非体外循环下冠状动脉旁路移植术中升主动脉钙化的处理

Off-pump Coronary Artery Bypass Grafting for Patients with Ascending Aorta Atherosclerosis

目的探讨非体外循环冠状动脉旁路移植术(OPCAB)中升主动脉钙化的处理方法,总结手术效果,以减少OPCAB后脑血管事件的发生。方法回顾分析2004年9月～2007年12月期间,我院连续治疗的236例伴有升主动脉钙化行冠状动脉旁路移植术患者的临床资料,其中4例采用"No-touch"技术,35例采用Enclose辅助完成近端吻合,197例采用Heartstring辅助完成近端吻合。术中监测血流动力学指标,所有移植血管桥均采用瞬时测血流量技术(TTFM)保证吻合口吻合质量。结果远端吻合口881个,近端吻合口267个,桥血管血流量16.2±18.7ml/min,弹力指数(PI)4.9±2.3,近端吻合口吻合前、后血流动力学指标为:平均动脉压(MAP)78.1±10.4mmHgvs.80.9±8.1mmHg,肺毛细血管楔压(PCWP)11.9±3.6mmHgvs.10.9±2.1mmHg,平均肺动脉压(MPAP)17.3±4.3mmHgvs.15.3±2.8mmHg,心排血量(CO)4.2±1.2L/minvs.4.5±1.6L/min,中心静脉压(CVP)9.2±2.3cmH2Ovs.9.3±1.8cmH2O,心率(HR)71.4±14.0次/分vs.73.4±16.5次/分等,其变化差异无统计学意义(P>0.05)。2例因术后发生低心排血量死亡,4例患者术后有脑供血不足症状,经内科治疗随访2个月后好转,其余患者无围手术期心肌梗死等重大并发症发生;住院时间10.5±4.2d。185例随访3～24个月,无心血管事件及脑血管意外,心功能改善、心绞痛缓解。结论术前及术中充分评估主动脉钙化程度,采用减少升主动脉操作的近端吻合器吻合技术,可减少脑血管意外的发生,取得良好的临床效果。

Objective To investigate the management during off-pump coronary artery bypass grafting （OPCAB） for patients with ascending aorta atherosclerosis and to find appropriate treatment for minimizing the postoperative cerebrovascular accidents. Methods 236 patients with ascending aorta atheroselerosis were retrospectively analyzed underwent OPCAB in this hospital from Sep. 2004 to Dec. 2007, 4 of them received ＂No- touch＂ technique, 35 of them had the proximal anastomoses with the Enclose assistant, and 197 of them had the proximal anastomoses with the assistant of Heartstring. Hemodynamie indexes were consecutively monitored, blood streams of grafts was monitored by transit time flow measurement （TTFM） to evaluate the quality. Results Distal anastomoses 881,proximal anastomoses 267, the blood stream of 881 grafts was monitored, the mean flow was 16.2±18.7 ml/min, and the pulsatility index （PI） were 4. 9±2. 3, indicating the good quality of all grafts. The change of hemodynamic indexes including mean artery pressure （MAP, 78.1±10.4 mmHg vs. 80.9±8.1 mmHg）, pulmonary capillary wedge pressure （PCWP, 11.9±3.6 vs. 10.9±2.1 mmHg）, mean pulmonary artery pressure （MPAP, 17.3±4.3mmHg vs. 15.3±2.8 mmHg）, cardiac output （CO, 4. 2±1.2 L/min vs. 4. 5±1.6 L/min）, center vinous pressure （CVP, 9.2±2.3cmH2O vs. 9.3±1.8 cmH2O）, heart rate （HR, 71.4±14.0 beats/min vs. 73.4± 16.5 heats/min）, there were no statistically difference between before and after proximal anastomoses （P〉 0.05）. Two patients died of low cardio output during operation, 4 patients with transient ischemic attack were improved by 2 months medical therapy, and others had no postoperative complications as perioperative myocardial infarction etc, and the time of stay hospital was 10. 5± 4.2d. Follow-up 3--24 months for 185 patients, all living patients had no myocardial or cerebrovascular accidents, the symptoms were alleviated and myocardiac function improved. Conclusion Assessing the degree of the ascending aorta atherosclerosis sufficiently before and during the operation, choosing different operational strategy, and decreasing the manipulation of aorta can decrease the incidence of cerebrovascular accident and get better clinical result.