急诊冠状动脉搭桥术在急性心肌梗死治疗中的临床应用

目的探讨急性心肌梗死（AMI）行急诊冠状动脉搭桥术的手术指征及外科处理要点,提高手术成功率。方法回顾性总结我院对2007年8月至2010年6月间急性心肌梗死患者行急诊冠状动脉搭桥术20例患者的临床资料,分析急诊冠状动脉搭桥术在AMI治疗中的临床应用。结果本组16例抢救成功,手术成功率为80％。非停跳搭桥11例,停跳搭桥9例,平均移植血管桥（2．8±0．5）支,使用主动脉内气囊反搏装置（IABP）8例;术后机械通气平均（18±14）h;术后低心排血量2例,难治性心律失常2例,脑血管意外1例,下肢感染1例。全组无一例发生围术期心肌梗死,无再次手术止血。平均随访时间为（15±3．4）个月,仅1例术后2个月反复出现右心功能衰竭症状,余患者心绞痛症状均完全消失,术后复查超声心电图示左室收缩功能明显改善。结论急诊冠状动脉搭桥术治疗急性心肌梗死可取得良好的疗效。     

左主干伴三支病变严重狭窄外科治疗体会

目的：探讨严重左主干狭窄伴三支血管病变严重狭窄患者的手术时机及方法选择。方法回顾分析2003年1月至2013年3月对严重左主干病变伴三支血管病变患者施行冠状动脉旁路移植术296例。其中体外循环冠状动脉旁路移植术（CCABG）276例,非体外循环冠状动脉旁路移植术（OPCAB）20例。60岁以上者172例（58.1％）。术前同时合并其他疾病患者246例（83.10％）,包括瓣膜病、高血压病、高血脂、糖尿病、陈旧性心肌梗死、室壁瘤、脑梗死等。冠状动脉旁路移植（3.85±0.6）支,左乳内动脉旁路移植281例（95.10％）。围术期使用主动脉内气囊反搏（IABP）32例。结果手术早期死亡7例（2.36％）,其中低心排综合征1例、心室纤颤2例、脑岀血1例、消化道岀血1例、肾功能衰竭1例、多脏器功能衰竭1例。术后并发症26例（8.78％）,其中低心排量综合征8例、心室纤颤4例、呼吸衰竭3例、多脏器功能衰竭3例、心包压塞2例、肾功能衰竭2例、消化道出血2例及脑岀血2例。212例（71.62％）患者随访2-84个月,3例死亡（1.01％）,2例与心脏病有关。结论严重左主干伴三支血管严重狭窄高危患者在体外循环下手术仍不失为一种安全有效的治疗方法,对左心功能低下者预先置入IABP可使CABG术的死亡率和并发症发生率均降低,改善了其预后。     

使用桡动脉和乳内动脉桥材料全动脉化冠状动脉旁路移植手术的近中期结果

目的评价使用桡动脉和乳内动脉作为惟一桥材料进行全动脉化冠状动脉旁路移植手术的近期和中期结果。方法从1999年1月到2005年1月共123例患者[男114例,女9例,平均年龄（51．9±9．4）岁]采用全动脉化冠状动脉旁路移植手术,目标血管桥在两根以上。术前左心室EF值30％～78％,24例患者（21．1％）心室收缩功能较差（EF〈50％）。64例患者有陈旧性心肌梗死病史,4例患者因不稳定性心绞痛进行了急诊手术。36例左主干病变患者。74％的患者使用非体外技术进行吻合,每个患者平均吻合口数为2．6±0．4。结果早期死亡率0．8％。术后并发症包括,7例患者出现一过性房颤（5．7％）,1例患者因为低心排安装主动脉球囊反搏（IABP）,3例患者因为心力衰竭、再发心绞痛和心律失常在术后1个月内再次入院。20例患者（1999--2001年）进行了5年随诊[平均随诊（62±13）个月]。3例患者在随诊中死亡,均为心脏原因。1例患者因再次心肌梗死而行二次冠状动脉旁路移植手术,另1例患者因原先动脉桥狭窄而行经皮冠状动脉内球囊扩张术（PCI）。结论使用桡动脉和乳内动脉作为桥材料进行全动脉化冠状动脉旁路移植近期效果较好,中期手术并发症较低。     

