Coronary endarterectomy on beating heart: Our experience

Introduction Coronary artery bypass grafting (CABG) associated with Endarterectomy is a high risk procedure. After the first report of coronary endarterectomy by Bailey et al in 1951, the preference for this surgical procedure was decreased due to increased morbidity and mortality In patients with total or subtotal large coronary artery obstructions in which there is no possibility to receive a conduit as graft for myocardial revascularisation, endarterectomy remains the procedure of choice. This study was designed to study early and midterm results of off pump coronary artery endarterectomy. Methods Of 172 Consecutive Off Pump CABG done at our institution from Jan 2003 to July 2005, 22 patients underwent supplementary coronary endarterectomy. 16 patients had chronic stable angina 4 had unstable angina two required emergency CABG with endarterectomy following perioperative infarction. The mean ejection fraction was 29.2±4.3 and all of the patients were in New York Heart Association (NYHA) III or IV. All patients were planned for complete total arterial revascularisation using Left Internal Mammary Artery (LIMA). Right Internal Mammary Artery (RIMA), Radial composite “Y” graft, Two patients operated for periop infarct received vein graft. In 16 patients closed endarterectomy was done in five patients double endarterectomy in single vessel was done to chase the plaque distally, in one patient open left anterior descending (LAD) endarterectomy with vein patch reconstruction was performed. Results There were no deaths. None of the procedures were converted to on pump operation. All endarterectomies and bypasses were performed on Beating Heart, all patients were completely revascularised. Peri operative cardiac enzymes studied showed no significant rise in the Creatinine Phoshpokinase (CPK)-Creatinine Phosphokinase myocardial Band (CPK-MB). The mean postoperative Ejection Fraction (EF) was 36.7%±7.2% which was significantly higher than the Preoperative one (p<.05). At the end of four months to one and half year 22 patients were in NYHA class I to II and all were angina free in canadian cardiovascular society class.f Conclusions Coronary End Arterectomy without cardiopulmonary bypass can be performed in patients who are expected to benefit from complete revascularisation. It can be performed with closed as well as open method. However to achieve complete endarterectomy by closed technique in some patients it is essential to chase the plaque. Early and mid term results are encouraging.     

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。     

非体外循环下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变

目的探讨非体外循环心脏跳动下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变的早期临床结果和经验。方法2003年5月—2005年5月,对53例弥漫性冠状动脉病变患者行非体外循环下冠状动脉内膜剥脱后搭桥手术治疗。53例中,男性41例、女性12例,年龄55～79(64±7)岁。加拿大心脏病协会心绞痛分级：Ⅰ～Ⅱ级15例,Ⅲ级6例,Ⅳ级32例。有心肌梗死史26例(49%)。冠状动脉造影：双支病变3例,3支病变50例,其中合并左主于病变9例。左心室射血分数0．26～0．65(0．52±0．17)。53例共行70支冠状动脉内膜剥脱：左前降支系统38支,其中5例内膜剥脱后先用大隐静脉片行前降支成形,再在补片上用乳内动脉搭桥;回旋支的钝缘支8支;右冠状动脉系统24支。应用左乳内动脉53支,桡动脉2支,余均为大隐静脉桥,人均搭桥(3．8±1．1)支,再血管化指数1．03±0．07。结果术中桥血流测定显示63支桥血流满意,7支欠满意。术后2例发生围手术期心肌梗死,但对血流动力学无明显影响。53例皆痊愈出院。44例随访6～29个月,无心绞痛发作;9例失访。6例在手术后3～27个月复查冠状动脉造影,显示桥血管均通畅。结论非体外循环下冠状动脉内膜剥脱后搭桥,安全可行,再血管化程度高,是治疗弥漫性冠状动脉病变的有效方法。     

