左室重建术加冠状动脉旁路术治疗左室室壁瘤

Surgical treatment of left ventricular aneurysm by reconstruction of the left ventricle plus CABG

目的：探讨穿壁性心肌梗塞的病人并发左室室壁瘤（ＬＶＡ）形成者手术指征，室壁瘤切除后左室重建的手术技术及原理。方法：１９９８年３月至１９９９年７月，连续手术治疗１５例有典型心绞痛史的ＬＶＡ病人，左室和冠脉造影示１４例前间壁ＬＶＡ，１例为下壁室壁瘤伴二尖瓣关闭不全。左室附壁血栓９例，冠状动脉单支病变２例；双支病变３例，３支病变１０例。手术在全麻中度低温体外循环下施行。胸骨正中切口，胸膜外游离左侧乳内动脉（ＬＩＭＡ）。前间壁ＬＶＡ，旁开左前降支动脉（ＬＡＤ）２．０ｃｍ平行切开ＬＶＡ。彻底清除左室内血栓。折叠下室间隔，以消除室间隔的反常运动和恢复远端室间隔的圆锥形。在心脏跳动或颤动下，用２０ｐｒｏｌｅｎｅ线，在室壁瘤基底的心内膜环缩，以恢复左室的几何形状。将多余的ＬＶＡ组织切除，然后外垫毡片线性缝闭左室，最后行冠状动脉旁路术（ＣＡＢＧ）。１５例均行ＬＩＭＡＬＡＤ吻合；１３例尚用大隐静脉和其它冠脉行ＣＡＢＧ。９例左室内有大量陈旧性及新鲜血栓。３例脱机困难使用了ＩＡＢＰ，其余顺利脱机。结果：术后无并发症，痊愈出院。随访１５例，随访率１００％，随访时间１～１５个月，平均５个月。心绞痛消失，心功能恢复到Ｉ～Ｉ级，无死亡?

Aim:Left ventricular aneurysm(LVA) occurs in 10% to 35% of patients who have had a transmural myocardial infarction.The study was conducted to discuss the surgical techniques and rationale for reconstructive left ventricular surgery for post aneurysmectomy and indications.Clinical material and methods:Between march of 1998 and July of 1999,15 patients with LVA underwent aneurysmectomy plus CABG,whose ages ranged from 47 to 68 years old(mean 54).All had typical angina,of which 6 had retractable angina,4 congestive heart failure,3 ventricular tachyarrhythmias.Left ventriculogram demonstrated that 9 patients had large anteroseptal LVA with mural thrombi,1 posterior basilar LVA.Surgery was performed via a median sternotomy with the use of cardiopulmonary bypass with hypothermia .The aneurysm was repaired using the method of Jatene.The aneurysm was opened by placing an incision parallel to and at least 2 cm lateral to the LAD coronary artery.The thrombi were removed intact.Large pledgeted imbricating sutures were placed in a posterior to anterior direction in the aneurysmal portion of the distal ventricular septum.To stabilize the septum and to restore the normal taper of the distal septum.With the heart either beating or fibrillating,the pursestring suture was placed at the junction of the endocardial scar and normal endocardium and tightened down,and the remaining opening less than 3 cm was left to restore the normal geometry of the left ventricle as nearly as possible to its original state.The thinned aneurysm portion of the ventricular wall was resected,leaving an edge of at least 1 cm of scar tissue to obtain a secure closure.Linear closure was then accomplished by placing large horizontal mattress sutures through parallel Teflon strips placed on the epicardial surface along either side of the ventriculotomy.Finally the Lima was used to bypass the LAD coronary artery in 15 patients,even if the LAD was not perfused preoperatively with detectable collateral circulation.Besides,saphaneous veins were used to revascularize the other coronary vessels in 13 patients.New and old mural thrombi in ventricle were found in 9 patients.Results:All the patients weaned from the pump,including 3 patients supported by IABP and recovered without complications.Within 1 month to 15 months(mean 5)follow up,all the patients no longer had angina,their cardiac function was recovered back to class I II(NYHA)and all survived.Conclusion:Preliminary results,with the number of cases limited,show that the reconstruction of the left ventricle plus CABG is satisfactory in surgical treatment of LVA.