再次冠状动脉旁路移植术的临床分析

Clinical Analysis of Redo Coronary Artery Bypass Grafting

目的总结再次冠状动脉旁路移植术(CABG)的经验,探讨适于国人的合理再次CABG方法。方法回顾性分析北京大学人民医院2000年1月至2010年1月再次CABG 27例患者的临床资料,男15例,女12例;年龄41～84(63±8)岁。第二次距第一次CABG时间平均45(4～168)个月,术前均为不稳定型心绞痛,其中心功能分级(NYHA)Ⅰ级、Ⅱ级21例,Ⅲ级、Ⅳ级6例。术前左心室舒张期末内径(LVEDD)41～69(51.0±0.7)mm,左心室射血分数(LVEF)32%～78%(58%±12%)。27例患者再次手术时新发病变6处,乳内动脉病变7处,桡动脉病变3处(其中1例仅为近端吻合口病变),大隐静脉病变49处(其中3处单纯近端病变、3处单纯远端病变)。结果再次手术入路选择正中原切口入路18例,左外侧切口8例,上腹正中联合剑突下切口1例。再次手术采用非体外循环冠状动脉旁路移植术(OPCAB)25例,术中中转为体外循环CABG 2例。再次手术共完成远端吻合口65个,近端吻合口41个;应用左乳内动脉10例次,右乳内动脉3例次,左桡动脉16例次,右桡动脉2例次,大隐静脉17例次。完成远端吻合口1～4(2.4±0.8)个/例。手术时间170～530(304±86)min,术后输红细胞0～10(4.3±3.5)U,输血浆0～1 600(685±549)ml。术后机械通气时间6～156(24±32)h,术后住院时间7～35(14±6)d,无住院死亡患者,术后所有患者心绞痛症状均消失,康复出院。随访26例,失访1例,平均随访80(13～133)个月;无症状生存16例,死亡4例,症状复发或心力衰竭6例。结论 OPCAB为再次CABG的一种有效术式,但应做好体外循环准备,再次CABG时应尽可能多选择动脉移植血管材料,术中把握个体化原则。

Objective To summarize our experience of redo coronary artery bypass grafting（CABG） and explore appropriate redo CABG strategy for Chinese patients.Methods We retrospectively analyzed clinical data of 27 patients who underwent redo CABG in People＇s Hospital of Peking University from January 2000 to January 2010.There were 15 male patients and 12 female patients with their age of 41-84（63±8） years.The mean time between the first CABG and the redo CABG was 45（4-168） months.Preoperatively all the patients had unstable angina pectoris.Twenty-one patients were in New York Heart Association（NYHA） functional classⅠ-Ⅱ,and 6 patients were in NYHA functional classⅢ-Ⅳ. Preoperatively,their left ventricular end-diastolic dimension（LVEDD） was 41-69（51.0±0.7） mm,and their left ventricular ejection fraction（LVEF） was 32%-78%（58%±12%）.At the time of redo CABG for the 27 patients,there were 6 new coronary artery lesions,7 left internal mammary artery（LIMA） lesions,3 radial artery lesions（including 1 proximal anastomosis lesion alone） and 49 saphenous vein graft（SVG） lesions（including 3 proximal lesions alone and 3 distal lesions alone）.Results The surgical approach of redo CABG included median sternotomy in 18 patients,left lateral thoracotomy in 8 patients,upper midline abdomen and subxiphoid incision in 1 patient.Off-pump coronary artery bypass grafting（OPCAB） surgery was performed in 25 patients,but intra-operatively 2 patients underwent conversion to CABG under cardiopulmonary bypass.A total of 65 distal anastomoses and 41 proximal anastomoses were performed during redo CABG.A total of 10 LIMA,3 right internal mammary artery（RIMA）,16 left radial artery,2 right radial artery and 17 SVG were used in redo CABG.There were 1-4（2.4±0.8） distal anastomoses for each patients.The operation time was 170-530（304±86）min.Postoperative transfusion was 0-10（4.3±3.5） U packed red blood cells and 0-1 600（685±549） ml fresh frozen plasma for each patient.Postoperative mechanical ventilation time was 6-156（24±32） h and postoperative hospital stay was 7-35（14±6） d.There was no in-hospital death.All the patients were discharged without any angina symptoms.A total of 26 patients were followed up and 1 patient was lost with the mean follow-up time of 80（13-133） months.During follow-up,16 patients were alive without angina symptoms,4 patients died,and 6 patients had recurrent angina symptoms or heart failure.Conclusion sOPCAB is an effective surgical strategy of redo CABG,but cardiopulmonary bypass should also be prepared.Arterial graft should be use as long as possible in redo CABG and the surgical strategy should be individualized.