182左室射血分数≤30%的病人冠状动脉旁路搭桥术的效果

作者评价了135例未经选择的左室射血分数（LVEF）≤30％的病人进行冠状动脉旁路搭桥术（CABG）的安全性及效果。方法研究组135例病人LVEF≤30％，CABG8年以上，年龄42～87（平均66）岁。男113例，女22例。手术前平均LVEF23．6％（10％～30％）。135例中，1支冠脉搭桥者9例，2支46例，3支66例，4支12例，5支2例，每例平均搭桥数为2．7支。手术指征：82例充血性心力衰竭（CHF），其中31例有显著性肺水肿；85例心绞痛；34例需植人自动心律转变除颤器治疗室性心律失常，并同时进行血管再形成术；36例在血管再形成术时因急性病予以加强…     

下肢远端动脉旁路移植治疗糖尿病下肢缺血

目的探讨治疗糖尿病下肢缺血动脉旁路移植的方法和疗效。方法从2000年7月至2004年7月，应用下肢远端动脉旁路移植手术治疗了82例2型糖尿病病人的96条下肢。主要方式为股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术31条（32．3％），胭动脉-小腿动脉旁路移植22条（22．9％），髂动脉支架＋股动脉-胭动脉人工血管＋小腿动脉自体血管旁路移植术12条（12．5％），股动脉-小腿动脉旁路移植10条（10．4％）。结果82例中，3例全麻手术病人（4条下肢）于术后死亡，病死率为3．7％；手术成功率为96．3％，总有效率为93．7％；救肢成功率为98．9％；足部创面愈合率37．3％。76例患者（96．2％）被随访，平均随访时间为13．5个月，移植血管通畅率为92．2％；死亡率为3．9％；总有效率为87．6％；截肢率为4．5％，保肢率为95．5％。93．8％（30／32）下肢创面分别于出院2～10个月（平均6个月）后愈合。结论糖尿病下肢缺血行远端动脉旁路移植手术，可以使大多数患者得到有效治疗，从而挽救肢体或降低截肢平面。     

60岁以上老年人冠状动脉旁路移植术19例报告

1994年5月至1996年9月间，澳门镜湖医院心外科为60岁以上的冠心病患者施行了冠状动脉旁路移植术共19例.其中男性18例，女性1例。年龄60至83岁，平均70．8岁。术前心功能Ⅳ级者1例，Ⅲ级者4例，Ⅱ级者14例。本组病人手术搭桥62条，其中应用内乳动脉7条。术中同时施行主动脉瓣──机械瓣替换2例，同时施行二尖瓣整形术1例。无手术死亡。本文就（1）高龄老人搭桥手术与复苏;（2）逆行灌注心肌保护；（3）内乳动脉的应用；（4）主动脉内球囊反搏在围术期的应用等问题进行了讨论。     

老年冠心病患者非体外循环冠状动脉搭桥术25例

目的 总结25例老年（≥70岁）冠心病患者非体外循环冠状动脉搭桥术（OPCABG）的临床体会.方法 回顾性分析我院2007年7月至2013年11月经OPCABG治疗的25例老年冠心病患者的临床资料.结果 全组手术均获成功.无手术死亡,无中转体外循环完成手术者,围手术期死亡率0,无围手术期心肌梗死及神经系统并发症.全组应用左乳内动脉（IMA）和大隐静脉（SVG）搭桥77支,平均（3.1±1.0）支,行左乳内动脉与前降支吻合20例（80％）,大隐静脉搭桥24例（96％）,共57支,包括左乳内动脉（IMA）和大隐静脉（SVG）搭桥19例（79％）41支,完全静脉桥5例（20％）16支,其中序贯静脉桥14例（56％）18支.术后低心排综合征3例,应用IABP 1例,术后出现肺部并发症5例,呼吸衰竭2例,开胸止血1例,伤口感染1例.不稳定型心绞痛者,除2例术后无缓解,后经PTCA治疗有所缓解外,大部分手术后完全缓解.心功能不全者术后逐渐得到纠正,心功能Ⅰ～Ⅱ级.术后随访3～60个月,随访期间除1例死于心肌再梗死,1例死于肝癌外,大部分患者生活质量明显改善.结论 老年冠心病患者行OPCABG是一种安全、有效的方法,特别是对一些左主干病变、三支病变、合并心功能及其他重要脏器功能不全患者是一种更具优势的方法.     

