室壁瘤切除左心室几何重建连续42例经验

目的总结42例室壁瘤切除左心室成形加冠状动脉搭桥无死亡的经验. 方法 42例左心室室壁瘤患者,男41例、女1例,平均年龄(55.5±2.4)岁(40～68岁).38例有不稳定性心绞痛,术前合并严重室性心律失常10例,其中有心室颤动病史2例,反复发作室性心动过速8例,合并高血压病26例,糖尿病3例,重症慢性阻塞性肺疾病1例;心功能(NYHA)Ⅲ级32例,Ⅳ级10例;合并二尖瓣轻至中度关闭不全6例.42例经左心室造影和手术证实为解剖性室壁瘤,位于前间壁41例、下壁1例.左心室射血分数(LVEF)平均41%(17%～63%),其中LVEF<40%29例.33例采用Jatene术式,8例Dor术式, 1例Cooley术式,其中10例在心脏跳动下完成左心室成形术.左主干病变7例,3支病变30例,2支病变6例,单纯左前降支病变5例.全部患者同期行冠状动脉搭桥术,乳内动脉使用率100%.术中证实左心室内附壁血栓21例.平均体外循环时间(135±11)min,阻断升主动脉(78±10)min. 结果术后平均住院天数(13.1±1.2)d,住ICU(2.8±0.6)d.使用主动脉内气囊反搏7例(17%),术后发生顽固性室性心动过速1例,胸骨哆开1例,术后早期渗血、二次开胸止血1例.术后左心室前后径、舒张末期和收缩末期容量较术前明显缩小(P<0.05),LVEF有增加趋势(P>0.05).围手术期无死亡,均痊愈出院.术后随访10个月至4年,无死亡. 结论室壁瘤切除左心室几何重建术同期行冠状动脉旁路术,除改善心功能外,可消除室性心动过速,手术安全、可靠,效果良好.

Left ventricular aneurysmectomy with geometric reconstruction

OBJECTIVE: To summarize the experience in performing left ventricular aneurysmectomy (LVA) with geometric reconstruction and concomitant coronary artery bypass grafting (CABG) without mortality. METHODS: Forty-two patients underwent LVA with geometric reconstruction and concomitant CABG. Forty-one patients were male, one was female with mean age of (55.5 +/- 2.4) years (40 - 68 years). Preoperative cardiac function was NYHA class III in 32 patients and class IV in 10. Thirty-eight patients had unstable angina pectoris and 10 had the history of severe ventricular arrythmia. Eight patients had ventricular tachycardia. Preoperative left ventricular ejection fraction (LVEF) was 41% (17% - 63%), LVEF was less than 40% in 29 cases. Left ventricular anatomic aneurysms were confirmed by ventriculography. Thirty-three cases underwent Jatene technique; 8 cases, Dor technique, and 1 case, Cooley technique. Mural thrombi were found in 21 patients and were completely removed. CABG was concomitantly performed in all patients. All of the left anterior descending artery was bypassed with left internal mammary artery and the other target vessels with saphenous vein. Mean cardiopulmonary bypass time was (135 +/- 11) minutes and aortic clamping time was (78 +/- 10) minutes. RESULTS: No hospital mortality occurred and all patients were discharged. Postoperative reexploration for bleeding in 1 patient. The diameter and end systolic and diastolic volume of left ventricle were significantly decreased to nearly normal after operation. Operative ejection fraction had a tendency to increase but without significance (P > 0.05). CONCLUSIONS: LVA with geometric reconstruction and concomitant CABG could not only improve heart function but also eliminate ventricular arrythmia. The clinical result was excellent.