胸骨下段小切口和全胸骨切口OPCABG治疗三支血管病变对比研究

A comparative study of mini-sternotomy and full-sternotomy for off-pump coronary artery bypass grafting in triple-vessel disease

目的 对比研究胸骨下段'L'形小切口微创不停跳冠状动脉旁路移植手术(OPCABG)与常规OPCABG治疗冠心病三支病变的可行性、有效性和安全性.方法 2013年8月至12月期间160例冠状动脉三支血管病变患者,按区组随机化分组为经胸骨下段小切口OPCABG、全胸骨切口OPCABG两组,每组80例.由同一术者实施手术,术后随访.结果 两组围手术期均无死亡,无术中中转体外循环.两组平均旁路血管数量、新发房颤例数差异无统计学意义(P＞0.05).与全胸骨切口组相比,胸骨下段小切口组的平均手术时间、左乳内动脉采集时间、气管插管时间、胸骨切口长度、ICU停留时间、住院天数等指标明显优于前者.另外,胸骨下段小切口组95.0％(76/80)保持了左侧胸膜的完整性,高于全胸骨切口组(75.0％,60/80).胸骨下段小切口组术后24 h心包纵隔引流量为(294.22±124.71) ml,明显少于全胸骨组(407.80±146.97) ml,差异有统计学意义(P=0.04).胸骨下段小切口组输血5例(6.3％),全胸骨组56例(70.0％).术后6个月所有患者均接受冠状动脉CT检查,两组各有4例大隐静脉旁路血管闭塞(6个月通畅率95.0％).随访12～ 16个月期间无患者死亡.结论 经胸骨下段小切口OPCABG手术不增加手术病死率及并发症发生率,避免了全胸骨切开,具有脱机拔管早、ICU停留时间短、输血少、住院天数少、恢复快等优势.经胸骨下段小切口OPCABG手术治疗三支血管病变有良好的可行性、有效性及安全性,是微创冠脉旁路移植治疗三支血管病变的有效方法.

Objective Evaluated the feasibility, validity, and safety of mini-sternotomy off-pump coronary artery bypass grafting for triple-vessel disease.Methods One hundred and sixty patients with triple-vessel coronary artery disease were randomly assigned to undergo OPCABG with mini-sternotomy or full-sternotomy.All operations were performed by the same surgeon, and followed up from 12 to 16 months.Results There was no perioperative mortality or conversion to on-pump.The mean number of grafts, new-onset atrial fibrillation was no statistical difference in both groups.The mean operative time, left internal mammary artery harvest time, duration of intubation time, the skin incision, intensive care unit and hospital lengths of stay were shorter in the mini-sternotomy group comparing with full-stertonomy group.Left pleural integrity was maintained in 76(95.0％) mini-sternotomy patients and in 60(75.0％) full-stemotomy patients.Drainage in the first 24 postoperative hours was (294.22 ± 124.71) ml for mini-sternotomy patients and (407.80 ± 146.97) ml for full-sternotomy patients (P =0.04).In the mini-sternotomy group, only 5 patients(6.3％) required red blood cell transfusion, whereas 56(70.0％) full-stemotomy patients needed blood cell transfusion.All patients were followed up with computed tomography coronary angiography 6 months postoperatively, only 4 saphenous vein grafts became occluded in each group(6-month patency 95.0％).There were no postoperative deaths in the following-up period for 12-16 months.Conclusion Mini-sternotomy OPCABG avoids full stemotomy,allows early extubation, shortens ICU and hospital stay, and allows an earlier return to normal activities than full-sternotomy OPCABG.We conclude that mini-sternotomy for coronary artery bypass on the beating heart in triple-vessel disease is a safe and feasible procedure in selected patients, with excellent procedural and short-term outcomes and midterm graft patency.