急诊冠状动脉搭桥术早期疗效分析
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摘要
背景：
冠心病是一种最常见的心脏病，是冠状动咏粥样硬化性心脏病的简称，指供给心脏营养物质的血管——冠状动咏发生严重粥样硬化或痉挛，使冠状动咏狭窄或阻塞，以及血栓形成造成管腔闭塞，导致心肌缺血缺氧或梗塞的一种心脏病，所以亦称之为缺血性心脏病。随着人们生活水平的提高和生活习惯的改变，冠状动咏粥样硬化性心脏病已成为严重危害中老年人生命的主要疾病。冠咏搭桥术(coroary artery bypass grafting，CABG)是目前治疗冠心病的一个常用而有效的手段，能够有效改善心肌缺血、恢复心肌功能，缓解心绞痛，改善生活质量，延长寿命。虽然随着介入技术和溶栓治疗的发展，使冠心病急性心梗的治疗进入了一个新的时代，但仍有相当一部分危重的急性心肌梗死患者需行急诊冠状动咏搭桥方能挽救生命。
急诊冠咏搭桥(emergency／urgent coronary artery bypass grming，EcABG)是相对于常规cABG而言，通常是指在急性心梗、或出现心梗后并发症、PCI意外，低心排、心源性休克等紧急情况下，数小时内开始并完成冠咏搭桥术。根据ACC／AHA 2004年的冠咏搭桥指南，EcABG的手术适应症有：(1)药物不能控制的不稳定心绞痛和非ST段抬高的MI，伴有左主干或相当于左主干明显狭窄(近段LAD和Lcx狭窄>70％)：(2)ST抬高的MI，其血管病变符合cABG并反复心绞痛发作或PCI失败并反复心绞痛发作；(3)合并室壁瘤、室间隔穿孔及腱索断裂出现心源性休克；(4)PCI失败并伴有心功能不稳或MI的危险者。目前可供人们选择的桥血管有乳内动咏(internal mammary artery，IMA)、大隐静咏(saphenous vein，SV)、桡动咏(radial artery，RA)，胃网膜右动咏(gastroepiploic artery，GEA)，右侧乳内动咏(right imernal mammary artery，RIMA)和腹壁下动咏(inferior epigastricartery，lEA)等。其中最常用的是乳内动咏(imernal mammary artery，IMA)、大隐静咏(saphenous vein，SV)。桥血管的通畅率决定着患者的远期生存率及生活质量，国内外报道，LIMA桥10年通畅率为90％~96％，SVG桥则为50％；大隐静咏桥的远期通畅率远低于动咏桥。
因在紧急情况下施行ECABG手术，通常无法进行充分的术前准备，一般患者的血压、血糖、血脂等因素控制欠佳，停用阿司匹林、氯吡格雷等药物的时间不足，并常合并肝。肾功能不全、颈动咏粥样硬化等疾病，因此手术风险较一般CABG手术更高。
目的：
总结164例急诊冠状动咏旁路移植术(emergency／urgent coronary artery bypassgrafting，ECABG)治疗冠状动咏狭窄患者的临床经验，探讨急诊冠状动咏搭桥术的手术指征、并发症及围术期处理方法。
资料和方法：
1．研究对象广东省人民医院2004年2月~2009年1月期间164例急诊冠状动脉搭桥术(ECABG)患者。
1.1入选标准：
①明确诊断为冠状动脉粥样硬化性心脏病，反复心绞痛发作，药物不能控制或效果不佳，心绞痛程度逐渐加重且频繁；②年龄、性别不限；⑧入院后3天内进行冠脉搭桥手术；④冠状动脉造影术提示左主干明显狭窄；⑤PCI失败并伴有心功能不稳或心肌梗塞可能；⑥冠心病合并室壁瘤、室间隔穿孔及腱索断裂出现心源性休克
1.2排除标准：
①非冠心病患者；②入院择期行冠脉搭桥手术的患者。
2．研究内容
2．2．1记录164例急诊冠咏搭桥术患者的性别、年龄、身高、体重、有无糖尿病、高脂血症、高血压等病史，既住有无脑血管意外、心血管手术史(既住搭桥史，既住瓣膜手术史和PcI手术史)，有无心绞痛发作史，最近心绞痛发作时间，心绞痛分型，有无心律失常史，冠状动咏造影结果提示冠咏病变数目(左主干有无病变、前降支、回旋支、右冠系统病变情况)，是否合并瓣膜病，术前有无肺动咏高压，手术前后LVEF值、术前术后肌酐值(cr)、术前术后左心室舒张末期容积(LVDd)、术前术后肺毛细血管楔压(PcwP)，术前术后中心静咏压(cVP)，手术方式(体外循环与非体外循环，停跳与不停跳)，体外循环时间，主动咏阻断时间，手术应用血管桥的数目(动咏桥和静咏桥)，有无合并瓣膜置换手术。
2．2．2记录手术后并发症发生情况(如新发房颤、三度房室传导阻滞、心跳骤停、心包填塞、切口感染、肺炎、肺栓塞、抗凝并发症、胃肠道并发症、围手术期心梗、败血症及多器官功能衰竭等)，病人生存率。
2．2．3各项资料以(x±s)或百分数表示，应用sPssl3．O软件包，对LvEF、LvDd、cvP，cr及PcwP等指标采用配对t检验方法，P 3方法和步骤
3．1 164例急诊冠状动咏搭桥术患者中，有123倒是在非体外循环下进行搭桥术，41倒是在体外循环支持下行搭桥术(其中32例在心脏停跳后手术，9例在体外循环心脏不停跳下手术)。
3．2常规术野消毒铺巾，取左侧大隐静咏(sVG)备用。取胸骨正中切口进入，锯开胸骨，游离左侧乳内动咏(LlMA)备用。
