高危患者主动脉内球囊反搏辅助下不停跳冠脉搭桥体会

目的探讨严重冠状动脉三支血管病变（狭窄〉75％）的高危患者在主动脉内球囊反搏（IABP）辅助下行非体外循环下冠脉搭桥术的安全性。方法回顾2002年1月至2007年12月间27例高危冠心病患者，在IABP支持下行非体外循环下冠脉搭桥术临床资料。结果本组患者冠状动脉造影均提示严重三支血管病变，15例合并左主干病变（狭窄〉75％），均属高危（EuroSeore〉6分），无术中死亡、术后死亡1例，搭桥2～7支、平均（3．2±1．1）支。结论对于冠脉严重三支血管病变高危病例，在预先置入IABP的辅助下可以安全地施行非体外循环下的冠脉搭桥术。     

冠状动脉心肌桥的外科治疗

目的探讨冠状动脉心肌桥(myocardial bridge,MB)的临床特点,手术适应证,手术方法及手术效果。方法1996年10月至2007年2月,阜外心血管病医院对34例MB患者施行冠状动脉心肌桥手术治疗,其中单纯MB10例;MB合并冠心病4例,心脏瓣膜疾病15例,肥厚梗阻型心肌病3例,马方综合征1例,房间隔缺损1例。34例MB患者均由冠状动脉造影明确诊断。术前心功能分级(NYHA)Ⅱ级30例,Ⅲ级4例。心肌桥位于左前降支32例,后降支1例,回旋支1例,长度为1～6cm。行心肌桥松解术15例,冠状动脉旁路移植术(CABG)19例。结果行心肌桥松解术患者,术中右心室穿孔1例,经修补后治愈;心肌桥松解术同期行二尖瓣置换术患者,左心室破裂死亡1例。无其他并发症发生。术后随访30例,随访时间15～124个月;其中有2例单纯MB患者行松解术后仍有心绞痛症状,均用药物控制。30例MB患者术后心功能分级Ⅰ级25例,Ⅱ级2例,Ⅲ级3例。结论MG的外科治疗可依据心肌桥的长度,位置的深浅及是否合并壁冠状动脉近端粥样硬化,选用心肌桥松解术或冠状动脉旁路移植术,这两种手术方法均可取得较为满意的临床结果。     

急性前壁心肌梗死患者心电图表现与冠脉造影对比研究

目的分析急性前壁心肌梗死的梗死相关血管特点和心电图分布特征，为临床判断冠状动脉病变部位提供线索。方法经冠状动脉造影证实为单支血管病变的142例初发急性前壁心肌梗死患者，根据心电图表现分为四组。比较各组间梗死相关动脉的病变特点。结果单纯前壁心肌梗死的犯罪血管病变82％（36／44）在前降支中段，前壁心肌梗死合并下壁导联ST段压低的犯罪血管病变80％（24／30）在前降支近段，前壁心肌梗死合并下壁导联ST段抬高者，犯罪病变54％（20／37）在右冠状动脉，46％（17／37）在左前降支，广泛前壁心肌梗死的犯罪病变主要在前降支近段85％（23/27），P〈0．001；前壁心肌梗死是否合并下壁导联ST段偏移，其血管病变程度与侧支循环建立相近，均好于广泛前壁心肌梗死患者。结论根据心肌梗死时心电图异常的分布特点，可以推测急性前壁心肌梗死病变的部位，良好的侧支循环有助于限制梗死面积。     

升主动脉疾病者的冠状动脉旁路移植术

老年人升主动脉粥样硬化发生率高 ,常与冠状动脉粥样硬化同时存在。严重时主动脉插管、阻断、部分阻断或冠状动脉旁路近端吻合都可造成致命的主动脉损伤、破裂出血和体循环包括冠状动脉本身栓塞〔1,2〕。临床资料　 2 0 0 1年 4月至 2 0 0 2年 3月我们在行冠状动脉旁路移植术 (CABG)中遇严重升主动脉粥样硬化 4例 ,其中 1例呈DeBakeyIII型夹层动脉瘤样改变。术前诊断不稳定型心绞痛 2例 ,急性心肌梗死 2例。 3例有陈旧性心肌梗死。冠状动脉造影均显示三支病变 ,左室射血分数 0 32～ 0 5 5。除 1例III型夹层动脉瘤者术前诊断明确外 ,其…     

