急性心肌梗死外科治疗的临床效果与手术时机探讨

目的探讨急性心肌梗死（AMI）患者行冠状动脉旁路移植术（cABG）的临床效果和手术时机。方法回顾性分析2007年1月至2011年2月青岛大学医学院附属青岛市市立医院133例AMI患者于发病30d内行CABG治疗的临床资料和结果，其中男104例，女29例；年龄46～84岁（67．12±8．90岁）；急诊／紧迫性手术39例，心肌肌钙蛋白I（cTnI）转归正常后行cABG94例。观察AMI后手术时间、手术死亡率、移植血管数、使用主动脉内球囊反搏（IABP）以及并发症发生情况等；采用免疫双抗体夹心法检测术前、术后cTnI的变化和持续时间。结果移植血管1～5支（2．72±1．06支），AMI后手术时间4h～29d（10．56±7．05d），围术期死亡14例，死亡原因主要为低心排血量、多器官功能衰竭和肾功能衰竭等，总死亡率10．53％（14／133）。行急诊／紧迫性手术患者的手术死亡率高于cTnI正常后手术患者（30．77％VS．2．13％，P=0．000）；使用IABP（58．97％VS．1．06％，P=0．000）、心律失常、低心排血量、多器官功能衰竭发生率、呼吸机辅助呼吸时间和住Icu时间均大于或长于cTnI正常后手术患者（P〈0．05）。随访115例，随访时间1～46个月（23．50±12．20个月），失访4例；l例急诊／紧迫性手术患者于术后2年死于脑血管意外；cTnI正常后手术患者在随访期间无晚期死亡和心血管事件发生。结论AMI合并心源性休克、机械并发症或左主干严重病变患者应紧急手术；对血流动力学相对稳定的AMI患者cTnI正常后尽早手术，可明显提高AMI的治疗效果，cABG对AMI患者是有效和可行的治疗方法。

Research on the Clinical Results and Operational Time of Surgical Treatment for Patients with Acute Myocardial Infarction

Objective To assess the clinical results and operational time of coronary artery bypass grafting （CABG） for patients with acute myocardial infarction （AMI）. Methods We retrospectively analyzed the clinical data and outcome of 133 patients who underwent CABG within 30 clays after the onset of AMI from January 2007 to Februray 2011 in Qingdao Municipal Hospital. Among them, there were 104 males and 29 females aged between 46 and 84 years （67.12±8.90 years）. Urgency or emergency surgeries were performed on 39 patients, and 94 patients underwent CABG after cardiac troponin I （cTnI） went back to normal. Operation time, operational mortality, number of graft vessels, intra-aortic balloon pump （IABP） use, and combined surgeries were observed after operation. The cTnI changes and duration were tested in all cases before and after operation by double antibody sandwitch method. Results The number of graft vessels ranged from 1 to 5, averaging at 2. 72 ± 1. 06; The operation time after myocardial infarction ranged from 4 hours to 29 days, averaging at 10.56±7.05 days; And 14 patients died in hospital with a total mortality of 10. 53% （14/133）. Reasons of the deaths included low cardiac output syndrome, multiple organ failure and renal failure, etc. Mortality in patients undergoing urgency or emergency surgery was higher than that in patients undergoing CABG after cTnI went back to normal （30.77%vs. 2.13%, P=0. 000）. Compared with urgency or emergency cases, the use rate of IABP （58. 97% vs. 1. 060/00, P〈0. 000）, the rates of arrhythmia, low cardiac output, and multiple organ failure, mechanical ventilation time, and ICU stay in patients undergoing CABG after cTnI went back to normal were all smaller or shorter. A total of 115 patients were followed up with a period ranged from 1 to 46 months （23. 50±12. 20 months） with 4 missing. One patient having undergone emergency or urgency surgery died from cerebrovascular accident two years after operation. No late death or cardiovascular event occurred to patients who underwent the surgery after cTnI went back to normal. Conclusion Emergency or urgencyCABG should be carried out for patients with AMI accompanied by cardiogenic shock, mechanical complications or severe left main lesion. For patients with stable hemodynamic indexes, operation should be performed right after cTnI goes back to normal. CABG is a feasible and effective surgery for patients with AMI.