3．3在LAD上找出冠咏狭窄部位，越过该处先行LIMA LAD吻合，吻合完毕后打水未见血液漏出，测血流量满意。依次用sVG吻合病变血管远端，然后将sVG与主动咏吻合。对病情稳定，搬动心脏过程中血流动力学不稳定者，则先将sVG与主动咏吻合，再依次吻合病变血管远端。
3．4部分患者合并瓣膜病变或术前心功能较差，需行主动咏、上下腔静咏插管，建立体外循环并开机支持。对合并瓣膜病者，阻断主动咏，先将sVG与前降支以外的病变血管远端进行吻合，然后行瓣膜置换，再将LIMA与LAD行端侧吻合。一般在开放主动咏，半阻断下完成SVG的近端吻合。
3．5待患者生命体征平稳，血流动力学稳定后，顺利撤除体外循环，仔细检查创面有无出血点及仔细止血，逐层止血并关胸。
结果：
通过对术前术后各项指标(cr，PcwP，cVP与LVDd)进行比较，P 本组患者合并糖尿病62例，高血压86例，高脂血症104例，脑血管意外11例，心肌梗死史115例，最近发生心肌梗死143例。冠咏左主干病变或合并左主干病变83例，前降支系统148例，回旋支系统140例，右冠系统141例。本组合并左室室壁瘤12例，肺动咏高压41例，二尖瓣狭窄(Ms)1例，二尖瓣关闭不全(MI)85例，主动咏瓣关闭不全(AI)36例，三尖瓣关闭不全(TI)54例。术前肌酐异常70例。本组患者中，有41例在体外循环支持下进行搭桥术(其中：32例在心脏停跳后手术，9例在体外循环心脏不停跳下手术)，体外循环时间为72-519 min，升主动咏阻断时间为21-330min；另有123倒是在非体外循环下进行搭桥术。围术期使用主动咏内气囊反搏装置(IABP)77例(其中：术前植入70例，术中植入3例，术后植入4例)，术中同期行主动咏瓣(AV)手术5例，二尖瓣(MV)手术12例，三尖瓣(TV)手术12例，左心室(LV)室壁瘤切除修补术12例，室间隔(VSD)修补术10例。术后ICU使用肾上腺素46例，去甲肾上腺素28例，再次开胸止血术16例，术后发生低心排46例，围术期心梗2例，新发AF：40例，新发房室传导阻滞3例，心跳骤停或室颤26例，心包填塞15例，肢体切口感染9例，胸部切口感染9例，败血症3例，持续昏迷多于24小时11例，卒中2例，气管切开4例，辅助通气超过24小时60例，肺炎26例，肾衰44例，抗凝并发症6例，胃肠道并发症13例，多系统衰竭10例。围术期死亡22例，占13．4％，康复出院142例。
结论
急诊冠状动咏搭桥手术是风险较大，但只要适应证选择得当，对急性心肌梗死、左主干严重狭窄和PTcA失败的患者行EcABG是安全、有效的，正确选择手术时机、手术方式及妥善的围术期处理是提高ECABG手术成功率的关键。
Backgroud:
CAD is the abbreviation of Coronary artery disease,it also called coronaryatherosclerotic heart disease and Ischemic heart disease.It means the arterieswhich provide nutritions to the heart cells have severe atherosclerosis orvasospasm,and the thrombosis will make the arteries become narrow even to beobstructed,and then myocardial infarction will happen. With the improvement ofpeople's living standard and lifestyle changes, Coronary atherosclerotic heartdisease in the elderly has become a serious risk of life. coronary artery bypassgrafting(CABG) is currently a common and effective method for the acute myocardialinfarction treatment.It can effectively improve the function of myocardialischemia and recovery, alleviate angina, improve life quality and prolong life.Although with technical and thrombolytic therapy in the development of acutemyocardial infarction (AMI), the treatment of coronary heart disease has entereda new era, there are still serious part of acute myocardial infarction patientsneed emergency coronary artery bypass graft can save lives.
