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。     

心脏直视术中被迫冠状动脉旁路移植术七例

心脏直视术中被迫紧急行冠状动脉旁路移植术（ＣＡＢＧ）,在临床上很少见。１９８５年３月～１９９７年７月我们在心肺转流术（ＣＰＢ）下行心脏直视术４１６３例,其中７例在心脏手术中发生冠状动脉意外被迫行ＣＡＢＧ,现报告如下。１　临床资料与方法１．１　一般资料　本组共７例,男６例,女１例。年龄８～６４岁,平均４０．７岁。术前全组均无心绞痛病史,心电图ＳＴＴ无改变,均未行心导管检查。按ＮＹＨＡ心功能分级,Ⅱ级３例、Ⅲ级４例。原发病：心脏联合瓣膜病４例,风湿性心脏病二尖瓣狭窄、法洛四联症（ＴＯＦ）、主动脉瓣…     

连续116例冠状动脉搭桥无手术死亡

我院近四年连续施行冠状动脉搭桥（ＣＡＢＧ）１１６例，无手术死亡，取得满意疗效。临床资料：男１０２例，女１４例。年龄３５～８０岁，平均６７４岁。心绞痛ＣＣＳＩ级４例，Ⅱ级１５例，Ⅲ级５０例，Ⅳ级４７例。８１例（６９８％）入院前曾有１～６次心梗史。合...     

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。     

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。     

风湿性瓣膜病合并冠心病的外科治疗

报告１９９１年１月至１９９５年１１月期间１５例风湿性瓣膜病合并冠心病病人瓣膜替换及冠脉桥术（ＣＡＢＧ）的体会。手术均在低温体外循环下进行。其中二尖瓣替换＋ＣＡＢＧ６例，主动脉瓣替换＋ＣＡＢＧ６例、双瓣替换＋ＣＡＢＧ３例，术后死亡３例，其余治愈出院，作者强调了术前明确诊断的重要性，并就冠脉搭桥、心肌保护、主动脉气囊反搏（ＩＡＢＰ）及药物的应用加以讨论。     

冠状动脉旁路移植术后长期随访

目的 总结１９８２年至１９９１年间３８例冠状动脉旁路移植术（ＣＡＢＧ）者的长期随访结果,以探讨术前危险因子对ＣＡＢＧ疗效的影响。方法 ３８例中男３６例,女２例。年龄４１－７３岁,平均５５．４岁,７３．７％病人年龄大于５０岁。有心肌梗死发作史者１５例,有心衰史者２例。ＰＴＣＡ失败后急症手术２例,３支,３支以上冠状动脉病变者１９例。心功能Ⅲ级及以上者３０例。应用Ｓｔａｔｉｓｔｉｃａ软件包中的Ｌｏｇｉｓ     

左主干狭窄的外科治疗

目的 探讨左主干狭窄（ＬＭＳ）≥５０％患者的外科治疗效果。方法 ４２例ＬＭＳ的患者接受了冠状动脉旁路移植术（ＣＡＢＧ）。平均年龄６８．７岁。ＬＭＳ介于５０％￣７５％者１６例,大于７５％者２６例,不稳定型心绞痛２９例。按ＣＣＳＳ标准心绞痛分级,Ⅰ级２例,Ⅱ级５例、Ⅲ级１７例,Ⅳ级１８例。左室射血分数小于５０％者２４例。结果 术前平均住院时间２．３ｄ人均移植血管３．３根,无手术死亡。术后所有患者心绞痛     

直视下胃冠状静脉栓塞术十年经验总结

本文对近十年来作者首创的直视下胃冠状静脉栓塞（ＧＣＶＥ）术治疗门静脉 的经验进行回顾总结。着重介绍了ＧＣＶＥ的设计原理、异位栓搴 防止及手术操作要占。并对２４６例的临床资料进行分析。结果：术后一月内死亡５例，手术死亡为２％，并发异位血管栓塞３例（１．２％）；术后一、三、五年存活率分别为９７．３％、８８．４％、８０．８％。认为该手术具有手术损伤小，死亡率低，并发症少。远期效果满意，手术适应症广等优点     

冠状动脉旁路手术麻醉处理的初步体会

冠状动脉旁路手术麻醉处理的初步体会景桂霞＊叶平安过去５年间，我院与美国手术队合作施行冠状动脉旁路术（ＣＡＢＧ）４７例，其中男４３例、女４例，年龄５０～６９岁。病种皆为冠心病。４２例伴不稳定型心绞痛２～９年；１７例有心肌梗塞史，其中５例有心源性休克史，...     

