冠状动脉旁路移植术同期行心脏瓣膜手术47例临床分析

目的总结47例冠状动脉旁路移植术(CABG)同期行心脏瓣膜手术的方法及疗效,分析死亡和并发症的相关危险因素,探讨如何降低CABG同期行心脏瓣膜手术的病死率和并发症。方法对CABG同期行心脏瓣膜手术的47例患者的临床资料进行总结分析。结果 2006年1月～2011年12月,共行CABG+心脏瓣膜等手术47例,共移植血管146支,平均每例移植血管3.1支。同期行二尖瓣替换术15例,二尖瓣成形术17例,主动脉瓣替换术6例,双瓣置换加三尖瓣成形术9例。术后早期死亡5例(10.6%),术后患者平均住院时间(17.6±7.8)d。主要死亡原因:感染1例,低心排致多器官功能衰竭3例,恶性心律失常1例。相关危险因素:有心肌梗死,射血分数低、心功能差和合并症多特别是有肺部疾病、肺功能不全等与术后并发症及早期死亡有关。随访40例(85.1%),随访时间1～72个月,2例有心绞痛发作,所有生存患者心功能均得到明显改善。结论 CABG联合心脏瓣膜手术是治疗冠心病合并心脏瓣膜病变的有效方法,术前积极改善心肺功能、术中加强心肌保护、缩短主动脉阻断和心肌缺血时间,手术彻底纠正瓣膜功能以及尽可能的心肌再血管化,术后加强呼吸道管理,避免感染,对提高手术成功率、降低病死率和并发症有重要意义。

Objective To summarize the method and effect of coronary artery bypass grafting （CABG） combined with cardiac valve surgery in 47 patients, analyze the risk factors of operative mortality and complication, and improve the success rate of surgery. Methods From January 2006 to December 2011, 47 patients received CABG combined with cardiac valve surgery. All patients received 146 grafts, an average of 3.1 grafts per patient. Meanwhile, 15 patients received mitral valve replacement,17 patients received mitral valvuloplasty, 6 patients received aortic valve replacement, 9 patients received double-valve replacement combined with tricuspid valvuloplasty. Results Five patients died in the early stage after surgery. The postoperative hospital stay of patients was 17.6±7.8 days on average. Leading causes of death：infection in 1 case ,low cardiac output syndrome combined with MODS in 3 case and malignant arrhythmia in 1 case. Risk factors： severe cardiac valvular heart disease,the history of preoperative myocardial infarction, heart dysfunction and low ejection fraction, combined with pulmonary diseases are related with death in the early stage after surgery. Postoperative complications included low cardiac output syndrome,pulmonary infection,hernorrhage,arrhythmias,neurological complications. All patients with postoperative complications were cured by appropriate treatment, 40 patients （85.1%） were followed for 1 to 72 months,angina and heart failure symptoms and signs were improved significantly. Conclusion CABG combined with heart valve surgery is an effective treatment way for coronary heart disease combined with valvular heart disease. The success rate of surgery can be improved by actively improving cardiopulmonary function before surgery, enhancing myocardial protection and reducing the aortic cross-clamping and myocardial ischemia time,as far as possible revascularization, enhancing management of respiratory tract and free from infecton.