冠状动脉搭桥同期行瓣膜置换术近期疗效

Short Term Follow-up for Coronary Artery Bypass Grafting Combined with Valve Replacement Surgery

目的探讨冠状动脉粥样硬化性心脏病（冠心病）合并心脏瓣膜病，风湿性心脏病合并冠心病同期行冠状动脉搭桥术（CABG）及瓣膜置换术的安全性及适应证。方法首都医科大学宣武医院心血管外科自2001年5月至2004年12月间，在中低温体外循环下完成12例冠心病合并瓣膜病变、风湿性心脏病合并冠心病同期施行冠状动脉搭桥和瓣膜替换手术。12例中男8例，女4例，年龄52～78岁，平均64．5岁。3例以多年风湿性心脏病、心功能不全为主诉，近年出现胸痛，手术前冠状动脉造影发现冠状动脉病变；9例以心肌缺血症状为主诉，同时合并瓣膜病变。冠状动脉造影提示单支病变1例，双支病变3例，3支病变8例。合并原发性高血压8例，糖尿病6例，心力衰竭病史5例，心房颤动7例。手术前左心室舒张末期内径（LVED）45～87mm[（56．7±77）mm]，左心室射血分数（LVEF）24％～67％（50．3％±11．7％）。心功能NYHAⅠ级1例，Ⅱ、Ⅲ和Ⅳ级分别为8、2和1例。12例患者中MVR（二尖瓣置换）＋CABG9例，AVR（主动脉瓣置换）＋CABG2例，DVR（双瓣置换）＋CABG1例。结果全组术后恢复顺利，随访3个月至2年无1例死亡。结论年龄超过50岁风湿性心脏病患者，无论有无心绞痛症状均需行冠状动脉造影检查，决定是否同期行CABG；冠心病合并二尖瓣中到重度反流及主动脉瓣严重钙化者，应同期行瓣膜置换术。对于冠状动脉病变与瓣膜病变同时存在的病例，2种手术同期进行可降低病死率，改善预后。

Objective To study the indications and safety in the surgery of CABG combined with valvular replacement for the patients with both CHD and rheumatic heart diseases （RHD） or valvular diseases. Methods In 12 cases of patients with combined coronary artery and valvular heart diseases CABG and valvular replacement surgery were performed from 2001 May to 2004 December in Xuanwu Hospital, CUMS. Moderate hypothermia myocardial protection was used in cardiopulmonary bypass. 8 cases of 12 are males, 4 cases are females, age ranging 52 to 78 （mean 64.5）. 3 cases presented with RHD, preoperative angiography indicated coronary artery disease. 9 cases presented with coronary artery disease （CAD） combined with valve disease. Angiography of 12 cases showed single vessel disease in 1 case, double vessel disease in 3 cases, and three vessel disease in 8 cases, associated with hypertension in 8, diabetes in 6, heart disfunction in 5, and atrial fibrillation in 7. Left ventriclar end diastolic diameter showed 45-87 mm [mean （56.7±77） mm], left ventriclar ejection fraction demonstrated 24% -67% （mean 50.3%±11.7%）. Heart function（NYHA） showed grade Ⅰ in 1 cases, Ⅱ , Ⅲ, Ⅳ in 8, 2, 1 cases respectively. 9 out of 12 underwent CABG＋MVR （mitral valve replacement）, CABG ＋AVR （aortic valve replacement） in 2, DVR （double valve replacement） in 1. Results All cases in this study recovered smoothly both peroperatively and postoperatively, no death was found after 3 months to 2 years follow up. Conclusion Coronary angiography is indicated for the patients presented with RHD aging above 50 regardless of the manifestation of pectoris angina or not. Valvar replacement is performed for the patients suffered from CAD combined moderate to severe MI or severe aortic valve calcification. For the cases with combined CAD and valve diseases, CABG plus valve replacement might result in the difficulty of procedures, however it might be beneficial for patients in terms of the prognosis and decreasing mortality in particular.