冠状动脉旁路移植术中骨骼肌化胸廓内动脉的应用

目的 探讨骨骼肌化胸廓内动脉（ITA）用于冠状动脉旁路移植术的优越性。方法采用剪刀和钛夹将骨骼肌化的ITA游离,并将其用于冠状动脉旁路移植术。结果共游离ITA 61根,并顺利用于60例冠状动脉旁路移植术患者,平均获取时间为26．8min。骨骼肌化ITA平均血流量吻合前为86．5ml／min,吻合后为26.4ml／min。随访1～31个月,无心脏相关性死亡和事件发生。结论在冠状动脉旁路移植术中应用骨骼肌化的ITA和带蒂ITA一样安全、有效。     

双侧胸廓内动脉搭桥在冠心病心肌再血管化中的应用

在心肌再血管化中采用单侧或双侧胸廓内动脉（ITA）各60例，单侧组完成200支冠状动脉吻合，平均每例3．3支，60支带蒂在ITA均与左前降支（LAD）吻合；双侧ITA组完成210支冠状动脉吻合，平均每例3．5支，其中60支带蒂左ITA与LAD吻合，60支右ITA中，54支为带蒂移植血管，6支为游离血管，12支经横窦与回旋支吻合，48支带蒂右ITA与右冠状动脉吻合。两组均无围术期死亡和胸骨感染，两级各有2例术后大出血开胸止血。单、双侧ITA组分别有35例和41例随诊6个月至4年，均无心绞痛再发。术后运动试验单侧组3例阳性，双侧组1例阳性。     

Coronary artery surgery: conventional coronary artery bypass grafting versus off-pump coronary artery bypass grafting

PURPOSE OF REVIEW: Coronary revascularization has become the principal treatment modality in patients with severe coronary artery disease. The broader application of percutaneous coronary interventions in patients with multivessel disease and the recent introduction of drug-eluting stents have both lead to a decline in the number of patients referred for surgical revascularization. Conventional coronary artery bypass grafting using cardiopulmonary bypass is an excellent treatment, however less invasive surgical approaches such as off-pump coronary artery bypass grafting have appeared in the past few years. The exact role of off-pump coronary artery bypass grafting is still vaguely defined and being critically evaluated. Our aim is to provide an objective review of the recent literature in regard to surgical outcomes. RECENT FINDINGS: A critical review of all relevant clinical series from May 2003 to May 2005 was conducted. Current prospective data suggests that both techniques have similar rates of mortality, in regard to morbidity, multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. The incidence of postoperative myocardial infarction does not appear to differ between techniques. When analyzed carefully, the results presented herein seem to indicate that both techniques provide similar rates for long-term patency and freedom from surgical reintervention. SUMMARY: Coronary artery bypass grafting and off-pump coronary artery bypass grafting are both safe and beneficial in patients with multivessel coronary artery disease. It appears that elderly patients with additional co-morbid risk factors may benefit most from off-pump coronary artery bypass grafting. It has become increasingly apparent that off-pump coronary artery bypass grafting can be performed safely in reference centers.     

胸廓内动脉行冠脉搭桥术的应用解剖学研究

目的了解胸廓内动脉的解剖结构,为临床进行冠状动脉搭桥术提供解剖学资料。方法选取甲醛固定的成人尸体标本40具,胸廓内动脉保留完好。观察记录胸廓内动脉的起始部位和终末分支,以及胸廓内动脉与胸横肌的关系。测量胸廓内动脉的长度和各肋间隙距胸骨侧缘的距离。结果多数胸廓内动脉起自锁骨下动脉第1段,沿胸骨侧缘外侧下行;多数胸廓内动脉在第6肋间隙形成终末分支;多数胸横肌上缘与胸廓内动脉相交在第3肋软骨处。左、右侧胸廓内动脉的长度分别为（19．34±1．69）cm和（18．86±1．73）cm,平均外径为（2．81±0．39）mm和（3．08±0．44）mm。结论胸廓内动脉行冠脉搭桥术是一种可行的搭桥方式,根据解剖学数据,在术中应取用第6肋软骨以上的血管进行吻合。     

Coronary artery bypass grafting using a bifurcated internal thoracic artery

Coronary artery bypass grafting was performed successfully on a patient by anastomosing the left internal thoracic artery and its pericardiacophrenic branch to the obtuse marginal and the posterior descending coronary artery, respectively, to form a Y graft. Preoperative angiography of the internal thoracic artery had revealed the presence of an unusually large pericardiacophrenic branch almost the size of the main trunk, which allowed us to plan for bifurcated artery grafting.     

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.     

Robotically assisted multivessel minimally invasive direct coronary artery bypass grafting with the use of bilateral internal thoracic arteries.

This case report presents the robotically assisted multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB) technique using the bilateral internal thoracic arteries. A 54-year-old man with multivessel coronary artery disease was considered eligible for a robotically assisted myocardial revascularization. The bilateral internal thoracic arteries were harvested completely in a totally skeletonized fashion through three 1-2-cm-long incisions on the left thoracic wall. A small left anterior thoracotomy was then performed. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery, and the composite radial artery graft from the right internal thoracic artery was sequentially anastomosed to the first diagonal branch, the obtuse marginal branch, and the distal right coronary artery on the beating heart without cardiopulmonary bypass. The harvesting time of the grafts was 66 min, and the total operative time was 5 h 58 min. Postoperative angiography revealed that all grafts were widely patent. The postoperative course was uneventful, and the patient was discharged 10 days after the operation. Robotically assisted MIDCAB using the bilateral thoracic arteries is a safe and effective means of myocardial revascularization for patients with multivesssel disease.     

