全动脉化冠状动脉搭桥术32例

自１９９６年１２月至１９９８年３月，为３２例冠心病病人施行以乳内动脉（ＩＭＡ）、胃网膜右动脉（ＧＥＡ）及桡动脉（ＲＡ）为血管材料的全动脉化冠状动脉（ＣＡ）搭桥术，同时施行贲门癌切除、胃食管吻合术１例，心梗后室间隔穿孔修补术１例，心梗后室壁瘤切除术６例。全组７例取用ＧＥＡ，２９例取用ＲＡ（１０例双侧），每例均取用左侧ＩＭＡ（１５例双侧），以人均２．９个动脉桥完成人均３．５个远端吻合（最多者６个）。７例采用了３种动脉桥，２５例采用ＩＭＡ和ＲＡ２种动脉桥。１７例用ＲＡ做“蛇”形桥。１例用右ＩＭＡ做第１室间隔支搭桥。创用“Ｖ”字形ＲＡ自体血管壁加宽近端吻合口的方法，成功地完成了较细ＲＡ与主动脉间的近端吻合。全组未发现与取材有关的并发症。术后心电图、超声心动图和核素心肌显像提示，搭桥区域的心肌灌注和心室功能均较术前明显改善。初步实践证明，全动脉化ＣＡ搭桥术虽然难度较大，但术后效果好，并可望比传统的静脉桥有更理想的远期通畅率     

桡动脉及乳内动脉在冠状动脉旁路移植术中的应用

1995年 10月至 2 0 0 0年 12月 ,我们应用桡动脉 (ＲＡ)和乳内动脉 (ＩＭＡ)对 32例冠心病病人实施了全动脉桥的冠状动脉搭桥术 (ＣＡＢＧ) ,无手术死亡 ,早期疗效满意。资料与方法　全组中男 19例 ,女 13例。年龄 44～ 5 9岁。不稳定型心绞痛 2 3例 ,稳定型心绞痛 9例。有陈旧性心肌梗死史 14例 ,脑血管栓塞史 2例 ,急性心肌梗死史 1例。合并高血压 15例 ,2型糖尿病 5例 ,高血脂症 4例。心功能(ＮＹＨＡ)ＩＩ级 2 5例 ,ＩＩＩ级 7例。冠状动脉造影显示 3支血管病变 2 7例 ,2支血管病变 5例 ,左前降支 (ＬＡＤ)病变 31例次 ,回旋支 (Ｃｘ)病…     

700例冠状动脉旁路移植术的临床回顾

作者对阜外医院７００例冠状动脉旁路移植术（ＣＡＢＧ）患者的临床资料和手术结果，按时间分Ａ、Ｂ两组进行对比分析，结果显示合并糖尿病、高血脂症、心功能Ⅲ～Ⅳ级、左主干病变、广泛三支病变等在患者中所占比例近三年有显著的增高（Ｐ＜０．０５）；合并高血压病（４１．３％）、陈旧性心肌梗塞（６５．０％）、有左室室壁瘤（２４．３％）、术后需使用ＩＡＢＰ（９．４％）发生率高，但两组间无显著性差异。心肌保护方法的改进、冠状动脉充分再血管化技术的提高和内乳动脉的广泛采用，使术后早期死亡率（Ｂ组９．６％，Ａ组２．７％）及围术期心梗发生率（Ｂ组９．０％、Ａ组３．２％，Ｐ＜０．００５）明显下降。     

乳内动脉在冠状动脉旁路移植术中的应用

冠状动脉旁路移植术（ＣＡＢＧ）治疗缺血性心脏病已取得了良好的效果,较为常用的旁路材料多为自体大隐静脉（ＳＶ）,但远期效果不满意,而乳内动脉（ＩＭＡ）作为旁路材料的远期通畅率明显优于静脉。我院近２年来采用ＩＭＡ联合ＳＶ行ＣＡＢＧ９例,具有较好的临床效果。１　临床资料与方法１．１　一般资料　全组９例,男８例,女１例。年龄３５～５６岁,平均年龄４９．３岁。均有心绞痛发作,按ＣＣＳＳ分级,心绞痛Ⅱ级１例,Ⅲ级和Ⅳ级各４例;陈旧性心肌梗死５例,有高血压病４例,糖尿病２例。冠状动脉造影示单支血管病变１例,双…     

