非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化手术的疗效分析

Analysis on the Clinical Efficacy of Off-pump Sequential Bilateral Internal Mammary Artery Grafting Combined with Selective Arterialization of the Coronary Venous System

目的评价非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化(CVBG)手术的临床疗效。方法回顾性分析2004年3月至2010年8月首都医科大学附属北京安贞医院38例有弥漫性右冠状动脉狭窄患者行手术治疗的临床资料。按手术方式不同将其分为两组,CVBG组:17例,男11例,女6例;年龄46.1±6.2岁;行非体外循环双乳内动脉序贯旁路移植加选择性心中静脉动脉化。对照组:21例,男14例,女7例;年龄45.9±5.7岁;仅行双乳内动脉序贯旁路移植,但对右冠状动脉系统未做处理。术中采用血流量仪测量移植血管的血流量,并对两组移植血管支数、气管内插管时间、住院时间、主要并发症发生情况、超声心动图指标、心肌核素扫描和冠状动脉造影检查结果等进行比较。结果围术期两组患者均无死亡,均无脑部、胸骨和纵隔感染等并发症发生。CVBG组移植血管支数与对照组比较差异有统计学意义(3.3±1.1支vs.2.2±1.6支,P<0.05)。CVBG组乳内动脉主干(81.5±32.7ml/min vs.76.8±28.4ml/min)、左乳内动脉主干(32.5±18.8ml/min vs.28.1±16.7ml/min)和右乳内动脉主干血流量(39.6±19.0ml/min vs.35.9±18.3ml/min)与对照组比较差异无统计学意义(P>0.05)。随访38例,随访率100%,随访时间3～55个月(37.4±9.8个月)。CVBG组所有患者均未出现心绞痛,心电图示:下壁心肌缺血明显改善;对照组术后有8例患者出现心绞痛,心电图示:有下壁心肌缺血,ST-T改变;两组间差异有统计学意义(P<0.05)。两组患者术后3个月心功能较术前明显改善。心肌核素扫描显示:CVBG组患者下壁心肌血液供应明显改善;冠状动脉造影证实动脉化后的冠状静脉内有血流通过。结论在非体外循环下行双乳内动脉序贯旁路移植加选择性心中静脉动脉化是可行的,术后患者心功能和生活质量均得到改善,为弥漫性右冠状动脉狭窄患者提供了新的外科治疗方法。

Objective To evaluate the clinical efficacy of sequential bilateral internal mammary artery grafting combined with selective coronary venous bypass graft（CVBG） during off-pump coronary artery bypass surgery.Methods We retrospectively analyzed the clinical data of 38 patients with diffuse right coronary arteriostenosis undergoing operation in Anzhen Hospital of Capital Medical University from March 2004 to August 2010.Based on the operation method,the patients were divided into two groups.In the CVBG group,there were 17 patients including 11 males and 6 females with an average age of 46.1±6.2 years who underwent off-pump sequential bilateral internal mammary artery grafting combined with CVBG.In the control group,there were 21 patients including 14 males and 7 females with an average age of 45.9±5.7 years,and they underwent the off-pump sequential bilateral internal mammary artery grafting without CVBG.Blood flow of bridged vessels was measured.The perioperative parameters including number of grafts,tracheal intubation time,hospitalization time,complications,results of echocardiography,myocardial nuclide imaging and coronary angiography were compared between the two groups of patients.Results There was no hospital mortality or complications such as cerebral events,sternal and mediastinal infections.There was statistical difference in graft number between CVBG group and control group（3.3±1.1 vessels vs.2.2±1.6 vessels,P〈0.05）.There were no statistical differences in internal mammary artery trunk blood flow（81.5±32.7 ml/min vs.76.8±28.4 ml/min）,left internal mammary artery trunk blood flow（32.5±18.8 ml/min vs.28.1±16.7 ml/min） and right internal mammary artery trunk blood flow（39.6 ±19.0 ml/min vs.35.9±18.3 ml/min） between CVBG and control group（P〉0.05）.Follow-up was done for all the 38 patients with a follow-up rate of 100%.Follow-up time was 3-55 months（37.4±9.8 months）.No angina symptoms occurred in CVBG group and myocardial blood supply of inferior wall in this groups improved obviously based on the results of electrocardiogram,while there were 8 cases of angina in the control group with inferior wall myocardial ischemia and ST-T changes according to the results of electrocardiogram（P〈0.05）.Heart functions were significantly improved in both groups three months after surgery.Through myocardial nuclide imaging,we found that myocardial blood supply of inferior wall was obviously improved in CVBG group.Coronary angiography in CVBG group showed that there was blood flow to myocardium in the arterialized vein.Conclusion Sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system can be performed during off-pump coronary artery bypass surgery.Cardiac functions and quality of life are improved after the surgery.This provides a new surgical method for diffuse right coronary lesions.