体外循环不停跳冠状动脉搭桥在心功能低下患者手术中的应用

目的:探讨危重冠心病患者进行体外循环下,心脏不停跳冠状动脉搭桥术的可行性。方法:2008年1月至2011年1月间1 030例冠状动脉搭桥术(CABG)中,选择64例(6.2%)进行体外循环下心脏不停跳CABG的患者进行回顾性分析。其中,常规手术组36例,19例为急诊行CABG,9例为非体外不停跳CABG紧急改为体外下不停跳CABG。术前观察其一般情况、心肌缺血情况、左心室射血分数(LVEF)及是否患有3支冠状动脉病变、左主干病变、术前是否放置主动脉内球囊反搏(IABP)等。结果:64例患者术前LVEF为(32±5)%,均进行了体外循环下不停跳CABG。平均体外循环(CPB)时间为(72±14)min,移植桥血管平均数为(2.8±0.7)根,其中53例(82.8%)使用了左乳内动脉。住院期间死亡3例(4.7%),均为紧急建立体外循环者,原因为严重心律失常或心力衰竭。其余患者无围术期心肌梗死发生,5例患者(7.8%)发生肾功能不全,3例(4.7%)发生肺部感染。平均住院时间为(14±6)d。61例患者全部随访,平均随访时间为(12±2)个月。随访期内1例患者死于严重心律失常,其余患者无心绞痛主诉或心衰表现。术后1年行超声心动图检查,平均LVEF为(38±8)%。结论:对于危重冠心病患者,CABG有较高的风险。体外循环下心脏不停跳CABG,是一种更安全可靠的方法。

On-pump beating heart coronary artery bypass grafting for high risk CAD patients

Objective:Cardiopulmonary bypass(CPB) with aortic cross-clamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization.Therefore,very high-risk patients presenting with acute coronary syndrome,unstable angina,onset of cardiac decompensation and requiring multiple myocardial revascularization,can have a poor outcome.The on-pump beating heart technique can reduce the mortality and the morbidity in such a selected group of patients and this report describes our clinical experience.Methods: Out of 1030 patients operated for CABG from January 2008 to January 2011,64(6.2%) selected high-risk patients suffering from life threatening coronary syndrome and requiring multiple myocardial revascularization,underwent on-pump beating heart surgery.The mean pre-operative left ventricle ejection fraction(LVEF) was(32 ± 5)%.The majority of them(88%) suffered of tri-vessel coronary disease and 33(52%) had a left main stump disease.Seven patients(11%) were on the state of severe cardiac failure and received a pre-operative intra-aortic balloon pump.Results: All patients underwent on-pump-beating heart coronary revascularization.The mean number of graft/patient was 2.8 ± 0.7 and the internal mammary artery was used in 53patients(82.8%).The mean CPB time was(72 ± 14) minutes.Three patients died during the recovery stay in the intensive care unit,and there was no postoperative myocardial infarctionamong the survivors.Transitorily renal failure occoured in five patients and another 3 patients developed pulmonary infection.The mean hospital stay was(14 ± 6) days.The follow-up was complete for all 61 patients survived at surgery and the mean follow-up time was(12 ± 2) months.One patient died during the follow-up period for cardiac arrest.One year after surgery they all took a standard trans-thoracic echocardiogram showing a mean LVEF rate of(38 ±8)%.Conclusion: Standard coronary surgery has higher mortality and morbidity for the patients with high risk.The on-pump beating heart myocardial revascularization seems to be a valid alternative for them.