经左胸前外侧小切口冠状动脉旁路移植术

目的 评价经左胸前外侧小切口冠状动脉旁路移植术的临床疗效及远期随访结果.方法 2002年1月至2006年10月,38例单支或多支冠状动脉病变患者经左胸前外侧小切口进胸,直视下或胸腔镜辅助下,完成非体外循环冠状动脉旁路移植术.其中男性25例.女性13例;年龄38～78岁,平均(63.3±11.1)岁.结果 38例手术均顺利完成.20例行单纯旁路移植1支;10例先行支架植入,后行胸廓内动脉至前降支端侧吻合,其中2例行胸廓内动脉与第一对角支、前降支序贯吻合;8例行旁路移植2支,其中3例为序贯吻合,5例应用桡动脉行"Y"形吻合.术后无死亡及严重并发症.37例患者获得26～82个月随访,平均(53.2±28.5)个月;无晚期死亡,无再发心肌梗死.心功能Ⅰ级26例,Ⅱ级12例.3例心绞痛复发,2例经药物控制后症状缓解,1例经造影证实吻合口狭窄于术后2年行支架植入.结论 左前外侧小切口非体外循环冠状动脉旁路移植术具有较低的病死率和心脏不良事件发生率,远期结果良好.     

经左前外侧小切口不停跳冠状动脉旁路移植术治疗多支血管病变的临床研究

目的 分析经左前外侧小切口行不停跳冠状动脉旁路移植术(CABG)治疗多支血管病变冠状动脉粥样硬化性心脏病(冠心病)的安全性和随访结果.方法 回顾性分析2018年1月至2020年3月在我院行左前外侧小切口不停跳CABG 30例多支血管病变冠心病患者的临床资料,其中男18例、女12例,平均年龄(61.3±7.5)岁;三支血...     

全机器人胸廓内动脉游离非体外循环冠状动脉旁路移植术

目的总结全机器人下不开胸胸廓内动脉（IMA）游离心脏不停跳冠状动脉旁路移植术的初步经验。方法使用da Vinci S全机器人系统,完成胸廓内动脉游离心脏不停跳下冠状动脉旁路移植术15例。所有患者均有心绞痛症状,其中4例患者有心肌梗死病史,冠状动脉造影显示严重的前降支病变,2例患者对角支及回旋支亦有病变。手术过程中于左侧胸壁打直径为1cm的器械臂孔3个,医生于操作台前在三维成像系统下操控机器人进行胸廓内动脉的游离,其中13例行左侧胸廓内动脉游离,1例行双侧胸廓内动脉游离,1例行对侧胸廓内动脉游离。游离结束后,沿左胸前第4肋间行长度为6cm小切口开胸,13例于心脏跳动下行胸廓内动脉和前降支的吻合,2例同时吻合对角支或回旋支。其中1例是完全机器人不停跳下冠状动脉旁路移植术。结果所有患者均成功接受胸廓内动脉游离,无胸廓内动脉损伤及术式的转变。胸廓内动脉和前降支、对角支和回旋支吻合后桥血流良好。术中平均出血量80ml,平均ICU时间20h,术后恢复好。结论全机器人不开胸胸廓内动脉游离技术精细、安全,不停跳下冠状动脉移植术效果确实、可靠,术后效果良好。     

不同手术方式重建左前降支血运的效果

目的 比较使用非体外循环心脏不停跳冠状动脉旁路移植术(OPCAB)、微创小切口直视下心脏不停跳冠状动脉旁路移植术(MIDCAB)和机器人辅助冠状动脉旁路移植术(RA-CAB)3种不同方式行左前降支(LAD)血运重建的围手术期效果.方法 2009年2月至2012年5月,接受单纯LAD血运重建患者102例,其中OPCAB组31例,MIDCAB组45例,RA-CAB组26例.MIDCAB手术方式为左胸小切口心脏不停跳冠状动脉旁路移植术,RA-CAB手术方式为da Vinci机器人辅助左乳内动脉(LI-MA)获取,左胸小切口心脏不停跳冠状动脉旁路移植术.结果 3组患者在术中旁路血管流量、搏动指数和围手术期死亡、心肌梗死、脑血管意外、再次血运重建、严重心脑血管不良事件(MACCE事件)、肾功能衰竭、再次开胸止血、新发心房颤动、纵隔感染以及术后并发症率上均无显著差异.相比OPCAB,MIDCAB和RA-CAB能显著减少输血率(4.4％对32.3％,P＜0.05;7.7％对32.3％,P＜0.05),其中RA-CAB更能显著缩短术后住院天数[(8.8±3.2)天对(12.4±7.7)天,P＜0.05)].MIDCAB与RACAB两组之间围手术期结果差异无统计学意义.结论 MIDCAB和RA-CAB治疗左前降支血管病变安全、有效、可行,围手术期效果满意,比OPCAB能显著减少血制品的使用,RA-CAB更能大大缩短术后住院天数,具有创伤更小、恢复更快的优势.     

