246例冠状动脉搭桥术的临床体会

Coronary Artery Bypass Grafting (CABG)—Experience with 246 Cases

总结自１９８５年以来，在国内、外主作的２４６例冠状动脉搭桥手术情况。其中男２０６例，女４０例。年龄３７～７９岁，平均５７岁。大于６５岁者７１例（２８．７％）。病变为１支血管者２０例，２支血管６３例，３支血管１４５例；合并左主干病变１８例。按ＮＹＨＡ评判心绞痛分级，Ｉ级３例、ＩＩ级３５例、ＩＩ级１０１例、ＩＶ级１０７例。左室射血分数＞４０％２１７例，＜４０％２９例。左室舒张末压＜２．４ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）２１３例，＞２．４ｋＰａ３３例。２２５例为单纯大隐静脉搭桥术，其中２１５例为序贯式搭桥术；２１例为单纯乳内动脉搭桥术或联合大隐静脉搭桥术。人均搭桥３．６支（１～７支）。死亡率为１．２％。作者认为，适宜的手术适应证，良好、正确的心肌保护，精确的吻合技术，用两条序贯式桥施行完全冠状动脉血运重建和正确的麻醉、体外循环技术是降低死亡率和减少并发症的关键所在。

This paper summarizes the clinical experience with 246 CABG patients operated upon by the first author,and the important factors affecting the postoperative morbidity and mortality.The operations were performed both at the Thoracic Center,Groningen Academic University,Holland,and the China Japan Friendship Hospital,Beijing,in the period from 1985 1995.This series of patients includes 206 (83.7%) males and 40 (16.3%) females with ages ranging from 37 to 79 (mean 57) years old.Angina pectoris (effort tolerance) was graded as class I (NYHA) in 3 (1.2%) cases,II in 35 (14.2%),III in 101 (41.5%) and IV in 107 (43.5%).The hemodynamic parameters determined in 246 patients showed LVEF >40% in 217 and <40% in 29 and LVEDP <2.4kPa in 213 (86.6%) and >2.4kPa in 33 (13.4%).The corronary arterial disease involved single vessel in 20 (8.1%) cases,2 in 63 (25.6%) and 3 in 145 (58.9%),and associated with lesion of the left main CA in 18 (7.3%).Coexisting valvular disease was present in 5 cases.Under both conventional CPB and myocardial protection with cold crystalloid cardioplegic solution and topical cooling,distal anastomoses were performed first.The isolated venous grafts were used in 225 (91.5%) patients and were grafted in sequential order in 215 (87.5%) of them.In the other 21 (8.5%) patients,however,isolated internal mammary artery (IMA) or combined with venous grafts were used.The number of grafts employed varied from 1 to 7 with a mean of 3.6/pt.Five patients associated with valvular disease underwent valvular surgery in one setting.The overall operative mortality was 1.2%.To obtain good results of CABG operation,the followling factors should be considered.(1) LVEF should be higher than 25%;(2) It is very important to perform complete myocardial revascuarization to as to reduce perioperative myocardial infarction and mortality;(3) Two sequential grafts revascularizing LAD system and CX plus RCA system separately may be better than a circular graft in long term result;(4) A good patency of both ends of the grabt should be ensured;(5) The myocardium should be protected by giving cardioplegic solution through aortic root and grafts and good anesthesia combined with adequate perfusion are essential.