Total Arterial Revascularization with Internal Mammary Artery or Radial Artery π Graft Configuration

Summary： To investigate the clinical use of π graft in total arterial revascularization and its outcomes, a retrospective analysis of 23 patients out of 1000 patients undergoing total arterial coronary bypass surgery with a π graft between September 1994 and December 2004 was performed. In the selected patients for the management of triple vessel disease with middle diagonal/intermediate ramus disease such that a skip with the left internal mammary artery （LIMA） or radial artery （RA）, the main stem of π graft, to the left anterior descending coronary artery （LAD） will not work and the right internal mammary artery （RIMA） or right gastroepiploic artery （RGEA） cannot pick up the diagonal/intermediate ramus, hence the LAD and diagonal/intermediate ramus were grafted with a mini Y graft using the distal segment of LIMA, RIMA, RA or RGEA, together with the bilateral internal mammary artery （BIMA） or LIMA-RA T graft to compose π graft. Twenty-three patients （18 males, 5 females） underwent the π graft procedure. There were no deaths or episodes of myocardial infarction, stroke, and deep sternal wound infection. One patient required reopening for controlling bleeding. Until the end of 2004, during a mean follow-up of 81.0±28.4 months, no angina needing re intervention or operative therapy or coronary related death occurred. In conclusion, in patients with specific coronary artery anatomy/stenosis, the BIMA （sometimes LIMA with RA or RGEA） π graft can be successfully performed for total arterial revascularization with good midterm outcomes.

Semi-skeletonized Internal Mammary Grafts and Phrenic Nerve Injury:Cause-and-effect analysis

Summary： Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complications. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectively collected data on 2084 consecutive patients who underwent cardiac surgery from Jan. 1995 to Feb. 2002 were analyzed. Twenty-eight preoperative and operation related variables were subjected to logistic analysis with the end point being phrenic nerve injury. Then phrenic nerve injury and 6 perioperative morbidities were included in the analysis as variables to determine their independent predictive value for perioperative pulmonary morbidity. An identical approach was used to identify the independent risk factors for perioperative mortality. There were 53 phrenic nerve injuries （2.5 %）. There was no phrenic nerve injury in non-coronary surgery or coronary surgery using conduits other than the internal mammary artery. The independent risk factors for phrenic nerve injury were the use of internal mammary artery （Odds ratio （OR）=14.5） and the presence of chronic obstructive pulmonary disease （OR=2.9）. Phrenic nerve injury was an independent risk factor （OR=8.1） for perioperative pulmonary morbidities but not for perioperative mortality. Use of semi-skeletonized internal mammary artery harvesting technique and drawing attention to possible vascular or mechanical causes of phrenic nerve injury may reduce its occurrence. Unilateral phrenic nerve injury, although rarely life-threatening, is an independent risk factor for postoperative respiratory complications. When harvesting internal mammary arteries, it should be kept in mind avoiding stretching, compromising, or inadvertently dissecting phrenic nerve is as important as avoiding damage of internal mammary artery itself.

Total Arterial Revascularisation in Left Ventricular Dysfunction

The feasibility and safety of total arterial coronary revascularization with 2 arterial conduits in patients with impaired left ventricular function was evaluated. Data were prospectively collected on all patients with multiple vessel disease and moderately or severely impaired left ventricular function, who underwent coronary surgery with the intention of total arterial revascularization with 2 conduits between March 1995 and August 2002. One hundred and seventy-nine patients were included in the study. Acute coronary insufficiency was present in 3 patients and 43 had unstable angina. Severe left ventricular impairment was present in 29 patients. There were 17 redo operations including 3 redo-redo procedures. Eighty-two percent of patients had a Y graft configuration from the left internal mammary artery （right internal mammary artery 40. 8 %, radial artery 33. 5 %, other 7.8 % ）. The perioperative mortality was 2. 2 %, myocardial infarction 1.7 % and stroke 0. 6 %. Total arterial revascularization in patients with ischaemic left ventricular dysfunction can be safely performed with 2 arterial conduits. The radial artery provides conduit length greater than the right internal mammary artery and allows full revascularization despite left ventricular dilatation.

双侧乳内动脉π型桥全动脉化冠状动脉旁路移植术

目的 研究 π型桥全动脉化心肌血运重建的临床应用。 方法 1994年 9月到 2 0 0 2年 8月对 2 2例患者根据冠状动脉病变解剖特点选用π型桥进行全动脉化心肌血运重建 ,即 3支血管病变合并对角支 /中间支中段病变时 ,采用由左侧乳内动脉小 Y型桥与前降支和对角支 /中间支吻合 ,与双侧乳内动脉 T型桥共同构成 π型桥。 结果本组无围术期死亡 ,无心肌梗死、脑血管意外和胸骨感染发生 ;1例患者术后二次开胸止血。随访 6 0 .7± 2 3.0个月 ,无心绞痛复发需要冠脉介入治疗或手术治疗者 ,也无冠心病导致的死亡发生。 结论 对 3支血管病变合并对角支 /中间支中段冠脉病变的患者 ,双侧乳内动脉 π型桥可以顺利完成全动脉化心肌血运重建 ,中期效果良好。