左胸小切口多支动脉化冠状动脉旁路移植术64例的有效性和安全性分析

目的探讨左胸小切口冠状动脉旁路移植术多支动脉桥策略的安全性及有效性,为该技术推广提供证据。方法回顾性分析2015年12月至2019年11月北京大学第三医院心脏外科64例左胸小切口多支搭桥手术患者的临床资料。男54例、女10例,年龄36~77(61.1±8.7)岁。经第5肋间长5~8 cm左胸前外侧切口进胸,在非体外循环下进行手术,借助胸壁悬吊装置及心脏固定器,完成升主动脉近端吻合,前降支、回旋支及右冠状动脉系统的靶血管远端吻合等操作。移植血管数量2~4(2.3±0.5)支,其中45例患者移植2支,17例移植3支,2例移植4支;手术结合经皮冠状动脉介入治疗(PCI)杂交治疗3例,全动脉化旁路移植62例。术后7 d内复查冠状动脉造影评估旁路血管通畅率,随访记录主要不良心脑血管事件(MACCE)发生情况,通过Kaplan-Meier法计算免于发生MACCE率。结果无患者中转开胸手术,术中未应用主动脉内球囊反搏或体外膜肺氧合。术后切口愈合不良1例,再次手术2例(均为术后胸腔出血)。术后30 d内发生非致死性心肌梗死1例,无死亡。术后早期复查造影旁路血管总体通畅率为96.2%,前降支旁路通畅率为98.2%。随访12~60个月(中位随访时间28个月)。失访率7.8%(5/64)。36个月免于MACCE发生率为84.9%(95%CI 79.5%~90.3%)。结论左胸小切口多支冠状动脉旁路移植术可以实现完全再血管化及全动脉化搭桥,近期及中远期效果良好。     

合并胸腔粘连患者行左前外侧胸部小切口冠状动脉旁路移植术的安全性

目的探讨左前外侧胸部小切口不停跳冠状动脉旁路移植技术在胸腔粘连患者中应用的安全性。方法2015年8月～2019年4月,16例合并左侧胸腔粘连的冠心病患者接受经左前外侧胸部小切口不停跳冠状动脉旁路移植手术。其中胸腔非特异性炎性粘连10例,左侧胸腔手术(肺叶切除)后粘连4例,左侧胸腔陈旧性结核性胸膜炎2例。经左前外侧第5肋间切口分离胸膜粘连并游离左侧乳内动脉,完成左侧乳内动脉到前降支的旁路移植。放置左侧胸腔引流管后恢复为双肺通气并关闭切口。结果 16例均按计划完成左侧乳内动脉的获取及与前降支的吻合。左乳内动脉获取时间22～37(27±6) min,呼吸机使用时间5～12(8. 1±3. 7) h,监护室停留时间16～31(22. 5±10. 6) h。16例均未输血,术后顺利恢复。其中10例出院前冠脉造影检查确认桥血管通畅。随访时间3～32个月,中位数15个月,无主要不良心脑血管事件发生。结论合并左侧胸腔粘连者接受左前外侧胸部小切口旁路移植手术是安全的,细致分离粘连胸膜可以改善术野显露,保证手术效果。     

胸部小切口冠状动脉搭桥术66例报告

目的：探讨胸部小切口冠状动脉搭桥术的临床效果。方法2002年1月～2013年1月采用胸部小切口取左乳内动脉（ left internal mammary artery,LIMA）心脏不停跳冠状动脉搭桥术66例。胸骨下段小切口59例,采用全麻、单腔气管插管,平卧位,倒“L”胸骨下段切口;胸骨旁小切口5例,采用全麻、双腔气管插管,平卧位左胸抬高30＆#176;,左前外侧第4或第5肋切口,用特制牵开器（法国圣骑士公司）牵开肋骨,游离乳内动脉,使用冠脉固定器下行冠脉吻合;2例胸腔镜辅助下完成乳内动脉与左前降支的吻合。结果66例均完成左乳内动脉至前降支的吻合,2例追加大隐静脉降主动脉至第一对角支的吻合。无围术期死亡。60例随访0．5～8年,（5．5±2．5）年,心绞痛症状消失42例,明显减轻24例。术后冠状动脉CT检查16例,冠脉造影12例,LIMA与左前降支（ left anterior descending, LAD）吻合口满意率100％,支架内再狭窄1例,大隐静脉桥血管闭塞1例。结论胸部小切口冠状动脉搭桥术主要适用于心脏前壁冠状动脉尤其是前降支的的再血管化,安全可靠,中期疗效好,在合并高危因素或常规冠状动脉搭桥术和经皮冠状动脉介入术效果不满意者中应用更佳。     