1110例冠状动脉搭桥术的早期结果

目的　回顾性总结１９９６ 年１ 月以来１１１０ 例冠状动脉搭桥术（ＣＡＢＧ） 的近期疗效,介绍冠心病搭桥术的体会和经验。　方法　体外循环下行ＣＡＢＧ１０４８ 例,非体外循环ＣＡＢＧ６０ 例。心肌保护均采用冷血含钾停跳液,体外循环时间１１５ ±３５ 分钟,主动脉阻断时间７２ ±２４ 分钟,单支搭桥１１０ 例,２ 支搭桥１４５ 例,３ 支搭桥４１５ 例（３７－３ ％） ,４ 支搭桥或４ 支以上４３９ 例（３９－５％） 。搭桥材料：左乳内动脉７５１ 例,大隐静脉８７７ 例,桡动脉１０１ 例,全动脉化７２ 例。合并手术：室壁瘤切除１１２ 例,室壁瘤折叠１４ 例,左室成形５ 例,瓣膜手术４８ 例,室间隔穿孔修补术５ 例。　结果　住院死亡９ 例,死亡率０－８１％ 。其余患者痊愈出院,心绞痛基本缓解。术后并发症：低心排１１ 例,主动脉球囊反搏７例,围术期心肌梗塞２ 例,脑部并发症３ 例,二次开胸止血４ 例。　结论　选择好靶血管和充分血管化是冠状动脉搭桥术的关键。另外要重视围术期处理。     

Hybrid技术治疗多支病变冠状动脉粥样硬化性心脏病

目的 为寻求创伤更小的治疗冠状动脉多支病变的手段。方法 从１９９９年８月￣２０００年４月，４例患者接受联合电视胸腔镜下冠状动脉旁路移植术（ＶＡＣＡＢ）和经皮腔内冠状动脉成形术（ＰＴＣＡ）的治疗，无为左前降支完全性闭塞和右冠状动脉９０％的狭窄，其中２例合并左回旋支９０％的狭窄。病例１首先进行ＰＴＣＡ和支架植入，术后即刻进行ＶＡＣＡＢ，后３例先施行ＶＡＣＡＢ，再进行ＰＴＣＡ和支架植入。结果 ４例患者均存活，且术后心绞痛均缓解，除病例１因术后早期抗凝治疗导致胸液过多二次开胸止血，其他患者均顺利恢复；病例１术后３个月冠状动脉造影显示移植血管和右冠状动脉通畅，其他３例ＰＴＣＡ时造影显示移植血管通畅。结论 Ｈｙｂｒｉｄ技术初步应用的经验显示联合ＶＡＣＡＢ和ＰＴＣＡ手术治疗冠状动脉多支病变是安全有效的。     

心肺转流下冠状动脉搭桥手术的麻醉及相关处理

冠状动脉搭桥术 (Ｃｏｒｏｎａｒｙａｒｔｅｒｙｂｙｐａｓｓｇｒａｆｔ,ＣＡＢＧ)诞生于 196 2年。国内于 1974年开始应用ＣＡＢＧ ,目前已近万例 ,每年还以 5 0 %的速度递增。ＣＡＢＧ病人年龄越来越大 ,病情越来越复杂 ,对麻醉的技术要求也越来越高。冠状动脉的解剖与循环生理特点解剖特点　麻醉医师熟悉冠状循环解剖 ,有助于了解麻醉手术期间心肌缺血和梗塞的范围和程度、病变部位和手术步骤。心脏的血供主要来自左和右冠状动脉 ,分别起源于升主动脉的左或右主动脉窦。左冠状动脉 (ＬＣＡ)主干长 10～2 0ｍｍ ,分出左前降支 (ＬＡＤ)和…     

桡动脉在冠状动脉旁路移植术中的应用

自１９９７年６月～１９９９年５月应用桡动脉行冠状动脉旁路移植术（ＣＡＢＧ）６９例（澳大利亚圣·文森特医院６８例，我院１例），现总结如下。１　临床资料与方法１－１　一般资料　６９例中男４７例，女２２例。年龄３７～７１岁，平均５３岁。均有心绞痛史。既往心肌梗死史１１例，糖尿病史２２例。冠状动脉病变为：左主干１例，单支血管９例，２支血管２４例，３支血管３５例。左心室射血分数＜５０％者１９例（２７％）。患者术前均接受非优势侧Ａｌｌｅｎ试验，以≤１０秒为安全时间。取用左桡动脉６４支，右桡动脉４支，１例再次…     

冠状动脉主干重建术治疗孤立性冠状动脉主干狭窄

外科手术治疗左冠状动脉主干（ＬＭＣＡ）狭窄不是一个新概念。Ｂａｉｌｅｙ等〔１〕首先报道了冠状动脉近段的内膜剥脱术,Ｅｆｌｅｒ等〔２〕首先报道了ＬＭＣＡ重建术。Ｆａｖｏｌｏｒｏ等〔３〕继续使用心包施行ＬＭＣＡ重建术治疗ＬＭＣＡ狭窄,但与传统的冠状动脉旁...     

