小切口直视应用双侧乳内动脉冠状动脉旁路移植术与不停跳冠状动脉旁路移植术的对比研究
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摘要
目的:总结及评估左前外侧小切口直视下应用双侧乳内动脉行多支冠状动脉(冠脉)旁路移植术(CABG)的早期经验及临床价值。方法:2015-05至2017-01连续入选在我院接受经左前外侧小切口获取双侧乳内动脉行多支CABG的患者38例(小切口组)。同一时期由同一术者完成的常规正中切口择期非体外循环冠脉旁路移植术(OPCAB)共236例患者作为正中切口组。比较两组患者围手术期资料以及并发症发生情况。结果:小切口组经左前外侧小切口直视下获取双侧乳内动脉成功率94.7%(36/38),获取右乳内动脉平均时间(42.3±10.5)min,获取左乳内动脉平均时间为(35.2±8.3)min,38例患者移植冠脉血管共78支,平均(2.05±0.31)支/例,无中转常规胸部正中切口CABG;与正中切口组比较,小切口组术后呼吸机使用时间[(8.9±3.8)h vs(23.6±15.9)h]、术后监护病房住院时间[(29.3±20.8)h vs(56.5±38.3)h]和住院时间[(11.3±3.2)d vs(15.7±4.2)d]均较短(P<0.05);围手术期主要不良心脑血管事件(死亡、心肌梗死、再次血运重建、脑血管意外)发生率(0%vs1.69%)、切口愈合不良发生率(0%vs 0.84%)虽较低,但差异无统计学意义(P>0.05)。术后冠脉造影复查,两组均未见吻合口闭塞情况。平均随访3个月,两组患者均无心绞痛或心肌梗死、死亡的发生。结论:经左前外侧小切口直视下可以成功获取双侧乳内动脉完成心脏不停跳多支CABG,近期临床效果良好。
Objective: To assess the early experience and clinical value of left anteriolateral minor thoracotomy minimally invasive directly coronary artery bypass(MIDCAB) for treating multi-vessel lesion coronary artery disease(CAD) with bilateral internal mammary artery(BITA). Methods: Our research included in 2 groups: MIDCABG group, n=38 consecutive patients received left anteriolateral minor thoracotomy MIDCAB with BITA in our hospital from 2015-05 to 2017-01 and Control group, n=236 patients received conventional off-pump coronary artery bypass(OPCAB) by the same surgeon at same period. Peri-operative condition and relevant complications were compared between 2 groups.Results: In MIDCAB group, the success rate for harvesting BIMA was 94.7%(36/38), the mean time for harvesting right internal mammary artery(RIMA) and LIMA were(42.3±10.5) min and(35.2±8.3) min respectively; a total of 78 grafts were made in 38 patients with the mean of(2.05±0.31) graft/patient, no patient was switching to conventional CABG during the operation. Compared with Control group, MIDCAB group had reduced post-operative mechanical ventilation time(8.9±3.8) h vs(23.6±15.9) h, ICU stay time(29.3±20.8) h vs(56.5±38.3) h and hospital stay time(11.3±3.2) d vs(15.7±4.2) d, all P<0.05; while the incidenceof peri-operative MACCE including death, myocardial infarction(MI), revascularization, cerebrovascular accident and poor incision healing were similar between 2 groups, P>0.05. No occlusion of anastomotic stoma was found by post-operative coronary angiography in neither group. The patients were followed-up for the average of 3 months, no death, angina or MI occurred.Conclusion: Through left anterolateral small incision, we can successfully get bilateral internal mammary artery and complete beating heart multi branch CABG.
Objective: To assess the early experience and clinical value of left anteriolateral minor thoracotomy minimally invasive directly coronary artery bypass(MIDCAB) for treating multi-vessel lesion coronary artery disease(CAD) with bilateral internal mammary artery(BITA). Methods: Our research included in 2 groups: MIDCABG group, n=38 consecutive patients received left anteriolateral minor thoracotomy MIDCAB with BITA in our hospital from 2015-05 to 2017-01 and Control group, n=236 patients received conventional off-pump coronary artery bypass(OPCAB) by the same surgeon at same period. Peri-operative condition and relevant complications were compared between 2 groups.Results: In MIDCAB group, the success rate for harvesting BIMA was 94.7%(36/38), the mean time for harvesting right internal mammary artery(RIMA) and LIMA were(42.3±10.5) min and(35.2±8.3) min respectively; a total of 78 grafts were made in 38 patients with the mean of(2.05±0.31) graft/patient, no patient was switching to conventional CABG during the operation. Compared with Control group, MIDCAB group had reduced post-operative mechanical ventilation time(8.9±3.8) h vs(23.6±15.9) h, ICU stay time(29.3±20.8) h vs(56.5±38.3) h and hospital stay time(11.3±3.2) d vs(15.7±4.2) d, all P<0.05; while the incidenceof peri-operative MACCE including death, myocardial infarction(MI), revascularization, cerebrovascular accident and poor incision healing were similar between 2 groups, P>0.05. No occlusion of anastomotic stoma was found by post-operative coronary angiography in neither group. The patients were followed-up for the average of 3 months, no death, angina or MI occurred.Conclusion: Through left anterolateral small incision, we can successfully get bilateral internal mammary artery and complete beating heart multi branch CABG.
引文
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[9]杨俊峰,顾承雄,韦华,等.非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例[J].中华外科杂志,2006,44(22):1529-1531.DOI:10.3760/j:issn:0529-5815.2006.22.005.
[2]BARI Investigators.The final 10-Year follow-up results from the BARI randomized trial[J].J Am Coll Cardiol,2007,49(15):1600-1606.DOI:10.1016/j.jacc.2006.11.048.
[3]Dai C,Lu Z,Zhu H,et al.Bilateral internal mammary artery grafting and risk of sternal wound infection:evidence from observational studies[J].Ann Thorac Surg,2013,95(6):1938-1945.DOI:10.1016/j.athoracsur.2012.12.038.
[4]Watanabe G,Misaki T,Kotoh K,et al.Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle[J].Ann Thorac Surg,1999,68(1):131-136.
[5]华琨,郑哲,王巍,等.2010年~2012年中国心血管外科微创技术的开展情况分析[J].中国循环杂志,2014,29(8):590-593.DOI:10.3969/j.issn.1000-3614.2014.08.009.
[6]Chan V,Lapierre H,Sohmer B,et al.Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy during minimally invasive multivessel coronary artery bypass grafting:a stepwise approach to safety and reproducibility[J].Semin Thorac Cardiovasc Surg,2012,24(1):79-83.DOI:10.1053/j.semtcvs.2011.12.010.
[7]Coulson AS,Glasgow EF,Bonatti J.Minimally invasive subclavian/axillary artery to coronary artery bypass(SAXCAB):review and classification[J].Heart Surg Forum,2001,4(1):13-25.
[8]Nambiar P,Mittal C.Minimally invasive coronary bypass using internal thoracic arteries via a left minithoracotomy:"the Nambiar Technique"[J].Innovations(Phila),2013,8(6):420-426.DOI:10.1097/IMI.0000000000000035.
[9]杨俊峰,顾承雄,韦华,等.非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例[J].中华外科杂志,2006,44(22):1529-1531.DOI:10.3760/j:issn:0529-5815.2006.22.005.