机器人辅助的微创冠状动脉旁路移植术

目的：介绍机器人辅助的微创冠状动脉旁路移植手术。方法：应用da Vinci机器人系统取左乳内动脉,然后经左胸第2肋间小切口在体外循环下行冠状动脉旁路移植术。结果：本组34例患者无围术期死亡和心肌梗死;术后有4例发生低心排血量综合征,2例发生急性肾功能不全。结论：机器人辅助的微创冠状动脉旁路移植术是一种安全可靠的手术方法,可以减轻术后疼痛和促进术后恢复。     

A Modified Thoracotomy for Minimally Invasive Coronary Artery Bypass Grafting

A bstract The optimal technique of minimally invasive coronary artery revascularization using the in situ internal thoracic artery (ITA), without extracorporeal circulation, is yet to be defined. To obtain adequate exposure for both ITA harvest and left anterior descending coronary artery anastomosis, an anterior chest wall defect is created which can be difficult to reconstruct. Based on the vascular anatomy of the acromiothoracic axis and three described osteocutaneous composite tissue flaps, we present a novel dissection that not only improves exposure, but also preserves chest wall integrity.     

Minimally Invasive Direct Coronary Artery Bypass Grafting: Two-Year Clinical Experience

Background. Interest in minimally invasive coronary artery bypass grafting has been increasing.

Methods. From April 1994 through December 1996, 199 patients (age, 36 to 93 years) underwent minimally invasive coronary artery bypass grafting through minithoracotomy, subxiphoid, and lateral thoracotomy incisions, with internal mammary artery, gastroepiploic artery, and composite grafts placed using local coronary artery occlusion.

Results. The conversion rate to sternotomy was 7% (14/199). Preoperative risk factors included unstable angina (n = 83), reoperative coronary artery bypass grafting (n = 54), low ejection fraction (n = 53), congestive heart failure (n = 44), renal insufficiency (n = 25), chronic obstructive pulmonary disease (n = 36), cerebrovascular accident (n = 22), and diffuse vascular disease (n = 47). Morbidity included wound infections (n = 5), reoperation for management of bleeding (n = 6) and acute graft occlusion (n = 2), perioperative stroke (n = 1), atrial fibrillation (n = 14), and perioperative myocardial infarction (n = 7). The operative mortality was 3.8% (7/185). The number of grafts placed in 185 patients was as follows: single, 156; double, 28; and triple, 1. Early (less than 36 hours) angiography and Doppler flow assessment of the coronary anastomoses in 85% of the patients showed that 92% were patent. Routine use of mechanical stabilization of the coronary artery since April 1996 was found to be associated with an increase in the patency rate of the left internal mammary artery–left anterior descending coronary artery anastomosis to 97%, versus 89% (p = 0.055) associated with conventional immobilization techniques. Of the 148 patients followed up beyond 1 month (range, 1 to 32 months; mean, 9.2 ± 7.4 months) postoperatively, 3 have died (3 to 7 months), and of the 145 survivors the cardiac-related event (percutaneous transluminal coronary angioplasty, reoperation, readmission for recurrent angina, and congestive heart failure)–free interval was 93%.

Conclusions. The minimally invasive coronary artery bypass grafting operation is safe and effective. Regional cardiac wall mechanical immobilization enhances the early graft patency and must be considered an essential part of this operation.     

Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries

Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting procedure without cardiopulmonary bypass for patients with multivessel disease.

Methods. Both ITAs were thoracoscopically harvested using video imaging. Limited bilateral anterior thoracotomies were performed in the fourth intercostal spaces, thus exposing the right coronary artery and the left anterior descending coronary artery. The right ITA–right coronary artery and ITA–left anterior descending coronary artery anastomoses were performed without cardiopulmonary bypass using 8-0 polypropylene sutures.

Results. This procedure was successfully performed in 3 patients. The patients were extubated in the operating room. Postoperative angiographic studies showed patent left ITA and right ITA grafts.

Conclusions. Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting can be used to treat patients with a proximally diseased left anterior descending coronary artery and right coronary artery. Bilateral thoracoscopic ITA harvesting is a less invasive surgical technique that may become an option for the management of multivessel coronary artery disease.     

