合并胸腔粘连患者行左前外侧胸部小切口冠状动脉旁路移植术的安全性

Safety of Minimally Invasive Direct Coronary Artery Bypass Grafting via Left Anterior Small Thoracotomy for Patients With Left Pleural Adhesion

目的探讨左前外侧胸部小切口不停跳冠状动脉旁路移植技术在胸腔粘连患者中应用的安全性。方法2015年8月~2019年4月,16例合并左侧胸腔粘连的冠心病患者接受经左前外侧胸部小切口不停跳冠状动脉旁路移植手术。其中胸腔非特异性炎性粘连10例,左侧胸腔手术(肺叶切除)后粘连4例,左侧胸腔陈旧性结核性胸膜炎2例。经左前外侧第5肋间切口分离胸膜粘连并游离左侧乳内动脉,完成左侧乳内动脉到前降支的旁路移植。放置左侧胸腔引流管后恢复为双肺通气并关闭切口。结果16例均按计划完成左侧乳内动脉的获取及与前降支的吻合。左乳内动脉获取时间22~37(27±6)min,呼吸机使用时间5~12(8.1±3.7)h,监护室停留时间16~31(22.5±10.6)h。16例均未输血,术后顺利恢复。其中10例出院前冠脉造影检查确认桥血管通畅。随访时间3~32个月,中位数15个月,无主要不良心脑血管事件发生。结论合并左侧胸腔粘连者接受左前外侧胸部小切口旁路移植手术是安全的,细致分离粘连胸膜可以改善术野显露,保证手术效果。

Objective To investigate the safety of minimally invasive direct coronary artery bypass grafting(MIDCAB)procedure via left anterior small thoracotomy for patients with left pleural adhesion.Methods From August 2015 to April 2019,16 patients who underwent MIDCAB were diagnosed with left pleural adhesion.There were 10 patients with nonspecific inflammatory pleural adhesion,4 patients with previous left lung surgery and 2 with tuberculous pleural adhesions.The left internal mammary artery was separated from the pleura through the left anterior lateral 5 th intercostal incision and the left internal mammary artery was freed to complete the bypass grafting from the left internal mammary artery to the anterior descending branch.After placement of the left thoracic drainage tube,double lung ventilation was restored and the incision was closed.Results The left internal mammary artery was obtained and anastomosed with anterior descending artery in all 16 cases.The acquisition time of left internal mammary artery was 22-37(mean,27±6)min,the use time of ventilator was 5-12(mean,8.1±3.7)h,and the stay time of monitoring room was 16-31(mean,22.5±10.6)h.None of the 16 patients received blood transfusion and recovered smoothly.Coronary angiography was performed in 10 patients before discharge.The follow-up time ranged from 3 to 32 months,with a median of 15 months.No major adverse cardiovascular and cerebrovascular events occured.Conclusions MIDCAB procedure under direct vision is safe for patients with left pleural adhesion.Careful separation of adherent pleura can improve the exposure of operation field and ensure the effect of operation.