左冠状动脉异常起源于肺动脉综合征CTCA表现的分折

[目的]分析左冠状动脉异常起源于肺动脉(ALCAPA)综合征的多排螺旋CT冠状动脉成像(MDCTCA)表现并复习文献,以期提高对该综合征的认识.[方法]对3例经手术证实的ALCAPA综合征患者的CTCA表现和临床资料进行回顾性分析.3例患者均于术前行CTCA检查,其中2例于术后各复查1次CTCA.[结果]3例患者术前CTCA检查均可清晰显示左冠状动脉起源于肺动脉,与术中所见相符;其中2例患儿出生后不久开始出现心功能不全症状,CTCA示双侧冠状动脉未见扩张,左心室增大,符合“婴儿型”;1例患儿婴儿期无症状,CTCA可见右侧冠状动脉主干及分支扩张迂曲,左、右冠状动脉间见多条侧枝血管吻合,符合“成人型”;1例患者合并动脉导管未闭及永存左上腔静脉,1例合并左肾重复畸形.[结论]CTCA技术是ALCAPA综合征诊断、分型及术后随访的重要手段.     

冠状动脉旁路移植术术与疗效观察

总结了５７例冠状动脉架桥手术治疗的体会。术前均经冠状动脉造影检查证实，采用自体大隐静脉和（或）左乳内动脉作移植血管。结果：死亡２例（３．５％），术后随访３～５年，心绞痛消失率为９１．２％，心功能改善至１级５３例；２组２例。表明冠状动脉旁路移植术能有效地改善心肌缺血，对解除心绞痛，提高痛员生活质量有明显效果。     

冠状动脉搭桥术212例

目的：总结成人冠状动脉搭桥术（CABG）的临床经验。方法：2002年4月至2010年2月共施行CABG术212例,同期行心脏瓣膜20例,升主动脉带瓣管道置换6例,室壁瘤切除8例,房间隔缺损（ASD）修补术2例,粘液摘除术1例,冠状动脉支架置入术（PTCA）后再狭窄、堵塞35例,冠状动脉支架置入术致心脏破裂修补术4例。结果：本组住院死亡9例（4.2%）,死亡原因包括：急性心梗行支架置入术后低心排在主动脉球囊反博仍无效下急诊搭桥术2例（1%,2/5）,肾功能衰竭2例（1.5%）,严重心律失常1例（1.5%）,严重肺部感染致败血症,多器官功能衰竭2例（0.4%）。随访147（69.3%,147/212）例,随访时间6个月至7年,死亡3例,原因均为严重心律失常。大多数患者心功能和生活质量明显改善,心功能（NYHA）Ⅰ级95例,Ⅱ级65例,Ⅲ级41例9例,Ⅳ级2例。结论：CABG手术随着手术和术后治疗经验的成熟,其安全性越来越大,已成为冠心病患者较为安全、可靠的治疗方法;但由于心脏介入手术的普及,由其并发症而需急诊搭桥的病例有所增加,这部分手术死亡率较择期手术高。     

主动脉内气囊反搏在冠心外科的应用(附91例分析)

目的：探讨主动脉内气囊反博（IABP）在冠心外科中的应用时机和效果。方法：对91例冠状动脉搭桥术（CABG）病人行IABP治疗,其中术前使用者12例（13．2％）,术中开放主动脉30min内使用者28例（30．8％）,开放主动脉30min后使用者51例（56％）。结果：使用IABP后,病人平均动脉压升高、心率、中心静脉压、左房压下降,升压药用量减少,频发室性心律失常消失,左心功能改善。术前置IABP有效率91．7％,病死率9．1％;术中开放升主动脉30min内使用IABP有效率89．3％,病死率14．3％;开放升主动脉30min后使用IABP有效率82．4％,病死率41．2％。1例发生下肢缺血,没有因IABP并发症导致死亡。结论：IABP对冠心外科病人的急性左心衰治疗作用是肯定的,但应用要及时。     

