正中开胸和小切口冠状动脉旁路移植术治疗单支血管病变的对比分析

Comparison of sternotomy off-pump coronary artery bypass and minimally invasive technique for isolated single vessel grafting

目的回顾性比较分析全机器人（daVinci）乳内动脉（IMA）游离小切口冠状动脉旁路移植术（CABG）和正中开胸术治疗单支血管病变，评估前者的疗效和安全性。方法2000年4月至2011年8月，解放军总医院心外科共完成194例单纯非体外循环单支CABG，根据手术方式分为正中开胸组（99例）和全机器人IMA游离、小切口CABG组（95例）。所有患者术前均有不同程度的心绞痛症状，经冠状动脉造影证实有严重的前降支（LAD）病变。小切口组以机器人游离IMA，再经胸部小切口徒手完成与靶血管的吻合。术中均以超声血流检测仪测量桥血管血流。术后以冠状动脉造影或64排CT评估桥血管的通畅性，并进行随访。结果小切口组呼吸机辅助时间和术后引流量优于正中开胸组，差异均有统计学意义[（5．1±2．1）h比（10．1±5．8）h，P=0．003；（411±295）ml比（605±244）ml，P=0．000]，两组桥平均血流量、病死率和并发症发生率差异均无统计学意义。术后早期CT检查及造影检查未发现桥血管狭窄。随访2个月至10年，均恢复正常工作生活。结论与正中开胸比较，全机器人IMA游离、小切口治疗单支病变是一种全新的术式，创伤轻、疗效肯定，手术安全。

Objective To compare the outcomes of minimally invasive coronary artery bypass grafting operation performed via a small thoracotomy versus da Vinci S system （Endo-A-CAB） with sternotomy off-pump coronary artery bypass grafting （OPCAB） for single vessel lesion. Methods From April 2000 to August 2011, a total of 194 patients with single coronary artery stenosis accepted CABG on beating heart were divided into 2 groups by different surgical approaches. Group A （ n = 99 ） received sternotomy OPCAB while Group B （ n = 95 ） underwent Endo-A-CAB. All patients had a history of unstable angina and coronary arteriography showed severe stenosis in left anterior descending artery （LAD）. The procedure performed in Group B included robotic internal mammary artery （IMA）harvesting and single manual anastomosis to LAD and/or diagonal branch through small incision thoracotomy. IMA flow was evaluated by the Doppler flow meter after the completion of anastomosis. Grafting patency was evaluated postoperatively by computed tomography angiography （CTA） or angiography. Results The ventilation time and postoperative drainage volume in Group B were less than those in Group A （ （ 5.1± 2.1 ） vs （ 10.1±5.8 ） h, P = 0.03 ; （411± 295 ） vs （605± 244 ） ml, P = 0. 000 ）. No significant difference existed in blood flow, mortality and postoperative complication morbidity between two groups. MI symptoms of angina disappeared. Conclusion As a new advanced modality of revascularization, in comparison with OPCAB, Endo- A-CAB procedure is a less invasive and safer method of coronary artery bypass grafting for single vessel lesion.