高龄冠状动脉左主干狭窄病变患者的外科治疗

目的总结高龄冠心病左主干病变患者接受冠状动脉旁路移植术的经验。方法2005年至2014年,101例冠心病左主干病变患者接受非体外循环冠状动脉旁路移植术,其中男82例,女19例,平均(81.4±1.7)岁,左主干狭窄(≥70%)76例,<70%者25例,平均左心室舒张末径(48.2±8.3)cm,心脏射血分数>50%89例,30~50%12例,合并二尖瓣关闭不全14例,合并室壁瘤1例,纽约心功能分级I~Ⅱ级56例,Ⅲ~Ⅳ级45例。加拿大心绞痛分级(CCS)I~Ⅲ级99例,Ⅳ级2例,合并急性心肌梗死13例,术前使用主动脉内球囊反搏6例。结果101例手术均顺利完成,平均手术(3.9±0.8)h,平均桥血管使用(3.0±1.0)根,ICU监护(50.2±46.0)h,呼吸机辅助呼吸(42.9±68.5)h,二次开胸止血6例(5.9%),二次气管插管5例(4.9%),术后持续透析4例(4.0%),主动脉内球囊反搏使用术中3例(2.9%),术后11例(10.9%),围术期心肌梗死2例(2.0%),术后院内死亡8例(7.9%)。中位随访时间6(1~11)年,全因死亡17例(16.8%)。结论尽管高龄、左主干狭窄病变这两种冠状动脉搭桥手术的独立高风险因素同时存在,非体外循环冠状动脉旁路移植术以及围手术期的相关处理仍然是目前安全、有效的治疗方法。

Surgical treatment for left main coronary artery stenosis in patients of advanced age

Objective To analyze the clinical efficacy of coronary artery bypass grafting(CABG)in patients of advanced age with left main coronary artery disease(LMCAD).Methods From 2005 to 2014,101 elderly patients(≥80 years)with LMCAD underwent off-pump CABG in our hospital.Among them,82 were male and 19 were female,with an average age of(81.4±1.7)years.Seventy-six cases(75.2%)had significant left main stenosis(≥70%)and twenty-five cases had left main stenosis less than 70%.The average left ventricular end diastolic diameter was(48.2±8.3)cm;left ventricular ejection fraction was more than 50%in 89 cases and 30%to 50%in 12 cases.Fourteen cases had mitral insufficiency and one had ventricular aneurysm.In addition,56 patients had New York Heart Association functional classificationⅠtoⅡ,and 45 patients had classificationⅢtoⅣ.Ninety-nine patients had Canadian Vascular Society(CCS)classification of angina pectorisⅠtoⅢ,two had classificationⅣand thirteen had acute myocardial infarction.Six patients were implanted with intra-aortic balloon counterpulsation before CABG.Results The average operation time was(3.9±0.8)h,the average number of bridging vessels were(3.0±1.0)roots,ICU monitoring time was(50.2±46.0)h,and ventilator assisted breathing time was(42.9±68.5)h.Six patients(5.9%)had secondary thoracotomy hemostasis,five(4.9%)had secondary tracheal intubation,and four(4.0%)had continuous dialysis.Intra-aortic balloon counterpulsation was implanted in 3cases(2.9%)during operation and in 11 cases(10.9%)after operation.Two cases(2.0%)had perioperative myocardial infarction and 8 cases(7.9%)died after operation during hospitalization.The median follow-up time was 6(1-11)years,and 17(16.8%)had all-cause mortality.Conclusions Although the two independent high-risk factors,old age and left main stenosis often coexist,off-pump CABG and perioperative management are still safe and effective treatments.