双侧半裸乳内动脉与胸部切口并发症

目的 评价双侧半裸乳内动脉冠脉旁路移植术胸部切口并发症的危险因素。方法 前瞻性收集 75 1例应用双侧半裸乳内动脉冠脉旁路移植术的患者进行分析。患者平均年龄 (5 5 .8± 7.8)岁 ,4 4例 (5 .8% )年龄 >6 6岁 ;男性 6 33例 (84 .3% ) ;糖尿病 170例 (2 2 .6 % )。结果 4 4例 (5 .8% )胸部切口并发症。 2 2例 (2 .9% )胸骨感染 ,其中 15例 (2 .0 % )胸骨感染合并纵隔炎 ,7例 (0 .9% )仅有胸骨感染。胸部切口并发症的独立危险因素包括周围血管疾病 (OR :5 .0 )、饮食控制的糖尿病 (OR :5 4 5 )和延迟关胸 (OR :2 2 .9)。胸骨感染的独立危险因素包括糖尿病 (OR :2 .70 )、术后肺部并发症 (OR :4 .80 )和术后脑血管意外 (OR :2 1.6 )。围术期死亡率 1.5 % (11/75 1) ,其中 2例胸骨感染。结论 应用双侧半裸乳内动脉进行全动脉冠脉旁路移植术不增加胸部切口并发症。糖尿病。

间歇微温血心脏停搏液改善心肌保护

目的 研究微温血心脏停搏液的心肌保护效果。方法 前瞻性收集 15 33例体外循环病人的临床资料进行分析。微温血组 :5 82例病人于 1998年 7月至 2 0 0 0年 7月用间歇微温血心脏停搏液 (2 8℃ ) ;冷血组 :95 1例病人于 1994年 9月至 1997年 11月用冷血心脏停搏液 (4℃ )。用χ2 检验、两样本均数 t检验和多变量 L o-gistic回归分析对 2 7项病人相关变量和 18项预后相关变量进行分析。对高危和常规冠状动脉旁路移植的病人进行进一步的分析。结果 两组临床资料相似 ,但微温血组病人症状重、有更多的再次手术和复合手术、更多的手术在急性心肌梗死 7d以内。微温血组术后需要主动脉内球囊反搏率 (2 .2 % vs4 .4 % ,P=0 .0 2 4 )和房颤率 (2 0 .6 %vs2 5 .7% ,P=0 .0 2 6 )明显较冷血组少。死亡率、围术期心肌梗死、脑血管事件和血管活性药物应用两组无明显区别。

心脏外科术后肺部并发症危险因素分析

目的:分析心脏外科术后肺部并发症的围手术期危险因素及其影响。方法:分析1995年1月～2002年2月间连续2084例正中切口右房-升主动脉体外循环心脏外科手术术前、术中及术后相关因素,观察它们在围手术期肺部并发症中的作用。结果:共有136例肺部并发症(6.5%)。肺部并发症的术前危险因素包括女性(相对危险度OR=1.49)、吸烟(OR=1.64)、慢性阻塞性肺部疾病(OR=2.36),术中危险因素包括应用冷心脏停搏液(OR=1.56),术后危险因素包括需要血管活性药物支持(OR=2.00)、2次开胸(OR=2.08)、主动脉内球囊反搏(OR=2.39)、胸腔积液(OR=2.63)、术后脑血管意外(OR=5.45)、膈神经损伤(OR=8.09)、以及术后肾功能衰竭需用肾透析(OR=12.87)。围手术期肺部并发症不是围手术期死亡的危险因素。结论:心脏外科术后多种围手术期危险因素增加术后肺部并发症的发生,特别是术后脑血管意外、膈神经损伤、以及肾功能衰竭需要肾透析对围手术期肺部并发症的发生影响最为明显。对此类患者需特别注意保护肺功能,以减少并发症的发生。围手术期肺部并发症不是围手术期死亡的危险因素。

全动脉化冠状动脉旁路移植术在左心功能不全患者中的应用

目的：评估2根动脉桥血管全动脉化冠状动脉（冠脉）旁路移植术在左心功能不全患者中应用的可行性和安全性。方法：前瞻性收集1994年11月～2002年8月用2根动脉桥血管进行全动脉化冠脉旁路移植术的179例左室射血分数（LVEF）〈50％（正常≥70％）的冠脉多支病变临床病例进行研究。其中急性冠脉综合征3例，不稳定型心绞痛43例；LVEF〈30％29例；2次手术14例，3次手术3例。82％的患者应用含有左侧乳内动脉的Y型桥（其中右乳内动脉40．8％，桡动脉33．5％，其他7．8％）。结果：左心功能不全组围术期死亡率2．2％，心肌梗死1．7％，脑血管意外0．6％，胸骨感染3．3％，呼吸衰竭7．8％，与左心功能正常组相比较差异无统计学意义。结论：左心功能不全患者可以安全地用2根动脉桥血管进行全动脉化冠脉旁路移植术。桡动脉长于右乳内动脉，即使左心功能不全（左室扩大）的情况下也足以完成全动脉化冠脉旁路移植术。