经左胸前外侧小切口冠状动脉旁路移植术

目的 评价经左胸前外侧小切口冠状动脉旁路移植术的临床疗效及远期随访结果.方法 2002年1月至2006年10月,38例单支或多支冠状动脉病变患者经左胸前外侧小切口进胸,直视下或胸腔镜辅助下,完成非体外循环冠状动脉旁路移植术.其中男性25例.女性13例;年龄38～78岁,平均(63.3±11.1)岁.结果 38例手术均顺利完成.20例行单纯旁路移植1支;10例先行支架植入,后行胸廓内动脉至前降支端侧吻合,其中2例行胸廓内动脉与第一对角支、前降支序贯吻合;8例行旁路移植2支,其中3例为序贯吻合,5例应用桡动脉行"Y"形吻合.术后无死亡及严重并发症.37例患者获得26～82个月随访,平均(53.2±28.5)个月;无晚期死亡,无再发心肌梗死.心功能Ⅰ级26例,Ⅱ级12例.3例心绞痛复发,2例经药物控制后症状缓解,1例经造影证实吻合口狭窄于术后2年行支架植入.结论 左前外侧小切口非体外循环冠状动脉旁路移植术具有较低的病死率和心脏不良事件发生率,远期结果良好.     

弥漫性冠状动脉病变的外科治疗

目的总结非体外循环心脏跳动下冠状动脉内膜剥脱后行非体外循环冠状动脉旁路移植术（off—pump CABG）治疗弥漫性冠状动脉病变的早期临床结果和经验，以提高手术疗效。方法2003年5月～2006年11月，对83例弥漫性冠状动脉病变患者在非体外循环下做冠状动脉内膜剥脱后行off—pump CABG，其中男61例，女22例；年龄55-80岁（65±7岁）；加拿大心脏病协会（CCS）心绞痛分级：Ⅱ级7例，Ⅲ级20例，Ⅳ级56例。有心肌梗死史36例（43．4％）。冠状动脉造影显示：双支血管病变5例，3支病变78例，其中合并左主干病变16例。左心室射血分数25％～65％（51％±16％）。83例共行110支冠状动脉内膜剥脱，其中左前降支系统67支，回旋支、钝缘支9支，右冠状动脉系统34支。20例内膜剥脱后先用大隐静脉片行左前降支成形，再在补片上用乳内动脉行旁路血管移植；应用左乳内动脉83支，桡动脉2支，余均为大隐静脉，每例移植血管3．9±1．2支。结果无手术死亡。术中移植血管血流满意101支（92％），血流量为22±16ml／min。术后发生心肌梗死4例，梗死面积小，无血流动力学改变，未给予特殊治疗。83例患者皆痊愈出院。随访75例（90．4％），8例失访，随访时间8～50个月，无心绞痛发作。8例患者在手术后3～29个月复查冠状动脉造影显示：冠状动脉内膜剥脱后行off—pump CABG的移植血管均通畅。结论非体外循环下冠状动脉内膜剥脱后行off—pump CABG，安全可行，再血管化程度高，是治疗弥漫性冠状动脉病变的有效方法。     

冠状动脉竞争血流对乳内动脉旁路血流及NO、ET含量影响的实验研究

目的研究冠状动脉旁路移植（CABG）术后,未完全闭塞冠状动脉的竞争血流对左乳内动脉（加雌）旁路血流量、方向及旁路血流中一氧化氮（NO）、内皮素（ET）含量的影响。方法15只猪行㈣术建立不同程度狭窄的冠状动脉左前降支（LAD）与LIMA旁路血管竞争血流动物模型,并检测LIMA旁路血流中NO、ET含量。结果LAD近端狭窄程度越轻,LIMA旁路平均血流量越小,且收缩期逆向血流越大,IAD近端30％狭窄、50％狭窄时LIMA旁路的血流量均明显低于90％狭窄时（P〈0．01）。IAD近端30％和50％狭窄时旁路血流NO含量均明显低于IAD近端90％狭窄时（P〈0．05）;LIMA旁路血流中ET含量均较移植前高（P〈0．05）。结论CABG术后,来自未完全闭塞冠状动脉的竞争血流导致加雌旁路血流量下降并产生双向血流,进而引起旁路血流中NO含量显著下降,可能是早期LIMA血管旁路闭塞的主要机制。     

