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胸骨下段小切口非体外循环行冠状动脉多支病变完全再血管化的临床研究

Complete revascularization for multi-vessel coronary diseases through lower ministernotomy on beating heart off-pump surgery

摘要:

目的 探讨使用胸骨下段小切口完成非体外循环冠状动脉多支病变完全再血管化的手术方法及临床经验.方法 回顾性分析2015年1月至2016年5月79例于首都医科大学附属北京友谊医院心血管中心心外科接受冠状动脉旁路移植术(CABG)的冠状动脉多支病变患者的临床资料.男性62例,女性17例,平均年龄(65±9)岁.患者行胸骨下段小切口非体外循环CABG.桥血管使用左胸廓内动脉、桡动脉和大隐静脉.记录术后呼吸机辅助时间、ICU停留时间、术后24 h胸腔纵隔引流量.使用超声心动图评价患者术后心功能.手术前后心脏指标的比较采用配对t检验.结果79例患者中,2例患者因血流动力学不稳定术中改为心肺转流下心脏不停跳CABG,未延长切口;2例患者因暴露主动脉根部困难,改为常规切口;其余患者均顺利完成手术,桥血管2~4支,平均(2.8±0.6)支.近端1个吻合口75例,2个吻合口4例.桥血管远端分别吻合至前降支79 支,后降支60 支,钝缘支及中间支56 支,对角支25支.使用左胸廓内动脉78例,桡动脉68例,大隐静脉74例.术后平均呼吸机辅助时间(19.0±2.2)h,平均ICU停留时间(60±20)h.术后发生围手术期心肌梗死1例,临时放置主动脉内球囊反搏支持;切口下端感染1例.全组无手术死亡.术后超声心动图左心室舒张末期内径和左心室收缩末期内径与术前相比差异无统计学意义,射血分数较术前升高(66.5%±1.6%比61.2%±2.3%,t=4.30,P=0.00).结论 经胸骨下段小切口可以完成冠状动脉各分支的血运重建,近期效果满意.手术操作具有一定难度,充分术前评估是手术成功的关键.

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abstracts:

Objective To discuss a novel method of complete revascularization for multi-vessel coronary diseases on beating heart off-pump surgery through lower ministernotomy.Methods Clinical data of 79 patients underwent ministernotomy off-pump coronary artery bypass from January 2015 to May 2016 at Department of Cardiac Surgery, Heart Center, Beijing Friendship Hospital, Capital Medical University were analyzed retrospectively. There were 62 male and 17 female patients, with an average age of (65±9) years. All the patients were multi-vessel coronary diseases and planned to receive coronary artery bypass grafting. Left internal mammary artery, radial artery and great saphenous veins were harvested and prepared, respectively. The perioperative clinical data was observed and collected. Postoperative ventilator-assisted time, intensive care time, and 24-hour thoracic mediastinal drainage volume were recorded. Postoperative cardiac function was evaluated by echocardiography. The data were compared between pre-and post-operative using paired t test.Results Cardiopulmonary bypass was used in 2 patients during operation because of unstable hemodynamic status, but the incision was not needed to extend for those 2 patients. The lower ministernotomy was converted to traditional full sternotomy in 2 patients due to limited space for proximal anastomosis. In total, 79 patients had an average of (2.8±0.6) grafts. One proximal anastomosis was performed in 75 patients and 2 anastomoses in 4 patients. Distal target vessels consisted of left descending arteries for 79 patients, posterior descending artery for 60 patients, obtuse marginal branch and intermediate branch for 56 patients and diagonal branches for 25 patients, respectively. Average postoperative ventilation time was (19.0±2.2) hours and ICU stay was (60±20) hours. One patient developed postoperative myocardial infarction and needed temporary intra-aortic balloon pump support. One patient was subjected to incision infection. None of patient died in this study. There were no significant differences in left ventricular end-diastolic diameter and left ventricular end-systolic diameter between pre-and post-operative. The post-operative ejection fraction was significantly higher than that pre-operative (66.5%±1.6% vs. 61.2%±2.3%, t=4.30, P=0.00). Conclusion With lower ministernotomy, the various sites of distal target vessels could be reached and complete revascularization could be achieved for selected patients with triple vessel diseases, although the procedure is technical demanding.

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作者: 肖志斌 [1] 张永 [1] 郭建中 [1] 李莹莹 [1] 张雅娉 [1]
第一作者: 肖志斌
期刊: 《中华外科杂志》2017年55卷6期 455-458页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2017.06.011
发布时间: 2017-06-30
基金项目:
北京市医院管理局临床技术创新项目(XM201312)Beijing Municipal Administration of Hospital Clinical Technical Innovation Program
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