同期行冠状动脉旁路移植术与瓣膜手术的临床研究

Clinical study of coronary artery bypass grafting combined with cardiac valve operation

目的 介绍同期施行冠状动脉旁路移植术与瓣膜手术的体会。方法 选择48例患者同期行冠状动脉旁路移植术与瓣膜手术，术前心功能分级（NYHA）Ⅰ级15例，Ⅱ级13例，Ⅲ级15例，Ⅳ级5例。其中双支病变13例，多支病变35例，二尖瓣病变11例，主动脉病变10例，联合瓣膜病变27例。手术均在全身麻醉体外循环下进行，心脏停跳后先做静脉桥的远端吻合，然后置换瓣膜，静脉桥与升主动脉的近端吻合在主动脉一次阻断下或心脏复苏后完成。11例二尖瓣反流者均行二尖瓣成形术，37例患者行瓣膜替换术。其他同期手术：行室壁瘤切除术2例，左心房血栓清除术8例。结果 手术后发生低心排出量综合征2例，其中死亡1例。术后呼吸机使用时间21-282h，平均（70．5±12．6）h。ICU停留时间4—42d，平均（5．6±2．3）d。1例因Ⅲ度房室传导阻滞植入永久性起搏器。术后发生心房纤颤11例，院内肺部感染2例。术后心功能均明显改善。出院的47例患者全部获得随访，随访期间无心绞痛发作。随访中心功能Ⅰ级18例，Ⅱ级26例，Ⅲ级3例，而且随访中未发现瓣周漏等人工瓣相关并发症，亦未发生与抗凝相关的出血、血栓或栓塞等事件。结论 冠状动脉旁路移植术同时行瓣膜手术是安全、有效的。详细的术前检查、充分的心肌保护及术后预防并发症等皆是手术成功的关键。

Objective To introduce the comprehension of coronary attery bypass grafting combined with cardiac valve operation. Methods From August 2003 to November 2006,48 eases coronary artery by- pass grafting combined with cardiac valve operations were studied. Cardiac functional grading （NYHA） Ⅰ grade of 15, Ⅱ grade of 13, Ⅲ grade of 15 and IVgrade of 5 before operation. Pair of pathological change 13 cases,many pathological changes 35 cases,bicuspid valve sickness bites 11 cases ,aorta sickness bites 10 cases, union valve pathological change 27 cases. The surgery performed entire anaesthesia external circulation. After the heart stopping jumps, made the vein bridge the distal end to tally, then replaced valve, under the vein bridge with rose the aorta the near end to tally after the aorta time blocks or the heart recovered completely. Eleven eases with valvula biscuspidalis backstreaming were performed valvula biscuspidalis plasty. Thirty-seven cases were given valve replacement. Other same time surgeD, ：2 implementation room wall lump excision, 8 left atrium thrombus elimination. Results After the surgery 2 cases had a low heart row of synthesis,death of 1 case. After surgery breath machine period of revolution was 21-282 h,average （70.5 ± 12.6） h, ICU resident time was 4-42 d,average （5.6 ± 2.3） d. One case because of Ⅲgrade of rank auriculo-ventricular conduction hinders implants the permanence to get up abundantly. After the surgery had the atrial fibrilation 11 cases,intra-hospital pulmonary infection 2 cases. The heart function postoperation obviously changed. Left the hospital of 47 examples completely obtained along with discusses, made a follow-up visit the period unintentionally colic sickness to manifest suddenly. Heart furction： Ⅰ grade 18, Ⅱ grade 26, Ⅲ grade 3, moreover made a follow-up visit had not discovered perivalvular leakage and so on the artificial petal correlation illness complication occared,also had not occurred with prevents clotting mailer and so on correlation hemorrhage, thrombus or hitch match. Conclusions The coronary artery bypass grafting with cardiac valve operation is safe and effective. The detailed inspects before operation, the full of the cardiac muscle protection and the preventing the illness complication and so on are the key for the surgery succeeds.