Bland‐White‐Garland syndrome: Choice of surgical technique

An anomalous origin of the left coronary artery from the pulmonary artery (Bland‐White‐Garland syndrome) was diagnosed in a 48‐year‐old woman complaining of angina for 2 years. The patient underwent surgical repair with ligation of the left coronary artery at the ostium, and a left internal mammary artery (LIMA) to the left anterior descending (LAD) coronary artery bypass. Arterial pressure monitoring and blood gas analysis of pulmonary artery and LAD was carried out before and after ligation and after LIMA to LAD anastomosis. We demonstrated an increase in systolic blood pressure in the LAD with the ligation of the fistula which did not improve significantly with LIMA to LAD reperfusion. However, there was an increase in coronary diastolic pressure with a persistent diastolic gradient. Review of the available literature and comparative analysis of different procedures suggests that ligation of the ostium plus off‐pump LIMA to LAD grafting could be the procedure of choice in adults with this rare but potentially life‐threatening, congenital coronary anomaly.     

非体外循环下冠状动脉旁路移植术治疗左冠状动脉主干合并3支血管病变

目的总结非体外循环冠状动脉旁路移植术(OPCAB)对左冠状动脉主干合并3支血管病变患者的治疗经验及体会。方法对33例左冠状动脉主干合并3支血管病变患者施行了OPCAB,用左乳内动脉作为移植血管与左前降支进行吻合,大隐静脉作为移植血管分别与回旋支、右冠状动脉/后降支、对角支和钝缘支进行吻合。结果每例患者行旁路血管移植2～5支,平均3.4支。无手术死亡,无围手术期心肌梗死、呼吸衰竭、肝肾功能衰竭等严重并发症,术后心绞痛均消失。结论OPCAB治疗左冠状动脉主干合并3支血管病变的高危冠心病患者是可行、有效的,手术损伤小;而积极的术前准备、主动脉内球囊反搏的应用、正确的手术方法和配合、建立一支熟练快速的应急队伍是确保手术成功的关键。     

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.     

Left anterior descending coronary endarterectomy: early and late results in 196 consecutive patients

Background

With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized.

Methods

Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations.

Results

All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years.

Conclusions

Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.     

34例非体外循环冠状动脉搭桥术

目的：报告３４例非体外循环下的冠状动脉搭桥术，。方法：秣在全麻常温下进行，正中切口２１例，左前外侧切口１１例，右前外侧切口和左胸骨旁切口各１例。单支病变１７例，双支病变１１例，三支病变６例；平均每例搭桥１．４支，其中１例同时激光打孔心肌血运重建。结果：全组无手术死亡平均手术时间３．１小时，平均带气管插管时间１０．９小时，２２例病人（６４．７％）不需输血，平均住院花费３．４万元。术后ＵＦＣＴ或ＭＲＩ     

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.     

非体外循环冠状动脉旁路移植术围手术期心肌梗死发生率与移植血管血流量的关系

目的探讨冠状动脉旁路移植术（CABG）中移植血管血流量与围手术期心肌梗死（MI）发生率之间的关系,为临床提供借鉴。方法采集2010年1～6月在北京大学第一医院连续58例因冠心病接受单纯择期非体外循环冠状动脉旁路移植术（（）PcAB）患者的临床资料。术中均采用左乳内动脉（I,IMA）吻合于左前降支（I．AD）,其他靶血管则以大隐静脉（SV）作为旁路移植血管,在关胸前循环状态稳定条件下,应用瞬时流量测定技术测量各移植血管的血流量,并计算移植血管总血流量。根据术后是否发生围手术期MI,将患者分成两组：MI组11例,其中男7例,女4例;年龄67．4±10．3岁;非MI组,47例,其中男38例,女9例;年龄63．3±9．9岁。分析两组患者术前及术中的相关危险因素。结果MI组与非MI组的手术时间差异无统计学意义（205．44±59．6rainVS．183．4±32．4min,t=1．69l,P=0．096）。MI组与非MI组移植血管数量（3．00±1．oo支VS．2．96±0．78支,t=0．154,P=0．878）、LIMA-LAD移植血管血流量（15．40±）1．37mi／minVS．16．50±10．83mJ／min,f=0．301,P=0．764）差异均无统计学意义;MI组与非MI组移植血管总血流量（41．03土19．50ml／minVS．64．09±32．44ml／min,t=2．254,P=0．028）差异有统计学意义。移植血管总血流量〈48．5ml／min为发生MI的危险因素EoR：4．706,95％CI（1．099,20．147）]。结论移植血管总血流量可在一定程度上预测CABG后急性心肌缺血事件的发生,总血流量〈48．5ml／min的患者术后发生围手术期MI的概率将明显增加。     

