冠状静脉原位动脉化旁路移植术应用解剖学基础及临床疗效近期观察

Anatomical basis and short-term effect of in situ coronary venous arterialization

目的研究冠状静脉原位动脉化(ICVA)灌注缺血心肌的解剖学径路及临床疗效近期观察。方法结扎离体猪心脏后降支模拟其闭塞,结扎心中静脉(MCV)近端,用印度墨汁经 MCV 远端灌注猪心肌5只,显微镜下观察。自2002年1月至2005年12月间连续收治右冠状动脉弥漫病变且远端闭塞病例64例,随机分成选择性冠状静脉原位动脉化组(ICVA 组)和对照组,每组32个病例。分析术前、术后的心电图、心肌核素扫描和超声心动图等临床资料,评价选择性冠状静脉旁路移植对心肌血供的影响和临床疗效。结果印度墨汁经 MCV 逆行灌注后,可在心肌组织细胞间隙毛细血管内均匀分布,并在微动脉内显现。ICVA 组32例临床病例无死亡,平均住院时间16.5 d±7.7 d。术后心电图 ST 段的恢复率96.88%;心绞痛分级的好转率为100%。对比术前与术后下壁心肌灌注程度和节段运动计分,差异有统计学意义(P<0.05)。结论选择性冠状静脉动脉化可有效灌注相应区域的心肌组织,对冠状动脉弥漫病变远端通畅不良的患者是一种有效、安全的治疗方法。

Objective To study the anatomical basis of in situ coronary venous arterialization （ICVA） and to observe the sbort-term clinical outcome thereof. Methods Five recently isolated pig hearts underwent ligation of the posterior descending artery and the proximal end of middle cardiac vein （ MCV）, solution of Indian ink was perfused into this vein, and slices of heart were made to observe the distribution of ink through microscope. From January 2007 to December 2005, 64 consecutive patients with diffuse lesion and distal occlusion of right coronary artery received coronary artery bypass grafting （CABG） were randomly divided into 2 equal groups to undergo ICVA during CABG （ICVA group） and conventional CABG only （control group） respectively. The pre- and post-operation clinical data, including ECG, SPECT and ultrasonic cardiograph （UCG） were analyzed. Results Indian ink was distributed in the intercellular spaces and capillaries of the myocardium and appeared in the micro-arteries in all 5 pig hearts. The mean hospitalization time of the ICVA patients was 16. 5 ±7.7 days. The mortality rate was 0. After the ICVA the ECG recovery rate in ST segment was 98.88%, and the improvement rate in the grade of the angina was 100%. SPECT and UCG both showed great improvement post-operatively （P 〈 0.05）. Conclusion After the ligation of the proximal end of MCV, the related myocardium can be perfused effectively by distal arterialization in situ. ICVA, fitting to patients with diffused lesion and distal occlusion of coronary artery, can be performed safely with satisfactory clinical outcomes.