骨骼化乳内动脉在不停跳冠状动脉旁路移植术中的应用研究

目的:总结将骨骼化乳内动脉(IMA)应用于不停跳冠状动脉旁路移植术(OPCABG)的临床结效果和经验。方法:选取从2015年7月至2016年6月期间,我科室60例包括冠状动脉前降支在内的多支冠状动脉狭窄需进行OPCABG,并经术前超声检查锁骨下动脉和IMA正常的患者。随机分为两组;A组:应用骨骼化方法获取左IMA,并与前降支行端侧吻合进行血运重建;B组:应用带蒂获取左IMA与前降支吻合进行血运重建。两组均应用静脉复合全身麻醉,取胸部正中切口,非体外循环下施行手术。结果:远端吻合口数两组分别为(2.6±0.5)个/例和(2.7±0.5)个/例,无胸骨感染病例;院内死亡1例,病死率1.7%,为带蒂方法采集左IMA组,死亡原因为围术期心肌梗死;术后发生并发症4例,每组各2例,发生率6.7%,其中发生肺部感染2例,低心排血量综合征2例,均通过抗感染、血管活性药物、IABP辅助治疗等措施治愈。生存患者随访3个月,随访率89.8%(53/59);所有患者无心绞痛复发,心功能恢复至Ⅰ~Ⅱ级(NYHA)。结论:在OPCABG中应用骨骼化IMA安全、疗效满意,但术中取材具有一定操作难度,易发生乳内动脉损伤,手术方式选择应根据具体情况决定。     

Percutaneous coronary intervention versus coronary artery bypass grafting in diabetic patients

Revascularization with CABG or angioplasty in diabetic patients is associated with a less favor-able outcome. The value of early intervention will be assessed in the ongoing BARI 2D trial. It remains to be determined whether the widespread use of GP IIb/IIIa drugs and prolonged dual antiplatelet therapy in diabetic patients who receive stents, and possibly drug-eluting stents, will alter results significantly so that outcomes become comparable or even better than CABG (Fig. 3). It seems prudent to consider CABG with LIMA grafting in diabetic patients who have severe multi-vessel disease and to consider angioplasty in selected patients who have more discrete and less severe disease.     

Combined coronary artery bypass grafting and lung surgery

Combined coronary bypass and lung surgery was performed in 3 patients. Through a median sternotomy or a left thoracotomy, bypass grafting was performed on beating heart or under cardiopulmonary bypass, followed by the lung operation. The lung lesion was diagnosed as carcinoma in 2 patients and hydatid cyst in 1 patient. With few exceptions, beating heart coronary bypass through a median sternotomy can be performed in a combined operation.     

Estimation of left internal thoracic artery flow reserve after coronary artery bypass grafting using Doppler flow wire]

The usefulness of the left internal thoracic artery (LITA) for aortocoronary bypass grafting is now established. Reports of variation in LITA graft function are rare. Graft flow was measured using a Doppler flow wire to estimate graft function in 27 patients (24 males, 3 females) who underwent LITA grafting to the left anterior descending artery. Patients were classified into the following 3 groups: Group A consisted of 9 patients with normal left ventricular function and no native flow; Group B consisted of 11 patients with normal ventricular function and good native flow; Group C consisted of 7 patients with abnormal left ventricular function and no native flow. LITA graft function was also estimated 1 year after operation in 12 of these 27 patients (4 in each group). Diastolic/systolic velocity ratio (DSVR) and flow reserve were determined in the proximal, middle, and distal portions of the LITA graft and native left anterior descending artery before and after papaverine administration (8-10 mg). DSVR was significantly higher in the distal portion than in the proximal portion (p < 0.01), but this value did not change after papaverine administration. After 1 year, DSVR in the proximal portion was significantly higher in Group C than in Groups A or B (p < 0.05 for both). Four weeks after operation, the flow reserve of the distal portion was significantly higher in Group A than in Group C (p < 0.001). After 1 year, this value was significantly higher in Group A than in either Groups B or C (p < 0.01, p < 0.001, respectively). The rate of increase in flow reserve in the distal portion was significantly greater in Group A (23.4%) than in groups B (2.53%) or C (1.94%; p < 0.05 for both). The distal portion of the LITA was the best measurement site, since the flow pattern in the LITA graft varied throughout all portions. Diastolic flow velocity in the LITA graft was dominant in patients with myocardial damage. The results indicate that flow reserve of the LITA graft depends on antegrade native coronary flow and distal myocardial damage.     

Histomorphological studies of the distal internal thoracic artery which support its use for coronary artery bypass grafting.

The use of the internal thoracic artery (ITA) for myocardial revascularization in coronary artery disease increased because of its relative immunity to atherosclerotic obstruction. This study investigated the distal part of the vessel, the region of anastomosis by means of histology to focus the visualization of this region of interest. The histological examination of arterial segments showed minor intimal thickening in 48 out of 100 patients. Twelve patients demonstrated a severe intimal thickening, the residual patients were without any changes. In 52% the elastic type dominated in the distal part. Hybrid and muscular patterns were found in 22 and 26%, respectively. The media could be classified into three different types: muscular, hybrid and elastic type. There was no correlation concerning the different histological type and the incidence of intimal thickening. No evidence whatsoever of atherosclerotic lesion was encountered in any of the investigated vessels. There is no limitation in the use of the distal part of the ITA for coronary artery revascularization.     

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。