Emergency/Urgent coronary artery bypass grafting is different fromconventional CABG. It happened in times of emergency, such as acute myocardialinfarction, complications after myocardial infarction, PCI failure, low cardiacoutput syndrome and cardiogenic shock, it need to have operations within few hours.According to the ACC/AHA 2004 guideline update for coronary artery bypass graft surgery. Sunnary article, these guidelines reports a class Irecommendation foremergency or urgent CABG in the following circumstances:(1) failed PCI withpersistent pain or haemodynamic instability;(2)patients who are not candidatesfor fibrinolysis or PCI and have a significant area at risk;(3)at the time ofsurgical repair of postinfarction septal rupture or mitralregurgitationl;(4)patients with cardiogenic shock or life-threateningventricular arrhythmias and with triple-vessel and /or left main disease.
There are some choices for bridge vessels,such as internal mammary artery(IMA),right internal mammary artery(RIMA)and inferior epigastric artery(IEA). The mostcommonly used are IMA and SV. The long-term results of patients were determinedby the late patency rates of grafting. In some reports, the ten year patency ratewas 90-96% in left internal mammary arterial(LIMA) grafting, while in saphaneousvenous grafting was only 50%. Saphenous vein bridge long-term patency rate isfar below the artery bridge.
ECABG happened in emergency, it usually cannot be sufficient preoperativepreparation, and the general situation cannot be ready for the operation, suchas blood pressure, blood sugar,blood-fat are too high, the drug withdrawal of timefor aspirin and drug withdrawal is not long enough. And patients who need to haveECABG, also have some other disease, such as renal insufficiency, hepaticinsufficiency or Carotid atherosclerosis, the risk is much higher thanconventional CABG.
OBJECTIVE: To summarize the clinical experience of 164 emergency coronary arterybypass grafting (ECABG) for coronary artery stenosis, and to explore the surgeryindications, complications and perioperative treatment of emergency coronaryartery bypass surgery.
MATERIALS AND METHODS:
Patients:
164 patients with acute ECABG from February 2004 to January 2009 in GuangDonggeneral Hospital.
1. Inclusion criteria:①the diagnosis is Coronary artery disease, anginahappened several times and become more and more severe, that it cannot be controlledby nitroglycerin;②Age and gender are not limited;③CAG show the LM is Severestricture;④failed PCI with persistent pain or haemodynamic instability;⑤haveECABG in three days;⑥at the time of surgical repair of postinfarction septalrupture or mitral regurgitationl.
2. Exclusion criteria;①the diagnosis is not Coronary artery disease;②haveCABG after three days.
Content:
1. Data records: Age, sex, height, weight, History of diabetes, Hyperlipidemia,Hypertension, Cerebrovascular accident, History of cardiovascular surgery(CABG,Valve operation, and PCI surgery), History of angina, time that heart attackshappened, Arrhythmia, quantity of narrow coronary arteries, Valvular Disease,Pulmonary hypertension, LVEF ,LVDd, PCWP,CVP, Creatinine, Operation mode(CPB ornon-CPB, off-pump or on-pump), Cardiopulmonary bypass time, Cardiopulmonarybypass time, quantity of vascular bridges(artery and vein), Merge valvularsurgery.
