非体外循环下对多支冠状动脉病变的外科治疗

The treatment of multivessel coronary artery off-pump bypass grafting

目的 为避免体外循环可为冠心病患者带来严重的并发症 ,本研究对一些选定的病例采用冠状动脉旁路移植术这一新的心肌血管重建技术 ,并证明该技术安全、有效。方法 选择 5 9例血管条件较好的患者接受非体外循环下多支冠状血管搭桥术 ,患者血管病变主要累及左冠状动脉 ,且大多伴有冠心病外科手术高危因素。平均搭桥 2 .7根。结果 早期结果 :手术死亡 1例 (1.7% ) ,手术转换 2例 (3.4 % ) ,“桥”失败 1例 (1.7% ) ,术后非致命性心肌梗塞 4例 (6 .8% ) ,肾功能衰竭 1例 (1.7% ) ,胸骨感染 1例 (1.7% ) ,接受输血 19例 (32 .3% )。早期随访情况 :死亡 2例 ,心绞痛复发 4例 ,充血性心功能衰竭 1例 ;术后均无脑血管意外、再次手术止血、室上性心律失常、下肢感染和呼吸衰竭等并发症。平均住院日减少 1.3d ,用血量减少 5 0 % ,住院费用减少 1/ 3。随访病例中行冠状动脉血管造影术 4 7例 ,其中仅 2 .6 %的血管桥狭窄大于 5 0 % ,所有胸廓内动脉血管桥均通畅。结论 对具有冠心病的外科手术高危因素、多支冠状动脉病变者 ,采用非体外循环下冠心搭桥术 ,可以降低术后并发症的发生率及手术死亡率。该技术仅适用于冠状动脉解剖条件较好的病例 。

Objective To avoid the deleterious effects of cardiopulmonary bypass(CPB) , especially in high-risk patients, coronary artery bypass grafting(CABG) without cardiopulmonary bypass is now an accepted technique of myocardial revascularization for a special subset of patients. The purpose of this study was to determine the safety and efficacy of off-pump multivessel CABG. Methods CABG was preformed on 59 patients without CPB between April 1998 and October 2000. Patients were selected on the basis of coronary anatomy, with significant stenosis in the left coronary and right coronary, some of them had high risk conditions. Mean number of grafts was 2.7. Results Early unfavorable outcome events include operation mortality (1 patient , 1.7%), conversion (2 patients, 3.4%) , graft failure (1 patient, 1.7%), nonfatal perioperative myocardial infarction (4 patients, 6.8%), renal failure (1 patient, 1.7%), sternal infection (1 patient, 1.7%), transfusion requirement (19 patients, 32.3%). Upon early follow up (postoperation range 1-13 months, mean 5.3 months), there were 2 deaths, and 4 patients in whom angina returned, 1 patient was suffered with congestive heart failure. There was no incidence of stroke, reentry for bleeding, ventricular arrhythmia and leg infection. There was a reduction in length of stay by 1.3 days, blood transfusion by 50% and hospital charges by one third in the group. Graft patency was investigated using angiography in 47 patients. 2.6% grafts were narrowed by more than 50%. All internal mammary artery grafts were widely patent. Conclusion CABG without CPB can be performed with relatively low operative mortality and morbidity in certain high risk subgroups of patients with symptomatic multivessel coronary artery disease. However, this procedure should be considered only for patients with suitable coronary anatomy. Long time follow up is needed to further clarify patients selection and the long term outcome of this approach.