冠状动脉左主干病变双源CTA影像学特征及临床应用

目的探讨冠状动脉左主干病变(LMCD)的双源CTA影像特征及临床应用。方法回顾性分析经双源CTA诊断的LMCD患者33例,分析其临床资料,按照左主干50%,左前降支、回旋支或右冠状动脉≥70%定义目标血管,经CT图像后处理,于心脏短轴层面观察节段心肌密度,分析其影像特点,同期行CAG,术后随访3个月。结果 33例患者中,双源CTA确定目标血管75支,以CAG为金标准,CTA诊断主要血管病变72支,准确率96.00%(72/75),9支(9/33,27.27%)冠状动脉左主干为单纯LMCD,24支(24/33,72.73%)LMCD合并其他主要血管病变,其中20支冠状动脉左主干合并末端岔口病变。29例(29/33,87.88%)例患者46节段CTA显示心肌密度减低,23例34节段位于心内膜下,6例12节段为透壁性。对42支(42/75,56.00%)血管行经皮冠状动脉介入治疗(PCI),其中22支病变局限、行单纯PCI,20支为左主干末端岔口病变、行PCI同时覆盖左前降支或回旋支开口。13支(13/75,17.33%)采用冠状动脉旁路移植术,20支(20/75,26.67%)采用药物保守治疗,随访3个月,未发现主要不良心血管事件。结论冠状动脉双源CTA可发现LMCD部位及范围,发现其他血管病变及异常血流灌注的节段心肌,为临床病情评估及治疗提供客观依据。     

弥漫性冠状动脉病变的外科治疗

目的总结非体外循环心脏跳动下冠状动脉内膜剥脱后行非体外循环冠状动脉旁路移植术（off—pump CABG）治疗弥漫性冠状动脉病变的早期临床结果和经验，以提高手术疗效。方法2003年5月～2006年11月，对83例弥漫性冠状动脉病变患者在非体外循环下做冠状动脉内膜剥脱后行off—pump CABG，其中男61例，女22例；年龄55-80岁（65±7岁）；加拿大心脏病协会（CCS）心绞痛分级：Ⅱ级7例，Ⅲ级20例，Ⅳ级56例。有心肌梗死史36例（43．4％）。冠状动脉造影显示：双支血管病变5例，3支病变78例，其中合并左主干病变16例。左心室射血分数25％～65％（51％±16％）。83例共行110支冠状动脉内膜剥脱，其中左前降支系统67支，回旋支、钝缘支9支，右冠状动脉系统34支。20例内膜剥脱后先用大隐静脉片行左前降支成形，再在补片上用乳内动脉行旁路血管移植；应用左乳内动脉83支，桡动脉2支，余均为大隐静脉，每例移植血管3．9±1．2支。结果无手术死亡。术中移植血管血流满意101支（92％），血流量为22±16ml／min。术后发生心肌梗死4例，梗死面积小，无血流动力学改变，未给予特殊治疗。83例患者皆痊愈出院。随访75例（90．4％），8例失访，随访时间8～50个月，无心绞痛发作。8例患者在手术后3～29个月复查冠状动脉造影显示：冠状动脉内膜剥脱后行off—pump CABG的移植血管均通畅。结论非体外循环下冠状动脉内膜剥脱后行off—pump CABG，安全可行，再血管化程度高，是治疗弥漫性冠状动脉病变的有效方法。     

