合并升主动脉钙化的冠心病人冠状动脉多支搭桥的策略

Strategies for Multiple Coronary Artery Bypass in Patients with Calcified Ascending Aorta

目的探讨冠状动脉粥样硬化性心脏病（冠心病）合并升主动脉钙化行冠状动脉多支搭桥的策略。方法2002年6月-2007年12月对36例合并升主动脉钙化的冠心病不使用主动脉侧壁钳行非体外循环冠状动脉搭桥术。常规取左乳内动脉（left internal mammary artery,LIMA）,19例同时取右乳内动脉（right internal mammary,RIMA）。15例以LIMA为唯一的桥血流来源（in-flow）,其余的静脉桥吻合到LIMA;14例使用Enclose或Heartstring近端吻合装置行静脉桥在主动脉上的吻合。术中用血流仪（Medi-Stim Butterfly Flow Meter,Oslo,Norway）行桥血流定量测定。结果36例共行远端吻合116个[2-5个,（3.2±0.9）个]。术后2-22 h病人完全清醒。手术中实时桥血流测定满意,15例以LIMA为唯一in-flow的患者,LIMA主干的总血流量基本是各分支桥血流量的数学和。无围手术期心肌梗死及脑卒中。8例（26.7%）手术后一过性心房颤动;肺部感染2例;胸腔积液4例;下肢切口感染1例,均治愈。死亡1例,死亡原因为多脏器功能衰竭。30例随访6-60个月,（33.8±11.2）月,11例造影显示37支桥中,LIMA-LAD均通畅,2支到对角支的静脉桥闭塞,余静脉桥均通畅。结论对升主动脉有明显钙化的冠心病患者,采用非体外循环冠状动脉搭桥结合主动脉No-touch技术或主动脉近端吻合装置,可有效避免因在病变主动脉上操作引起的术后脑卒中发生。

Objective To review the strategies for multiple coronary artery bypass in patients with calcified ascending aorta. Methods From June 2002 to December 2007, 36 patients with multiple coronary artery disease and calcified ascending aorta underwent OPCAB without aortic side-bite clamping. The patients （28 males and 8 females） aged from 60 to 83 years with a mean of （69.1 ± 6.7） years. Fifteen of the patients had a history of stroke. Coronary angiogram revealed that 3 patients had double vessels disease and the others had triple vessels disease, involving the left main stem in 14 cases. The left ventricular ejection fraction ranged from 0.32 - 0.69. Calcified ascending aortic plaque can be explored in 30 of the patients during operation while intra-operative transesophageal eehocardiography indicated calcified aorta only in 28. No-touch technique was used in 22 patients either with LIMA as the only inflow and the saphenous vein grafts was anastomosed to the LIMA in 15 patients, or with bilateral internal mammary arteries as the only inflows in 7 patients. Proximal anastomotic device was employed in 14 patients to finish the proximal anastomosis of greater saphenous vein grafts without aortic side-biting clamping. Intra-operative graft flow meter was used to check the flow of grafts before chest closure. Results Totally 116 cases of distal anastomosis were performed in the 36 patients （2 - 5 in each, mean 3.2 ±0.9）. The patients woke up from anesthesia in 2 to 22 hours. Intraoperative measuring of graft flow revealed satisfying blood flow in all the grafts. In the 15 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. Only one patient died after surgery, showing a mortality rate of 2.7%. Eight patients （26.7%） had transient atrial fibrillation after the operation, 2 showed pulmonary infection, 4 had chest fluid, 1 showed infection of the incision at the lower limb. All the complications were cured. 30 patients achieved a 6- to 60-month follow-up with a mean of （33.8 ±11.2） months. During the period, 11 patients （37 grafts） were examined by angiography, which showed that all the grafts of LIMA to LAD and vein grafts were patent, except in two vein grafts, which were occluded in the diagnol branches. Conclusions In patients with remarkable ascending aortic calcification, OPCAB combined with aorta no-touch technique or proximal anastomosis device can effectively decrease the incidence of postoperative stroke.