“分站式”杂交冠状动脉血运重建术治疗73例冠状动脉多支血管病变临床中期随访结果分析
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摘要
目的:观察"分站式"杂交冠状动脉血运重建术(HCR)治疗冠状动脉多支血管病变中期随访结果,评价"分站式"HCR的可行性、安全性和疗效。方法:入选2012-01至2014-06因冠状动脉多支血管病变在我院行择期"分站式"HCR的患者共73例,其中男性50例(68.5%),女性23例(31.5%),平均年龄(61.1±10.7)岁,所有患者均为包括左前降支在内的多支病变。"分站式"HCR要点为:全麻双腔气管插管,左前胸第4或第5肋间小切口,直视下获取左乳内动脉,心脏跳动下完成左乳内动脉和左前降支的吻合。在小切口冠状动脉旁路移植术(CABG)术后3~7天,在介入导管室先行冠状动脉造影,观察左乳内动脉-左前降支旁路血管情况,证实其通畅后对非左前降支病变行经皮冠状动脉介入治疗(PCI)并置入支架。患者术后每年进行超声心动图、X线胸片和心电图检查,如患者出现心肌缺血表现,则进行冠状动脉增强计算机断层摄影术(CTA)或冠状动脉造影检查等。结果:本组患者均顺利施行"分站式"HCR,全组无手术死亡。外科手术时间(152.9±43.8)min,处理冠状动脉(2.6±0.5)支,术后总引流量(558.6±441.3)ml,输红细胞(0.8±1.9)U,机械通气时间(10.5±13.0)h。小切口CABG与PCI间隔时间(5.3±2.9)d,冠状动脉置入支架(1.6±0.7)枚。术后随访期间,主要不良心脑血管事件(MACCE)发生5例(6.8%),其中死亡1例(1.4%),再发心肌缺血3例(4.1%),需要接受CABG/PCI者1例(1.4%,因支架再狭窄,再次置入支架)。结论:"分站式"HCR是一种安全,有效的手术方式,其围手术期和中期随访结果满意,"分站式"HCR适合于左前降支严重病变无法接受PCI而右冠状动脉主干和(或)回旋支等非左前降支病变可以进行PCI的冠状动脉多支病变患者。
Objective:To observe the midterm outcomes of "2-staged" hybrid coronary revascularization(HCR) for treating the patients with multi-vessel coronary artery disease(CAD) and to evaluate the feasibility,safety and efficacy of "2-staged" HCR.Methods:A total of 73 relevant patients received elective "2-staged" HCR in our hospital from 2012-01 to 2014-06 were studied.There were 50(68.5%) male and 23(31.5%) female at the age of(61.1±10.7) years and all patients had multi coronary artery lesions including left anterior descending(LAD) artery.The key points of "2-staged" HCR wereas follows:double-chamber intubation with general anesthesia,small incision between 4-5 ribs of left front thorax,take left internal mammary artery(LIMA) by direct view and make anastomosis of LIMA and LAD with heartbeat.At(3-5) days postminimally invasive direct coronary artery bypass(MIDCAB),coronary angiography(CAG) was conducted to confirm that LIMA-LAD bypass vessel was unobstructed;then percutaneous coronary intervention(PCI) was performed in non-LAD coronary artery for stent implantation.Post-operative echocardiography,chest X-ray and ECG were examined in each year;coronary CTA or CAG would be taken if the patients with myocardial ischemia.Results:All patients finished "2-staged" HCR smoothly and no operative death occurred.The average surgical time was(152.9±43.8) min and(2.6±0.5) coronary branches were treated,total post-operative drainage volume was(558.6±441.3) ml,red blood cell transfusion was(0.8±1.9) U,mechanical ventilation time was(10.5±13.0) h.The interval between MIDCAB and PCI was(5.3±2) days and(1.6±0.7) stents was implanted.During post-operative follow-up period,there 1(1.4%) patient died,3(4.1%) with recurrent myocardial ischemia,1(1.4%) with in-stent restenosis and received PCI again,4(5.5%) with MACCE.Conclusion:"2-staged" HCR is a safe and feasible operation with satisfactory peri-operative and mid-term outcomes;it is suitable for the patients with multi-vessel CAD including severe LAD lesions.