肺静脉节段性消融治疗心房颤动40例

目的初步分析肺静脉节段性消融治疗心房颤动。方法心房颤动40例，其中阵发性30例、持续性10例，年龄26～75（60±10）岁，行肺静脉节段性消融。结果达到消融终点（4根肺静脉均完全隔离）27例，完成3根肺静脉隔离9例，完成2根肺静脉隔离4例。手术操作时间（200±37）min；x线曝光时间（55±10）min。手术相关并发症9例（9／40，22．5％），其中急性心包填塞2例（2／40，5．0％）；肺静脉狭窄5例（5／40，12．5％）（其中有症状1例，无症状4例）；严重迷走神经反应2例（2／40，5．0％）。二次消融2例，手术成功，未复发。随访1～4年，总成功率为（30／40，75％）。结论经导管治疗心房颤动有效及相对安全；消融效果与左心房内径，心房颤动发作病史，是否持续性，肺静脉是否被完全隔离有关，术者通过学习曲线将能进一步提高手术成功率及降低并发症。     

冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

老年急性心肌梗死患者急诊PCI的疗效

目的：探讨直接经皮冠状动脉介入治疗（PCI）对老年急性心肌梗死（AMI）的疗效。方法：75例AMI患者在发病12小时内接受冠状动脉造影，并对73例的梗死相关动脉行急诊PCI，随访1～12个月主要心血管事件发生情况。结果：73例接受PCI的患者中7例行单纯PTCA，66例（88％）置入支架；2例行急诊冠状动脉旁路移植术（CABG）；1例术中发生室颤，复律无效死亡，共有3例于住院期间死亡。随访期间主要心血管事件发生率11．6％（8／69），其中2例猝死，4例出现再梗死，2例因支架内再狭窄行再次PCI。结论：急诊经皮冠状动脉介入术治疗老年急性心肌梗死可有效地使梗死相关动脉再通，成功率高，死亡率低，近期预后良好。     

肝动脉化疗栓塞联合三维适形放疗治疗肝癌合并门脉癌栓的临床对照研究

目的研究肝动脉化疗栓塞（TACE）联合三维适形放疗（3DCRT）治疗肝癌合并门脉癌栓（PVTT）的疗效。方法138例肝癌患者随机分为2组：A组（62例）单纯行TACE；B组（76例）行TACE结合3DCRT。大体肿瘤靶区（GTV）只包括癌栓，不包括原发灶，使90％等剂量曲线覆盖PTV，照射总量40～65Gy，单次照射剂量2～4Gy。结果A组1、2年生存率分别为20．3％、3．9％，平均生存期7．2个月，有效率（CR＋PR）为16．1％（10／62）；B组1、2年生存率分别为40．6％、22．3％，平均生存期15．5个月，总有效率为42．11％（32／76），P〈0．05。结论TACE联合3DCRT能明显提高合并门脉癌栓的肝癌的治疗效果。     

阑尾与尿道吻合的回盲肠代膀胱术治疗膀胱癌62例远期效果观察

1985～1994年，我院对62例膀胱癌行阑尾与尿道吻合的回盲肠代膀胱术，效果满意。现报告如下。临床资料：本组62例膀胱癌患者，男48例，女14例;年龄47～70岁．平均59岁。多发性膀胱癌50例，复发性膀胱癌21例（平均手术2．3次）；膀胱移行细胞乳头状癌Ⅰ级5例、Ⅱ级39例、Ⅲ级17例，鳞癌1例；TNM分期：T1 3例，T2 33例，T326例。     