急性心肌梗死心源性休克反复室颤紧急冠状动脉搭桥2例

我们对２例急性心肌梗死（ＡＭＩ）、心源性休克、反复室颤病人施行心肺复苏和紧急冠状动脉搭桥（ＣＡＢＧ）手术,效果满意。例１　男,４０岁。急性广泛前壁心梗伴心源性休克、脑梗塞。置入主动脉内球囊反搏（ＩＡＢＰ）,冠脉造影示左冠状动脉主干（ＬＭ）狭窄大于９５％,直接送手术室,２次发生室颤,经胸外挤压配合药物及胸外电除颤转复。紧急建立体外循环（ＣＰＢ）,用大隐静脉行冠状动脉搭桥２支。开放升主动脉后心脏自动复跳,病人顺利脱机。术后第５天再次脑梗塞,经治疗２５天基本恢复,术后１个月康复出院。例２　男,５７岁。…     

The right gastroepiploic artery in coronary artery bypass grafting

The right gastroepiploic artery (RGEA) has been used as a conduit in coronary artery bypass grafting. Although some reports presenting good results justify its use in clinical settings, there is still much concern about using the RGEA in bypass surgery. The RGEA demonstrates different behaviors from the internal thoracic artery (ITA) in bypass surgery due to its histological characteristics and anatomical difference, which might contribute to the long-term outcome. Now that left ITA (LITA) to left anterior descending artery (LAD) is the gold standard, other grafts are expected to cover the rest of the coronary arteries. It should be elucidated how we can use other grafts and what we can expect from them. RGEA, as an arterial graft, can be used as an in situ graft or a free graft. The RGEA is mainly used to graft to the right coronary artery (RCA) because of its anatomical position, and its patency is not inferior to that of the saphenous vein (SVG). The RGEA can cover the lateral walls when its length is long enough or by making a composite graft with other grafts. However, when used to graft to the LAD, its mid-term patency is not favorable.     

Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG

Objectives: Arterial grafts have been used to achieve better long-term results and improve graft patency in coronary artery bypass grafting. Composite graft was proposed to overcome inconveniences of proximal anastomoses to the aorta and increase the use and surgical options of arterial grafts. However, lack of prospective randomized studies with this kind of grafts is evident. We compare the results of composite Y-grafts of the radial artery (RA) and the right gastroepiploic artery (RGEA) proximally anastomosed to the left internal thoracic artery (LITA) for CABG, evaluated through angiography, in a prospective randomized study. Methods: Between August 1998 and November 1999, 60 patients were randomly divided into two groups: group I (GI) received RGEA graft and group II (GII), RA graft. LITA was used to graft the left anterior descending artery and RGEA or RA was placed to obtuse marginal or first diagonal branch. The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had ≥75% proximal stenosis and diameter ≥1.5 mm. Results: GI and GII preoperative data were similar, 63 distal anastomoses were performed with the LITA, 32 with the RA and 32 with the RGEA. There were two perioperative deaths (3.3%), one in each group, none related to cardiac causes. Four (6.6%) q-wave myocardial infarctions were found and two (3.3%) patients showed low cardiac output syndrome. Angiography was performed in all surviving patients from the 8th to 15th postoperative day and showed a patency rate of 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025).Conclusions: Radial artery had better early results than right gastroepiploic artery. Use of the LITA as inflow graft seems not to affect its good patency. Use of the RGEA as composite graft should not be encouraged. Long-term follow-up with objective investigation and randomized trials is required to confirm better results of composite conduits.     

