лет и КШ на работающем сердце. С учетом полученных данных и выявленных предикторов подход к КШ для обоих полов предполагает полную реваскуляризацию миокарда с увеличением количества дистальных анастомозов, применение артериальных графтов, формирование секвенциальных графтов, минимизация использования венозных кондуитов, для женщин — лимитирование формирования композитных шунтов, для мужчин — следование анаортальной стратегии и формирование композитных графтов.Заключение. В основе разработанного алгоритма хирургической тактики лежит дифференцированный гендерно-половой подход и комплексный анализ широкого спектра техник КШ, направленный на улучшение исходов пациентов после коронарной реваскуляризации, в частности уменьшения бремени неблагоприятных исходов КШ среди женщин. Общим рекомендуемым подходом для женщин и мужчин являются полная аутоартериальная реваскуляризация миокарда и секвенциальные анастомозы; для женщин – методики доступов, снижающие риск стернальных и раневых осложнений и лимитирование композитных графтов; для мужчин предлагается использование композитных графтов и анаортальной методики.

Aim. Optimization of surgical coronary revascularization tactics for women and men, based on a comparative analysis of modern coronary surgery techniques from the CROWN-SAGA (Coronary Revascularization Outcomes Within Necessary Sex And Gender Aspects) study.Material and methods. Single-center CROWN-SAGA study (NCT06749171) presented a comparative analysis of the impact of preoperative profile and range of surgical techniques in coronary artery bypass grafting (CABG) surgery on short- and long-term outcomes in women and men. The primary endpoint was a composite of all-cause mortality, myocardial infarction (MI), stroke or transient ischemic attack (TIA) and repeat revascularization (major adverse cardiovascular and cerebrovascular events, MACCE) during the long-term follow-up. The secondary endpoint was allcause mortality during the long-term followup.Results. Among the included sample of 400 patients (200 women and 200 men) in the CROWNSAGA study, women were older than men and had less favorable preoperative profile. Short-term in-hospital outcomes in terms of mortality and MACCE were comparable between women and men. Over long-term follow-up, the incidence of MACCE was 21.2 % in women and 16.2 % in men (hazard ratio (HR) = 1.15 [95 % confidence interval (CI) 0.72; 1.82], p = 0.557) and the incidence of death was 11.1 % in women and 10.2 % in men (HR = 0.94 [95 % CI 0.51; 1.72], p = 0.83), women had higher risks of MI (HR = 6.66 [95 % CI 0.83; 53.28], p = 0,038), repeat revascularization (HR = 4.11 [95 % CI 1.18; 14.32], p = 0.016) and stroke (HR = 1.24 [95 % CI 0.59; 2.6], p = 0.567). ONCAB compared to OPCAB within the men cohort had a significantly lower risk of death (HR = 0.28 [95 % CI 0.09; 0.91], p = 0.03). Women had an increased risk of graft occlusion. All Off-pumps strata (OPCAB, NTA, MICSCAB) compared with ONCAB showed higher risk of adverse long-term outcomes among all patients in regard to MACCE (HR = 1.54 [95 % CI 0.95; 2.49], p = 0.08), death (HR = 2.17 [95 % CI 1.14; 4.14], p = 0.016) and graft occlusion. Predictor of long-term MACCE and death for women was use of composite grafts, while for men — ejection fraction (EF) ≤ 40 %, age > 70 years, and off-pump CABG. Considering the obtained data and identified predictors, CABG approach for both sexes implies complete coronary revascularization with an increased number of distal anastomoses, the use of arterial grafts, use of sequential grafts, limiting use of venous conduits, for women limiting use of composite grafting, while for men an adherence to an anoartic technique and the use of composite grafting.Conclusions. The developed algorithm for surgical management is based on a sex and gender approach and a comprehensive analysis of a wide range of CABG techniques aimed at improving patient outcomes after coronary revascularization, particularly reducing the burden of adverse CABG outcomes among women. Recommended approach for both women and men involves complete arterial revascularization and sequential anastomoses; for women we advise surgical techniques that reduce the risk of sternal and wound complications, along with limiting the use of composite grafts; for men the use of composite grafts is permissible and the no-touch-aorta (NTA) technique is advised.

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The authors declare that there are no conflicts of interest present.