左胸小切口微创冠状动脉旁路移植术五例

小切口微创冠状动脉旁路移植术(MIDCAB)最经典的术式是从左胸小切口游离左乳内动脉(LIMA),然后吻合到左前降支(LAD)[1]。我院2010年10月至2011年6月完成5例MIDCAB,现总结其临床经验。     

经左胸肋间切口实施冠状动脉旁路移植术

目的探讨经左胸肋间切口实施冠状动脉旁路移植术的临床应用与特点。方法我院1996年9月~2005年8月共实施经左胸肋间切口的冠状动脉旁路移植术36例,左侧胸骨旁第4肋间前外侧切口6~10 cm进入胸膜腔,使用M IDCAB专用牵开器,分离左侧乳内动脉与冠状动脉吻合。主要有4种情况:①单纯前降支系统病变;②再次冠状动脉旁路移植术而存在通畅的左乳内动脉至前降支桥;③严重的升主动脉钙化;④合并其他左胸手术。单支病变26例,双支病变3例,三支病变7例。既往介入治疗史5例,冠状动脉旁路移植术史6例。左心室射血分数为(0.562±0.107)。结果36例均成功实施非体外循环心脏跳动下的冠状动脉旁路移植术,远端吻合口1~4个,手术时间(190.4±44.1)m in。合并激光心肌打孔术2例,合并肺癌切除术1例,食管癌切除术1例。无住院死亡病例。32例随访1个月~9年,中位数32月,2例远期死亡。2例术后1年再发心绞痛,1例经介入治疗,另1例再次手术,症状消失。其余患者均没有心绞痛症状。结论经左胸肋间切口实施冠状动脉旁路移植术对某些特殊类型的冠心病患者是安全实用的选择,非体外循环方式下进行此类手术是可行的。     

胸骨下段小切口行非体外循环冠状动脉旁路移植术

目的探讨胸骨下段小切口在非体外循环冠状动脉旁路移植术中应用的效果。方法回顾性分析2012年6月至2014年12月前降支单支病变的冠心病患者行胸骨下段小切口非体外循环冠状动脉旁路移植术19例的临床资料,其中男11例、女8例,年龄59.6(44～68)岁。所有患者均游离左乳内动脉与前降支吻合,其中1例因术中探查见第一对角支近端明显粥样斑块且对角支粗大,遂向上延长切口,全胸骨打开,游离大隐静脉行对角支搭桥,近端吻合于升主动脉,术后1、3、6、12个月进行随访。结果其中1例术中转为常规胸骨正中切口手术,其余18例手术胸骨下段小切口完成,术中血流动力学稳定,无围术期急性心肌梗死及死亡病例,无乳内动脉损伤、无吻合口漏血及恶性心律失常发生,无大出血、二次开胸止血及切口感染等并发症出现,术后住院4～6 d,监护室入住时间、呼吸机辅助通气时间及住院费用均较常规开胸手术明显降低,术后随访期间无心绞痛复发病例。结论胸骨下段小切口行非体外循环冠状动脉旁路移植术,创伤较小,安全可靠;而且是一种操作相对简单,容易掌握及可灵活应变的小切口微创手术,尤其适合于初学小切口冠状动脉旁路移植术术者。     

Minimally invasive direct coronary artery bypass: technical considerations and instrumentation

Minimally invasive coronary artery bypass is defined as any maneuver or modification of conventional coronary bypass that decreases adverse effects. These adverse effects fall into three broad categories, which are access trauma, consequences of cardiopulmonary bypass, and aortic manipulation. In the minimally invasive direct coronary artery bypass (MIDCAB) approach, coronary revascularization is performed via a limited access incision, usually a left anterior thoracotomy, through which a left internal mammary artery is anastomosed under direct vision to the left anterior descending artery on a stabilized beating heart. Harvest of the left internal mammary artery can be performed with video assistance (two- or three-dimensional or under direct vision). A variety of offset chest wall retractors that allow internal mammary artery harvest under direct vision have simplified the procedure, and several mechanical stabilization devices (with or without suction) allow local wall immobilization for a target vessel anastomosis. Graft patency data from early series of stabilized MIDCAB procedures and published series of left internal mammary artery graft patency with conventional bypass grafting appear to be comparable. Current indications for MIDCAB include restenosis of the left anterior descending artery after catheter-based therapy and the necessity for target vessel revascularization in elderly high-risk patients with multivessel disease. Limitations of the MIDCAB procedure include mostly single vessel revascularization of the anterior aspect of the heart.     