2. Record any complications(such as atrial fibrillation, third degree a-v block,cardiac arrest, cardiac tamponade, infection of incision, infection of incision,pulmonary embolism, hemorrhage, myocardial infarction, Septicemia, Multiple OrganDysfunction Syndrome MODS, survival)
3. The information to (X S±) or percentage that the application of SPSS13.0package of LVEF, LVDd, CVP, Cr, and PCWP were measured using paired t test method,P <0.05 indicated significant difference.
Methods:
1.There are 41 cases with bypass grafting under cardiopulmonary bypass support(32 cases of cardiac arrest in the post-surgery),and 123 cases without.
2.Disinfection, spread towels,harvest the saphenous vein,after median sternotomyunder general anesthesia,LIMA was harvested.
3. In the LAD coronary artery stenosis on to find out, over there first LIMA-LADanastomosis, anastomotic leakage after kick was no blood, measuring blood flowsatisfaction. In turn consistent with lesions distal SVG then SVG and aortic. Ona stable condition, the heart of the process of moving unstable hemodynamics whoare first and aortic SVG, and then followed by distal anastomosis lesions.
4.Some patients with valve disease or poor cardiac function before surgery isrequired aortic, inferior vena cava cannulation to establish cardiopulmonarybypass and startup support. Of the valve with the patient, occlusion of aorta,first with SVG lesions outside the left anterior descending artery distal toanastomosis, then underwent valve replacement, and then LIMA and LAD line sideto side anastomosis. Generally in the open aorta, semi-occlusion of the proximalSVG anastomosis completed.
5. When vital signs were normal, stable hemodynamics, the successful removal ofpump, carefully check whether the bleeding wound and carefully stop the bleeding,and sternal bleeding layer by layer.
RESULTS:
On the indicators before and after operation (Cr, PCWP, CVP and LVDd) werecompared, P <0.05, shows the data before and after operation the difference wasstatistically significant. Which left ventricular end diastolic diameter (LVDd)increased compared with that before surgery, indicating improvement in leftventricular diastolic function after surgery; pulmonary capillary wedge pressure(PCWP), central venous pressure (CVP) decreased after surgery than before surgery;creatinine (Cr) level increased after surgery, which required higher creatinineserious there were 20 cases of hemodialysis.
There are 62 patients with diabetes mellitus, 86 cases with hypertension, 104 cases with hyperlipidemia, 11 cases with cerebrovascular accident, 115 cases withmyocardial infarction event and 143 cases with recent myocardial infarction. 83patients with coronary lesions complicating left main disease, 148 cases with leftanterior descending artery system, 140 cases with circumflex system and 141 caseswith right coronary system. 12 cases complicating left ventricular aneurysm, 41cases with pulmonary hypertension, 1 cases of mitral stenosis (MS), 85 cases withmitral insufficiency (MI), 36 cases with aortic insufficiency (AI) and 54 caseswith tricuspid incompetence. 70 patients with abnormal preoperative creatinine.There are 41 cases with bypass grafting under cardiopulmonary bypass support (32cases of cardiac arrest in the post-surgery), and cardiopulmonary bypass time was72-519 min, aortic cross-clamp time was 21-330min; the other 123 cases were underthe off-pump to carry out bypass surgery. There were 77 cases with perioperativeintra-aortic balloon counterpulsation device (IABP). Meanwhile, 5 cases withaortic valve (AV) surgery, 12 cases with mitral valve (MV), 12 cases with tricuspidvalve (TV), 18 cases with other cardiac surgeries, 12 cases with left ventricular(LV) aneurysm repair and 10 cases with interventricular septum (VSD) repair. Duringpostoperative ICU, 46 cases with noradrenaline saline and 28 cases with adrenalinesaline, 16 cases with re-open chest surgery to stop bleeding, 46 cases withpostoperative low cardiac output, 2 cases with perioperative myocardial infarction,40 cases with first AF, 3 cases with atrioventricular conduction block, 26 caseswith cardiac arrest or ventricular fibrillation, 15 cases with pericardialtamponade, 9 cases with physical wound infection in, 9 cases with chest woundinfection, 3 cases with sepsis, 11 cases with persistent coma more than 24h, 2stroke cases, 4 cases with trachea incision, 60 cases assisted ventilation morethan 24h, 26 pneumonia cases, 44 renal failure cases, 6 cases with anticoagulationcomplications, 13 gastrointestinal complications cases, 10 cases withmulti-system failure. 22 perioperative death cases accounted for 13.4%, and 142patients recovered.
