摘要
目的总结体外与非体外循环冠状动脉旁路移植术治疗冠心病患者的临床经验,以提高相关手术技术水平及治疗效果。方法2000年1月至2009年3月我科对698例冠心病患者行冠状动脉旁路移植术,其中男551例,女147例;年龄28.0～79.0岁,平均年龄67.2岁。典型心绞痛552例,陈旧性心肌梗死131例。心功能分级(NYHA)Ⅱ级301例,Ⅲ级339例,Ⅳ级58例。选择性冠状动脉造影显示:单支血管病变21例,2支病变87例,3支病变590例,合并左主干病变201例。行非体外循环下冠状动脉旁路移植术346例,体外循环下冠状动脉旁路移植术352例。择期手术687例,急诊手术11例。结果全组共移植血管2025支,每例移植血管1～6支,平均2.9支。术中取左乳内动脉693支,游离右乳内动脉115支,左桡动脉229支,右桡动脉81支;全动脉化126例。呼吸机辅助呼吸时间0～127h,平均11.5h。应用"快通道"技术在手术室清醒并拔除气管内插管后回ICU38例。应用主动脉内球囊反搏28例(术前置入1例,术中、术后置入27例)。择期手术死亡25例(3.64%),死于急性心肌梗死5例,低心排血量综合征3例,鱼精蛋白过敏2例,呼吸衰竭3例,肾功能衰竭2例,多器官功能衰竭10例;急诊手术死亡4例(36.36%),死于低心排血量综合征3例,急性心肌梗死1例。术后新发心房颤动151例(21.63%),其中147例(97.35%)给予补充电解质、应用抗心律失常(盐酸胺碘酮)等治疗后转为窦性心律;二次开胸止血术12例;出院时心绞痛消失511例,缓解20例。随访415例(62.03%),随访时间1个月～8.2年,随访期间死亡3例,死于肺癌1例,交通伤1例,原因不明1例。心绞痛消失317例,复发21例。心功能分级(NYHA)Ⅱ级269例(65.29%),Ⅲ级142例(34.46%),Ⅳ级1例(0.24%)。结论结合中国人的病情特点,制定相应的手术方案,合理选择旁路移植血管,可保证和优化外科手术效果;主动脉内球囊反搏可有效地改善重症患者的预后,对其使用应积极果断,以免失去最佳的支持时机。
Objective To summarize the experiences of off-pump coronary artery bypass grafting （off-pump CABG） and on-pump coronary artery bypass grafting （on-pump CABG） for patients with coronary artery diseases and to improve the surgical techniques and clinical results. Methods Coronary artery bypass grafting（CABG） were performed from January 2000 to March 2009 on 698 consecutive cases,including 551 male and 147 female with a mean age of 67.2 years（range,28.0-79.0）. There were 552 cases with angina pectoris and 131 with old myocardial infarction. Preoperative cardiac function showed 301 cases in New York Heart Association classⅡ,339 in class Ⅲ,and 58 in class Ⅳ. Coronary angiography revealed single vessel disease in 21 cases,2-vessel disease in 87,3-vessel disease in 590,and 201 cases had concomitant left main lesions.There were 687 elective CABG and 11 emergency / urgent ones. Off-pump CABG were performed on 346 cases and the others received on-pump CABG. Results A total number of 2 025 grafts（ range,1-6 grafts,mean,2.9 grafts /case ） were constructed with 693 left internal mammary arteries,115 free right mammary arteries,229 left radial arteries,and 81 right radial arteries. Total arterial bypass grafting was feasible on 126 cases. Postoperative ventilation duration varied from 0-127 hours （mean,11.5 hours）. Fast-track procedure was offered to 38 cases with good results.Intro-aortic balloon pump support were provided to 1 patient preoperatively and 27 postoperatively. There were 25 deaths with a mortality of 3.64% for the elective cases with the cause of acute myocardial infarction （ 5 cases ）,low cardiac output syndrome （3 cases）,protamine reaction （2 cases）,respiratory failure （3 cases）,renal failure （2 cases）,and multiorgan failure （10 cases）.Four deaths occurred to urgent cases with a mortality of 36.36% from low cardiac output syndrome （ 3 cases） and acute myocardial infarction （1 case）. One hundred and fifty-one cases（21.63%）developed atrial fibrilation among which 147（97.35%）returned to sinus rhythem with administration of electrolytes and Amiodarone. Resternotomy were performed for bleeding in 12 cases. Upon discharge from the hospital,511 patients were free from angina while 20 other patients still had coexisting relieved angina. Postoperative follow-up was carried out on 415 cases（62.03%）for a period of 1month to 8.2 years with 3 deaths for lung cancer （1 case）,car accident（1case）,and unknown reasons （1 case）. Number of patients who were free from angina was 317 and 21 for those who had recurrent angina. The cardiac function improved with 269 cases（65.29%）in New York Heart Association class Ⅱ,142（34.46%）class Ⅲ,and 1（0.24%） class Ⅳ. Conclusion Good surgical results could be achieved with careful analysis of native Chinese patients＇ coronary vessels,individualized operative plan,control of operative risk factors,and proper selection of bypass conduits. Aggressive use of IABP can provide essential support for patients with poor left ventricular function and other high risk factors.
出处
《中国胸心血管外科临床杂志》
CAS
2009年第6期430-434,共5页
Chinese Journal of Clinical Thoracic and Cardiovascular Surgery
基金
卫生部2008年科学研究基金医学科技攻关计划重大项目(WKJ2008-2-009)~~
关键词
冠心病
冠状动脉旁路移植术
非体外循环
桡动脉
全动脉化
Coronary arterial disease
Coronary artery bypass grafting
Off-pump
Radial artery
Totalarterial bypass
