左胸前外侧小切口不停跳冠状动脉旁路移植术26例

目的探讨左胸前外侧小切口不停跳冠状动脉旁路移植术的效果.方法26例单支或2支血管病变经左胸前外侧小切口进胸,其中14例直视下游离乳内动脉,12例在胸腔镜辅助下游离,肝素化后切开心包,显露病变的靶血管,心脏跳动下行冠状动脉旁路移植术.结果26例手术顺利完成,22例旁路移植1支,4例旁路移植2支(1例行序贯吻合,3例桡动脉与乳内动脉行"Y"形吻合).术后无死亡及严重并发症.26例随访3个月～3年,平均16.8月,无心绞痛复发,心功能Ⅰ级18例,Ⅱ级8例.结论左前外侧小切口不停跳冠状动脉旁路移植术主要适用于前降支单支病变者,对于合并高危因素,不宜行常规冠状动脉旁路移植的多支血管病变病人亦适用.     

冠状动脉旁路移植术中胸腔镜与小切口直视获取胸廓内动脉的对比研究

目的 对比胸腔镜和小切口直视获取左侧胸廓内动脉进行微创冠状动脉旁路移植手术的效果。方法 回顾性研究2020年1月～2022年6月完成的胸腔镜辅助微创冠状动脉旁路移植术18例和小切口直视冠状动脉旁路移植术20例。2组年龄、左室射血分数、左室舒张末内径差异无统计学意义(P>0.05)。腔镜组使用胸腔镜器械获取左侧胸廓内动脉,应用微创心脏稳定器在左前外侧胸部小切口、非体外循环下完成冠状动脉旁路移植手术,包括左侧胸廓内动脉与冠状动脉前降支单支旁路移植16例,多支冠状动脉旁路移植2例。小切口组20例行左前外侧胸部小切口直视获取左侧胸廓内动脉,与前降支行旁路移植手术。结果 腔镜组18例中16例成功获取左侧胸廓内动脉,1例转为肋间小切口直视获取左侧胸廓内动脉,1例胸腔镜获取血管时损伤远端,经肋间小切口直视修补后完成血管吻合。小切口组20例均成功获取胸廓内动脉并行旁路移植手术。与小切口组相比,腔镜组术后呼吸机使用时间短[(4.9±2.0)h vs.(6.5±2.3)h,t=-2.318,P=0.026],术后住院时间短[(4.5±0.9)d vs.(5.3±0.8)d,t=-2.859,P=0....     

胸廓内动脉、桡动脉及大隐静脉在冠状动脉旁路移植术中的应用

目的　报告胸廓内动脉和桡动脉在冠状动脉旁路移植术中的应用。　方法　 2 9例冠状动脉粥样硬化性心脏病患者接受冠状动脉旁路移植术 ,共用移植血管 84根 ,平均每例移植血管 2 .9根。左侧胸廓内动脉 19根 (游离胸廓内动脉 2根 ) ,桡动脉 10根 ,大隐静脉 5 5根 (序贯吻合 3根 )。左侧胸廓内动脉与左前降支吻合 19例 ;桡动脉与左前降支吻合 8例 ,与右冠状动脉吻合 1例 ,与对角支吻合 1例 ;左前侧壁室壁瘤切除术 1例。平均主动脉阻断时间 97.3±16 .5分钟 ,平均体外循环时间 16 5 .2± 2 8.2分钟。　结果　术后 1例并发低心排血量 ,1例并发十二指肠溃疡穿孔 ,1例再次开胸止血。全部患者均痊愈出院 ,术后平均住院时间 12 .5± 2 .5天。术后随访 ,无心绞痛发作 ,心电图正常。　结论　胸廓内动脉是冠状动脉旁路移植术的首选材料 ;桡动脉内径大于胸廓内动脉 ,有足够长度 ,取材容易 ,是理想的移植血管材料之一。     

