弥漫性冠状动脉病变的外科治疗

Surgical Treatment for Patients with Diffused Coronary Artery Disease

目的总结非体外循环心脏跳动下冠状动脉内膜剥脱后行非体外循环冠状动脉旁路移植术（off—pump CABG）治疗弥漫性冠状动脉病变的早期临床结果和经验，以提高手术疗效。方法2003年5月～2006年11月，对83例弥漫性冠状动脉病变患者在非体外循环下做冠状动脉内膜剥脱后行off—pump CABG，其中男61例，女22例；年龄55-80岁（65±7岁）；加拿大心脏病协会（CCS）心绞痛分级：Ⅱ级7例，Ⅲ级20例，Ⅳ级56例。有心肌梗死史36例（43．4％）。冠状动脉造影显示：双支血管病变5例，3支病变78例，其中合并左主干病变16例。左心室射血分数25％～65％（51％±16％）。83例共行110支冠状动脉内膜剥脱，其中左前降支系统67支，回旋支、钝缘支9支，右冠状动脉系统34支。20例内膜剥脱后先用大隐静脉片行左前降支成形，再在补片上用乳内动脉行旁路血管移植；应用左乳内动脉83支，桡动脉2支，余均为大隐静脉，每例移植血管3．9±1．2支。结果无手术死亡。术中移植血管血流满意101支（92％），血流量为22±16ml／min。术后发生心肌梗死4例，梗死面积小，无血流动力学改变，未给予特殊治疗。83例患者皆痊愈出院。随访75例（90．4％），8例失访，随访时间8～50个月，无心绞痛发作。8例患者在手术后3～29个月复查冠状动脉造影显示：冠状动脉内膜剥脱后行off—pump CABG的移植血管均通畅。结论非体外循环下冠状动脉内膜剥脱后行off—pump CABG，安全可行，再血管化程度高，是治疗弥漫性冠状动脉病变的有效方法。

Objective To summarize the early outcomes and clinical experience of off-pump coronary artery bypass grafting （off-pump CABG） after off-pump coronary endarterectomy （CE） for patients with diffused coronary artery disease. Methods From May 2003 to November 2006,83 patients with diffused coronary artery disease underwent CE without cardiopulmonary bypass and off-pump CABG. There were 61 males and 22 females with age ranged from 55 to 80 years （65±7 years）. There were 7 patients in Canadian Cardiac Society（CCS） angina class Ⅱ ,20 patients in class Ⅲ ,and 56 patients in class Ⅳ.36（43. 4%） patients had history of myocardial infarction. Coronary angiogram revealed that 5 patients had double vessels disease, and other 78 patients had triple vessels disease with 16 left main stem disease. The left ventricular ejection fraction（LVEF） ranged from 25% to 65% （51%± 16%）. One hundred and ten endarterectomies were performed in 83 patients totally which included 67 in left anterior descending artery（LAD） ,9 in circumflex artery and 34 in right coronary artery. Twenty patients received on-lay venous patch after CE in LAD and then grafted by internal mammary artery （IMA） on the patch. There were 83 left IMA, 2 radial arteries, others were great saphenous veins, the mean number of grafts was 3. 9 ± 1.2. Results There was no death in all patients. Intra-operative graft flow-meter was used to check the flow in the grafts before chest closure. One hundred and one （92%） out of 110 grafts after CE showed a satisfactory grafts flow （22 ± 16ml/min） intraoperatively. Four patients had perioperative myocardial infarctions but none had hemodynamic changes. All patients discharged uneventfully. Seventy-five patients （90.4%） had 8 to 50 months follow-up with no angina reoccurrence. Eight patients had coronary angiogram from 3 to 29 months after operation with all patent grafts to the CE coronaries. Conclusion Off-pump CABG with coronary endarterectomy is feasible and achieves surgical revascularization in patients with diffuse coronary artery disease.