体外循环下心脏不停跳与非体外循环冠状动脉搭桥术治疗冠状动脉左主干病变的对比研究

A comparative study of on-pump beating heart and off-pump coronary artery bypass for patient with left main disease

目的对比研究体外循环下行心脏不停跳与非体外循环下冠状动脉搭桥治疗冠状动脉左主干病变的临床效果。方法 180例单纯冠状动脉左主干病变患者分别进入非体外循环下冠状动脉搭桥组(OPCAB组,n=90)和体外循环下心脏不停跳行搭桥组(OPBH,n=90)。两组患者在心绞痛程度、合并慢性阻塞性肺病(COPD)、心肌梗死史和糖尿病、高血压、高血脂、中风、肾功能受损等方面无统计学差异(P>0.05),但OPBH组低左室射血分数(LVEF)的患者的比例明显多于OPCAB组(P<0.05)。所有患者均采用胸骨正中切口。OPCAB组用单根心包深吊线,引入一橡皮管,帮助暴露各冠状动脉分支,采用心脏局部固定器,辅以腔内分流栓,完成远端吻合。OPBH组在体外循环(CPB)的辅助下,用OPCAB的方法显露冠状动脉各个分支,完成各个吻合。所有患者术终行桥血流定量测定。结果 OPCAB组无1例需转成OPBH。两组人均冠状动脉远端吻合数(OPCAB组:3.22±0.58。OPBH组:3.06±0.72)和再血管化指数相似,术后呼吸支持时间、胸腔引流量和输血量明显少于OPBH组(P<0.05);两组围手术期心肌梗死、出血再开胸、呼吸功能不全、肾功能异常、脑卒中、心房颤动、纵隔炎、下肢切口感染和围术期死亡例数无统计学差异(P>0.05)。结论对比研究结果显示,两种手术方式均可以取得良好的临床效果。对于低LVEF的患者,OPBH可用于治疗冠状动脉左主干病变,能达到完全性再血管化,虽然出血和输血量较大,术后呼吸支持时间和ICU停留时间较长,但能取得与OPCAB相同的疗效。

Objective To make a comparative analysis of the clinical results of on-pump beating heart and off-pump coronary artery bypass surgery in patients with left main disease.Methods 180 consecutive isolated multiple coronary artery bypass patients entered into off-pump coronary artery bypass（group OPCAB,n = 90） or coronary artery bypass with cardiopulmonary bypass beating heart（on-pump beating heart OPBH）（group OPBH,n = 90）.Before surgery there was no significant difference between the two groups with regards to the degree of angina,history of myocardial infarction,COPD,diabetes,hypertension,hyperlipidemia,stroke and impaired renal function.Group OPBH had more patients with low LVEF（P 0.05）.All patients had coronary bypass surgery through full sternotomy.Group OPBH underwent the support of CPB but Group OPCAB did not.A single deep pericardial stay suture with a sling snared down was used to expose the target coronary vessels in group OPCAB,along with stabilizers and coronary shunts.The Medi-StimButterfly Flowmeter was used to measure the flow grafts in both groups.Results No one in group OPCAB needed to be converted into OPBH.The mean number of the distal anastomosis and the ICR（index of completeness of revascularization） was similar in both groups.The respiratory support time,the chest tube drainage and blood transfusion were less in group OPCAB than in group OPBH post-operatively（P 0.05,P 0.01）.There was no significant difference in the mortality and other morbidities（peri-operative MI,reopen,respiratory dysfunction,renal dysfunction,stroke,atrial fibrillation,mediastinitis,and low extremity infection）.Conclusion Compared to OPCAB,to patients of low LVEF,OPBH applied to patients with left main disease can achieve similar completeness of revascularization,similar early surgica1 results with longer respiratory support,and more transfusion requirement,and more ICU stay time.