急性A型主动脉夹层手术同期行冠状动脉旁路移植术的手术指征及策略  

Surgical repair of acute type A aortic dissection with concomitant coronary artery bypass grafting ： surgical indicationand strategy

作　　者：郑军[1] 董松波[1] 李建荣[1] 李庆[1] 潘旭东[1] 许尚栋[1] 高峰[1] 刘永民[1] 朱俊明[1] 孙立忠[1] 

机构地区：[1]首都医科大学附属北京安贞医院心脏外科北京市大血管疾病诊疗中心,100029

出　　处：《中华胸心血管外科杂志》2016年第4期201-204,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的总结急性A型主动脉夹层手术同期行冠状动脉旁路移植术的手术指征及外科策略。方法2009年2月至2012年12月，355例急性A型主动脉夹层患者行手术治疗。21例（5．9％）同期完成冠状动脉旁路移植术，男14例，女7例；年龄（50．3±10．2）岁。冠状动脉夹层15例（Neff分型A型1例，B型2例，c型12例），合并冠心病5例，主动脉根部血肿1例。移植大隐静脉旁路血管23支，靶血管包括右冠状动脉和左前降支。弓部手术包括孙氏手术19例，半弓替换1例。结果体外循环（252．5±76．9）min，主动脉阻断（134．9±43．8）rain。围手术期死亡5例，分别为低心排血量综合征2例，多脏器功能衰竭2例，心室纤颤1例。围手术期死亡占23．8％（5／21），显著高于单一主动脉手术组（6．0％），P=0．002。术后截瘫及下肢轻瘫各1例。随访（37＋8±11．4）个月，无晚期心血管不良事件发生。结论急性A型主动脉夹层外科手术合并同期冠状动脉旁路移植术，显著增加围手术期死亡。同期行冠状动脉旁路移植术指征包括冠状动脉夹层（B型及C型）和由合并冠心病或冠状动脉受压导致的复搏后血流动力学不稳定。Objective To analyze the indication and strategy of concomitant coronary artery bypass grafting （CABG） during repair of acute type A aortic dissection. Methods Between February 2009 and December 2012, among 355 patients with acute type A aortic dissection repair, 21 （5.9%） underwent concomitant CABG using saphenous vein grafts. Mean age was（50.3 ＋ 10.2） years and 14 were males. Indications were coronary dissection in 15 patients（ Neri type A in 1, type B in 2, type C in 12） , preexisting coronary artery disease in 5, and coronary compression in 1. Twenty-three vein grafts were per- formed to bypass the right coronary and left anterior descending artery. Aortic repair included Sun＇ s procedure in 19 cases and hemiarch replacement in 1. Results The time of cardiopulmonary bypass and aortic clamp averaged（252.5 ~ 76.9） min and （ 134.9 ~ 43.8 ） minutes respectively. Five early deaths occurred due to ventrieular fibrillation in 1 patient, low cardiac output syndrome and multiorgan failure, each in 2. Mortality in CABG group was 23.8% （5/21） , while 6.0% （20/334） in isolated aortic repair group（ P =0. 002）. Paraplegia and paraparesis occurred, each in one patient. No late cardiovascular events oc- curred at （37.8 ±11.4） months. Conelusion Surgical repair for acute type A aortic dissection with concomitant CABG was associated with higher perioperative mortality. During acute type A aortic dissection repair, concomitant CABG is indicated in patients with type B or C dissected coronary arteries, and hemodynamic compromise due to preexisting coronary artery disease or coronary comoression.

关 键 词：主动脉夹层 冠状动脉旁路移植术 心脏外科手术 手术指征 

分 类 号：R654.2[医药卫生—外科学]