Coronary artery bypass grafting in two patients with single coronary artery

We experienced two patients with single coronary artery who underwent CABG using arterial grafts successfully. In two patients coronary angiography demonstrated a single coronary artery which was originated in left coronary sinus and was bifurcated to LAD and LCx, and then RCA branched off proximal LAD, passing in front of the right ventricular out flow tract (Sharbaugh Type L-IIa). To the first patient, a 52-year-old man who had angina on exertion due to long stenosis of RCA, CABG to RCA using RITA was carried out. To the second patient, a 57-year-old man who had inferior myocardial infarction due to 90% stenosis of proximal LAD, CABG to RCA using RITA and LAD using LITA was carried out. Single coronary artery without additional congenital cardiac anomalies may lead to myocardial ischemia, necessitating CABG as coronary reconstructions.     

Two cases of coronary artery bypass grafting associated with antiphospholipid syndrome in systemic lupus erythematosus]

We report two cases of coronary artery bypass grafting (CABG) associated with antiphospholipid syndrome (APS) in systemic lupus erythematosus (SLE). Patient 1, 65-year-old female, who had been treated for SLE with prednisolone for 11 years was transferred to our hospital due to unstable angina caused by stenosis of the left main trunk (LMT) and the left anterior descending artery (LAD). She underwent emergency CABG of the LAD using left internal thoracic artery (LITA). Post operative doppler study demonstrated patent LITA to the LAD. Patient 2, 67-year-old female who had been treated for SLE with prednisolone for 8 years was transferred to our hospital due to acute myocardial infarction caused by stenosis of the LMT and the left circumflex artery (LCX). She underwent emergency CABG of the LAD and the LCX using saphenous vein grafts (SVGs). Post operative angiography confirmed a patent SVG to the LAD and an occuluded SVG to the LCX. In cases of SLE, the frequency of occurrences of ischemic heart diseases is high. Until now, however, there are few instances reported on performing CABG for patients with SLE. We are reporting here our particular cases of APS with SLE, discussing the involvement of APS as causative factor of ischemic heart diseases and related issue of surgical and post surgical antithrombotic treatments.     

Reoperative off-pump coronary artery bypass via left thoracotomy with porcelain aorta; left axillary artery to circumflex artery bypass; report of a case

A 62-year-old man who underwent coronary artery bypass grafting (CABG) [left internal thoracic artery (LITA)-left anterior descending (LAD), saphenous vein graft (SVG) right coronary artery (RCA)] 13 years previously developed angina pectoris and congestive heart failure because of occlusion of SVG and native vessels. Coronary angiography (CAG) revealed that inflow to the coronary artery remained only from LITA. Repeat off-pump CABG (OPCAB) with SVG to the circumflex artery via left thoracotomy was performed. The proximal end of SVG was anastomosed to the left axillary artery because of the porcelain aorta and the patent LITA graft. The patient developed no complications and was discharged from hospital on postoperative day 21. OPCAB for circumflex artery by left thoracotomy is an effective and safe approach in redo CABG, particularly in instances of patent LITA.     

Re-do coronary artery bypass grafting with the descending branch of the lateral femoral circumflex artery in a patient with chronic hemodialysis

A 52-year-old man with hemodialysis had undergone coronary artery bypass grafting (CABG); left internal thoracic artery (LITA) to left anterior descending artery (LAD), right gastroepiploic artery (RGEA) to posterolateral branch (PL), saphenous vein graft (SVG) to diagonal artery (Dx) 5 years previously. After 3 years, angiography was performed due to recurrence of angina pectoris and revealed RGEA and SVG was totally occluded. Since repeated intervention was unsuccessful, reoperation was necessary. Therefore, we performed re-do CABG without cardiopulmonary bypass using lateral femoral circumflex artery (LFCA) as an arterial conduit for myocardial revascularization via the 6th left intercostal posterolateral thoracotomy. Postoperative angiography showed that the LFCA bypass graft was patent and supplied sufficient blood to anastomosed vessel. The patient has had no angina pectoris subsequently. We believe this procedure is useful for re-do myocardial revascularization, and LFCA deserves to be taken into account as an alternative graft in a patient with chronic hemodialysis.     

