14例尿毒症透析患者冠脉搭桥手术临床分析

目的 探讨尿毒症透析患者合并冠心病的外科治疗方法及其治疗效果.方法 2009年1月至2014年12月东风汽车公司总医院心胸大血管外科对14例尿毒症透析合并冠心病患者实施冠状动脉旁路移植术(CABG).尿毒症透析患者中慢性肾功能衰竭13例,急性肾功能衰竭1例,合并室壁瘤1例;3例采用非体外循环心脏不停跳冠脉旁路移植术(OPCABG),11例采用体外循环下冠状动脉旁路移植术(CCABG),前降支均采用左乳内动脉(LIMA)作为桥血管,移植血管1~4支;同期行室壁瘤折叠术1例.比较术前、术后2周及术后一年患者的左心室舒张末期内径(LVEDD)、左室射血分数(LVEF)、NYHA心功能分级、血肌酐(Cre)、血尿素氮浓度(BUN)等指标,并评价手术治疗效果.结果 所有患者均手术成功,术后2例出现重症感染.14例患者术后随访1~3年,1例于术后27个月因重症感染死亡.未见其他并发症和死亡病例.术后2周,患者NYHA心功能分级为Ⅱ级(M=Ⅱ),LVEF、LVEDD、Cre、BUN等指标与术前比较差异均无统计学意义(P>0.05).术后1年,患者NYHA心功能分级为Ⅰ级(M=Ⅰ),较术后2周显著改善(P<0.05);LVEF为(55.74±7.84)%、LVEDD为(50.21±5.28) mm,较术前的(51.23±6.46)%和(56.73±6.33) mm均改善(P<0.05),而Cre、BUN等指标与术前比较差异均无统计学意义(P>0.05).结论 尿毒症透析患者合并冠心病行CABG风险较大,经过严格的术前评估、充分的冠状动脉再血管化,并加强围手术期管理,可取得满意疗效.

Clinical analysis of coronary artery bypass grafting in uremic patients during hemodialytic treatment

Objective To investigate the surgical treatment methods for uremic patients with coronary heart disease (CHD) on maintenance hemodialysis. Methods Fourteen patients with uremia and CHD on maintenance hemo-dialysis were operated with coronary artery bypass grafting (CABG) from January 2009 to December 2014 in Dongfeng General Hospital. Among the 14 patients, there were 13 patients of chronic renal failure, 1 patient of acute renal failure, with one patient complicating ventricular aneurysm. Three patients were treated with off-pump CABG (OPCAB), and 11 patients were treated with conventional CABG (CCABG), all using left internal mammary artery (LIMA) as grafts and with 1~4 graft vessels. One patients received placation for ventricular aneurysm. The left ventricular end-diastolic diame-ter (LVEDD), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) heart function classifica-tion, Serum creatinine (Cre) and blood urea nitrogen (BUN) were compared in all patients before operation, 2 weeks af-ter operation and 1 year after operation. The curative effects of surgical treatment were evaluated. Results All the 14 patients were successfully operated, and 2 patients obtained severe postoperative infection after operation. During the fol-low-up of 1~3 years, one patient died of severe infection 27 months after operation, and the rest all developed well. Two weeks after operation, NYHA heart function classification was Ⅱ (M=Ⅱ), and the levels of LVEF, LVEDD, Cre, BUN showed no significant difference compared with the levels before operation (P≥0.05). One year after operation, NYHA heart function classification was Ⅰ (M=Ⅰ), which were significantly improved than that of two weeks after operation. LVEF and LVEDD one year after operation were significantly improved compared with those before opera-tion (55.74±7.84)%vs (51.23±6.46)%, (50.21±5.28) mm vs (56.73±6.33) mm, P<0.05], while Cre and BUN showed no significant difference between one year after operation and before operation (P≥0.05). Conclusion There is a high risk for patients with uremia and CHD on maintenance hemodialysis to accept CABG. Rigorous preoperative evaluation, adequate coronary revascularization and perioperative period management should be performed to achieve a satisfactory efficacy.