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。

Emergency redo coronary artery bypass grafting for acute myocardial infarction peri-operatively after coronary artery bypass surgery

Objective To review retrospectively the clinical experiences on emergency redo coronary artery bypass grafting (CABG) for acute myocardial infarction (MI)peri operatively after CABG Methods Out of 510 patients with coronary artery bypass grafting, 5 needed to have emergency redo CABG for acute MI within 4 hours after surgery with the incidence of 0 98% There were 4 males and 1 female with average of 63 6(56 77)years All 5 patients had triple vessel disease and 3 of them also had left main coronary disease The number of grafts is 3 6(3 5) per patient with all left internal mammary arteries (IMA) to the left anterior descending (LAD) and saphenous veins to the other coronaries All 5 patients had acute myocardial ischemia(obvious ST T changes) with unstable hemodynamics (2 with ventricle fibrillation) within 20 minutes in 2 patients and 2 to 4 hours in the other three patients post operatively All of them had to be taken back to operating room (2 of them were still in the operating room )immediately and re opened Four patients had to be put on cardiopulmonary bypass(CPB) again for the unstable hemodynamics Three of them had hypokinetic anterior wall of the left ventricle Along with EKG changes, the internal mammary artery malperfusion syndrome had been diagnosed and another vein graft had to be put to the distal LAD The other 2 patients had acute occlusion of the vein grafts(one was to second obtuse marginal, the other one was to the posterior descending artery of the right coronary)because of acute formation of thrombosis These two vein grafts had to be re do(one with CPB and the other with off CPB) Results All 5 patients got through the second surgery with the support of intra aortic balloon pump for average 42 (22 55) hours post operatively and all develoved peri operative Q wave MI Patients were ventilated for average 7 3(4 hours 18 d) days The other complications after surgery included gastrointestinal bleeding in 4 patients, renal insufficiency in 2, lung infection in 2 and incision infection in 1 All patients recovered and discharged from hospital with average hospital stay of 21 (12 35)days post operatively Conclusion It has been emphasized to prevent the peri operative MI after CABG Emergency redo CABG should be the best choice if the graft problem had been suspected. The incidence of complications after redo surgery is much higher