慢性稳定性心绞痛患者冠状动脉临界病变斑块性质的血管内超声分析

目的探讨慢性稳定性心绞痛患者冠状动脉临界病变血管内超声斑块影像学特征。方法对慢性稳定性心绞痛患者行冠状动脉造影检查,对冠状动脉造影显示为临界病变者,行血管内超声检查,评估斑块特征。结果 163例冠状动脉临界病变患者中薄帽纤维粥样硬化斑块(TCFA)、厚帽纤维粥样硬化斑块(ThCFA)患者分别为37、50例。TCFA、ThCFA患者临床特征、冠状动脉分布情况差异无统计学意义;超过50%的临界病变血管在左冠状动脉前降支;ThCFA患者平均斑块负荷、斑块面积高于TCFA患者;ThCFA及TCFA患者斑块成分以纤维组织最多,其次为纤维脂肪组织和坏死核心成分,高密度钙化面积最低。TCFA患者最小管腔面积≤4.0mm2者占18.92%(7/37),显著高于ThCFA患者。结论慢性稳定性心绞痛冠状动脉临界病变ThCFA患者斑块负荷更重,管腔面积更大。TCFA患者最小管腔面积≤4.0mm2比例更高。     

冠心病合并2型糖尿病患者冠脉病变特点的研究

目的探讨冠心病合并2型糖尿病患者冠状动脉病变的特点。方法对经冠状动脉造影诊断的冠心病患者395例,按是否合并2型糖尿病分为两组。冠心病合并2型糖尿病组（DM组）81例以及冠心病不合并2型糖尿病组（对照组）314例。采用冠状动脉造影对两组的冠状动脉特点进行对照分析。结果合并DM的CHD患者冠状动脉病变血管较多,多支病变、弥漫病变、小血管病变以及闭塞型病变较单纯冠心病患者的发生率高（P〈0.05）。结论冠心病合并2型糖尿病患者冠脉病变程度重,累计范围较广且弥散。     

周围血管动脉粥样硬化与冠状动脉粥样硬化相关性的研究

目的应用超声方法检测外周动脉内-中膜厚度（IMT）及斑块情况,探讨外周动脉与冠状动脉粥样硬化的相关性,评价超声检测外周动脉粥样硬化对冠状动脉病变的预测价值及其临床意义。方法对110例天津医科大学第二医院心脏科住院行冠状动脉造影（CAG）的患者术后1—2周内,行外周动脉（包括颈总、颈内、颈外、股总、股浅、股深、胭、足背动脉）粥样硬化情况进行超声检查,以动脉IMT和粥样硬化斑块厚度作为观测指标,对各组病例外周动脉粥样硬化的情况进行比较,进行统计学分析,探讨动脉粥样硬化发生的危险因素,外周动脉与冠状动脉粥样硬化的相关性。结果（1）CCA IMT、颈动脉IMT、CFA IMT、SFA IMT、DFA IMT、下肢动脉IMT在冠脉未见异常组与其余三组任一组均差异有统计学意义（P〈0．05）,冠脉未见异常组IMT值小于其余三组。（2）随着冠状动脉粥样硬化血管的数量增加,颈动脉和下肢动脉动脉粥样硬化情况加重,斑块形成呈明显增加趋势。（3）多因素Logistic回归分析（STEPWISE）,CFAIMT和P下肢与冠状动脉粥样硬化具有显著相关性,有统计学意义（P〈0．05）。结论（1）颈动脉、下肢动脉和冠状动脉粥样硬化的趋势一致。（2）颈部和下肢血管的IMT及斑块对冠状动脉粥样硬化有很好的预测价值;P下肢、CFAIMT可作为预测冠状动脉粥样硬化的重要指标。（3）年龄、吸烟时间、患有高血压及高血压患病时间、甘油三酯、空腹血糖、胰岛素水平是动脉粥样硬化的高危因素。     

冠心病合併糖尿病与患者血脂血糖冠状动脉造影的分析研究

目的:探讨冠心痛合併糖尿病(DM)患者的临床特点和冠状动脉病变特徵.方法:210例冠心痛患者分为合併糖尿病(DM)和无合併糖尿病(N-DM)2组,并对2组的临床资料及冠状动脉造影结果进行统计学分析.结果:DM组的体重指数、高血压、血脂异常比N-DM组高,但无统计学差异(p＞0.05).DM组冠状动脉2支及3支血管病变、冠状动脉狭窄性病变比N-DM组更严重、置入支架数较多(P＜0.05),两组的差异有显着的统计学意义.结论:合併糖尿病的冠心病患者的冠脉硬化病变范围更广、程度更重,多支病变、弥漫病变更常见.选择合适的糖尿病患者行冠脉介入治疗可得到较好的治疗效果.     