冠状动脉旁路移植术8例临床分析

１９９４年５月１９９５年１０月间，澳门镜湖医院心血管外科连续进行了冠状动脉旁路移植（搭桥）术８例。其中男性７例，女性１例，年龄６０至７９．５岁，平均６８．２岁。术的心功能Ⅱ至Ⅲ级（其中１例术前２月曾发生急性心肌梗塞，心跳骤停）。本组病例术前均行冠状动脉造影证实诊断。术中共搭桥２４根，平均每例３根。包括利用大隐静脉２３根，其中以序贯式吻合１很；利用左内乳动脉１根。术后出现严重低心排和出血性心包填塞共２例，经抢救成功，８例均痊愈。本文就（１）高龄病人接受冠状动脉搭桥手术；（２）术中心肌保护；（３）术后复苏处理；（４）ＩＡＢＰ在术中术后低排治疗的应用等问题进行了讨论。     

冠状动脉旁路移植术1077例临床分析

目的:探讨冠状动脉旁路移植术(CABG)指征、时机、危险因素及并发症防治。方法:选择2003年1月至2013年3月,我院施行CABG患者1 077例,其中体外循环下CABG(CCABG)1 027例,非体外循环CABG(OPCAB)50例。术前不稳定性心绞痛患者834例,60岁以上者671例(62.3%)。合并其他疾病患者854例(79.3%)。左主干病变343例;3支或3支以上病变955例。左乳内动脉旁路移植992例,使用率92.1%(992/1077)。围术期使用主动脉内气囊反搏36例。结果:死亡10例(0.99%),分别死于低心排出量综合征(低心排)、心室颤动、感染性休克、脑干梗死、肾衰竭、消化道出血及多脏器衰竭。随访2~96个月,获访941例(88.2%)。结论:合理掌握手术指征、时机,严密术后监测和及时并发症防治,可使CABG术的病死率和并发症明显下降。     

Coronary artery bypass surgery in patients aged 80 years or older

Between August 1980 and January 1986, 23 patients aged 80 years or older underwent coronary artery bypass grafting (CABG) operations. These patients had a higher incidence of severe left main coronary artery narrowing (p less than 0.0001), 3-vessel coronary artery disease (p less than 0.05) and moderate to severe left ventricular dysfunction (p less than 0.05) than patients in the Coronary Artery Surgery Study registry older than 65 years. Of 14 patients undergoing elective simple CABG procedures, none died; of 19 elective cases overall, 2 patients died (11%). Three of 4 patients undergoing emergency procedures (75%) and 4 of 6 patients (67%) requiring intraaortic balloon counterpulsation died. Significant complications occurred in 9 of 18 survivors (50%). All operative survivors improved at least 1 New York Heart Association class, with a mean classification improvement of 3.7 to 1.6 (p less than 0.0001); 13 of 16 long-term survivors were in class I or II. Actuarial survival at 1 and 2 years is 94% and 82%, respectively. CABG can be performed electively in octogenarian patients with increased but acceptable mortality and morbidity risks. Functional improvement and long-term survival are excellent.     

冠状动脉旁路移植手术315例临床分析

目的总结315例冠状动脉旁路移植手术的临床经验。方法对315例冠状动脉旁路移植手术患者的临床资料、手术方法、术后并发症及随访结果进行分析。结果本组患者围术期(术后30d)死亡1例(0.32%)。术后早期并发症包括心包填塞、低心排综合征、中枢神经系统并发症、肾功能不全和心律失常等。结论高危患者与常规患者冠状动脉旁路移植手术结果一样,手术近、远期结果满意。     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.     

Coronary artery bypass surgery in patients with severe left ventricular dysfunction