Objective:To observe the midterm outcomes of "2-staged" hybrid coronary revascularization(HCR) for treating the patients with multi-vessel coronary artery disease(CAD) and to evaluate the feasibility,safety and efficacy of "2-staged" HCR.Methods:A total of 73 relevant patients received elective "2-staged" HCR in our hospital from 2012-01 to 2014-06 were studied.There were 50(68.5%) male and 23(31.5%) female at the age of(61.1±10.7) years and all patients had multi coronary artery lesions including left anterior descending(LAD) artery.The key points of "2-staged" HCR wereas follows:double-chamber intubation with general anesthesia,small incision between 4-5 ribs of left front thorax,take left internal mammary artery(LIMA) by direct view and make anastomosis of LIMA and LAD with heartbeat.At(3-5) days postminimally invasive direct coronary artery bypass(MIDCAB),coronary angiography(CAG) was conducted to confirm that LIMA-LAD bypass vessel was unobstructed;then percutaneous coronary intervention(PCI) was performed in non-LAD coronary artery for stent implantation.Post-operative echocardiography,chest X-ray and ECG were examined in each year;coronary CTA or CAG would be taken if the patients with myocardial ischemia.Results:All patients finished "2-staged" HCR smoothly and no operative death occurred.The average surgical time was(152.9±43.8) min and(2.6±0.5) coronary branches were treated,total post-operative drainage volume was(558.6±441.3) ml,red blood cell transfusion was(0.8±1.9) U,mechanical ventilation time was(10.5±13.0) h.The interval between MIDCAB and PCI was(5.3±2) days and(1.6±0.7) stents was implanted.During post-operative follow-up period,there 1(1.4%) patient died,3(4.1%) with recurrent myocardial ischemia,1(1.4%) with in-stent restenosis and received PCI again,4(5.5%) with MACCE.Conclusion:"2-staged" HCR is a safe and feasible operation with satisfactory peri-operative and mid-term outcomes;it is suitable for the patients with multi-vessel CAD including severe LAD lesions.
引文
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[14]Shen L,Hu S,Wang H,et al.One-Stop Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention for the Treatment of Multivessel Coronary Artery Disease.J Am Coll Cardiol,2013,61:2525-2533.
[15]Zhu P,Zhou P,Sun Y,et al.Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary arterydisease:systematic review and meta-analysis.J Cardiothorac Surg,2015,10:63.
[16]Phan K,Wong S,Wang N,et al.Hybrid coronary revascularization versus coronary artery bypass surgery:systematic review and metaanalysis.Int J Cardiol,2015,179:484-488.
[17]Repossini A,Tespili M,Saino A,et al.Hybrid coronary revascularization in100 patients with multivessel coronary disease.Ann Thorac Surg,2014,98:574-581.
[2]Tatoulis J,Buxton BF,Fuller JA.Patencies of 2127 arterial to coronary conduits over 15 years.Ann Thorac Surg,2004,77:93-101.
[3]Weisz G,Leon MB,Jr Holmes DR,et al.Two-year outcomes after sirolimus-eluting stent implantation:results from the SirolimusEluting Stent in de Novo Native Coronary Lesions(SIRIUS)trial.J Am Coll Cardiol,2006,47:1350-1355.
[4]Jaffery Z,Kowalski M,Weaver WD,et al.A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery.Eur J Cardiothorac Surg,2007,31:691-697.
[5]Kim KB,Cho KR,Jeong DS.Midterm angiographic follow-up after off-pump coronary artery bypass:serial comparison using early,1-year,and 5-year postoperative angiograms.J Thorac Cardiovasc Surg,2008,135:300-307.
[6]Hannan EL,Racz M,Holmes DR,et al.Comparison of coronary artery stenting outcomes in the eras before and after the introduction of drugeluting stents.Circulation,2008,117:2071-2078.
[7]Byrne JG,Leacche M,Vaughan DE,et al.Hybrid cardiovascular procedures.JACC Cardiovasc Interv,2008,1:459-468.
[8]Verhaegh AJ,Accord RE,van Garsse L,et al.Hybrid coronary revascular ization as a safe,feasible,and viable alternative to conventional coronary arterybypass grafting:what is the current evidence?.Minim Invasive Surg,2013,2013:142616.
[9]Avgerinos DV,Charitakis K.Hybrid coronary revascularization:present and future.Hellenic J Cardiol,2015,56:193-196.
[10]Kang J,Song H,Lee SI,et al.Hybrid coronary revascularization using limited incisional full sternotomy coronary artery bypass surgery in multivessel disease:early results.Korean J Thorac Cardiovasc Surg,2014,47:106-110.
[11]Halkos ME,Walker PF,Vassiliades TA,et al.Clinical and angiographic results after hybrid coronary revascularization.Ann Thorac Surg,2014,97:484-490.
[12]Kramer RS,Quinn RD,Groom RC,et al.Same admission cardiac catheterization and cardiac surgery:is there an increased incidence of acute kidney injury?.Ann Thorac Surg,2010,90:1418-1424.
[13]杨航,凌云鹏,张鲁锋,等.分站式HCR技术治疗冠心病多支病变的可行性和安全性分析.中国循环杂志,2016,31:113-115.
[14]Shen L,Hu S,Wang H,et al.One-Stop Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention for the Treatment of Multivessel Coronary Artery Disease.J Am Coll Cardiol,2013,61:2525-2533.
[15]Zhu P,Zhou P,Sun Y,et al.Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary arterydisease:systematic review and meta-analysis.J Cardiothorac Surg,2015,10:63.
[16]Phan K,Wong S,Wang N,et al.Hybrid coronary revascularization versus coronary artery bypass surgery:systematic review and metaanalysis.Int J Cardiol,2015,179:484-488.
[17]Repossini A,Tespili M,Saino A,et al.Hybrid coronary revascularization in100 patients with multivessel coronary disease.Ann Thorac Surg,2014,98:574-581.