冠脉搭桥术体外转流24h抢救成功一例

患者男 ,48岁 ,70ｋｇ ,心功能Ⅱ～Ⅲ级 ,有高血压病史 ,因不稳定型心绞痛 ,冠状动脉造影 :左冠状动脉主干 5 0 %狭窄 ;左前降支局限性狭窄 95 % ;左回旋支中段局限性狭窄 80 %。心动超声 :左心室舒张功能减退 ,ＥＦ6 0 %。择期在全麻体外循环下行冠状动脉搭桥术 (左乳内动脉 左前降支吻合 ,胃网膜右动脉 左回旋支吻合 )。入室前患者频发心绞痛4次 ,静脉硝酸甘油 0 2 μｇ·ｋｇ- 1 ·ｍｉｎ- 1维持。入室后再次发作心绞痛 ,口含硝酸甘油缓解。麻醉诱导平稳 ,胸腹联合切口。先游离左乳内动脉 ,当分离胃网膜右动脉时 (手术 1 5ｈ) ,出现室…     

胸骨下段小切口冠状动脉旁路移植治疗右位心完全器官转位合并三支血管病变1例

患者 女,65岁.间断胸闷、胸痛1年.X线胸片显示右位镜面心(图1),腹部超声证实完全性脏器转位.冠状动脉造影显示3支血管病变,左前降支开口90％狭窄,回旋支近中段50％～80％狭窄,右冠状动脉近段99％狭窄,不适合经皮冠状动脉介入治疗(图2).     

终末期肝病/肝移植术后合并冠状动脉粥样硬化性心脏病患者不停跳冠状动脉旁路移植术三例

正临床资料患者1,男,47岁,主因"间断后背疼痛2年余"入院。入院后行冠状动脉造影提示:冠状动脉左主干合并三支血管病变,其中左冠状动脉主干(LMd)病变40%～50%节段性狭窄,左前降支(LAD)o-m 70%～90%弥漫性狭窄,LADd 70%～80%节段狭窄,左旋支(LCX)o-d70%～90%弥漫性狭窄,右冠状动脉右旋支(RCA)p-d90%～99%节段狭窄,右冠状动脉后降支(PDA)o-m80%～90%弥漫狭窄。患者既往"乙型病毒性肝炎,肝硬     

冠状动脉旁路移植术后15年静脉桥全部通畅1例

病人 男，58岁。因冠心病、陈旧性下壁心肌梗死（心梗），重度稳定型心绞痛，高血压病人入院手术治疗。冠状动脉造影示冠状动脉右优势型，左心室射血分数（EF）0.36，左主干正常，前降支近心端90%狭窄累及第1、2对角支，回旋支中段有大于50%狭窄，并向右冠远端有侧支提供少量循环。右冠状动脉近心端完全性闭塞。1990年8月在中低温体外循环下行冠状动脉旁路移植手术，应用两条静脉序贯式桥带5支冠状动脉对心脏血管进行完全性血运重建。     

肾移植术后非体外循环下冠状动脉旁路移植术1例

病人　男 ,5 1岁。反复发作性胸痛 15年。 3年前冠状动脉造影显示左前降支近段局限性偏心性狭窄 70 %、中段不规则狭窄 90 % ,行近中段经皮经腔冠状动脉成形术(ＰＴＣＡ)。 1年前冠状动脉造影显示左前降支狭窄达 95 % ,旋支及右冠状动脉轻度狭窄 ,行左前降支ＰＴＣＡ加支架手术。病人有慢性肾炎史 33年 ,高血压史 2 7年。 5年前因慢性肾炎、肾功能衰竭接受同种肾移植手术 ,移植肾功能良好。本次入院冠状动脉造影显示 :左冠状动脉前降支放支架部位 2 0 %狭窄 ,第一对角支中段 70 %狭窄 ,回旋支远段 95 %狭窄 ,右冠状动脉近、中段全闭。超声心…     

