非体外循环冠状动脉旁路移植术后隐性肺动脉栓塞的治疗和预后

The treatment and prognosis of silent pulmonary embolism after off-pump coronary artery bypass graft surgery

目的探讨非体外循环冠状动脉旁路移植术（CABG）后隐性肺动脉栓塞（PE）的发生率及其治疗、预后。方法2009年12月至2012年9月，连续582例冠状动脉粥样硬化性心脏病（CHD）患者接受单纯非体外循环CABG。手术均由同一术者完成。患者平均（61．4±9．3）岁。常规取左乳内动脉及大隐静脉。术后当天胸腔积液少于50mFh后，给予普通肝素20mg静脉注射，6h1次。术后第1天开始口服阿司匹林100mg，每日1次。术后5～7天行64排冠状动脉cT检查旁路血管通畅情况并观察有无急性肺动脉栓塞（PE）。结果无住院死亡。术后共10例患者冠状动脉CT示急性PE，发生率为1．7％，均无明显胸闷气短等症状，心电图及超声心动图检查无特殊，无明显低氧血症。急性PE累及双侧肺动脉叶段分支6例，仅累及右肺动脉叶段分支4例。9例患者采用华法林抗凝治疗，1例未经特殊治疗。随访6～18个月，10例患者生活质量良好。8例患者经华法林抗凝治疗3～6个月后复查CT示急性PE完全消失。结论急性PE是非体外循环CABG术后少见并发症。临床表现均为隐性PE，不易诊断。冠状动脉CT检查是发现非体外循环CABG术后急性PE的敏感方法。非体外循环CABG术后急性PE预后较好，经华法林抗凝治疗后PE可完全消失。

Objective The purpose of this study was to assess the incidence, treatment and prognosis of silent pulmonary embolism （PE） after off-pump coronary artery bypass graft （CABG）. Methods From December 2009 to September 2012, 582 consecutive patients underwent off-pump CABG by a same surgeon. Their age ranged from 16 to 86 years with a mean age of （61.4 ±9.3） years. Left internal mammary artery and saphenous vein were harvested routinely. A dose of 20 mg unfraction- ated heparin was given intravenously every 6 hours on the operative day after postoperative pleural fluid less than 50 ml per hour. All patients received aspirin 100 mg daily starting on postoperative day 1. The 64-slice coronary MDCT was performed to assess the graft patency on postoperative day 5 - 7. Results There were no in-hospital death. PE, which involved the lobar or more proximal arteries, was detected on the CT images of 10 patients （ 1.7% ）. In these 10 patients, there were no significant dyspnea or hypoxemia postoperatively; echocardiography and ECG showed no specific signs of PE; all bypass grafts were patent in CT images except a LIMA to LAD graft with LAD endarterectomy. PE involved both lungs in 6 patients, and only the right lung in 4 patients. All patients received anticoagulation with warfarin for 3 to 6 months except one. All patients were with good quality of life during 6 to 18 months of follow-up. Three to six months after discharge, 8 patients received repeated MDCT, which showed diminish of PE. Conclusion Acute PE after off-pump CABG was an uncommon complication and was difficult to diagnose. MDCT played an important role in examining the patency of graft vessels and helped detect silent PE in CABG pa- tients. The prognosis of acute PE after off-pump CABG was acceptable. PE diminished after 3 months of anticoagulation with warfarin.