A case report of coronary subclavian steal syndrome in a young woman

A 41-year-old woman presented with complaints of increasing angina pectoris and coldness of her left arm for 1 month. Six months ago, she had undergone triple coronary artery bypass grafting (CABG) including left internal mammary artery (LIMA) to left anterior descending artery (LAD) and two saphenous vein grafts to the diagonal branch of LAD and obtuse marginal branch of the circumflex artery. Coronary angiography revealed that contrast media injected into the saphenous vein graft coursing down the diagonal branch flowed up to LAD and drained into the LIMA opacifying the left subclavian artery. Arch angiography documented a total occlusion of the left subclavian artery. A polytetrafluoroethylene graft was anastomosed between the left common carotid and axillary artery. After operation, the symptoms disappeared and blood pressure in her left arm recovered. This complication could be prevented by identification of subclavian artery stenosis during coronary angiogram or CABG. This study may suggest that subclavian artery angiography should be performed in patients who will undergo CABG even for a young woman such as our case.     

Mid-term results after extensive vein patch reconstruction and internal mammary grafting of the diffusely diseased left anterior descending coronary artery

Objective: To analyze the results of extensive reconstruction of the left anterior descending coronary artery (LAD) by an autologous vein patch, with or without endarterectomy (EA), associated with left internal mammary artery grafting onto the patch. Methods: Between January 1994 and April 2001, among 5871 myocardial revascularizations, 83 patients (1.4%), 77 male (93%), with a mean age±SD of 64±8 years (range 44–84) underwent the above mentioned procedure. Seventy-three of them (88%) were in Canadian Cardiovascular Society (CCS) Class III or IV, and 78 (94%) had a three-vessel disease. Mean preoperative ejection fraction was 58±12%. Risk factors included hypertension (63%), family history (51%), hyperlipidemia (41%), smoking (38%), diabetes (19%). Mean number of anastomoses/patient was 3±0.6. Mean length of vein patch was 2.8±0.9 cm (range 2–6 cm). A total of 16% of the patients underwent associated LAD-EA (mean cardiopulmonary bypass time: 132±21 min; mean aortic crossclamp time: 81±15 min). Results: There was one hospital death (recurrent MI, 1.2%). Seven patients (8%) had a perioperative myocardial infarction, in three cases in the region supplied by the LAD (none after associated LAD-EA). Mean follow-up period was 47±20 months (range 5–90) and is 99% complete. There were five late cardiac deaths (6%). A total of 74% survivors have no symptoms, 12% are in CCS Class I–II, and 14% in III–IV. Actuarial freedom from recurrent angina at 3 and 5 years is 77 and 69%, respectively. Follow-up angiograms (49 patients, 60%) revealed a full patent LAD graft in 82% of the cases (GI), versus poor run-off/occluded graft in the remaining 18% (GII). Anginal status was significantly worse in GII patients (P<0.05). Conclusions: Extended reconstruction of the LAD coronary artery increases surgical risk. The procedure however enhances the probability for a complete revascularization in patients with an unfavourable anatomical substrate, with acceptable mid-term results.     