前上纵隔恶性肿瘤姑息切除并冠状动脉旁路移植一例

患者,男,69岁,左前胸痛伴左肩放射痛频繁发作1年。查体:桶状胸,左肺呼吸音减弱。胸部X线:左侧膈肌麻痹。胸部CT:前上纵隔占位,有中心液化和环形钙化。肺功能:重度通气功能减损。心电图:Ⅲ、AVF导联不典型Q波。冠状动脉造影:右冠状动脉后三叉病变,狭窄80%;左冠状动脉前降支近端、主干及四条分支均狭窄,约85%;回旋支中段及远段两处80%狭窄。造影诊断:冠心病,三支病变。术前诊断:(1)冠心病;不稳定性心绞痛。(2)前上纵隔肿瘤。2006年12月行纵隔肿瘤切除并冠状动脉旁路移植术(CABG)。胸骨正中切口,见左前上纵隔有一10cm×8cm×8cm不规则肿瘤…     

连续静脉-静脉血液透析治疗冠状动脉旁路移植术后慢性肾功能衰竭一例

患者男,53岁。胸闷、气促8个月,加重15d ,以冠状动脉粥样硬化性心脏病(冠心病),不稳定型心绞痛,心功能Ⅲ级,高血压Ⅲ级,糖尿病,糖尿病肾病,慢性肾功能不全失代偿期,乙型肝炎收入院。入院后冠状动脉造影显示3支血管病变,右冠状动脉及回旋支100%闭塞,左冠状动脉主干狭窄达管径的60%,左前降支狭窄70%;术前尿量为20m l/h,血尿素氮(BUN )22.13mm o l/L,血肌酐(C r)511μm o l/L,动脉血氧分压(PaO2)为47mmHg (1kPa=7.5mmHg)。患者因出现呼吸衰竭经气管内插管后急诊行冠状动脉旁路移植术,术中用左乳内动脉与左前降支吻合,大隐静脉行钝缘支-对…     

64层螺旋CT冠状动脉成像对心肌桥-壁冠状动脉的诊断价值

目的探讨64层螺旋CT冠状动脉成像对壁冠状动脉-心肌桥的诊断价值。方法收集2006年12月至2007年5月462例在我院行64层螺旋CT冠状动脉成像患者的影像资料，分析确诊的壁冠状动脉的影像表现。结果462例受检者中有63例存在73段壁冠状动脉，发生率为13．6％（63／462）。以左前降支中段最多（60．3%，44／73），其次为钝缘支（15．1％，11／73），第一对角支（13．7%，10／73），中间支（2．7％，2／73），第二对角支（2．7％，2／73），左前降支近段、远段、回旋支远段、右冠状动脉中段各1段（1．4%）；心肌桥的平均长度为17．6mm，平均深度为2．7mm。CT表现为冠状动脉在心肌内行走一段距离后又浅露于心肌表面，即“上下台阶”征。结论64层螺旋CT血管造影能准确显示壁冠状动脉与心肌的解剖关系，是确诊壁冠状动脉的首选方法之一。     

冠状动脉CT成像技术在诊断不同程度冠状动脉狭窄中的敏感性和特异性分析

目的评估320排冠状动脉CT成像(CT angiography,CTA)诊断冠状动脉粥样硬化性心脏病(coronary artery disease,CAD)的价值。方法收集55例未确诊CAD的患者,在7 d内先后接受了320排冠状动脉CTA及冠状动脉造影(coronary angiography,CAG)的数据进行比较。结果 55例患者4个主要冠状动脉包括左主干、左前降支、左回旋支及右冠状动脉共220支在检查中显影良好。CAG结果显示冠状动脉病变者94例,显示无病变者126例。冠状动脉CTA结果显示冠状动脉病变共94例,显示无病变者126例。冠状动脉CTA与CAG均发现病变者68例,均未发现冠脉病变者100例。冠状动脉CTA的敏感性和特异性分别为0.72、0.79。结论 320排CT冠状动脉CTA是CAD患者无创检查诊断的重要手段,可为CAD患者诊断提供依据,虽然尚不能替代目前的金标准检查CAG,但由于CTA对于重度狭窄有高度特异性,因此对于那些拒绝CAG检查的患者(特别是存在严重狭窄的患者)是一个便捷的检查手段。     