CONCLUSIONS:
Emergency coronary artery bypass surgery is risky, but when the indication ischose rightly, it is safe and effective for patients with acute myocardialinfarction (AMI), left main (LM) stenosis and failed PTCA by ECABG. It is key toimprove the success rate of ECABG with correct choice of timing of surgery, surgicalmethod and proper Wai operative treatment.
冠心病是一种最常见的心脏病，是冠状动咏粥样硬化性心脏病的简称，指供给心脏营养物质的血管——冠状动咏发生严重粥样硬化或痉挛，使冠状动咏狭窄或阻塞，以及血栓形成造成管腔闭塞，导致心肌缺血缺氧或梗塞的一种心脏病，所以亦称之为缺血性心脏病。随着人们生活水平的提高和生活习惯的改变，冠状动咏粥样硬化性心脏病已成为严重危害中老年人生命的主要疾病。冠咏搭桥术(coroary artery bypass grafting，CABG)是目前治疗冠心病的一个常用而有效的手段，能够有效改善心肌缺血、恢复心肌功能，缓解心绞痛，改善生活质量，延长寿命。虽然随着介入技术和溶栓治疗的发展，使冠心病急性心梗的治疗进入了一个新的时代，但仍有相当一部分危重的急性心肌梗死患者需行急诊冠状动咏搭桥方能挽救生命。
急诊冠咏搭桥(emergency／urgent coronary artery bypass grming，EcABG)是相对于常规cABG而言，通常是指在急性心梗、或出现心梗后并发症、PCI意外，低心排、心源性休克等紧急情况下，数小时内开始并完成冠咏搭桥术。根据ACC／AHA 2004年的冠咏搭桥指南，EcABG的手术适应症有：(1)药物不能控制的不稳定心绞痛和非ST段抬高的MI，伴有左主干或相当于左主干明显狭窄(近段LAD和Lcx狭窄>70％)：(2)ST抬高的MI，其血管病变符合cABG并反复心绞痛发作或PCI失败并反复心绞痛发作；(3)合并室壁瘤、室间隔穿孔及腱索断裂出现心源性休克；(4)PCI失败并伴有心功能不稳或MI的危险者。目前可供人们选择的桥血管有乳内动咏(internal mammary artery，IMA)、大隐静咏(saphenous vein，SV)、桡动咏(radial artery，RA)，胃网膜右动咏(gastroepiploic artery，GEA)，右侧乳内动咏(right imernal mammary artery，RIMA)和腹壁下动咏(inferior epigastricartery，lEA)等。其中最常用的是乳内动咏(imernal mammary artery，IMA)、大隐静咏(saphenous vein，SV)。桥血管的通畅率决定着患者的远期生存率及生活质量，国内外报道，LIMA桥10年通畅率为90％~96％，SVG桥则为50％；大隐静咏桥的远期通畅率远低于动咏桥。
因在紧急情况下施行ECABG手术，通常无法进行充分的术前准备，一般患者的血压、血糖、血脂等因素控制欠佳，停用阿司匹林、氯吡格雷等药物的时间不足，并常合并肝。肾功能不全、颈动咏粥样硬化等疾病，因此手术风险较一般CABG手术更高。
目的：
总结164例急诊冠状动咏旁路移植术(emergency／urgent coronary artery bypassgrafting，ECABG)治疗冠状动咏狭窄患者的临床经验，探讨急诊冠状动咏搭桥术的手术指征、并发症及围术期处理方法。
资料和方法：
1．研究对象广东省人民医院2004年2月~2009年1月期间164例急诊冠状动脉搭桥术(ECABG)患者。
1.1入选标准：
①明确诊断为冠状动脉粥样硬化性心脏病，反复心绞痛发作，药物不能控制或效果不佳，心绞痛程度逐渐加重且频繁；②年龄、性别不限；⑧入院后3天内进行冠脉搭桥手术；④冠状动脉造影术提示左主干明显狭窄；⑤PCI失败并伴有心功能不稳或心肌梗塞可能；⑥冠心病合并室壁瘤、室间隔穿孔及腱索断裂出现心源性休克
1.2排除标准：
①非冠心病患者；②入院择期行冠脉搭桥手术的患者。
2．研究内容
2．2．1记录164例急诊冠咏搭桥术患者的性别、年龄、身高、体重、有无糖尿病、高脂血症、高血压等病史，既住有无脑血管意外、心血管手术史(既住搭桥史，既住瓣膜手术史和PcI手术史)，有无心绞痛发作史，最近心绞痛发作时间，心绞痛分型，有无心律失常史，冠状动咏造影结果提示冠咏病变数目(左主干有无病变、前降支、回旋支、右冠系统病变情况)，是否合并瓣膜病，术前有无肺动咏高压，手术前后LVEF值、术前术后肌酐值(cr)、术前术后左心室舒张末期容积(LVDd)、术前术后肺毛细血管楔压(PcwP)，术前术后中心静咏压(cVP)，手术方式(体外循环与非体外循环，停跳与不停跳)，体外循环时间，主动咏阻断时间，手术应用血管桥的数目(动咏桥和静咏桥)，有无合并瓣膜置换手术。
2．2．2记录手术后并发症发生情况(如新发房颤、三度房室传导阻滞、心跳骤停、心包填塞、切口感染、肺炎、肺栓塞、抗凝并发症、胃肠道并发症、围手术期心梗、败血症及多器官功能衰竭等)，病人生存率。
2．2．3各项资料以(x±s)或百分数表示，应用sPssl3．O软件包，对LvEF、LvDd、cvP，cr及PcwP等指标采用配对t检验方法，P
3．1 164例急诊冠状动咏搭桥术患者中，有123倒是在非体外循环下进行搭桥术，41倒是在体外循环支持下行搭桥术(其中32例在心脏停跳后手术，9例在体外循环心脏不停跳下手术)。
