“一站式”复合（Hybrid）技术治疗冠状动脉多支病变35例

＂One-stop＂ hybrid approach for multi-vessel coronary artery disease in 35 patients

目的总结“一站式”复合（“Hybrid”）技术治疗冠状动脉多支病变经验，探讨其临床应用价值。方法2007年6月至2008年5月，35例冠心病病人在“一站式”复合手术室内接受治疗。冠状动脉病变平均2．5支／例。左心室射血分数0．62±0．07。经胸骨下端小切口在不停跳状态下行左乳内动脉（LIMA）至前降支（LAD）旁路移植术。即刻冠状动脉造影证实LIMA—LAD通畅后同期对其他冠状动脉病变靶血管行经皮冠状动脉介入治疗（PCI）。结果住院期间无出血再次开胸、卒中、围术期心梗、急性。肾功能衰竭或死亡等发生。全组34例顺利行“一站式”复合手术，旁路移植后即刻冠状动脉造影示吻合口通畅，LAD血运重建满意。1例PCI时因钝缘支夹层转为体外循环下冠状动脉旁路移植术（CABG）。全组PCI治疗冠状动脉病变61处，其中6处病变行单纯球囊扩张冠状动脉成形术，其余部位病变置入药物洗脱支架，共62枚，平均1．8枚／例，置入支架的平均直径为（3．2±0．5）mm，每例病人支架的平均长度为37．3mm。顺利进行“一站式”复合手术的34例病人呼吸机辅助平均（10．8±7．9）h，其中4例在术后即刻于手术室拔除气管插管；ICU滞留平均（33．6±33．0）h；24例病人未使用血液制品；术后恢复顺利，平均（9±3）天出院。结论“一站式”复合技术治疗冠状动脉多支病变安全可行，尤其对合并高危因素病例安全有效。

Objective To summarize the clinical experience of ＂ One-stop＂ hybrid procedure that performs minimally invasive direct coronary artery bypass （MIDCAB） and percutaneous coronary intervention （PCI） concurrently on 35 patients with muhivessel coronary artery disease （CAD）. Methods Between June 2007 and May 2008, 35 patients [ 33 men and 2 women, mean age （63.5 ± 9.2） years ] with multivessel CAD （ two-vessel CAD, n = 19 ; three-vessel CAD, n = 16, left main coronary artery disease, n =7; coronary artery lesions, 2.5 lesions per patient） underwent ＂one-stop＂ hybrid procedure. The hybrid strategy was performed as a primary MIDCAB procedure for bypassing the left internal mammary artery （LIMA） to the left anterior descending artery （ LAD ）, simultaneously followed by PCI （ percutaneous transluminal coronary angioplasty （PTCA） and/or stenting） on the remaining non-LAD vessels. Concomitant diseases included hypertention in 20 patients, hyperlipemia in 12 patients, previous myocardial infarction （MI） in 10 patients, diabetes mellitus （type 2） in 9 patients, previous cerebrovascular disease in 2 patients, chronic obstructive pulmonary disease （COPD） in 1 patient, renal dysfunction in 1 patient, and ostium secundum atrial septal defect in 1 patient. The left ventricular ejection fraction （LVEF） averaged 0.62 ±0.07. Results There were no reexploration for bleeding, strokes, myocardial infarctions, acute renal dysfunctions, or deaths in hospotal. Of the total 35 patients, 34 patients （97.1% ） were successfully treated with ＂one-stop＂ hybrid procedure, and 1 patient （2.9%） was converted to conventional coronary artery bypass grafting （CABG） because of dissection of one obtuse marginal branch during PCI. One of the LIMA-LAD grafts was confirmed to be anastomotic stenosis by followed coronary angiog- raphy and was corrected immediately. The patient with ostium secundum defect underwent tranesophageal echocardiography guiding transcatheter closure after LIMA-LAD anastomosis. Catheter-based interventions were carried out in 61 coronary lesions, including PTCA in 6 lesions and implantation of 62 drug-eluting stents （DES） in the rest appropriate lesions. The mean number of DES implantation was 1.8 per patient, and the average diameter and length of implanted DES were respectively （ 3.2 ±0.5 ） mm and 37.3 mm per patient. Of the 34 patients receiving hybrid procedure, the average mechanical ventrilation time was （ 10.8 ±7.9） hours, and 4 （ 11.8% ） pateints were extubated in the operating room; length of stay in the intencive care unit averaged （ 33.6 ±33.0） hours and hospital stay （ 9 ± 3 ） days; 24 patients （ 70.6% ） avoided transfusion requirement. Conclusion Our findings indicate that in high-risk patients with muhivessel CAD, the ＂one-stop＂ hybrid procedure by performing MIDCAB and PCI simultaneously is a feasible and safe ahemative.