非体外循环与体外循环冠状动脉旁路移植血管中远期通畅率比较

目的 比较非体外循环不停跳与体外循环冠状动脉旁路移植手术后中远期移植血管的通畅率.方法 对同一术者行冠状动脉旁路移植手术后5年以上病例50例.按手术方式分为两组.第1组采用传统体外循环下进行冠状动脉旁路移植(体外循环组,25例);第2组采用非体外循环不停跳技术进行冠状动脉旁路移植(非体外循环组,25例).对所有病例进行冠状动脉造影随访,比较两组移植血管的通畅情况.结果 两组均男21例,女4例.第1组手术年龄(55.4±8.9)岁;随访70～110个月,平均(86.52±12.48)个月;移植血管共83支,其中动脉移植血管41支,静脉移植血管42支,平均移植血管(3.32±0.63)支/例;随访移植血管通畅61支,狭窄6支,闭塞16支,动脉移植物通畅率为78.05%,静脉通畅率69.05%,总通畅率73.49%.第2组手术年龄(58.2±9.09)岁;移植血管共65支,其中动脉移植血管31支,静脉移植血管34支,平均移植血管(2.52±0.71)支/例,随访64～99个月,平均(82.68±12.48)个月;随访移植血管通畅47支,狭窄4支,闭塞14支,动脉移植物通畅率为74.19%,静脉通畅率70.59%,总通畅率72.31%.结论 非体外循环不停跳冠状动脉旁路移植手术移植血管中远期通畅率与传统体外循环手术一致,均可达到较好的中远期疗效.

Abstract：

Objective Off-pump coronary artery bypass grafting (OPCAB) is used more widely in recent years in China. However, there is an argument on benefits and risks of off-pump surgery. Many studies shown that OPCAB had more benefits in short-term outcomes than conventional coronary artery bypass grafting(CCABG). But evidences from other studies suggested that OPCAB resulted in less long-term graft patency as compared with on-pump surgery. This study examined the longterm graft patency of OPCAB and CCABG performed by one surgeon. Methods 50 patients who had received surgical revascularization by a surgeon for more than 5 years were reviewed, 25 patients received conventional coronary artery bypass grafting ( group 1 ) and 25 patients received OPCAB ( group 2). All patients had angiograms for compareing the graft patency between the two groups. Results Among 25 patients in group 1,21 were male and 4 were female. The mean age of patients at surgery was (55.4 ±8.9) years. 15 cases had unstable angina, 16 patients had old myocardial infarction and 6 cases had diabetes.The ejection fraction (EF) was 0.58 ±0.14. The mean number of bypasses per patient was 3.32 ±0.63. Mean duration of operation was (3.58 ± 0. 82) hours. Mean follow-up duration was ( 86.52 ± 12.48) months. 83 grafts were evaluated for patency ( open vs. closed) and were graded by Fitzgibbon as grade A ( excellent graft), B ( impaired graft, with a stenosis of ≥50%, or a diameter less than 50% of the grafted artery), or O ( completely occluded). The graft patency was 73.49%, 61grafts were graded as Fitzgibbon A, 6 grafts as Fitzgibbon B and 16 grafts as Fitzgibbon 0. 25 patients were in group 2, 21males and 4 females. The mean age of patients at procedure was (58.2 ± 9.09) years, 11 patients had unstable angina, 13 patients had old myocardial infarction and 6 cases had diabetes. The ejection fraction (EF) was 0.59 ± 0. 14. Conclusion No 2011.03.013 difference in long-term graft patency was identified between on-pump and off-pump coronary artery bypass grafting. Off-pump oronary artery bypass grafting preformed by an experienced surgeon may gain similar long-term graft patency to that of conventional bypass.     

Saphenous vein graft angioplasty pseudoaneurysm: A surgical challenge

A 73-years-male, hypertensive, non-smoker and nondiabetic underwent coronary artery bypass grafting (CABG) in 1986. Three years earlier he had undergone angioplasty for anastomotic lesion in left anterior descending (LAD) and right coronary artery (RCA). Patient again developed unstable angina in august 2006. Angiogram revealed patent stents with discrete lesion in proximal saphenous venous graft(SVG) to LAD, Graft angioplasty was done and a drug eluting stent was deployed. He presented with low grade fever and pain left shoulder two days following intervention. Serial computed tomography (CT) angiograms revealed expanding pseudoanaeurysm at the distal end of stent. Redo CABG with excision of Pseudoanaeurysm done. Psuedoaneurysm with a patent graft is a surgical challenge.     