全机器人胸廓内动脉游离非体外循环冠状动脉旁路移植术

目的总结全机器人下不开胸胸廓内动脉（IMA）游离心脏不停跳冠状动脉旁路移植术的初步经验。方法使用da Vinci S全机器人系统,完成胸廓内动脉游离心脏不停跳下冠状动脉旁路移植术15例。所有患者均有心绞痛症状,其中4例患者有心肌梗死病史,冠状动脉造影显示严重的前降支病变,2例患者对角支及回旋支亦有病变。手术过程中于左侧胸壁打直径为1cm的器械臂孔3个,医生于操作台前在三维成像系统下操控机器人进行胸廓内动脉的游离,其中13例行左侧胸廓内动脉游离,1例行双侧胸廓内动脉游离,1例行对侧胸廓内动脉游离。游离结束后,沿左胸前第4肋间行长度为6cm小切口开胸,13例于心脏跳动下行胸廓内动脉和前降支的吻合,2例同时吻合对角支或回旋支。其中1例是完全机器人不停跳下冠状动脉旁路移植术。结果所有患者均成功接受胸廓内动脉游离,无胸廓内动脉损伤及术式的转变。胸廓内动脉和前降支、对角支和回旋支吻合后桥血流良好。术中平均出血量80ml,平均ICU时间20h,术后恢复好。结论全机器人不开胸胸廓内动脉游离技术精细、安全,不停跳下冠状动脉移植术效果确实、可靠,术后效果良好。     

经左胸肋间切口实施冠状动脉旁路移植术

目的探讨经左胸肋间切口实施冠状动脉旁路移植术的临床应用与特点。方法我院1996年9月~2005年8月共实施经左胸肋间切口的冠状动脉旁路移植术36例,左侧胸骨旁第4肋间前外侧切口6~10 cm进入胸膜腔,使用M IDCAB专用牵开器,分离左侧乳内动脉与冠状动脉吻合。主要有4种情况:①单纯前降支系统病变;②再次冠状动脉旁路移植术而存在通畅的左乳内动脉至前降支桥;③严重的升主动脉钙化;④合并其他左胸手术。单支病变26例,双支病变3例,三支病变7例。既往介入治疗史5例,冠状动脉旁路移植术史6例。左心室射血分数为(0.562±0.107)。结果36例均成功实施非体外循环心脏跳动下的冠状动脉旁路移植术,远端吻合口1~4个,手术时间(190.4±44.1)m in。合并激光心肌打孔术2例,合并肺癌切除术1例,食管癌切除术1例。无住院死亡病例。32例随访1个月~9年,中位数32月,2例远期死亡。2例术后1年再发心绞痛,1例经介入治疗,另1例再次手术,症状消失。其余患者均没有心绞痛症状。结论经左胸肋间切口实施冠状动脉旁路移植术对某些特殊类型的冠心病患者是安全实用的选择,非体外循环方式下进行此类手术是可行的。     

机器人非体外循环冠状动脉旁路移植术

目的 总结使用da Vinci S机器人系统完成的微创机器人非体外循环冠状动脉旁路移植术(CABG)的技术特点和临床效果.方法 2007年4月至2008年12月,共有56例患者接受微创机器人非体外循环CABG.所有患者术前均有心绞痛症状,冠状动脉造影显示严重的前降支病变,10例患者合并有回旋支或右冠状动脉病变.其中25例患者有心肌梗死病史.心功能(NYHA分级)Ⅱ级45例,Ⅲ级11例,平均射血分数为57%±11%.所有患者肺功能良好,无胸膜炎和左侧胸腔手术史.术前常规行64排CT检查双侧胸廓内动脉(ITA)的解剖情况.共采用三种术式:(1)机器人单侧或双侧ITA游离并同期小切口非体外循环CABG;(2)全机器人非体外循环CABG;(3)对合并有回旋支或右冠状动脉局限性狭窄的患者,接受上述两种术式的一种后行分站式支架置入杂交术.行单支或多支CABG时于左侧胸壁第4肋间做长6 cm的小切121,直视、心脏跳动下行ITA和前降支的吻合;行全机器人非体外循环CABG时无需胸壁切口.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受了上述手术.术中平均ITA桥血流量为(23.2±16.7)mL/min,无中转开放手术和手术死亡.ITA移植到前降支53例,双支桥3例,其中10例患者旁路移植后接受了回旋支或右冠状动脉的支架植入杂交术.术后复查未见桥血管狭窄或闭塞.结论 微创机器人非体外循环CABG手术效果确实、可靠,不破坏胸腔骨性结构、创伤小,是微创CABG的发展方向之一.     