3．2常规术野消毒铺巾，取左侧大隐静咏(sVG)备用。取胸骨正中切口进入，锯开胸骨，游离左侧乳内动咏(LlMA)备用。
3．3在LAD上找出冠咏狭窄部位，越过该处先行LIMA LAD吻合，吻合完毕后打水未见血液漏出，测血流量满意。依次用sVG吻合病变血管远端，然后将sVG与主动咏吻合。对病情稳定，搬动心脏过程中血流动力学不稳定者，则先将sVG与主动咏吻合，再依次吻合病变血管远端。
3．4部分患者合并瓣膜病变或术前心功能较差，需行主动咏、上下腔静咏插管，建立体外循环并开机支持。对合并瓣膜病者，阻断主动咏，先将sVG与前降支以外的病变血管远端进行吻合，然后行瓣膜置换，再将LIMA与LAD行端侧吻合。一般在开放主动咏，半阻断下完成SVG的近端吻合。
3．5待患者生命体征平稳，血流动力学稳定后，顺利撤除体外循环，仔细检查创面有无出血点及仔细止血，逐层止血并关胸。
结果：
通过对术前术后各项指标(cr，PcwP，cVP与LVDd)进行比较，P
结论
急诊冠状动咏搭桥手术是风险较大，但只要适应证选择得当，对急性心肌梗死、左主干严重狭窄和PTcA失败的患者行EcABG是安全、有效的，正确选择手术时机、手术方式及妥善的围术期处理是提高ECABG手术成功率的关键。
Backgroud:
CAD is the abbreviation of Coronary artery disease,it also called coronaryatherosclerotic heart disease and Ischemic heart disease.It means the arterieswhich provide nutritions to the heart cells have severe atherosclerosis orvasospasm,and the thrombosis will make the arteries become narrow even to beobstructed,and then myocardial infarction will happen. With the improvement ofpeople's living standard and lifestyle changes, Coronary atherosclerotic heartdisease in the elderly has become a serious risk of life. coronary artery bypassgrafting(CABG) is currently a common and effective method for the acute myocardialinfarction treatment.It can effectively improve the function of myocardialischemia and recovery, alleviate angina, improve life quality and prolong life.Although with technical and thrombolytic therapy in the development of acutemyocardial infarction (AMI), the treatment of coronary heart disease has entereda new era, there are still serious part of acute myocardial infarction patientsneed emergency coronary artery bypass graft can save lives.
Emergency/Urgent coronary artery bypass grafting is different fromconventional CABG. It happened in times of emergency, such as acute myocardialinfarction, complications after myocardial infarction, PCI failure, low cardiacoutput syndrome and cardiogenic shock, it need to have operations within few hours.According to the ACC/AHA 2004 guideline update for coronary artery bypass graft surgery. Sunnary article, these guidelines reports a class Irecommendation foremergency or urgent CABG in the following circumstances:(1) failed PCI withpersistent pain or haemodynamic instability;(2)patients who are not candidatesfor fibrinolysis or PCI and have a significant area at risk;(3)at the time ofsurgical repair of postinfarction septal rupture or mitralregurgitationl;(4)patients with cardiogenic shock or life-threateningventricular arrhythmias and with triple-vessel and /or left main disease.