Mistaken grafting to diagonal branch in minimally invasive direct coronary artery bypass: a case required reoperation

The patient was a 75 year-old male who was admitted with recurrent chest pain during hemodialysis one year after PTCA to the right coronary artery and left circumflex branch (LCX). He had the history of cerebral infarction and chronic renal insufficiency. Coronary angiography showed severe stenosis from the left main trunk to left anterior descending artery (LAD) and restenosis at the PTCA site of LCX. The LCX lesion was dilated with PTCA. Minimally invasive coronary artery bypass (MIDCAB) with left internal thoracic artery (LITA) to LAD was carried out uneventfully. However, chest pain appeared on 1 POD. LITA angiography revealed that LITA was anastomosed to the diagonal branch that had occluded completely in the preoperative angiography. Off-pump CAB to LAD using inferior epigastric artery was carried out through median sternotmy on the same day. He recovered smoothly, and LITA angiography before discharge demonstrated that both grafts to LAD and diagonal branch are patent.     

Robotically assisted coronary artery bypass grafting: a prospective single center clinical trial.

AIM: This prospective study was performed as a Phase 1 Food and Drug Administration clinical trial to assess the safety and feasibility of robotically assisted coronary artery bypass grafting (CABG). METHODS: Eighteen patients undergoing elective CABG were enrolled in this study. Full sternotomy was performed in 17 of 18 patients, while cardiopulmonary bypass and cardioplegic arrest was used in all cases. Robotically assisted CABG of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD) was performed through three ports using a robotically assisted microsurgical system. Conventional techniques were used to perform all other grafts. Blood flow in the LITA graft was measured in the operating room, and when necessary, angiography was performed. Six weeks after the operation, all patients underwent selective coronary angiography of the LITA graft. RESULTS: Robotically assisted coronary artery anastomoses were successfully completed in all patients. Blood flow through the LITA graft was adequate in 16 of 18 patients (89%). The two inadequate grafts were revised successfully by hand. Six weeks after the operation, angiography demonstrated a graft patency of 100% (13 of 13). Mean follow-up has been over 190 days. All patients remain New York Heart Association Angina Class I. CONCLUSION: Robotic assistance represents an enabling technology that may allow the surgeon to perform endoscopic coronary artery anastomoses. Further clinical trials are needed to explore the clinical potential and value of robotically assisted CABG.     

Limited Left Thoracotomy for Reoperative Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for Circumflex Grafting in Patients with Patent Internal Thoracic Artery Graft

Abstract Background: We describe our experience with the limited left thoracotomy strategy for reoperative coronary artery bypass graft (CABG)to the circumflex coronary artery system, emphasizing the indications, our particular operative technique, and early clinical follow-up. Methods: From January 2001 to January 2002, 8 consecutive patients underwent redo revascularization via limited left thoracotomy and without cardiopulmonary bypass. This operation was indicated for patients with recurrent myocardial ischemia confined to the lateral wall of the left ventricle, especially if a patent left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD)graft was present. Results: All 8 patients underwent successful redo revascularization via limited left thoracotomy. Eight patients received 14 saphenous vein grafts (mean 1.7 grafts/patient). No instances of postoperative myocardial infarction or death occurred. During a follow-up period ranging from 1 to 12 months (mean, 5. 2 months), all patients were asymptomatic and without evidence of ischemia or infarction. Conclusions: For select patients who have patent LITA grafted into the LAD and who need redo CABG to the coronary artery circumflex system, the limited left thoracotomy approach without cardiopulmonary bypass is a safe operation and a less invasive alternative to repeat sternotomy and conventional CABG.     

Left atrial myxoma combined with coronary artery bypass grafting

We experienced 2 cases of surgical treatment for left atrial myxoma combined with coronary artery bypass grafting (CABG) using only in situ arterial grafts. A 58-year-old man who had undergone CABG [left internal thoracic artery (LITA)-right coronary artery (RCA) and saphenous vein graft (SVG)-left anterior descending artery (LAD)] 14 years before was admitted to our hospital, complaining of anterior chest pain. Coronary arteriography demonstrated total occlusion of the LAD and RCA, as well as the stenosis of high lateral branch (HL) and SVG. Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then the right internal thoracic artery (RITA) was anastomosed to the LAD. The postoperative course was uneventful. A 69-year-old woman was admitted to another hospital, complaining of chest pain and dyspnea. Coronary arteriography revealed stenosis of LAD, left circumflex artery (LCx) and HL, as well as left main trunk (LMT). Left atrial myxoma was incidentally detected by echocardiography. Myxoma was resected at first, and then CABG [LITA-HL, gastroepiploic artery (GEA)-RCA and RITA-LAD] was carried out. The postoperative course was uneventful. The priority between CABG and the surgical treatment for cardiac myxoma remains controversial from the point of view of myocardial protection and prevention of systemic embolism of myxomal fragment.