经左胸后外侧切口进行非体外循环下二次冠状动脉旁路移植术的临床运用

目的总结经左胸后外侧切口实施二次冠状动脉旁路移植术的临床应用与特点。方法我院自2014年7月～2016年3月共实施经左胸后外侧切口实施二次冠状动脉旁路移植术2例,使用普通肋骨撑开器,经左第五肋间进胸。从心尖部逐渐向心包内游离,分离原有初次手术造成的粘连面。合理暴露靶血管并判断选取远端吻合区域,使用大隐静脉或者小隐静脉作为血管桥,游离下肺韧带,侧壁钳夹取降主动脉为近端吻合口,从而进行二次冠脉血运重建。结果 2例均成功实施非体外循环心脏跳动下的冠状动脉旁路移植术,远端吻合口2～3个,平均手术时间182分钟。无住院死亡病例。目前随访尚无死亡及并发症报道。结论经左胸后外侧切口实施二次冠状动脉旁路移植术对某些二次开胸的冠心病病人是安全实用的选择,非体外循环方式下进行此类手术是可行的。     

左胸小切口多支动脉化冠状动脉旁路移植术64例的有效性和安全性分析

目的探讨左胸小切口冠状动脉旁路移植术多支动脉桥策略的安全性及有效性,为该技术推广提供证据。方法回顾性分析2015年12月至2019年11月北京大学第三医院心脏外科64例左胸小切口多支搭桥手术患者的临床资料。男54例、女10例,年龄36~77(61.1±8.7)岁。经第5肋间长5~8 cm左胸前外侧切口进胸,在非体外循环下进行手术,借助胸壁悬吊装置及心脏固定器,完成升主动脉近端吻合,前降支、回旋支及右冠状动脉系统的靶血管远端吻合等操作。移植血管数量2~4(2.3±0.5)支,其中45例患者移植2支,17例移植3支,2例移植4支;手术结合经皮冠状动脉介入治疗(PCI)杂交治疗3例,全动脉化旁路移植62例。术后7 d内复查冠状动脉造影评估旁路血管通畅率,随访记录主要不良心脑血管事件(MACCE)发生情况,通过Kaplan-Meier法计算免于发生MACCE率。结果无患者中转开胸手术,术中未应用主动脉内球囊反搏或体外膜肺氧合。术后切口愈合不良1例,再次手术2例(均为术后胸腔出血)。术后30 d内发生非致死性心肌梗死1例,无死亡。术后早期复查造影旁路血管总体通畅率为96.2%,前降支旁路通畅率为98.2%。随访12~60个月(中位随访时间28个月)。失访率7.8%(5/64)。36个月免于MACCE发生率为84.9%(95%CI 79.5%~90.3%)。结论左胸小切口多支冠状动脉旁路移植术可以实现完全再血管化及全动脉化搭桥,近期及中远期效果良好。     