Intraoperative Angiography in Minimally Invasive Direct Coronary Artery Bypass Grafting

Intraoperative angiography in minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass and in hybrid procedures is reported. Twelve procedures were performed in a specially designed surgical-radiologic suite with a cross-disciplinary organization. In 2 patients the anastomosis was successfully revised on the basis of angiographic findings. In 4 of the 12 patients anastomosis of the left internal mammary artery to the left anterior descending coronary artery performed as a minimally invasive direct coronary artery bypass grafting procedure was combined with percutaneous transluminal coronary angioplasty of lesions in other coronary vessels in the same session. Intraoperative angiography allows a reliable diagnosis of an anastomosis or graft failure and prompt and reliable correction, and it allows the combination of minimally invasive direct coronary artery bypass grafting and angioplasty in one session.     

胸骨下段正中小切口直视冠状动脉旁路移植术

目的总结72例胸骨正中下段小切口直视冠状动脉旁路移植术(MIDCAB)的经验,探讨其手术方法和适应证。方法经胸骨下段正中小切口游离左乳内动脉用于左前降支旁路移植,并切取大隐静脉,在非体外循环下完成单支或多支病变血管的冠状动脉旁路移植手术。结果手术死亡1例(1.4%),术后发生并发症3例(4.2%)。手术时间195.6±50.6min,吻合口数2.3±0.8个(1~4个);术后气管内插管时间0~364h,中位数11h;住ICU时间1~23d,中位数3d;术后住院时间10.9±5.4d(6~36d,中位数9d);胸腔引流量8.5±5.9ml/kg;47例患者需输血,输血量为1091.3±636.2ml;所有患者胸部切口长9~11cm。术后随访时间36.2±17.6个月,随访率92.9%(66/71),无远期死亡,心绞痛完全免除率65.2%(43/66);明显改善占27.3%(18/66)。结论胸骨正中下段小切口直视下冠状动脉旁路移植术创伤小,无须特殊器械;皮肤切口小,美观;操作简单,安全可靠,可获得冠状动脉多支病变充分再血管化的效果。     

Lung Herniation Secondary to Minimally Invasive Direct Coronary Artery Bypass Grafting

Lung herniation after thoracotomy is rare. We report a 66-year-old man who presented with this complication after undergoing attempted minimally invasive direct coronary artery bypass grafting. The defect was repaired with a composite of Marlex mesh and methyl methacrylate.     

Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting

We report about a 71-year-old man with coronary artery double-vessel disease who received minimally invasive coronary artery bypass grafting through a 9-cm left lateral chest incision in the third intercostal space. Both mammary arteries were harvested either directly (left internal mammary artery) or thoracoscopically (right internal mammary artery) and anastomosed to the left anterior descending artery and the circumflex artery through this single left lateral chest incision. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.     

Minimally Invasive Axillary– Coronary Artery Bypass

Axillary artery-to-coronary artery bypass using reversed saphenous vein provides a simple method of applying the minimally invasive coronary bypass grafting procedure when the internal thoracic artery is not an adequate conduit. Although this may allow extended use of the minimally invasive coronary bypass procedure, the long-term patency of this technique is unknown.     

Minimally lnvasive Coronary Artery Bypass Grafting: One-Year Follow-Up

Background: Use of the minimally invasive direct coronary artery bypass grafting (MIDCAB) technique has been associated with excellent primary results, and sparing of resources has been assumed. There is, however, a limited amount of information available concerning the results of mid-term follow-up. The purpose of this study was to present 1-year follow-up results of our first 130 consecutive MIDCAB patients. Methods: MIDCAB operations, defined as no sternotomy, no cardiopulmonary bypass, and no aortic manipulation were started in our clinic in February 1996. One hundred thirty patients requiring invasive treatment of coronary artery disease who were not suitable for percutaneous transluminal angioplasty were included in this series. The main outcome measures were mortality, the need for subsequent invasive treatment, and 1-year NYHA classification. Results: There was one hospital death, but during the first-year follow-up, four additional deaths occurred and three patients were reoperated on with conventional techniques. Five percutaneous transluminal coronary angioplasties (PTCAs) had to be performed, two because of anastomosic stenosis. Additionally, cardiac- or operation-related symptoms caused a total of 27 hospital visits among 23 patients during the first-year follow-up. Angiographic left internal thoracic artery (LITA)-left anterior descending artery (LAD) patency was 97.4% (37/38) (confidence interval [CI] ranged from 86.2% to 99.9%) at 3 months. After 1 year, 86.9% (113/130) of the patients were without symptoms. A clear improvement of the follow-up results was observed to be associated with increased experience during the study period. Conclusions MIDCAB operations, after some experience, can be performed with relatively good outcome. However, special attention should be directed to determination of correct anastomosic site and to avoiding anastomosic stenosis. We also recommend extended mobilization of the ITA and use of specific stabilizers. (J Card Surg 1999;14:231–237)     

Minimally Invasive Multiple Coronary Artery Bypass Grafting with Composite Graft Using in situ Right Gastroepiploic and Radial Arteries

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.     