小儿左冠状动脉异常起源于肺动脉(ALCAPA)的手术治疗

 目的   总结小儿左冠状动脉异常起源于肺动脉(anomalous origin of the left coronary artery from pulmonary artery,ALCAPA)的手术治疗经验。方法   回顾性分析2005年5月至2011年12月在我中心行手术治疗的9例小儿ALCAPA的病例资料,男性4例,女性5例,平均年龄3.1±0.8岁(2个月至13岁)。其中3例采用延长左冠状动脉后再植入术,6例采用左冠状动脉直接植入术。1例患儿合并重度二尖瓣关闭不全伴返流,同期行二尖瓣成形术,术后7个月因二尖瓣重度返流伴急性左心功能衰竭行二尖瓣机械瓣置换术。结果  全组病例无住院和随访死亡。平均体外循环时间(137.5±35.0) min,平均主动脉阻断时间(67±21) min,平均机械通气时间(70.6±52.6) h,平均监护室滞留时间(9.2±6.0)天。1例术后左心功能衰竭无法脱离体外循环,经体外膜肺氧合支持治疗,辅助18 h撤机。随访6~40个月,平均(30±8)个月,冠状动脉血流通畅,左心室射血分数从术前40%±8%增加至术后65%±10% (P<0.05),左心室缩短分数从术前23%±7%增加至术后40%±6% (P<0.01),心功能均恢复至NYHA Ⅰ级。结论   ALCAPA应尽早诊断,尽早手术矫治,冠状动脉再植入术是首选术式。     

双侧乳内动脉在冠状动脉搭桥中的应用

目的：探讨双侧乳内动脉在冠状动脉搭桥中的应用及效果。方法：自1998年1月到2001年3月,运用双侧乳内动脉连续为51例患者行冠状动脉搭桥手术。所有患者均为男性,年龄36-65岁（平均49.9岁）,48例患者为3支病变,3例为左主干病变,37例术前有心梗,4例合并室壁瘤。47例在体外循环下行冠状动脉搭桥手术,4例在非体外循环下行冠状动脉搭桥手术。39例行左侧乳内动脉（LIMA）到钝缘支、右侧乳内动脉（RIMA）到前降支;9例行LIMA到前降支、RIMA到右冠状动脉手术;LIMA到前降支、RIMA到钝缘3例。运用胃网膜右动脉或桡动脉行其他病变血管搭桥手术。4例同时行室壁瘤切除。1例行冠状动脉内膜剥脱。人均搭桥3支。结果：手术早期死亡3例（手术早期死亡率5.9％）。死亡原因：1例术后围术期心梗导致低心排,1例顽固性心律失常,1例因脑栓塞在术后40d死亡。4例需主动脉球囊反搏支持。2例术后出现切口感染,再次清创处理。随访2-39月（平均15.5个月）,患者均无心绞痛再次发作。B超检查显示双侧乳内动脉均通畅。结论：双侧乳内动脉在冠状动脉搭桥中具有较好的应用效果,近期效果比较满意,远期效果尚待进一步随访。     

急诊冠脉旁路移植术治疗冠状动脉介入术后并发症5例效果观察

目的：探讨冠状动脉介入手术并发症需行急诊冠脉旁路移植术的疗效与安全性。方法：冠状动脉介入术5例术中出现严重并发症时,在常温不停跳或低温体外循环下行急诊CABG治疗,出院后以患者死亡为随访终点。结果：左前降支病变4例,左回旋支1例。PCI术中出现冠状动脉穿孔2例,冠状动脉夹层2例,冠状动脉急性闭塞1例。急诊冠脉旁路移植术后随访（70±58）个月。术后第1天急性肾功能衰竭1例,术后7天恢复。心力衰竭1例,术后9个月经住院积极纠正心力衰竭,目前心功能Ⅱ级。结论：急诊冠脉旁路移植术治疗冠状动脉介入术后严重并发症疗效可靠。     