微创冠状动脉旁路移植手术33例报告

目的探讨微创冠状动脉旁路移植手术(minimally invasive direct coronary artery bypass graft,MIDCABG)的可靠性及安全性. 方法 2001年3月～2003年9月,我院在全麻、非体外循环、心脏不停跳下进行了33例单支MIDCABG.14例采用左前外侧小切口,19例采用胸骨下段正中切口.31例行左乳内动脉至前降支旁路移植,1例使用大隐静脉行主动脉根部至前降支旁路移植,1例行胃网膜右动脉至后降支旁路移植. 结果全组无手术死亡.术中出血量(163±120)ml,术后引流量(193±169)ml,术后拔管时间(6.4±5.5)h,ICU时间(17.8±4.4)h.随访(14.7±7.4)月,无死亡. 结论 MIDCABG安全可靠,具有创伤小、出血量少、并发症少的优点.     

冠状动脉旁路移植术麻醉处理的体会

本文介绍26例冠状动脉旁路移植术(CABG)的麻醉处理和血流动力学变化的有关体会. 资料与方法 22例在低温心肺转流(CPB)下完成2～4支旁路移植,4例在常温下行胸廓内乳动脉与前降支吻合,11例同时行室壁瘤切除、左心腔成形术.     

胸部小切口冠状动脉搭桥术66例报告

目的：探讨胸部小切口冠状动脉搭桥术的临床效果。方法2002年1月～2013年1月采用胸部小切口取左乳内动脉（ left internal mammary artery,LIMA）心脏不停跳冠状动脉搭桥术66例。胸骨下段小切口59例,采用全麻、单腔气管插管,平卧位,倒“L”胸骨下段切口;胸骨旁小切口5例,采用全麻、双腔气管插管,平卧位左胸抬高30＆#176;,左前外侧第4或第5肋切口,用特制牵开器（法国圣骑士公司）牵开肋骨,游离乳内动脉,使用冠脉固定器下行冠脉吻合;2例胸腔镜辅助下完成乳内动脉与左前降支的吻合。结果66例均完成左乳内动脉至前降支的吻合,2例追加大隐静脉降主动脉至第一对角支的吻合。无围术期死亡。60例随访0．5～8年,（5．5±2．5）年,心绞痛症状消失42例,明显减轻24例。术后冠状动脉CT检查16例,冠脉造影12例,LIMA与左前降支（ left anterior descending, LAD）吻合口满意率100％,支架内再狭窄1例,大隐静脉桥血管闭塞1例。结论胸部小切口冠状动脉搭桥术主要适用于心脏前壁冠状动脉尤其是前降支的的再血管化,安全可靠,中期疗效好,在合并高危因素或常规冠状动脉搭桥术和经皮冠状动脉介入术效果不满意者中应用更佳。     

MIDCAB for redo patients using the LITA-RA composite graft

Redo coronary artery bypass grafting (CABG) is associated with higher mortality, low-output syndrome, perioperative myocardial infarction than primary CABG. Minimally invasive direct coronary artery bypass grafting (MIDCAB) technique avoids the manipulation of old graft and injury of the adhesive heart in redo operation. We performed the MIDCAB procedure for 2 redo cases using the left internal thoracic artery (LITA)-radial artery (RA) composite graft. The LITA-RA composite graft was anastomosed to the left anterior descending branch (LAD) through small left anterior thoracotomy without cardiopulmonary bypass. Postoperative coronary artery graphy shows the widely patent of new graft. The MIDCAB procedure using the LITA-RA composite graft is safe and useful to regulate the bypass graft length and avoid the widely harvest of LITA in redo operation.     

Minimally invasive direct coronary artery bypass grafting using the saphenous vein in redo CABG.

We describe a patient who underwent minimally invasive direct coronary artery bypass (MIDCAB), who had previously undergone coronary artery bypass grafting (CABG) through a median sternotomy with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and a right gastroepiploic artery (GEA) graft to the posterior descending artery. MIDCAB was less invasive and was an effective alternative procedure for the second operation. Because the patient had no LIMA or GEA available for a graft because of prior use, we used a saphenous vein graft (SVG) for bypassing from the left subclavian artery to the coronary artery by MIDCAB via a left minithoracotomy. The left subclavian artery was selected as the proximal anastomotic site because this artery was less diseased and was easier to reach. The SVG-to-coronary artery anastomosis was facilitated by firm adhesion between the epicardium and the pericardium, which reduced the motion of the epicardium itself. These results suggest that the procedure is safe and promising in selected cases of redo CABG.     

