升主动脉粥样硬化患者的冠状动脉旁路移植

Coronary artery bypass graft for patients with ascending aorta atherosclerosis

目的 总结冠状动脉粥样硬化性心脏病合并升主动脉粥样硬化患者冠状动脉旁路移植手术的特点。 方法 2 2例患者中 ,13例采用非体外循环、心脏不停跳下冠状动脉旁路移植术(5 9% ) ;9例采用低温体外循环 (41% ) ,其中 5例在深低温、低流量并间断停循环条件下不阻断升主动脉行旁路 升主动脉近端吻合。 结果 2 0例康复出院 ,术后早期死亡 2例 ;并发症有肺部感染、心绞痛、室颤、急性心肌梗死和血胸 ,无神经系统并发症。 结论 减少术中升主动脉操作是防止升主动脉损伤和减少并发症的关键。应用带蒂动脉旁路、旁路远端序贯吻合和近端Y形吻合可避免或减少旁路 升主动脉吻合 ;低温体外循环加左心室引流时 ,可不阻断升主动脉行旁路远端吻合 ;深低温、低流量并间断停循环下行旁路 升主动脉吻合 ,可避免阻断和部分阻断升主动脉 ,利于控制并发症。

Objective The increasing number of aged patients with severe ascending aorta atherosclerosis who are undergoing coronary artery bypass graft (CABG) present high risk for ascending aortic cannulation, cross clamping or partial occluding and proximal anastomosis. We reviewed the surgical experience in 22 patients of CABG with ascending aorta atherosclerosis and tryied to find the way to minimize the complications. Methods Twenty two patients with severe atherosclerotic and calcified ascending aorta underwent CABG in our hospital. Thirteen of them received CABG on beating heart. Nine patients had their CABG with extracorporeal circulation. With deep hypothermia, we reduced the flow rate and intermittently arrested the circulation for the proximal anastomosis on ascending aorta in 5 patients with neither cross clamping nor partial occluding. The sequential grafts and “Y” type anastomosis between reversed saphenous venous grafts were employed. Results Twenty of the patients survived after surgery. One died of inhalation pneumonia in two weeks after surgery. Another died of right hemothorax in ten days after surgery. The complications include: pneumonia 4 patients (18%), angina 2 patients (9%), ventricular fibrillation 1 patients (5%), post CABG myocardium infarction 1 case(5%) and hemothorax 1 case(5%). There is no neurologic complications or aortic dissection after CABG. Conclusion CABG on beating heart with pedicel arterial grafts is the best approach to performing the surgery without touching the diseased ascending aorta. Ventricular fibrillation under mild hypothermia cardiopulmonary bypass and left ventricular suction were employed for quiet and bloodless field while distal anastomosis had no cross clamping the ascending aorta. Also deep hypothermia and intermittently circulatory arrest offer quiet and bloodless field for the proximal anastomosis on ascending aorta without cross clamping or partial occluding. Distal sequential anastomosis and proximal “Y” type anastomosis are the effective approach to minimizing the proximal anastomosis on the ascending aorta.