Surgical treatment of anomalous origin of coronary artery from the pulmonary artery

Background Anomalous origin of coronary artery from the pulmonary artery is a rare congenital cardiac malformation with a mortality rate of up to 90% within the first year of life without surgical intervention. Direct implantation of the anomalous coronary artery （ACA） into the aorta is successful in early life, but it may have increased surgical difficulty and risk with age. This retrospective study summarized our operative experience in direct implantation for treatment of this coronary anomaly in pediatric and adult patients.
Methods From August 2000 to January 2003, 4 consecutive patients aged from 9 months to 41 years underwent dual coronary repair. Among them, two children and one infant with anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA） and one adult was anomalous origin of right coronary artery from the pulmonary artery （ARCAPA）. Coronary arteries were directly implanted into the ascending aorta in 4 patients. In a boy with ALCAPA associated with moderate mitral insufficiency （MI）, whose ACA arose remotely from the ascending aorta, we created a tube-shaped graft using part of the pulmonary arterial wall in continuity with the origin of the left coronary artery （LCA）. Concomitant moderate MI was repaired in 2 patients, including this boy, after a dual-coronary repair.
Results All patients survived. There were no hospital or late deaths and no major complications as well. Echocardiography revealed that the left ventricular （LV） function including LV end-diastolic dimension （EDD） and ejection fraction （EF） was markedly improved at hospital discharge. At 3-6 years follow-up after surgery all patients were asymptomatic and currently in NYHA class 1.
Conclusions The best results are achieved with direct implantation of the ACA into the ascending aorta and simultaneous mitral valve repair if needed. Direct implantation is feasible in pediatric and adult patients with ALCAPA or ARCAPA including the coronary artery in a location remote from th     

Clinical features and long-term prognosis of patients with anomalous origin of the left coronary artery from the pulmonary artery

Background Anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA） is a rare congenital heart anomaly. We aimed to illustrate the clinical features and long-term prognosis of patients with ALCAPA.Methods Twenty three patients （13 males and 10 females, ages ranging from 2.5 months to 65 years） identified as ALCAPA in Beijing Anzhen Hospital from April 1984 to June 2009 were divided into two groups, based on the age of onset： group 1 （≤12 months, n=16） and group 2 （〉12 months, n=7）.Results Fifty six point three percent of patients in group 1 had been misdiagnosed as endocardial fibroelastosis （9/16）,18.8% as dilated cardiomyopathy （3/16） and 6.3% as myocardial infarction （1/16）. Patients in group 2 were usually diagnosed as coronary heart disease, myocarditis, or patent ductus arteriosus. Electrocardiography in group 1 revealed abnormal Q waves with T wave inversion in leads I, avL, V4-V6, especially in lead avL （deep and wide Q wave）; but no specific manifestations in group 2. A higher percentage of patients in group 1 had cardiomegaly on chest radiograph （86.7% vs. 33.3%, P=0.031）, while pulmonary artery protrusion was more common in group 2 （26.7% vs. 83.3%,P=0.046）. Lower left ventricular ejection fraction （LVEF） was present in group 1 than in group 2 （（48.5±11.5）% vs.（65.0±6.1）%, P 〈0.001）. Apical ventricular aneurysm （62.5% vs. 0%, P=0.007）, enhanced echogenicity of papillary muscles （87.5% vs. 28.6%, P=0.011） and endocardial thickening （93.8% vs. 14.3%, P 〈0.001） were more frequent in group 1 than in group 2. The ratio of the proximal right coronary artery （RCA） diameter to the aortic root diameter exceeded 0.14 in all cases, more prominent in group 2 （0.26±0.05 vs. 0.33±0.03, P=0.009）. Increased coronary artery collaterals within the interventricular septum were detected in 18 patients （78.3%） by Doppler imaging. Twenty one patients underwent cardiac surgery, including left coronary artery （LCA） ligation （1/21）, LCA ligation plus coronary artery bypass grafting （1/21）, Takeuchi operation （7/21）, and LCA reimplantation surgery （12/21）. Four patients underwent concomitant mitral valve repair and one received mitral valve replacement. Aneurysm resection was performed in 3 cases. Six patients died in hospital after surgery, and the rest of the cohort had no overt symptoms during a follow-up period of 6 to 166 months. Their abnormal Q waves gradually regressed or disappeared, and the LVEF and left ventricle size returned to normal range with alleviation of mitral insufficiency.Conclusions The accurate diagnosis of ALCAPA can be made with serial diagnostic methods. ALCAPA can be successfully treated with several types of cardiac surgery, and surgeries of establishing two-coronary-artery circulation are the preferred operations nowadays, with good long-term prognosis.     

