合并升主动脉钙化的冠心病患者不用主动脉侧壁钳非体外循环冠状动脉多支搭桥

Off-Pump Coronary Artery Bypass Without Aortic Side-Bite Clamping in Patients With Multiple Coronary Artery Disease and Calcified Ascending Aorta

目的:总结不用主动脉侧壁钳的非体外循环冠状动脉多支搭桥治疗合并升主动脉钙化的冠心病病人的临床经验。方法:不用主动脉侧壁钳的非体外循环冠状动脉搭桥(OPCAB)30例,男23例,女7例,年龄53～83岁,平均69.1岁。有脑中风史13例。双支和三支系统病变为2例和28例,同时有左主干病变11例。左心室射血分数0.52±0.19。30例病人均可以摸到明显的升主动脉片状或弥漫性钙化斑块,21例病人手术中食道超声心动图提示主动脉明显钙化。9例以左乳内动脉(LIMA)为唯一供血来源(in-flow),其余静脉桥吻合到LIMA,1例静脉桥吻合到无名动脉,其余静脉～静脉"Y"吻合,6例使用主动脉隔离装置(Enclose)行主动脉上的近端吻合,14例采用双侧乳内动脉。术中用血流仪定量测定桥血流。结果:本组30例人均远端吻合3.40(3～5)处。术后8例需多巴胺>5ng/(kg·min)支持16～45小时。手术后2～12小时病人完全清醒,人均带气管插管时间(8.9±3.7)小时。手术中实时桥血流测定显示桥血流均满意(17～110ml/ min),9例以LIMA为唯一in-flow,LIMA总血流量基本是各分支桥血流量之数学和。无围手术期心肌梗死、无出血再开胸、无脑中风,无手术后急性肾衰。下肢切口感染1例,8例(26.7%)术后一过性房颤。全组无围手术期死亡。术后心绞痛均消失,术后(12.7±4.6)天出院。结论:在升主动脉有明显钙化的冠心病病人,采用OPCAB结合主动脉不接触(no-touch)技术或主动脉近端吻合装置,安全可行,临床效果满意。

Objective： To review and summarize the early outcomes and clinical experience of off-pump coronary artery bypass （ OPCAB） without aortic slde-bite clamping in patients with multiple coronary artery disease and calcified ascending aorta. Methods： Thirty patients with multiple coronary artery disease and calcified ascending aorta underwent OPCAB without aortic side-bite clamping. There were 23 males and 7 females aged from 53 to 83 （ mean 69. 1 ） years. Thirteen patients had a history of stroke. Coronary angiogram revealed that 2 patients had double vessels disease and the other 28 had triple vessels disease, and out of them 11 had extra left main stem disease. The left ventricular ejection fraction ranged from 0. 35-0. 68. Calcified ascending aortic plaque can be felt in all patients during operation ,and intra-operative transesophageal echocardiography indicated calcified aorta only in 21. Left internal mammary artery （LIMA） was used as the only inflow in 9 patients,and greater saphenous veins were anastomozed to LIMA. The proximal greater saphenous vein graft was anastomozed to the innominate artery in one. Proximal anastomotic device was applied in six patients to finish the proximal anastomosis of greater saphenous vein grafts. Bilateral internal mammary arteries were used in 14 patients. Intra-operative graft flow meter was used to check the flow in the grafts before chest closure. Results： The mean number of distal amastomosis in each patient was 3.40 （from 3 to 5 ）. Dopamine （ 〉 5ng/kg/min ） was used in 8 patients for 16-45 hours after surgery to stabilize hemodynamics. Postoperative mean tracheal intubation time was 8.9 ± 3.7 hours. Intra-operative measuring of graft flow revealed satisfied flow in all grafts. In 9 patients with LIMA as the only inflow the total graft flow in the main stem of LIMA was basically the sum of each connected grafts. There were no peri-operative death and stroke. The mean post-operative hospital stay was 12.7 ±4. 6 days. Conclusions： In patients with remarkable ascending aortic calcification, OPCAB combined with aorta no-touch technique or proximal anastomosis device is a safe and feasible alternative, can achieve a good surgical results.