微创冠状动脉搭桥术(附23例报告)

目的　探索冠状动脉搭桥术的微创治疗方法。　方法 1999年 1月至 2 0 0 0年 8月 ,用Octo pus方法给 2 3位冠状动脉狭窄的患者行冠状动脉搭桥术。搭桥数 1根 1例 ,2根 3例 ,3根以 19例。移植部位 :前降支 2 3例 ,对角支 8例 ,回旋 15例 ,右冠 14例 ,后降支 8例。移植血管 :左乳内动脉 2 0根 ,大隐静脉 4 8根。　结果　无手术死亡 ,无中转体外循环 ,术后心绞痛消失 ,MRI提示桥血管通畅。　结论　非体外循环下冠状动脉搭桥术适用于多支血管病变 ,包括回旋支和后降支。桥血管通畅率与常规冠状动脉搭桥术相同。并发症少 ,费用低 ,是一种安全、经济的微创手术方法。     

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.     

Emergent coronary artery bypass grafting (CABG) for over-80-year-old patients

We experienced 2 emergent CABG for over-80-year-old patients. First patient, an 81-year-old male, showed total occlusion of left main truncus (LMT) and 90% stenosis of right coronary artery (RCA), and fell in shock. He underwent PTCA for LMT under intraaortic balloon pumping (IABP) and recovered from shock. But 3 days later, pulmonary congestion and heart failure developed along with mitral regurgitation. Emergent CABG to left anterior descending branch (LAD) and RCA was performed using saphenous vein grafts in combination with mitral annuloplasty by Kay's method. Second patient, an 82-year-old male, showed 50% stenosis of LMT, 99% stenosis of LAD and total occlusion of RCA, and fell in shock. Emergent CABG to LAD and RCA was performed using saphenous vein grafts under IABP. In spite of some perioperative serious complications, both patients survived and have been doing well. Some problems of CABG for elderly patients were discussed.     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。     

Coronary artery bypass grafting to left anterior descending coronary artery diagnosed by multidetector-row computed tomography

A 64-year-old male received coronary angiography because of chest pain. Although coronary angiography showed total occlusion of right coronary artery (RCA) # 2 and left anterior descending branch (LAD) #6, and a significant stenosis of left circumflex (LCx) #11, it could not visualize LAD distal to LAD # 6. Since coronary multidetector-row computed tomography (MD CT) could visualize the distal LAD, coronary artery bypass grafting (CABG) was indicated for this patient. Left internal thoracic artery (LITA) was anastomosed to LAD and saphenous vein graft (SVG) was used for distal anastomoses to obtuse marginal branch (OM) and 4-posterior descending branch (# 4 PD). Postoperative course was uneventful. LITA anastomosed to LAD and SVG to OM and # 4 PD were visualized by postoperative coronary angiography. MD CT in addition to coronary angiography was demonstrated useful to assess precise lesions of the coronary artery disease in this case.     

Off-pump coronary artery bypass grafting for single coronary artery; report of a case

A 55-year-old male with single coronary artery complicated by angina pectoris was referred to our department for coronary artery bypass grafting (CABG) . Coronary arteriography could not identify the left coronary orifice. Right coronary arteriography showed that the circumflex branch (Cx) followed the course of the normal right coronary artery (RCA) , and the left anterior descending branch (LAD) followed the Cx. Other findings included 90% stenosis in #4 posterior descending (PD) of RCA. Off-pump CABG was successfully performed to D1 with the left internal thoracic artery graft and to #4PD with the radial artery graft.     

