再次冠状动脉旁路移植术的临床应用  

Clinical Application of Re-do Coronary Artery Bypass Grafting

作　　者：陈鑫[1] 徐明[1] 石开虎[1] 蒋英硕[1] 汪黎明[1] 邱志兵[1] 肖立琼[1] 赵海鹏[1] 刘培生[1] 王睿[1] 郑林[1] 

机构地区：[1]南京医科大学附属南京第一医院南京市心血管病研究所心胸外科,南京210006

出　　处：《中国胸心血管外科临床杂志》2007年第6期407-410,共4页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

摘　　要：目的总结再次冠状动脉旁路移植术(CABG)治疗冠心病的临床经验和手术效果。方法2001年6月～2006年12月,对18例冠心病患者行再次CABG。术前心绞痛(CCS分级)级7例,级11例;冠状动脉造影显示:16例均有原移植静脉狭窄/闭塞,2例左乳内动脉(LIMA)-左前降支(LAD)桥狭窄/闭塞,6例自体冠状动脉出现新的病变。全组均经原胸骨正中切口径路手术,常规体外循环(CPB)下CABG15例,非体外循环冠状动脉旁路移植术(OPCAB)3例;同期行室壁瘤切除、左心室成形1例,二尖瓣成形术3例,主动脉瓣和二尖瓣双瓣膜置换联合右颈动脉内膜剥脱术1例。应用LIMA12例次、双侧IMA4例次、桡动脉3例次,其余为大隐静脉或小隐静脉。结果15例常规CABG患者主动脉阻断时间45～112min(57±26min),CPB时间66～140min(78±24min)。再次CABG每例移植血管1～5支,平均每例远端吻合口3.11个。手术结束用血流仪测定移植血管血流量均满意(血流量27.0±12.5ml/min),搏动指数均<4.2。手术后因低心排血量需主动脉内球囊反搏辅助1例,术后6d发生肾功能衰竭死亡。其余17例患者术后呼吸机辅助呼吸时间5～15h,心绞痛均消失,围手术期无心肌梗死发生,胸腔引流量为290～1040ml,顺利恢复,均出院。术后随访17例,随访时间6.0个月～4.5年,均无心绞痛发作,4例复查冠状动脉造影,显示移植血管均通畅。结论再次CABG难度大于首次CABG,但只要手术中能正确找到靶血管,移植血管的血流可靠、完全再血管化和有良好的围术期管理,再次CABG可达到与首次手术同样的效果。Objective To summarize and analyze the clinical experience and surgical results of re-do coronary artery bypass grafting （Re-CABG） for reconvert coronary artery disease. Methods Eighteen patients who underwent Re-CABG in this hospital between June 2001 and December 2006 were analyzed. There were 15 males and 3 females aged from 65 to 78 years old. Seven patients were in class Ⅲ angina（CCS） and 11 patients were in class Ⅳ. Coronary artery angiography showed stenosis or occlusion of great saphenous vein grafts in 16 patients, occlusion of left internal mammary artery（LIMA） grafts in 2 patients and new significant stenosis of the native coronary artery in 6 patients. All Re-CABG were done through re-sternotomy. Fifteen patients underwent cardiopulmonary bypass （CPB） for their Re-CABG and 3 patients underwent off-pump Re-CABG. The concomitant procedures included left ventricular aneurysmectomy in 1 patient, mitral valve repair in 3 patients, combined aortic and mitral valve replacement and carotid endarterectomy in 1 patient. Bilateral IMA were used in 4 patients, LIMA in 12 patients, radial artery in 3 patients, and the rest of the grafts consisted of great and lesser saphenous vein. Results In onpump Re-CABG, the aortic cross clamp time was 57±26min （range 45 to 112 min）, the CPB time was 78±24min （range 66 to 140 min）. The mean number of distal anastomosis per patient was 3. 11（range 1 to 5）. Intraoperative flow study of the grafts by Medi-Stim Butterfly showed a mean flow rate of 27.0±12.5 ml/min with pulsatility index （ PI）less than 4.2. Intra-aortic balloon pump （IABP） was used in 1 patient who underwent concomitant aortic and mitral valve replacement and carotid endarterectomy. Post-operatively this patient developed renal failure and expired 6 days later. There was no residual angina and peri-operative myocardial infarction in the remain 17 patients. The post-operatively mechanical ventilation time varied from 5 to 15 hours, chest drainage varied from 290 to 1 040ml.

关 键 词：冠状动脉粥样硬化性心脏病 再次冠状动脉旁路移植术 移植血管 

分 类 号：R654.2[医药卫生—外科学]