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.     

机器人辅助冠状动脉搭桥术4例报告

目的:微创手术是将来外科的发展方向,机器人在心脏外科领域应用越来越广。本文报告4例机器人辅助冠状动脉搭桥术的临床经验。方法:2001年3月～2002年4月,共有4例冠心病患者接受机器人辅助冠状动脉搭桥术,均为男性,平均年龄62±5岁。1例有心肌梗死史。1例为PTCA术后再狭窄,1例PTCA未成功。冠状动脉造影示左前降支单支病变,狭窄程度90％～100％。平均LVEF55％±9％。在胸腔镜、AESOP 3000机器人辅助下左取乳内动脉,经左第4肋间前外侧小切口完成左乳内动脉与左前降支直接吻合(MIDCAB)。结果:全组无手术死亡和围术期并发症。手术时间平均1.5h,其中取LIMA时间0.5h。平均胸腔引流量150ml,无1例输血。平均ICU时间18h,平均住院时间5.5d。病人疼痛较轻,感觉满意。结论:机器人辅助冠状动脉搭桥术创伤小,恢复快。