There are some choices for bridge vessels,such as internal mammary artery(IMA),right internal mammary artery(RIMA)and inferior epigastric artery(IEA). The mostcommonly used are IMA and SV. The long-term results of patients were determinedby the late patency rates of grafting. In some reports, the ten year patency ratewas 90-96% in left internal mammary arterial(LIMA) grafting, while in saphaneousvenous grafting was only 50%. Saphenous vein bridge long-term patency rate isfar below the artery bridge.
ECABG happened in emergency, it usually cannot be sufficient preoperativepreparation, and the general situation cannot be ready for the operation, suchas blood pressure, blood sugar,blood-fat are too high, the drug withdrawal of timefor aspirin and drug withdrawal is not long enough. And patients who need to haveECABG, also have some other disease, such as renal insufficiency, hepaticinsufficiency or Carotid atherosclerosis, the risk is much higher thanconventional CABG.
OBJECTIVE: To summarize the clinical experience of 164 emergency coronary arterybypass grafting (ECABG) for coronary artery stenosis, and to explore the surgeryindications, complications and perioperative treatment of emergency coronaryartery bypass surgery.
MATERIALS AND METHODS:
Patients:
164 patients with acute ECABG from February 2004 to January 2009 in GuangDonggeneral Hospital.
1. Inclusion criteria:①the diagnosis is Coronary artery disease, anginahappened several times and become more and more severe, that it cannot be controlledby nitroglycerin;②Age and gender are not limited;③CAG show the LM is Severestricture;④failed PCI with persistent pain or haemodynamic instability;⑤haveECABG in three days;⑥at the time of surgical repair of postinfarction septalrupture or mitral regurgitationl.
2. Exclusion criteria;①the diagnosis is not Coronary artery disease;②haveCABG after three days.
Content:
1. Data records: Age, sex, height, weight, History of diabetes, Hyperlipidemia,Hypertension, Cerebrovascular accident, History of cardiovascular surgery(CABG,Valve operation, and PCI surgery), History of angina, time that heart attackshappened, Arrhythmia, quantity of narrow coronary arteries, Valvular Disease,Pulmonary hypertension, LVEF ,LVDd, PCWP,CVP, Creatinine, Operation mode(CPB ornon-CPB, off-pump or on-pump), Cardiopulmonary bypass time, Cardiopulmonarybypass time, quantity of vascular bridges(artery and vein), Merge valvularsurgery.
2. Record any complications(such as atrial fibrillation, third degree a-v block,cardiac arrest, cardiac tamponade, infection of incision, infection of incision,pulmonary embolism, hemorrhage, myocardial infarction, Septicemia, Multiple OrganDysfunction Syndrome MODS, survival)
3. The information to (X S±) or percentage that the application of SPSS13.0package of LVEF, LVDd, CVP, Cr, and PCWP were measured using paired t test method,P <0.05 indicated significant difference.
Methods:
1.There are 41 cases with bypass grafting under cardiopulmonary bypass support(32 cases of cardiac arrest in the post-surgery),and 123 cases without.
2.Disinfection, spread towels,harvest the saphenous vein,after median sternotomyunder general anesthesia,LIMA was harvested.
3. In the LAD coronary artery stenosis on to find out, over there first LIMA-LADanastomosis, anastomotic leakage after kick was no blood, measuring blood flowsatisfaction. In turn consistent with lesions distal SVG then SVG and aortic. Ona stable condition, the heart of the process of moving unstable hemodynamics whoare first and aortic SVG, and then followed by distal anastomosis lesions.
4.Some patients with valve disease or poor cardiac function before surgery isrequired aortic, inferior vena cava cannulation to establish cardiopulmonarybypass and startup support. Of the valve with the patient, occlusion of aorta,first with SVG lesions outside the left anterior descending artery distal toanastomosis, then underwent valve replacement, and then LIMA and LAD line sideto side anastomosis. Generally in the open aorta, semi-occlusion of the proximalSVG anastomosis completed.