成人型左冠状动脉起源于肺动脉1例报告及文献复习

目的：探讨左冠状动脉起源于肺动脉（ALCAPA）的发病机制、临床特点、诊断和治疗方法,提高临床医生对该疾病的认识。方法：对1例曾误诊为心内膜弹力纤维增生症（EFE）的成人型ALCAPA患者的临床资料进行回顾性分析,并结合相关文献复习。结果：患者因间断心前区疼痛、胸闷、气短2月余并加重3d入院,入院后初步诊断为心肌病（EFE所致可能性大）、心律失常-心房颤动、心功能Ⅲ级。给予相关治疗后仍有阵发性胸骨后疼痛,并出现1次心室颤动,后行冠状动脉螺旋CT血管成像（CTA）确诊为ALCAPA,于心外科行冠状动脉旁路移植术,术后恢复良好。结论：ALCAPA相对罕见,临床表现缺乏特异性,容易误诊,冠状动脉CTA是有效诊断方法,手术是首选治疗方案。     

肾动脉狭窄心衰和冠脉结扎心衰大鼠模型的对比研究

目的比较肾动脉狭窄心衰和冠脉结扎心衰大鼠模型的实验效果。方法分别使用双肾动脉结扎和结扎冠脉前降支近段的方法制备心衰大鼠模型,在术后2周、1个月、3个月、6个月、8个月分别测定血压、心率、左室舒张末期内径(LVDD)、收缩末期内径(LVSD)、左室射血分数(EF)。结果双肾动脉结扎组与冠脉结扎术组对比,24 h内动物死亡率分别为22.2%、44.4%(P<0.01);心衰模型成功率分别为56%、43%(P<0.01);心衰模型成功时间分别为6个月、2周(P<0.01);高血压发生率分别为65%、1.8%(P<0.01);两种心衰大鼠模型平均心率分别为430 bpm、670 bpm(P<0.01);两种方法制备成功的大鼠心衰模型,在LVDD、LVSD、EF指标两者无统计学差异。结论两种实验方法均可制成心衰大鼠模型,肾动脉结扎模型可作为高血压导致心力衰竭的临床研究的动物模型,冠脉结扎大鼠模型可作为冠心病心衰模型来研究。     

冠状动脉异常起源于肺动脉的超声诊断及误诊分析

目的:探讨超声心动图在冠状动脉异常起源于肺动脉的诊断价值,并对误诊原因作分析。方法:对超声诊断为冠状动脉异常起源于肺动脉并手术证实的5例病例进行分析。结果:5例冠状动脉异常起源于肺动脉首次正确诊断全部由超声实现,其主要超声特征是:主动脉发出单支扩张冠脉;肺动脉发出异常分支并且血流倒灌;丰富冠脉侧支循环;常伴有左室长期心肌缺血继发表现。3例患者曾经进行超声心动图检查曾误诊为冠状动脉肺动脉瘘。结论:超声心动图诊断冠状动脉起源于肺动脉有非常重要的诊断价值。     