Time to first new myocardial infarction in patients with severe angina and three-vessel disease comparing medical and early surgical therapy: a CASS registry study of survival

We compared time to first new myocardial infarction during a 6-year follow-up in patients in the registry of the Coronary Artery Surgery Study who had three-vessel coronary artery disease and Canadian Cardiovascular Society Class III-IV angina pectoris. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. A broad definition of myocardial infarction incorporating electrocardiographic and clinical criteria was used to include as many new infarctions as possible. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, 86% of surgical and 73% of medical patients were free of new myocardial infarction at 6 years (p less than 0.0001). This advantage of surgical treatment was observed in subgroups of patients with at least one proximal 70% (or greater) stenosis in the left anterior descending coronary artery and moderate or severe impairment of left ventricular function, as well as those patients with two proximal coronary artery narrowings. In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was the strongest predictor of freedom from new myocardial infarction.     

合并严重冠心病的短锚定区主动脉弓降部疾病的腔内修复

目的:探讨合并严重冠心病,已经接受或近期可能接受冠状动脉旁路移植手术须保留左锁骨下动脉,且近端锚定区又不足的主动脉弓降部疾病患者腔内修复治疗的策略及注意事项。方法:回顾性分析2016年4月—2016年7月期间阜外医院血管外科中心收治的9例合并严重冠心病、近端锚定区不足的主动脉弓降部疾病患者资料,其中男7例,女2例,平均年龄60(37~76)岁,均行胸主动脉腔内修复术治疗,均需保留左锁骨下动脉,从而保留作为冠脉前降支桥血管最佳来源的左侧乳内动脉。结果:手术成功率100%,无手术死亡,所有患者左侧乳内动脉均保留成功。术后发生I型内漏1例(1/9),随访3个月后内漏消失;术后4个月因冠状动脉回旋支狭窄行经皮冠状动脉成形术1例(1/9)。所有患者均获得门诊或电话随访,随访时间6(4~7)个月,所有患者临床症状消失或明显减轻,生活质量改善,无随访死亡病例。结论:对于已经接受左侧乳内动脉-冠脉前降支搭桥或即将接受冠脉搭桥手术的主动脉弓降部疾病患者,在实施胸主动脉腔内修复手术时可采取个性化措施保留左锁骨下动脉,进而保留左乳内动脉,必要时可以采用"烟囱"等技术辅助。     

256层螺旋CT冠状动脉成像评价心肌桥相关冠心病危险因素

目的采用256层螺旋CT定量评价心肌桥相关冠心病(MB-CAD)危险因素。方法收集78例心肌桥(MB)患者的CT冠状动脉成像及临床资料,记录患者年龄、性别,分析MB长度、MB厚度、壁冠状动脉(MCA)近段血管动脉粥样硬化(AS)、MCA成角及MCA收缩期狭窄率;根据临床及影像学资料综合诊断MB-CAD,采用Logistic回归分析检验上述MB-CAD危险因素。结果共14例(14/78,17.95%)发生MB-CAD。MB厚度为发生MB-CAD的危险因素,其OR值为19.50,95%CI(1.86~20.47),MB厚度在MB-CAD(2.7~7.1mm,中位数3.70mm)与非MB-CAD患者(0~1.9mm,中位数0.65mm)间差异有统计学意义(χ2=35.91,P0.05)。结论 256层螺旋CT冠状动脉成像可定量检测MB特征,MB厚度是发生MB-CAD的危险因素。     

Surgical treatment of right coronary arteries with anomalous origin and slit ostium

