左胸微创小切口多支冠状动脉旁路移植术的应用  

Minimally invasive multi-vessel coronary artery bypass grafting through a small incision in left chest

作　　者：王春[1] 谷天祥[1] 张玉海[1] 师恩祎[1] 喻磊[1] 房勤[1] 

机构地区：[1]中国医科大学附属第一医院心脏外科,沈阳110001

出　　处：《中国胸心血管外科临床杂志》2017年第7期547-550,共4页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

摘　　要：目的研究左胸微创小切口多支冠状动脉旁路移植术(minimally invasive cardiac surgery for coronary artery bypass grafting,MICS CABG)的技术特点、临床效果以及近远期疗效,探讨MICS CABG的可行性及有效性。方法回顾性分析2012年4月至2014年12月中国医科大学附属第一医院心脏外科行MICS CABG11例患者的临床资料,患者均为男性,平均年龄62.7(47.0~73.0)岁,冠状动脉3支病变8例,2支病变3例。双腔气管插管,术中单肺通气。患者15°至30°右侧卧位。左前外第4肋间小切口(5~7 cm),切口的内2/3位于腋前线。切口窗内直视下于第3肋间开始获取LIMA,上至锁骨下静脉,下至超过第5肋间。通过剑下、第6肋2个辅助切口(各1 cm)安置Starfish和Octopus系统固定心尖、显露主动脉及靶血管,直视完成近端、远端吻合。吻合顺序:后降支-钝缘支(和/或对角支)-前降支。第6肋间留置胸腔引流管、剑下切口留置心包引流管。结果手术时间4.1(3.2~5.8)h,其中体外循环辅助5例,辅助时间21.0(17.0~38.0)min。吻合口数目2.8(2.0~3.0)个,左乳内动脉(LIMA)获取11例,使用率100.0%。平均引流量425.0(180.0~750.0)ml,呼吸机辅助时间7.8(4.3~11.2)h,住ICU时间15.9(11.0~38.0)h,住院时间7.7(5.0~14.0)d。全组无手术死亡,围术期心肌梗死1例,阵发性心房颤动1例,无手术中转正中开胸,无再次开胸、无出血并发症。平均随访19.4(12.0~36.0)个月,无心绞痛发作,无再次入院及再次介入或外科手术。术后1年行冠状动脉CT检查,LIMA全部通畅,动脉桥通畅率100.0%;静脉桥吻合口闭塞4个,静脉桥通畅率80.0%。结论 MICS CABG具有恢复快、美容效果好、切口感染率低等优点。与机器人手术相比,手术费用低,与常规手术相同。MICS CABG手术在国内外均为新开展的手术,一定要在严格的医生培训、病例选择的基础上,慎重开展,遵循学习曲线规律。MICS CABG手术近中期效果良好,而远期效果的评价,有待�Objective To study the technical characteristics, clinical outcomes and short- and long-term results of minimally invasive multi-vessel coronary artery bypass grafting and to evaluate the feasibility and efficacy. Methods From April 2012 to December 2014, minimally invasive cardiac surgery for coronary artery bypass grafting （MICS CABG） in 11 patients was performed in the First Hospital of China Medical University. All patients were males and the average age was 62.7 （47.0-73.0） years. Eight patients with 3-vessel lesions and 3 patients with 2-vessel lesions. General anesthesia was performed with double lumen endotracheal intubation and single lung ventilation. The patient was positioned 15 degrees to 30 degrees in right lateral position. The left anterior and lateral incision was made at the fourth/fifth intercostal space with the length of 5-7 cm and 2/3 part of the incision located in the medial side of anterior axiUary line. Left internal thoracic artery （LIMA） was harvested from the third intercostal space up to the subclavian vein and down to more than fifth intercostal space through the surgical window. Through the xiphoid and sixth intercostal space incision with the length of 1 cm, the Starfish and Octopus system were placed to fix apex and ascending aorta and target vessels were exposed. The proximal and distal anastomosis was done under the direct vision. The sequence of distal anastomosis was from posterior descending branch to obtuse/diagonal branch and left anterior descending branch. The chest and pericardial draining tubes were placed through the xiphoid and sixth intercostal space incision. Results The mean operation time was 4.1 （3.2-5.8） h. Five patients underwent the operation with the assist of cardiopulmonary bypass and the mean assisting time was 21.0 （17.0-38.0） min. The mean number of distal anastomosis was 2.8 （2.0-3.0） and LIMA was harvested and grafted in all 11 patients. The mean drainage was 425.0 （180.0-750.0） ml, mean ventilation time 7.8 （4.3-11.2）

关 键 词：冠心病 微创 冠状动脉旁路移植术 多支病变 

分 类 号：R654.2[医药卫生—外科学]