Coronary artery bypass grafting without cardiopulmonary bypass: MIDCAB and OPCAB

Minimally invasive direct coronary artery bypass grafting via left anterior small thoracotomy (MIDCAB) and coronary artery bypass grafting without cardiopulmonary bypass (OPCAGB) are accepted technique as less invasive than conventional coronary artery bypass grafting (CABG). We reported our experience with these procedures. From 1996 to December 1999, 176 patients underwent MIDCAB or OPCAB with the internal thoracic artery. The left internal thoracic arteries were used for grafting of the left anterior descending artery (LAD) in 131 patients, LAD and diagonal branches sequentially in 8 patients, using free radial artery conduits for grafting of the right coronary artery (RAC) or left circumflex (LCx) in 7 patients, using radial artery conduits as Y-graft from LAD for grafting of the RAC or LCx in 24 patients, and bilateral internal thoracic artery grafting was performed in 4 patients. One patient (0.6%) died in the hospital. One patient (0.6%) had perioperative myocardial infarction. No patient had cerebrovascular accident and sever wood infection. One-hundred-seventy-four patients (98.8%) had resolution of their angina symptom.     

Minimally invasive direct coronary artery bypass: technical considerations

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.     

手术联合介入技术治疗冠状动脉多支病变

目的介绍手术联合介入技术治疗冠状动脉多支病变的临床经验。方法联合应用左前外侧小切口不停跳冠状动脉旁路移植术和经皮腔内冠状动脉成形术治疗9例病人,其中冠状动脉两支病变者7例,三支病变者2例。结果9例手术均顺利完成,各植入支架1枚,7例病人搭桥1根,2例病人搭桥各2根。术后心绞痛明显缓解,无死亡及严重并发症发生,随访3月~3年生活质量良好。结论手术和介入技术复合治疗冠状动脉多支病变安全、有效,创伤小、恢复快,值得临床推广。     

Off-pump redo coronary artery bypass grafting

BACKGROUND: Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique. METHODS: Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta. RESULTS: Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days. CONCLUSIONS: In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.     

Reoperative MIDCAB grafting: 3-year clinical experience

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits. Methods: Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization. Results: Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0–39). Conclusions: Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.     

Minimally invasive direct coronary artery bypass: technical considerations and instrumentation

Minimally invasive coronary artery bypass is defined as any maneuver or modification of conventional coronary bypass that decreases adverse effects. These adverse effects fall into three broad categories, which are access trauma, consequences of cardiopulmonary bypass, and aortic manipulation. In the minimally invasive direct coronary artery bypass (MIDCAB) approach, coronary revascularization is performed via a limited access incision, usually a left anterior thoracotomy, through which a left internal mammary artery is anastomosed under direct vision to the left anterior descending artery on a stabilized beating heart. Harvest of the left internal mammary artery can be performed with video assistance (two- or three-dimensional or under direct vision). A variety of offset chest wall retractors that allow internal mammary artery harvest under direct vision have simplified the procedure, and several mechanical stabilization devices (with or without suction) allow local wall immobilization for a target vessel anastomosis. Graft patency data from early series of stabilized MIDCAB procedures and published series of left internal mammary artery graft patency with conventional bypass grafting appear to be comparable. Current indications for MIDCAB include restenosis of the left anterior descending artery after catheter-based therapy and the necessity for target vessel revascularization in elderly high-risk patients with multivessel disease. Limitations of the MIDCAB procedure include mostly single vessel revascularization of the anterior aspect of the heart.