Simultaneous coronary artery bypass grafting and vascular operations: early and mid-term results

AIM: The purpose of this study was to estimate the results of surgical strategy for patients undergoing simultaneous coronary and peripheral artery surgical interventions and to compare their early and mid-term clinical results with the results of the isolated coronary artery bypass grafting (CABG) operations. METHODS: From 1999 to 2005, 78 patients underwent simultaneous vascular reconstructions following CABG. All the patients were divided into 3 groups: CABG and carotid artery group (CAG), CABG and peripheral vascular group (PVG), and CABG and abdominal aortic aneurysm group (AAAG). RESULTS: In CAG, early mortality was 2%, postoperative myocardial infarction and stroke rates were 2% and 6.1%, respectively. In PVG, one (4%) patient had postoperative stroke, and there were neither deaths nor myocardial infarctions. PVG and CAG did not differ significantly in postoperative complications and mortality rates from the isolated CABG group. The simultaneous abdominal aortic aneurysm operations were related to higher early mortality rate (2 out of 6). Using the Kaplan-Meier analysis, the 3-year overall survival probability in the simultaneous operation group was 82%; the 5-year overall survival probability, 74%. PVG and CAG did not differ in the survival probability from the isolated CABG group. The survival probability in AAAG was lower than in the isolated CABG group. CONCLUSION: The simultaneous CABG and vascular operations whenever indicated are feasible procedures to be performed on patients with concomitant carotid artery and/or peripheral vascular occlusive disease. The surgical management of coronary artery disease followed by abdominal aortic aneurysm repair remains still controversial.     

Off-pump coronary artery bypass and right ventricular branch translocation for coronary aneurysm; report of a case

The successful surgical treatment for a coronary artery aneurysm was reported. A 38-year-old female presented with angina pectoris due to right coronary artery stenosis. Angiography revealed a right coronary artery aneurysm and 90% stenosis at a site just proximal to the aneurysm, accompanied by the relatively large right ventricular (RV) branch originating from a mid portion of the aneurysm. Off-pump coronary artery bypass grafting (CABG) to the right coronary artery (RCA) #3, translocation of RV branch to RCA #3, and ligation of RCA proximal and distal to the aneurysm were successfully performed. Post-operative course had been uneventful with satisfactory angiographic results. Coronary translocation with CABG could be a treatment option for coronary artery aneurysms.     

Surgical treatment of coexistent aortic, peripheral vascular and coronary disease

To determine the priority of the surgical treatment of coexistent aortic and coronary disease (CAD), we reviewed 19 cases of aortic aneurysm combined with severe coronary lesions who underwent operation from Jan, 1984 to Aug, 1989. There were 15 cases of abdominal and 4 cases of thoracic aneurysm. All patients had graft replacement for the aneurysm and 12 patients had elective aortocoronary bypass surgery (CABG), one had percutaneous transluminal coronary angioplasty and 6 received medical treatment for CAD. In 6 cases, CABG preceded abdominal aneurysm operation. In 3 cases of ascending thoracic aneurysm, simultaneous coronary and aortic operation were performed. There were no early and late operative death. In an attempt to reduce perioperative myocardial infarction which is one of the most frequent complications of aneurysmal operation, we performed routine coronary angiogram before operation. In 104 patients considered for elective aortic and peripheral vascular disease, coronary angiogram were performed. The incidence of coexistent coronary artery disease in peripheral vascular and aortic disease were 46.1%. The incidence of multiple vessel CAD in patients with aortic and peripheral disease were high. Our surgical strategy for coexistent aortic, peripheral vascular and coronary disease is basically staged operation and simultaneous operation are performed only in ascending and proximal arch aneurysm.     