MIDCAB for redo patients using the LITA-RA composite graft

Redo coronary artery bypass grafting (CABG) is associated with higher mortality, low-output syndrome, perioperative myocardial infarction than primary CABG. Minimally invasive direct coronary artery bypass grafting (MIDCAB) technique avoids the manipulation of old graft and injury of the adhesive heart in redo operation. We performed the MIDCAB procedure for 2 redo cases using the left internal thoracic artery (LITA)-radial artery (RA) composite graft. The LITA-RA composite graft was anastomosed to the left anterior descending branch (LAD) through small left anterior thoracotomy without cardiopulmonary bypass. Postoperative coronary artery graphy shows the widely patent of new graft. The MIDCAB procedure using the LITA-RA composite graft is safe and useful to regulate the bypass graft length and avoid the widely harvest of LITA in redo operation.     

Coronary artery bypass grafting without cardiopulmonary bypass: MIDCAB and OPCAB

Minimally invasive direct coronary artery bypass grafting via left anterior small thoracotomy (MIDCAB) and coronary artery bypass grafting without cardiopulmonary bypass (OPCAGB) are accepted technique as less invasive than conventional coronary artery bypass grafting (CABG). We reported our experience with these procedures. From 1996 to December 1999, 176 patients underwent MIDCAB or OPCAB with the internal thoracic artery. The left internal thoracic arteries were used for grafting of the left anterior descending artery (LAD) in 131 patients, LAD and diagonal branches sequentially in 8 patients, using free radial artery conduits for grafting of the right coronary artery (RAC) or left circumflex (LCx) in 7 patients, using radial artery conduits as Y-graft from LAD for grafting of the RAC or LCx in 24 patients, and bilateral internal thoracic artery grafting was performed in 4 patients. One patient (0.6%) died in the hospital. One patient (0.6%) had perioperative myocardial infarction. No patient had cerebrovascular accident and sever wood infection. One-hundred-seventy-four patients (98.8%) had resolution of their angina symptom.     

Minimally invasive direct coronary artery bypass: technical considerations

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.     

Minimally invasive direct coronary artery bypass grafting using the saphenous vein in redo CABG.

We describe a patient who underwent minimally invasive direct coronary artery bypass (MIDCAB), who had previously undergone coronary artery bypass grafting (CABG) through a median sternotomy with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and a right gastroepiploic artery (GEA) graft to the posterior descending artery. MIDCAB was less invasive and was an effective alternative procedure for the second operation. Because the patient had no LIMA or GEA available for a graft because of prior use, we used a saphenous vein graft (SVG) for bypassing from the left subclavian artery to the coronary artery by MIDCAB via a left minithoracotomy. The left subclavian artery was selected as the proximal anastomotic site because this artery was less diseased and was easier to reach. The SVG-to-coronary artery anastomosis was facilitated by firm adhesion between the epicardium and the pericardium, which reduced the motion of the epicardium itself. These results suggest that the procedure is safe and promising in selected cases of redo CABG.     

Reoperative MIDCAB grafting: 3-year clinical experience

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits. Methods: Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization. Results: Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0–39). Conclusions: Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.     

手术联合介入技术治疗冠状动脉多支病变

目的介绍手术联合介入技术治疗冠状动脉多支病变的临床经验。方法联合应用左前外侧小切口不停跳冠状动脉旁路移植术和经皮腔内冠状动脉成形术治疗9例病人,其中冠状动脉两支病变者7例,三支病变者2例。结果9例手术均顺利完成,各植入支架1枚,7例病人搭桥1根,2例病人搭桥各2根。术后心绞痛明显缓解,无死亡及严重并发症发生,随访3月~3年生活质量良好。结论手术和介入技术复合治疗冠状动脉多支病变安全、有效,创伤小、恢复快,值得临床推广。     

Re-coronary artery bypass grafting using a MIDCAB technique in a patient with a patent RITA-LAD graft]

In a patient with a patent RITA-LAD (right internal thoracic artery-left anterior descending artery) graft, re-CABG (re-coronary artery bypass grafting) with re-median sternotomy has been a high risk procedure. A 56-year-old male underwent 4-CABG (RITA-LAD, LITA-Dx, SVG-PL, and SVG-RCA) nine years ago. Coronary angiography showed that the RITA-LAD graft was well patent, but there was 95% stenosis distal to RITA-LAD anastomosis site. We performed re-CABG (right gastroepiploic artery-LAD; RGEA-LAD), using MIDCAB (minimally invasive direct coronary artery bypass) technique with neither re-median sternotomy nor cardiopulmonary bypass. The right gastroepiploic artery was harvested through a small upper median laparotomy and anastomosed to LAD through a small left anterior thoracotomy. The postoperative course was uneventful. This technique seems to be useful for re-revascularization of the LAD in a patient with a patent RITA-LAD graft.