乳内动脉桡动脉大隐静脉的内皮型一氧化氮合酶表达

目的 应用免疫组织化学方法，探讨内皮型一氧化氮合酶(eNOS)在冠状动脉旁路移植术中常用的3种血管材料乳内动脉(LIMA)、桡动脉(RA)及大隐静脉(SV)中的定位及表达。方法取20例行冠状动脉旁移植术((LMIG)的冠心病病人的LIMA、RA及SV的废弃血管标本，行光镜观察及eNOS的免疫组织化学染色进行半定量观察。并行计算机图像分析，比较灰度值。结果eNOS在3种血管材料的内膜均有明显表达，LIMA灰度值明显高于RA及SV，RA灰度值高于SV；LIMA、RA的肌性中层可见eNOS的表达而SV无表达，LIMA灰度值明显高于RA。结论各种血管材料中eNOS的不同表达，可能是CABG术后的远期效果不同的原因之一。     

Left internal mammary artery use in patients with poor left ventricular ejection fraction: a propensity-matched analysis of mid-term survival

We aimed to determine whether the use of left internal mammary artery (LIMA) to the left anterior descending (LAD) artery during coronary artery bypass grafting (CABG) confers an improved survival benefit to patients with an impaired preoperative left ventricular ejection fraction (LVEF). Between April 1997 and March 2004, 7198 consecutive patients underwent first time CABG to the LAD. There were 627 patients who had an LVEF <30% and of these, 548 patients (87.4%) received a LIMA graft, while 79 patients (12.6%) did not. A propensity-matched analysis was performed to provide matched cohorts for analysis of deaths occurring over time, which were described using Kaplan-Meier techniques. Propensity-matching produced two cohorts of 77 patients with or without the use of LIMA. Patient characteristics were reasonably matched between the groups. Forty-six (29.9%) deaths occurred in the propensity-matched groups. Freedom from death in patients with LIMA used at 4-years was 77.1%, compared with 60.7% for the patients with no LIMA used (P=0.026). The use of the LIMA as a bypass conduit is not contraindicated in patients with a poor preoperative LVEF. The usage of LIMA markedly improves survival.     

机器人非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变

目的 总结达芬奇S机器人系统行非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变的技术特点和优势.方法 2007年至2011年,使用da Vinic S全机器人系统完成非体外循环冠状动脉旁路移植术163例,其中12例患者因两支或三支冠状动脉病变,在机器人手术后行分站式支架置入术.男9例,女3例;年龄(56.0±9.7)岁;均有心绞痛症状,冠状动脉造影显示严重的前降支或对角支病变,合并回旋支或右冠状动脉的病变;4例有心肌梗死病史.先对所有患者前降支病变行机器人非体外循环下冠状动脉旁路移植术,术后待患者恢复平稳再行其他病变冠状动脉支架置入术.冠状动脉造影评价在再血管化效果.结果 所有患者均成功接受机器人非体外循环冠状动脉旁路移植术,术后恢复顺利,随后成功接受支架置入术.全组无并发症.结论 机器人非体外循环冠状动脉旁路移植和支架置入"杂交"手术可最大限度的减小手术创伤并实现冠状动脉完全再血管化.

Abstract：

Objective Summary the first group of robotic bypass surgery on the beating heart and stent placement in distinct hybrid session in China. Methods 163 cases patients accepted selective operation of robotic coronary bypass grafting on the beating heart form April 2007 to January 2011. 12 cases had multi coronary vessels stenosis accepted stent placement after robotic surgery in a hybrid manner. The average age of patients was ( 56. 0 ± 9.74 ) years old. 3 case was female and 9 cases were male. All the patients had a medical history of angina. The coronary arterioangiography showed sever left anterior descend ing or diagonal branch stenosis in all patients. And 4 cases had myocardial infarction history. All the patients had good lung function and had no medical history of pleurisy. Without sternotomy, through 3 ports about 1 cm in left thorax, the left internal mammary artery was obtained and simultaneously single vessel coronary artery bypass grafting through small thoracotomy or totally endoscopic coronary bypass (TECAB) was performed on beating heart. The bridge patency and revascularization was accessed by arterioangiography. Results All cases successfully accepted robotic bypass surgery on the beating heart and stent placement in distinct hybrid session without complication. Conclusion Hybrid coronary artery revascularization enable adequate revascularization of patients with multivessel coronary artery disease without sternotomy and with the advantage of the most durable option.