冠状动脉旁路移植术1018例临床分析

目的总结、探讨冠状动脉搭桥术的外科技术及临床治疗效果。方法回顾分析1997—2004年同一术者完成的冠状动脉搭桥术1018例患者的临床资料,其中非体外循环冠状动脉旁路移植术(OPCAB)510例,体外循环下冠状动脉旁路移植术(CCABG)508例。≥60岁的患者582例(57.2%)。不稳定性心绞痛患者852例;术前同时合并其他疾病患者784例(77.0%),包括瓣膜病、高血压病、糖尿病、陈旧性心肌梗死、室壁瘤、室间隔穿孔、脑梗死、阻塞性肺疾病(COPD)、慢性肾功能不全、恶性肿瘤术后等。左主干病变156例;三支病变671例,三支病变以下347例。结果死亡4例(0.39%),总体并发症(胸骨哆开、脑梗死、纵隔炎)发生率1.6%(16/1018)。OPCAB者平均搭桥(2.5±0.4)支,CCABG者平均搭桥(3.3±0.6)支。左乳内动脉使用率93.8%(955/1018),术后早期使用主动脉内气囊反搏29例。全组随访2个月～7年,随访1002例(98.4%)。结论科学的外科策略,精湛的手术技术及麻醉、体外循环技术的改进,可使CABG术的死亡率和并发症明显下降,冠状动脉旁路移植术安全、可靠,效果满意。     

主动脉手术并同期冠状动脉旁路移植术的临床总结

目的总结行主动脉手术同期行冠状动脉旁路移植术的临床经验。方法回顾分析1997年11月至2004年8月,36例同期行主动脉手术和冠状动脉旁路移植术患者的临床资料。36例中,主动脉夹层19例,主动脉瘤17例。年龄(57±12)岁。其中急性A型主动脉夹层10例,术中探查见冠状动脉开口受累7例,冠状动脉为索条状2例,1例在外院行冠状动脉造影检查发现;慢性A型主动脉夹层7例,术中发现冠状动脉开口受累2例,冠状动脉呈索条状3例,术前造影检查发现冠状动脉病变2例;B型主动脉夹层2例;真性主动脉瘤均为术前冠状动脉造影检查发现冠状动脉病变。移植血管共57支,其中动脉6支,静脉51支。结果平均体外循环时间(157±54)m in,心肌阻断时间(98±31)m in。围手术期死亡5例(均为A型主动脉夹层),分别为低心排血量综合征、心源性休克并发多脏器功能衰竭3例,脑疝1例,内脏缺血坏死1例。术后发生并发症2例,发生率为6%,分别为二次开胸止血和呼吸功能衰竭气管切开。结论主动脉夹层累及冠状动脉和冠状动脉本身的病变严重影响预后。对年龄>50岁的主动脉瘤患者,于术前常规行冠状动脉造影检查,行单纯主动脉瘤手术并同期行冠状动脉旁路移植手术安全、可靠。     

Aortic arch aneurysm complicated with coronary artery disease: still a surgical challenge?

Recent surgical strategies and outcomes for the simultaneous operation of aortic arch repair (AAR) and coronary artery bypass grafting (CABG) were reviewed. The surgical treatment of aortic arch aneurysm complicated with coronary artery arteriosclerosis has been a challenge. In spite of recent improvements in cerebral protection during AAR such as deep hypothermia and circulatory arrest with/without retrograde cerebral perfusion, or antegrade selective cerebral perfusion (SCP), additional CABG poses a considerable surgical risk resulting in extremely higher mortality rates when compared with solo AAR. To minimize the cardiac ischemic time, several techniques such as distal coronary artery anastomosis on the perfused fibrillating heart, and coronary artery perfusion through a cardioplegic line during AAR have been employed. Recently, open stent grafting instead of aortic distal anastomosis has been attempted to minimize the cardiopulmonary time and operative complexity. Our recent experience suggested off-pump coronary artery bypass and AAR with the aid of SCP decreased cardiac ischemic time and cardiopulmonary time followed by improved operative morbidity and mortality. Further less-invasive surgical modalities that enhance the adequate myocardial protection and minimize the adverse effect of cardiopulmonary bypass can improve the outcome of this demanding operation for these elderly patients with aortic arch aneurysm and coronary artery occlusive disease.     