5. When vital signs were normal, stable hemodynamics, the successful removal ofpump, carefully check whether the bleeding wound and carefully stop the bleeding,and sternal bleeding layer by layer.
RESULTS:
On the indicators before and after operation (Cr, PCWP, CVP and LVDd) werecompared, P <0.05, shows the data before and after operation the difference wasstatistically significant. Which left ventricular end diastolic diameter (LVDd)increased compared with that before surgery, indicating improvement in leftventricular diastolic function after surgery; pulmonary capillary wedge pressure(PCWP), central venous pressure (CVP) decreased after surgery than before surgery;creatinine (Cr) level increased after surgery, which required higher creatinineserious there were 20 cases of hemodialysis.
There are 62 patients with diabetes mellitus, 86 cases with hypertension, 104 cases with hyperlipidemia, 11 cases with cerebrovascular accident, 115 cases withmyocardial infarction event and 143 cases with recent myocardial infarction. 83patients with coronary lesions complicating left main disease, 148 cases with leftanterior descending artery system, 140 cases with circumflex system and 141 caseswith right coronary system. 12 cases complicating left ventricular aneurysm, 41cases with pulmonary hypertension, 1 cases of mitral stenosis (MS), 85 cases withmitral insufficiency (MI), 36 cases with aortic insufficiency (AI) and 54 caseswith tricuspid incompetence. 70 patients with abnormal preoperative creatinine.There are 41 cases with bypass grafting under cardiopulmonary bypass support (32cases of cardiac arrest in the post-surgery), and cardiopulmonary bypass time was72-519 min, aortic cross-clamp time was 21-330min; the other 123 cases were underthe off-pump to carry out bypass surgery. There were 77 cases with perioperativeintra-aortic balloon counterpulsation device (IABP). Meanwhile, 5 cases withaortic valve (AV) surgery, 12 cases with mitral valve (MV), 12 cases with tricuspidvalve (TV), 18 cases with other cardiac surgeries, 12 cases with left ventricular(LV) aneurysm repair and 10 cases with interventricular septum (VSD) repair. Duringpostoperative ICU, 46 cases with noradrenaline saline and 28 cases with adrenalinesaline, 16 cases with re-open chest surgery to stop bleeding, 46 cases withpostoperative low cardiac output, 2 cases with perioperative myocardial infarction,40 cases with first AF, 3 cases with atrioventricular conduction block, 26 caseswith cardiac arrest or ventricular fibrillation, 15 cases with pericardialtamponade, 9 cases with physical wound infection in, 9 cases with chest woundinfection, 3 cases with sepsis, 11 cases with persistent coma more than 24h, 2stroke cases, 4 cases with trachea incision, 60 cases assisted ventilation morethan 24h, 26 pneumonia cases, 44 renal failure cases, 6 cases with anticoagulationcomplications, 13 gastrointestinal complications cases, 10 cases withmulti-system failure. 22 perioperative death cases accounted for 13.4%, and 142patients recovered.
CONCLUSIONS:
Emergency coronary artery bypass surgery is risky, but when the indication ischose rightly, it is safe and effective for patients with acute myocardialinfarction (AMI), left main (LM) stenosis and failed PTCA by ECABG. It is key toimprove the success rate of ECABG with correct choice of timing of surgery, surgicalmethod and proper Wai operative treatment.
引文
[1] Taggart DP, Surgery is the best intervention for severe coronary artery diease.BMJ.2005 Apr 2;330(7494):785-6.
[2] Taggart DP. Thomas B. Ferguson Lecture. Coronary artery bypass grafting isstill the best treatment for multivessel and left main disease,but patientsneed to know. Ann Thorac Surg.2006 Dec;82(6):1966-75.
[3] ACC/AHA 2004 guideline update for coronary artery bypass graft surgery.Sunnaryarticle [J]. Circulation,2004,(110):1168-1176
[4]牛兆倬，池一凡，侯文明，等。急诊冠状动脉旁路移植手术22例经验总结。心肺血管病杂志，2009，28：18-20。
[5] Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg, 2003,75 :1400-1405
[6] He GW et al, Arterial grafts for coronary artery bypass surgery. A testbookfor cardiovascular clinicians and reaschers. Published in 1999;
[7] Weisz D,Hamby RI,Aintablian A,et al. Late coronary bypass graft flow.Quantitative assessment by roentgendensitometry. Ann ThoracSurg,1979,28:429-435.
[8] