对冠脉搭桥术几个问题的商榷

基于作者行冠状动脉搭桥术的临床经验，就有关冠脉搭桥术的几个问题提出自己的观点，以供同行专家讨论。作者认为：（1）慢性心功能不全不应再作为CABG的手术禁忌，应视其有无屯抑心肌及梗阻远端的冠脉能否接受搭桥而考虑有无手术指征；（2）对有大面积心肌梗死的病人，若要查明梗塞区内有无顿抑的心肌，必须作PET检查；（3）近年在严重左心功能不全病例的冠脉搭桥手术前后预防性使用IABP取得了很好的效果，使得许多曾经被认为是不能随手术治疗的病人获得了很好的治疗效果；（4）Off-pump冠脉搭桥术与体外循环下的搭桥术各有利弊，其手术指征尚无定论；（5）蛇形桥亦有利有弊，在靶血管较粗，可供利用的移植血管较少，升主动脉钙化较重，靶血管较多等情况下，合理利用其优点，避开其缺点，可取得很好的临床效果；（6）一般而言，作血管内膜切除之后的靶血管容易因血栓形成而闭塞，但有时不作血管内膜切除无法吻合血管，如何取舍有3条原则可借鉴。

Considerations in coronary artery bypass grafting: problems for discussion.]

Based on the experience in coronary artery bypass grafting (CABG), the author addresses some problems emerging from the practice of this surgery. The author proposes that (1) Coronary artery diseases with extensive myocardial infarction and chronic congestive heart failure may not be the absolute contraindications to CABG, and the decision for the operation should be derived from the presence of extensive stunned myocardium and a careful evaluation if the artery in the infarcted area can afford CABG. (2) To decide on the presence of stunned myocardium in the infarcted area, examination with positive electron tomography (PET) should be performed. (3) In recent years, CABG has been successfully performed in some cases of serious heart failure (with left ventricular eject fraction<30%) with the support of intraaortic balloon pump during and after operation. Intraaortic balloon pump has made off-pump CABG possible for patients that used to be denied this chance. (4) Similar to standard CABG procedures, off-pump CABG is by no means faultless and its indications at the time being have not yet been well defined. (5) Sequential anastomosis also has its disadvantages. When not a few large target arteries need anastomosis while graft vessels are not sufficient and serious atherosclerosis of the ascending aorta is present, this technique should been adequately applied. (6) Endarterectomy may give rise to thrombosis but in some cases it seems to be compulsory. The author suggests 3 indications for considering endarterectomy.