Technical problems during coronary artery bypass grafting

In this paper we have reviewed 300 more or less consecutive coronary artery bypass grafting (CABG) cases with regard to the technical problems that can occur. Only first time revascularisation operations were considered, including those combined with resection of left ventricular (LV) aneurysm and valve replacement. Redo operations were not included. Specific complications related to vein grafting and some miscellaneous problems inherent in open heart surgery are discussed in depth. The morbidity and perioperative mortality are analysed. There was only one perioperative death giving a mortality rate of .3%. 300 first-time CABG operations, including CABGs with resection of LV aneurysm or valve replacement were reviewed in depth to focus on the technical complications encountered whilst the patient was on the operating table. Although CABG is one of the most frequently performed cardiac surgical procedures in the western world, there is still about a 1% mortality rate associated with the operation in the centres doing a large number of these operations and the authors have attempted to highlight those technical complications that contribute to perioperative morbidity and mortality and their management.     

Rescue Coronary Artery Bypass Grafting (CABG) after Aortic Composite Graft Replacement

Abstract Background: Aortic root replacement (ARR) has been recognized as the standard therapy for diseases of the aortic root since its introduction into clinical practice. ARR currently provides excellent long‐term benefit with acceptable perioperative risk and excellent long‐term morbidity and mortality. During ARR, coronary button misalignment may produce myocardial ischemia, ventricular arrhythmias, and pump failure leading to death if unrecognized. Here we review our experience with coronary insufficiency after ARR. Methods: Between January 1995 and March 2006, 139 consecutive patients underwent ARR at Yale‐New Haven Hospital. A retrospective review of their medical records was conducted. The mean age of the patients was 54.5 years. Aortic root aneurysm was the indication for surgery in 123 patients, acute type A dissection in 14, and endocarditis in two. Results: All patients underwent a modified Bentall operation with a mechanical (87%) or biological (13%) valve prosthesis and coronary artery button reimplantation. The overall 30‐day mortality was 4.3% (six patients). Three patients (2.2%) underwent rescue coronary artery bypass grafting (CABG) to the left, right, or both coronary arterial systems for ischemia due to presumed coronary button misalignment. These patients presented with ventricular arrhythmias or hemodynamic compromise. All three showed excellent response to rescue CABG and remain alive and well in late follow‐up. Conclusion: Coronary insufficiency after reconstruction of the aortic root is an uncommon but acutely life‐threatening occurrence. This lethal condition may present with difficulty in weaning from cardiopulmonary bypass; echocardiographic signs of major wall motion abnormalities; and electrocardiographic evidence of ischemia, pump failure, and ventricular arrhythmias. Rescue CABG in this situation is life‐saving. Immediate rescue CABG should be performed if coronary ischemia is suspected after composite graft replacement of the aortic root.     

The changing mortality of myocardial revascularization: coronary artery bypass and angioplasty

The risk factors and outcome for the first 150 consecutive patients undergoing coronary artery bypass grafting (CABG) in 1985 (CABG '85) were compared with those of the first 150 patients undergoing CABG in 1975 (CABG '75) and those of the first 150 patients to have percutaneous transluminal coronary angioplasty (PTCA) in 1985 (PTCA '85). The CABG '85 patients had a significantly higher (p less than 0.05) incidence of known operative risk factors including advanced age, female sex, severity of angina, history of recent infarction, triple-vessel disease, left ventricular dysfunction, and emergency operation than the CABG '75 cohort. The clinical profile of the PTCA '85 patients closely resembled the low-risk profile found in the CABG '75 patients. Overall mortality following CABG more than doubled during the decade studied (3% versus 7%, p = 0.07). This study suggests that the increased mortality associated with CABG in 1985 is due in part to the inclusion of more high-risk patients in the surgical population. In addition, the application of PTCA removes low-risk patients from the surgical candidate pool and adds more patients requiring emergency operations, thereby further contributing to the overall decline in the clinical status of patients referred for operation.