Objective: The role of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction was evaluated. Methods: Two hundred and twelve patients (152 men, 60 women; age 35 to 82, mean 55) with ejection fraction (EF) of less than 30% underwent CABG between January 1996 and February 2001 by a single surgeon (SA). They compromised of 12% of 1759 patients operated on in this period. EF ranged from 17% to 30% (mean 25%). Preoperatively 68% had congestive heart failure and 72% had severe angina (CCS 3 or 4). A left main lesion was found in 26% of the cases. The mean number of grafts was 3.18 per patient. The left internal mammary artery (LIMA) was used on 107 patients (50.4%). Preoperative intraaortic balloon pump (IABP) was used on 32 patients (15%). Endarterectomy was performed on 53 patients (25%). The patients were followed for up to 58 months (mean 28.7). Results: Twelve patients died in hospital (5.6%). Survival was 94%, 87%, 80% and 73% at 1, 2, 3 and 4 years respectively. Among the preoperative variables survival was negatively affected by chronic renal failure, older age, congestive heart failure, elevated pulmonary artery pressure and recent myocardial infarction, by means of multivariate analysis. Preoperative IABP support improved the operative mortality significantly (P=0.002). Use of LIMA did not have any influence on survival. Conclusion: CABG on patients with poor left ventricular function: (1) Can be performed with an acceptable mortality. (2) Mid term results are encouraging. (3) Preoperative IABP support improves the chance of survival.     

乳内动脉─冠状动脉旁路移植术──68例外科技术探讨

本文报告６８例乳内动脉（ＩＭＡ）冠状动脉（冠脉）旁路移植术。手术均在中度低温体外循环下进行，心肌保护主要采用Ｓｔ．Ｔｈｏｍａｓ液经主动脉根部间断灌注，冠脉病变较重者加用冠状静脉窦持续逆灌。８例患者只用ＩＭＡ移植，６０例患者还同时用自体大隐静脉，应用左侧ＩＭＡ６６例，双侧ＩＭＡ２例，２例患者应用左侧ＩＭＡ作续贯式移植。ＩＭＡ与冠脉的吻合部位包括前降支６６例、对角支４例、右冠脉１例、回旋支１例。以冠脉吻合口计算，平均每例作２．８个吻合口。同期左室室壁瘤切除５例，冠脉内膜剥脱１４例。７例需安装主动脉内球囊反搏。术后３０天内死亡１例，手术死亡率１．４％，死亡原因为脑缺氧昏迷。手术存活的６７例中，６２例近期心绞痛症状消失，５例明显减轻；活动量均明显增加。远期结果有待进一步观察。结论：只要掌握好ＩＭＡ的游离和吻合技术，中国人应用ＩＭＡ作冠脉旁路移植术能取得满意的结果。     

64层螺旋CT对冠心病患者再血管化治疗后的疗效评价

目的探讨64层螺旋CT追踪观察冠心病患者冠状动脉再血管化治疗后冠状动脉再狭窄的发生和心功能的变化。方法对28例冠状动脉旁路移植术患者和114例支架植入术患者进行64层螺旋CT冠状动脉造影和左心功能分析;观察吻合口的形态和桥血管/支架再狭窄的发生,计算左心功能指标,用以评价并比较二种冠状动脉再血管化治疗方法的疗效。结果冠心病患者在接受冠状动脉旁路移植术和支架植入术后左心室射血分数和每搏输出量明显增高;1年以后支架植入术后再狭窄发生率高于冠状动脉旁路移植术后;冠状动脉旁路移植术后3年以上者左心室射血分数和每搏输出量明显高于支架植入术后。结论64层螺旋CT心脏检查在冠心病患者再血管化治疗后疗效评价和随访中具有重要意义。     

Outcome following emergency coronary artery bypass grafting for failed elective balloon coronary angioplasty in patients with prior coronary bypass

To assess frequency and outcome of emergency coronary artery bypass grafting (CABG) for failed coronary angioplasty in patients with prior CABG, 2,136 elective angioplasty procedures in prior CABG patients were reviewed over a 10-year period. Emergency surgical revascularization was required in 19 patients (0.9%) with prior CABG, compared with 130 of 6,974 patients (1.9%) without prior CABG (p = 0.001). The interval from the most recent CABG to the failed coronary angioplasty was 6.8 years (range 1 to 16). Referral for emergency CABG was made on the basis of an acute closure not responding to repeat dilatation in 12 native coronary arteries and in 7 saphenous vein grafts. Severe hemodynamic instability after acute closure required the placement of an intraaortic balloon pump in 3 patients, including 2 who required cardiopulmonary resuscitation. A total of 34 saphenous vein grafts and 1 internal mammary artery graft were placed emergently. Three patients with high-risk features (3 prior CABG operations in 1 patient, single remaining vessel to heart in 2 patients) could not be weaned from cardiopulmonary bypass. The remaining 16 patients were discharged after a mean hospital stay of 16 days. Four patients developed new Q waves after CABG. At follow-up (mean 52 months, range 3 to 99), 1 patient died late from an acute myocardial infarction. The 15 survivors had no or mild angina and were free of further CABG. Thus, emergency CABG after failed angioplasty in patients with prior CABG is required infrequently. In patients without extreme high-risk features, emergency repeat CABG can be accomplished with good hospital and long-term results.     