冠状动脉旁路移植术动脉材料的选择

目的 为了克服大陷静脉长期通畅率不佳的问题,在冠状动脉旁路移植术中寻求多动脉材料做旁路移植术。方法 从１９９４年１０月￣２０００年４月,４５６例冠状动脉粥样硬化性心脏病的患者使用乳内动脉和桡动脉做冠状动脉旁路移植术,采用不接触血管技术妈材,减少损伤及应用钙拮抗剂防止桡动脉痉挛。结果 共取乳内动脉４４８根,桡动脉２１９根,平均移植血管３．２支,死亡８例,死亡率１．８％。结论 使用动脉材料做旁路移植术是安全有效的,预计能保持移植血管的远期通畅。     

Intraoperative Angiography During Minimally Invasive Direct Coronary Artery Bypass Operations

Background. The technical demands of beating heart operations raise concerns about anastomotic patency. This feasibility study tested the usefulness of intraoperative angiography during minimally invasive direct coronary artery bypass grafting (MIDCABG).

Methods. Ten patients underwent intraoperative angiography of the internal thoracic artery (ITA) after MIDCABG. Minimally invasive direct coronary artery bypass grafting was performed on a beating heart through the fourth or fifth intercostal space. Angiography was performed through the right or left femoral artery with a 7F introducer system placed before the operation. Views were obtained in the right and left anterior oblique and straight anterior projections.

Results. There were no deaths or intraoperative morbidities related to MIDCABG or angiography. Seven patients demonstrated widely patent MIDCABG anastomoses with obliteration of all intercostals, widely patent ITA pedicles, good distal runoff, and placement of the ITA into the proper native coronary artery. Two patients had revisions of their ITA pedicles, which on repeated angiography showed correction. One patient’s procedure was converted to a sternotomy because of poor distal runoff and haziness at the level of the MIDCABG anastomosis.

Conclusions. This feasibility study demonstrates the utility of intraoperative ITA angiography in identifying problems after MIDCABG. Intraoperative angiography may facilitate MIDCABG by documenting proper placement of conduits, obliteration of intercostal vessels, and patency of the MIDCABG anastomosis and ITA pedicle.     

Very Long-term Outcome of Minimally Invasive Direct Coronary Artery Bypass

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非体外循环辅助下冠状动脉旁路移植术

目的 总结非体外循环辅助下冠状动脉旁路移植术（Ｏｆｆ－ｐｕｍｐ ｃｏｒｏｎａｒｙ ａｒｔｅｒｙ ｂｙｐａｓｓ ｇｒａｆｔｉｎｇ,ＯＰＣＡＢ）的临床经验。方法 自１９９９年８月￣２０００年６月,我们行ＯＰＣＡＢ７３例。在进行旁路移植吻合时,冠状动脉的暴露和制动借助Ｏｃｔｏｐｕｓ机械制动器以及冠状动脉腔内空心通条。结果 无手术死亡,无围手术期心肌梗死等严重并发症发生;术后短期随访结果显示临床效果满意。结论 ＯＰＣＡＢ可作为冠状动脉旁路移植的手术方法之一,但手术操作时要求较高的技术水平,其远期疗效尚待探讨。     

非体外循环下冠状动脉旁路移植术

目的　探讨和评价微创非体外循环冠状动脉旁路移植术 (OPCAB)的临床效果。　方法　 38例 OPCAB患者中左冠状动脉主干病变 4例 ,1支血管病变 10例 ,2支 14例 ,3支 10例 ,均经胸骨正中切口行 OPCAB,每例移植血管 1～ 5支 ,平均移植血管 2 .42支。应用左乳内动脉 38支 ,大隐静脉 5 4支。　结果　全组无手术死亡 ,36例顺利完成手术 ,2例转为心肺转流术下冠状动脉旁路移植术。38例均在手术后 2～ 12小时 ,平均 4.9± 2 .6小时顺利拔除气管内插管。全组均顺利康复 ,15例手术后 1个月内恢复了原工作。　结论　对有适应证的患者 ,OPCAB是一项安全有效的术式