冠心病合并左室室壁瘤行冠状动脉旁路移植术未同期行左心室成形术的疗效分析

目的 分析冠心病合并左室室壁瘤形成患者仅行冠状动脉旁路移植术（CABG）但未同期行左心室成形术的疗效。 方法 2008年1月至2012年12月武汉亚洲心脏病医院收治冠心病合并室壁瘤患者共105例，术中探查发现室壁瘤边界欠清或活动欠佳或无明显矛盾运动而未处理室壁瘤患者共74例，其中男59例，女15例；年龄 （60.96±9.09） 岁。冠状动脉造影显示：单支血管病变5例，双支病变10例，3支病变45例，左主干＋3支病变14例。术中发现30例室壁瘤界限不清，29例心尖室壁变薄、室壁瘤不明显，15例室壁瘤未见明显的矛盾运动、心尖部质地较厚。所有患者均行冠状动脉旁路移植术。在体外循环下手术62例，非体外循环下手术12例。70例采用左乳内动脉吻合于左前降支，2例行左前降支内膜剥脱术。因二尖瓣中-重度反流行二尖瓣成形术3例，二尖瓣置换术2例；因合并主动脉瓣重度狭窄同期行主动脉瓣置换术1例。 结果 术后因恶性心律失常、缺血、缺氧性脑病死亡2例 （2.7%）；因低心排血量、围术期心肌梗死、恶性心律失常等行主动脉内球囊反搏 （IABP） 辅助6例。术后随访70例，随访时间24～60 （43±12） 个月。随访期间发现心室内血栓形成8例，其中5例服用华法林1年内血栓消失，无1例发生血栓脱落栓塞事件。超声心动图检查提示：室壁瘤消失18例 （25.7%）。出院时、术后6个月、1年射血分数较术前明显增高 （术后6个月与术前比较：44%±6% vs. 39%±5%），左心室舒张期末内径 ［术后6个月与术前比较：（54.37±6.28） mm vs. （59.24±6.24）mm］、左心室收缩期末内径与术前比较明显缩小 （P＜0.01）。但随着时间延长，左心室舒张期末内径、左心室收缩期末内径较出院时逐渐增大。 结论 对于合并室壁瘤的冠心病患者，根据术中探查实际情况未行左心室成形术仅行冠状动脉旁路移植术，术后射血分数、左心室舒张期末内径、左心室收缩期末内径均较术前明显改善，但术后心室扩大呈进行性发展。

Clinical Analysis of Patients with Coronary Artery Disease and Left Ventricular Aneurysm Undergoing Coronary Artery Bypass Grafting without Concomitant Surgical Ventricular Restoration

Objective To analyze clinical outcomes of coronary artery bypass grafting （CABG） without concomitantsurgical ventricular restoration （SVR） for patients with coronary artery disease （CHD） and left ventricular aneurysm （LVA）.Methods A total of 105 patients with CHD and LVA underwent surgical treatment in Wuhan Asia Heart Hospital from January 2008 to December 2012. Among them,74 patients were found to have no clear boundary LVA,poor wall motionor no obvious contradictory wall motion during surgical exploration,and didn’t received SVR,including 59 male and 15 female patients with their age of 60.96±9.09 years. Coronary angiography showed 5 patients with single-vessel disease,10 patients with double-vessel disease,45 patients with triple-vessel disease,and 14 patients with left main and triplevessel disease. Intraoperative findings showed no clear boundary LVA in 30 patients,apical thinning without obvious LVA in 29 patients,LVA without obvious contradictory wall motion but thickening of the apex in 15 patients. All the 74 patientsreceived CABG including 62 patients undergoing on-pump CABG and 12 patients undergoing off-pump CABG. Seventypatients received left internal mammary artery to left anterior descending anastomosis,and 2 patients received endarterectomyof the left anterior descending coronary artery. For moderate to severe mitral regurgitation,3 patients received concomitant mitral valvuloplasty,and 2 patients received concomitant mitral valve replacement. One patient received concomitant aortic valve replacement for severe aortic stenosis. Results Postoperatively,2 patients （2.7%） died of malignant arrhythmia and hypoxic ischemic encephalopathy respectively. Six patients received intra-aortic balloon pump （IABP） support for low cardiac output syndrome,perioperative myocardial infarction and malignant arrhythmias. Seventy patients were followed up after discharge for 24-60 （43±12） months. During follow-up,left ventricular thrombus was found in 8 patients,disapp-eared within 1 year after warfarin treatment in 5 patients,and no thromboembolic event happened. Echocardiogram showed that LVA disappeared in 18 patients （25.7%）. Ejection fraction （EF） at discharge,6 months and 1 years after discharge weresignificantly higher than preoperative EF （EF at 6 months after discharge versus preoperative EF：44%±6% vs. 39%±5%）.Left ventricular end-diastolic diameter （LVEDD,LVEDD at 6 months after discharge versus preoperative LVEDD：54.37±6.28 mm vs. 59.24±6.24 mm） and left ventricular end-systolic diameter （LVESD） were significantly reduced compared with preoperative values （P〈0.01）. But as time went by,LVEDD and LVESD gradually became larger than those values at discharge. Conclusion For patients with CHD and LVA,CABG without SVR,which is decided according to actual surgical exploration,can significantly improve postoperative EF,LVEDD and LVESD,but left ventricular enlargement may happen progressively after discharge.