冠心病患者介入治疗失败后行急诊冠状动脉旁路移植术的预后

目的 探讨冠心病患者经皮冠状动脉介入治疗失败后行急诊冠状动脉旁路移植术(CABG)的预后.方法回顾性分析2002年1月至2010年12月阜外心血管病医院11例经皮冠状动脉介入治疗失败后行急诊CABG患者的临床资料,并进行随访.院内随访内容包括心脏性死亡、Q波心肌梗死、肾功能不全、神经系统事件;院外随访的研究终点为主要心血管不良事件,包括死亡、心肌梗死和靶病变血管重建.结果 患者年龄(61±5)岁.冠状动脉造影显示三支病变患者5例(45.5％).在介入治疗的靶血管病变中,9例(81.8％)位于左前降支,中、重度钙化、慢性完全闭塞及弥漫性长病变分别为3例(27.3％)、4例(36.4％)和4例(36.4％).11例患者均有行急诊CABG的指征,其中冠状动脉夹层5例(45.5％)、冠状动脉穿孔 3例(27.3％)、病变无法充分扩张1例(9.1％)、血管急性闭塞1例(9.1％)和支架脱载1例(9.1％).CABG术后随访(47±33)个月.院内随访期间,发生心脏性死亡1例(9.1％),Q波心肌梗死2例(18.2％).院外随访期间,1例(9.1％)患者死于肾功能衰竭,无因心原性事件再次住院的患者.结论经皮冠状动脉介入治疗失败后行急诊CABG多见于复杂冠状动脉病变,术后患者的长期预后良好.     

Initial and long-term results of coronary angioplasty and coronary bypass surgery in patients of 75 or older.

OBJECTIVE--To evaluate clinical outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients of 75 or older who underwent either procedure between 1980 and 1987. SUBJECTS--93 patients aged 75-89 with angina pectoris class III-IV (Canadian Cardiovascular Society) who underwent PTCA and 81 patients aged 75-84 with angina class III-IV who underwent CABG. Follow up was 8.2 years in the PTCA group and 8.3 years in the CABG group. MAIN OUTCOME MEASURES--In-hospital complications and survival at follow up. RESULTS--Primary success rate for PTCA was 84% (78/93). Two patients died, two had emergency CABG, three had a myocardial infarction, and one had a cerebrovascular accident. PTCA failed in seven patients (five underwent elective CABG and two were treated conservatively). Median hospital stay was 4.3 days. Primary success rate for CABG was 63% (53/81). Six patients died, two had a cerebrovascular accident, eight had a myocardial infarction, 10 had a rethoracotomy, and four the adult respiratory distress syndrome. Median hospital stay was 14.2 days. In the PTCA group during follow up eight patients died, three had a non-fatal myocardial infarction, two had elective CABG, 10 had repeat PTCA, and four had recurrence of angina. Sixty four patients were free of angina (69%). In the CABG group during follow up eight patients died, one had a non-fatal myocardial infarction, six had PTCA, and three had recurrence of angina. Fifty seven patients were free of angina AP (70%). Actuarial survival after 10 years was 92% for PTCA and 91% for CABG. CONCLUSIONS--PTCA is safe in elderly patients. The complication rate is lower and hospital stay significantly shorter compared with CABG (p < 0.05). Long-term follow up showed no significant difference between PTCA and CABG.