急性心肌梗死行急诊冠状动脉旁路移植术的手术时机与方式探讨

目的总结对急性心肌梗死（AMI）患者行急诊冠状动脉旁路移植术（E-CABG）的治疗效果,探讨手术时机和手术方法。方法回顾性分析孙逸仙心血管医院自1999年6月至2009年12月行E-CABG患者21例的临床资料,其中男14例,女7例;年龄24~81岁。AMI发生时间〈6 h 6例,6 h~3 d 7例,3~30 d 8例,包括心源性休克8例,室间隔破裂穿孔合并心源性休克1例,经皮冠状动脉球囊扩张术致冠状动脉破裂2例,不稳定型心绞痛、频发性室性心律失常8例,发生心室颤动、心脏停搏1例,心脏外伤术后1例,10例安放主动脉内球囊反搏（IABP）;采用体外循环CABG（on-pump）12例,非体外循环CABG（off-pump）5例,体外循环下心脏不停跳CABG（on-pump-beating）4例。结果早期死亡5例,病死率23.8%,E-CABG的病死率明显高于CABG总体病死率（23.8%vs.3.1%,χ2=21.184,P〈0.05）,其中AMI发生时间〈6 h者死亡2例,6 h~3 d者死亡2例,3~30 d者死亡1例,病死率分别为33.3%、28.6%和12.5%。3 d后的病死率明显较低（P〈0.05）。死亡的主要原因为低心排血量综合征、围术期心肌梗死（MI）和败血症,其中行off-pump和on-pump-beating手术患者中各死亡1例。出院16例,随访6个月~10年,晚期死亡6例,5例死于心力衰竭合并肺部感染,1例死于非心脏因素;生存10例,其中5例生活质量较差。结论 AMI发生3 d以内行E-CABG病死率高,如果通过IABP等支持治疗,待AMI发生3 d后手术,合理采用off-pump和on-pump-beating手术方法,将有利于提高手术的成功率。

The Optimal Timing and Operation Pattern of Emergent Coronary Artery Bypass Grafting after Acute Myocardial Infarction

Objective To summarize the efficacy and clinical experiences of emergent coronary artery bypass grafting（E-CABG） in patients with acute myocardial infarction（AMI） and to discuss the operative opportunity and procedures.Methods We retrospectively analyzed the clinical data of 21 patients with AMI undergoing E-CABG in Sun Yat-sen Cardiovascular Disease Hospital between June 1999 and December 2009.Among the patients,there were 14 males and 7 females with their age ranged from 24 to 81 years（63.9±12.4 years）.Six patients were operated within 6 hours after the onset of AMI,7 patients were operated from 6 hours to 3 days after the onset of AMI,and 8 patients were operated from 3 days to 30 days after the onset of AMI.Eight patients had the cardiogenic shock after AMI,one had rupture of ventricular septum and cardiogenic shock,two had rupture of coronary artery after percutaneous transluminal coronary angioplasty,eight had unstable angina and frequent ventricular arrhythmia,one had ventricular fibrillation and cardiac arrest,and one had cardiac trauma.Ten patients were treated with intra-aortic balloon pump（IABP）.Conventional CABG was performed for 12 patients,off-pump CABG for 5 patients,and on-pump-beating CABG for 4 patients.Results Five patients died after E-CABG with a mortality of 23.8% which was obviously higher than the overall CABG mortality（23.8% vs.3.1%,χ2=21.184,P0.05）.There were respectively 2,2 and 1 deaths with a mortality of 33.3%,28.6% and 12.5% respectively for operations within 6 hours,6 hours to 3 days and 3 to 30 days after the onset of AMI.The mortality of those patients who were operated within 3 days after AMI was obviously lower（P0.05）.The primary causes of death were low cardiac output syndrome,perioperative acute myocardial infarction after CABG and sapremia.There was one death each for patients operated with off-pump and on-pump-beating CABG.Sixteeen patients were discharged from the hospital.The follow-up was from 6 months to 10 years.There were 6 late deaths among which 5 died of cardiac failure accompanied by pulmonary infection,one died of non-cardiac factor.Ten patients survived at present,and the quality of life among 5 patients was unsatisfactory.Conclusion The mortality of E-CABG is obviously higher in patients operated within 3 days of AMI.With the support of IABP,if the operation can be carried out 3 days after the onset of AMI,the surgical success rate will be greatly improved by adopting proper off-pump and on-pump-beating procedures.