小儿左冠状动脉异常的矫治术麻醉管理方法探讨

目的 分析小儿起源于肺动脉的左冠状动脉异常矫治手术的麻醉特点,为今后开展类似手术提供可行的麻醉管理方法.方法 回顾性分析2006年3月至2010年7月本院20例小儿起源于肺动脉的左冠状动脉异常矫治术的麻醉管理方法.结果 采用静吸复合全麻,术中均未出现急性心衰或心梗,CPB时间为58～204( 80.6±44.4)min,主动脉阻断时间为25～ 125( 53.4±32.2) ain,开放主动脉后均自动复跳,适时应用血管活性药物,以保证麻醉平稳,停CPB时SBP为(78.6+8.0)mmHg,DBP为(45.4±3.5)mmHg,HR为(130.8±10.5)次/min,术中无死亡及麻醉并发症.1例术后第2天死于严重低心排综合征,死亡率为5％,其余痊愈出院.结论 小儿左冠状动脉异常矫治术以静吸复合全麻的方法,辅以严密监测,尽力维持血流动力学稳定,积极采取各种措施避免加重心肌缺血的麻醉管理方法是正确可行的,可以推广应用于术前有心功能损害的手术.     

Single coronary artery anomaly: the left main coronary artery originating from the proximal segment of right coronary artery

This case report we presented is that the anomalous left main coronary artery (LMCA) originates from the proximal segment of right coronary artery. In order to confirm the origin and course of the anomalous LMCA, a multi-slice computed tomography (MSCT) of the heart was performed on a 64-slice machine (Philips 64 Slice, Philips, USA) after 6 months of coronary angiography operation. The results showed that the anomalous LMCA originates from the proximal segment of right coronary artery, lies posteriorly to the aorta before taking acute sharply to go between the aorta and left atrium. It was classified as R-II P subtype according to Lipton’s classification. It is a rare case in the clinical practice.

     

法洛四联症伴冠状动脉畸形的外科治疗

目的：总结对19例法洛四联症伴冠状动脉畸形的外科治疗的结果和经验。方法：对2000年7月至2010年7月施行19例法洛四联症伴冠状动脉畸形的外科治疗进行总结。年龄8个月-25岁,体重8.5-52.0 kg。其中右冠状动脉起源于左冠状动脉或前降支6例,左前降支起源于右冠状动脉9例,有异常粗大的圆锥动脉4例,均横跨右室流出道（近肺动脉瓣环处）,其中一期手术16例,在中度低温体外循环下手术。采用绦纶片或者牛心包补片修补室间隔缺损。采用心包片补片或心包片加绦纶片加宽右心室流出道、肺动脉。姑息手术3例。结果：手术死亡3例,手术死亡率为15.8%,手术死亡率较高,手术死亡原因主要为低心排综合征。结论：法洛四联症合并冠状动脉畸形的手术死亡率较高,选择适当的手术方式和右室流出道重建方法可提高手术效果。但横跨右室流出道的冠状动脉畸形是法洛四联症治疗手术中的风险因素之一。     

Off-pump sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system

Background  Off-pump coronary artery bypass surgery (OPCAB) has been widely applied in recent years as a less invasive method of myocardial revascularization. This study evaluated the sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system during OPCAB.

Methods  From April 2004 to August 2010, patients with diffuse right coronary lesions were studied retrospectively and divided into two groups. Group 1 included seventeen patients who underwent this surgery while group 2 included twenty-one patients without right coronary artery surgical therapy. All patients presented with symptoms of angina. Blood flow of bridged vessels was measured. The perioperative ventricular parameters including left ventricular ejection fraction and end diastolic diameter were compared. During follow-up, myocardial nuclide imaging and coronary angiography were carried out.

Results  Off-pump coronary artery bypass was performed with an average of 3.6 grafts per patient. Hospital mortality was zero. At the time of follow-up, the patients in group 1 recovered better than in group 2 (P <0.05). In both groups, the mean New York Heart Association (NYHA) class and ejection fraction increased significantly (P <0.001) and the mean left ventricular end-diastolic diameter decreased significantly (P <0.05). Myocardial blood supply of inferior wall in group 1 was obviously improved by myocardial nuclide imaging. Coronary angiography for eight patients in group 1 verified that there was blood flow to myocardium in the arterialized vein.

Conclusions  Sequential bilateral internal mammary artery grafting combined with selective arterialization of the coronary venous system can be performed during OPCAB. A postoperative improvement in the cardiac functions and the quality of life was documented, increasing our expectation for extensive application.