BACKGROUND: Right coronary arteries arising in the left sinus or ectopically in the anterior coronary sinus with slit ostium course inside the aorta. They are subject to variable systolic compression and can cause myocardial ischemia with its sequelae or death. METHODS: From May 1991 to March 2003, we treated 16 patients with anomalous origin of the right coronary artery from the left sinus and 4 whose right coronary artery arose ectopically in the anterior sinus. All patients had a slit ostium and underwent transaortic unroofing of the trunk to modify the proximal portion of the anomalous artery. RESULTS: All patients survived operation, although 1 patient died of unrelated causes. Nineteen patients were followed for a period from 0.2 to 11.8 years (median age, 53 years). One experienced angina 1 year after surgery and underwent percutaneous transluminal coronary angioplasty of a left internal thoracic to left anterior descending coronary artery anastomosis. All patients are New York Heart Association class I, without angina; none has sustained a myocardial infarction or required reoperation. CONCLUSIONS: Right coronary arteries that arise in anomalous fashion with a slit ostium can cause myocardial ischemia or death. Transaortic modification of the anomalous trunk addresses the anatomic and pathophysiologic features of the malformation that cause myocardial ischemia. Excellent results can be achieved with this surgical approach.     

Giant coronary aneurysms exceeding 5 cm in size

Giant coronary artery aneurysms (gCAAs) with a diameter exceeding 5 cm are extremely rare. The pathomechanisms and therapeutical measures in such cases have been controversial topics of discussion. Twenty-seven patients with gCAAs exceeding 5 cm in size described in the literature were evaluated. A case with multiple gCAAs at our department was included in the analysis. Apart from atherosclerosis of all coronary arteries, a large (1.5 2.5 cm) left anterior descending coronary artery aneurysm (CAA) and a gCAA (10.6 9.2 cm) originating from the right coronary artery, the latter causing recurrent myocardial ischaemia with the occlusion of the peripheral right coronary artery and compressing the right cardiac cavities, were the pathological findings in our 43-year old male patient. gCAAs predominantly develop at the proximal right coronary artery. The majority of these aneurysms develop secondary to atherosclerotic lesions in young patients. We performed a successful surgical excision of the right gCAA, tightening of the left anterior descending artery aneurysm and concomitant coronary artery bypass grafting. A pathological examination confirmed advanced atherosclerosis. Microbiological examinations could find no signs of infectious causes. CAAs bear a significant risk of severe complications and have a high risk of mortality. A more aggressive surgical approach should be recommended.     

Total arterial coronary revascularization: techniques and results in 3,220 patients

Background. To overcome the problems of late vein graft atherosclerosis, occlusion and need of coronary reoperations, we have adopted a strategy of total arterial coronary revascularization. We evaluated our experience with this strategy to establish its safety and efficacy.

Methods. All 3,220 consecutive patients who had total arterial coronary revascularization from January 1988 to June 1998 were evaluated. Data were collected prospectively. The mean age was 62.2 years. Of the patients, 595 (18.8%) had diabetes; 739 (23%) had a left ventricular ejection fraction of less than 0.50; and 484 (15%) were classified unstable/urgent. The conduits included 3,140 left internal thoracic arteries, 1,224 right internal thoracic arteries, and 2,417 radial arteries, 654 of which were bilateral. A or graft with the left internal thoracic artery was used in 467 patients. Patients were followed up at 1 month, 3 months, and yearly thereafter. Postoperative angiography was performed for symptoms or as part of an ethics committee–approved prospective study.

Results. The operative mortality rate was 0.7% (21 patients). Complications included stroke in 26 patients (0.8%), myocardial infarction in 27 (0.8%), sternal infection in 35 (1.1%), and reoperation for hemorrhage in 23 (0.7%). The peak level of the myocardial enzyme of creatine kinase was 16.4 ± 14.9 IU/L. Twenty-five patients (0.8%) required intraoperative or postoperative intraaortic balloon pump support. Mortality and stroke rates were higher in patients having reoperation (0.6% versus 1.8%; p = 0.11; and 0.7% versus 2.2%; p = 0.07, respectively). Postoperative angiographic patency was 97% at 5 years for the left internal thoracic artery (620 grafts), 89% at 5 years for the right internal thoracic artery (276 grafts), and 91% at 1 year for the radial artery (65 grafts).

Conclusions. Total arterial coronary revascularization can be performed safely with good patency rates in a large number of patients and may potentially avoid the sequelae of vein graft atherosclerosis.     

