急诊冠状动脉搭桥救治急性冠状动脉综合征及中期随访  

Emergency coronary artery bypass grafting for acute coronary syndrome:mid-term follow-up results

作　　者：肖苍松[1] 王嵘[1] 李伯君[1] 吴扬[1] 王刚[1] 任崇雷[1] 叶卫华[1] 盛炜[1] 李佳春[1] 王加利[1] 陈婷婷[1] 周琪[1] 张涛[1] 马兰[1] 高长青[1] 

机构地区：[1]全军心脏外科研究所//解放军总医院心血管外科,北京100853

出　　处：《南方医科大学学报》2014年第5期679-682,共4页Journal of Southern Medical University

基　　金：国家高技术研究发展计划"863"重大项目(2006AA02A104)~~

摘　　要：目的总结急诊冠状动脉旁路移植手术(ECABG)治疗急性冠脉综合征的经验及中期随访结果。方法 ECABG共45例。手术指征包括急性心梗(AMI)后心源性休克(5例)、急性左心衰(6例)及药物难以控制的心绞痛(34例)。20例AMI1周内手术,术前使用主动脉气囊反搏(IABP)18例。均为三支血管病变,左主干病变15例。两次以上心肌梗死10例,慢性肾功能不全6例,其中2例须血液透析。全部在体外循环(CPB)心脏停跳下手术。左乳内动脉(LIMA)与前降支(LAD)吻合,大隐静脉(GSV)与其它靶血管吻合。采用顺灌加静脉桥灌冷血停跳液或HTK液保护心肌。CPB时间104.2±29.7 min,阻断升主动脉69.0±21.3min。左乳内动脉(LIMA)使用率100%,平均搭桥2.9±0.6支。结果痊愈出院41例,住院死亡4例(8.9%),其中与心脏相关死亡1例(2.2%)。术前放置IABP者除1例死于MOSF外,余者术后25.5±9.7 h停用IABP。随访到38例,随访率92.7%,随访时间平均37.3±16.7月,随访期间死亡2例,生存率94.7%。心功能(NYHA)Ⅰ级和Ⅱ级共35例(92.1%),心血管事件免除率90.5%。随访超声心动图,左室前后径(43.4±5.4 mm)较术前(48.5±5.5 mm)缩小(P<0.05);左室射血分数(LVEF)(55.7%±8.9%)与术前(43.5%±9.6%)显著改善(P<0.05)。冠脉CTA评价LIMA桥血管通畅率为95.8%,GSV通畅率为90.5%。结论尽管ECABG风险高,但如果手术指征和时机选择得当,围术期处理完善,心脏相关死亡率虽有所增加,但近中期生存率、心血管事件免除率和心功能等结果良好。Objective To summarize the experience with emergency coronary artery bypass grafting （ECABG） for management of acute coronary syndrome and analyze the mid-term follow-up results. Methods Forty-five ECABG surgeries were performed in 34 male and 11 female patients （aged 65.6＆#177;5.8 years） for cardiogenic shock （5 cases）, acute heart failure （6 cases） and refractory unstable angina （34 cases）. Twenty patients received the operation within one week after acute myocardial infarction （AMI） and 18 were preoperatively supported by intra-aortic balloon pumping （IABP）. All patients had triple-vessel disease and 15 had left main stenosis. Ten patients experienced two myocardial infarctions and 6 had chronic renal dysfunction including two requiring hemodialysis. On-pump operations were performed in all cases with a mean CPB time of 104.2 ＆#177; 29.7 min and cross clamping time of 69.0 ＆#177; 21.3 min. Cold blood or HTK cardioplegia was used for myocardial protection. The left internal mammary artery （LIMA） was routinely anastomosed to the left anterior descending artery （LAD）, and the great saphenous vein （GSV） to other target vessels. The mean number of grafts was 2.9＆#177;0.6. Results Forty-one patients were cured and discharged and 4 patients died with an in-hospital mortality of 8.9%, including one associated with cardiac event （2.2%）. IABP was weaned off within 28.5 ＆#177; 10.6 h after surgery except for one patient who died of multiple organ and system failure （MOSF）. Thirty-eight patients （92.7%） were followed up for a mean of 37.3 ＆#177; 16.7 months, during which 2 patients died with a mid-term survival rate of 94.7%. Thirty-five （92.1%） patients had New York Heart Association （NYHA） class I and II. The freedom from cardiac event was 90.5%. Follow-up echocardiography showed significantly improved left ventricular dimension and ejection fraction in these cases （P＆lt;0.05）, and graft patency was 95.8%for the LIMA and 90.5%for the GSV. Conc

关 键 词：急诊冠状动脉旁路移植术 急性冠脉综合征 心源性休克 心力衰竭 随访 

分 类 号：R541.4[医药卫生—心血管疾病]