The influence of coronary artery bypass grafting to totally occluded coronary arteries on the left ventricular contractility

Sixteen patients underwent 16 coronary artery bypass grafts (CABG) to totally occluded coronary arteries (TOCA), including 12 left anterior descending coronary arteries (LAD) and 4 right coronary arteries (RCA). Of these 16 CABGs, 2 of the RCA grafts became obstructed postoperatively and the remaining 14 patients with patent grafts were divided into the two following groups: 8 with previous infarcts in the region perfused by the TOCA (Group I) and 6 with no previous infarcts (Group II). The left ventricular (LV) ejection fraction and the mean verocity of circumferential fiber shortening significantly increased postoperatively in both groups and the PLVSP/LVESV significantly increased postoperatively in Group II. The LV segmental wall motion (SWM) in the region of TOCA significantly increased postoperatively in both groups. In 5 of the Group I patients, whose anterior and apical SWM was less than the lowest value of the normal subjects, the anterior and apical SWM significantly increased postoperatively. We thus concluded that CABG to totally occluded LAD results in an excellent graft patency rate, a significant improvement of SWM in the region of the TOCA and global LV contractility, even in patients with severe segmental dysfunction due to previous infarcts.     

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.     

The influence of coronary artery bypass grafting to totally occluded coronary arteries on the left ventricular contractility

Sixteen patients underwent 16 coronary artery bypass grafts (CABG) to totally occluded coronary arteries (TOCA), including 12 left anterior descending coronary arteries (LAD) and 4 right coronary arteries (RCA). Of these 16 CABGs, 2 of the RCA grafts became obstructed postoperatively and the remaining 14 patients with patent grafts were divided into the two following groups: 8 with previous infarcts in the region perfused by the TOCA (Group I) and 6 with no previous infarcts (Group II). The left ventricular (LV) ejection fraction and the mean verocity of circumferential fiber shortening significantly increased postoperatively in both groups and the PLVSP/LVESV significantly increased postoperatively in Group II. The LV segmental wall motion (SWM) in the region of TOCA significantly increased postoperatively in both groups. In 5 of the Group I patients, whose anterior and apical SWM was less than the lowest value of the normal subjects, the anterior and apical SWM significantly increased postoperatively. We thus concluded that CABG to totally occluded LAD results in an excellent graft patency rate, a significant improvement of SWM in the region of the TOCA and global LV contractility, even in patients with severe segmental dysfunction due to previous infarcts.     

A case of successful emergency coronary artery bypass grafting surgery for failed coronary angioplasty using percutaneous cardiopulmonary support]

This is the first Japanese case of the successful emergency coronary artery bypass grafting (CABG) surgery for failed percutaneous transluminal coronary angioplasty (PTCA) using percutaneous cardiopulmonary support (PCPS). A 81-year-old woman with old myocardial infarction and angina pectoris is presented. Her coronary angiogram showed the 90% and 50% stenosis of the right coronary artery (RCA) and the total occlusion of the left anterior descending artery (LAD). PTCA for the 90% stenosis of RCA was performed. But, during the balloon dilation, her heart rate and blood pressure decreased. PTCA was stopped. As her chest pain was worse, re-PTCA was tried, using PCPS. Under PCPS (3 l/min), the balloon dilation was performed safely and smoothly. But, the unexpected dissection of RCA occurred, and became larger rapidly. After 85 minutes, the emergency CABG was performed. By using PCPS, the stable hemodynamics was given till the operation. CABG to RCA and LAD was performed safely. After the surgery, the patient progressed well. PCPS was a very useful cardiopulmonary assist device.     

Emergent coronary artery bypass grafting for a patient with cardiopulmonary arrest

A 59-year-old man was admitted to our hospital due to sudden onset of unconsciousness caused by myocardial infarction with ventricular fibrillation. Emergent coronary angiography under intraaortic balloon pumping revealed 90% stenosis of the left main trunk and left anterior descending artery (LAD), and complete obstruction of the left circumflex artery (Cx) and right coronary artery (RCA). Emergent coronary artery bypass grafting (CABG) to LAD, Cx, and RCA was performed. During the postoperative course, the patient developed ventricular tachycardia/fibrillation. After implantation of an implantable cardioverter defibrillator (ICD), he was discharged on the postoperative day 36. The patient has now resumed normal daily life.