Normal coronary artery dimensions in Indians

Background There is no available data on normal coronary artery size in the Indian population. We attempted to establish a database for normal dimensions of the coronary artery segments during life by using quantitative coronary angiography and compared these with Western estimates of coronary artery size. Material and Methods Between december 2003 and June 2004, 94 patients who underwent quantitative coronary angiography for evaluation of symptoms of ischemic heart disease and were found to have no coronary artery disease form the sample size. Results The dimensions of branches in the left coronary system in our patients were less and those of the distal circumflex, and the proximal and distal left anterior descending coronary arteries were significantly greater than those of Indian Asians living in the United Kingdom and the native Caucasians but the dimensions of the right coronary artery were significantly greater in our patients. Conclusions Coronary artery dimensions for at least some branches of the left coronary system are similar to that reported in the West and the dimensions of the right coronary are greater. These findings contradict the general perception that Indians have smaller coronary arteries.     

Anomalous LAD and CX artery arising separately from the proximal right coronary artery--a case report of single coronary artery with coronary artery disease

Coronary artery anomaly has been reported at a rate of 0.6% to 1.3% in routine angiographic series. Moreover, single coronary artery is one of the rarest anomalies among coronary anomalies. Eventhough patients with coronary anomalies are usually asymptomatic, they may also be associated with myocardial ischemia, ventricular fibrillation, syncope, congestive heart failure, and sudden death. In this article, we report a case of single coronary artery anomaly with the left anterior descending (LAD) and left circumflex (LCx) coronary artery arising separately from the proximal right coronary artery. Since the presented case was associated with ischemic heart disease, coronary artery bypass grafting was carried out. He is currently well.     

Iatrogenic left main coronary artery stenosis following aortic valve replacement: two cases report

Two cases of iatrogenic left main coronary artery stenosis (ICOS) following aortic valve replacement (AVR) are documented. The first patient began to have chest pain due to myocardial ischemia 7 months after AVR. Angiographically, the ostium of her left coronary artery was severely stenotic. She refused coronary bypass grafting. She died of myocardial infarction due to ICOS, 23 months after AVR. Histologically, a loose cellular connective tissue was found around the stenotic coronary arterial lumen. The other patient had chest pain 4 months after aortic and mitral valve replacement. The ICOS was diagnosed angiographically. After she had coronary bypass grafting, she was free from myocardial ischemic symptoms. The onset of myocardial ischemic symptoms in the first six months after AVR is highly suggestive of ICOS, and urgent coronary angiography is recommended and, if proximal stenosis of the coronary arteries is diagnosed, coronary bypass grafting should be performed.     

Myocardial ischemia caused by postoperative malfunction of a patent internal mammary coronary arterial graft

The internal mammary artery is used with increasing frequency for myocardial revascularization. However, preoperative coronary angiography does not always provide adequate visualization of subclavian arteries. If a proximal subclavian artery stenosis exists or develops in a patient who has myocardial revascularization with the internal mammary artery, graft malfunction can occur resulting in myocardial ischemia. We have identified four cases of internal mammary artery graft malfunction at our own institution and identified an additional 12 cases from the literature. These 16 cases are analyzed for age, sex, time of onset of symptoms, clinical findings, method of revascularization, and long-term follow-up. Sixty-three percent of the patients were men, and the mean age was 52.9 +/- 9.0 years. Onset of symptoms occurred after a mean interval of 25.1 months from the time of myocardial revascularization. Three patients had asymptomatic reversal of flow in the internal mammary artery as diagnosed by coronary arteriography during routine follow-up examination before 1980. One death after internal mammary artery-coronary bypass grafting was related to immediate malfunction. In the remaining 12 patients with symptomatic malfunction, all but one were treated by placement of a carotid-subclavian bypass graft with no mortality. Relief of myocardial ischemia was complete in 93% of the patients with a mean follow-up of 29.3 months. Carotid-subclavian bypass grafting appears to be the treatment of choice for the usual management of internal mammary artery graft dysfunction. Careful preoperative evaluation and postoperative follow-up of the subclavian arteries, even by simple comparison of bilateral arm blood pressure should help reduce the incidence of this syndrome.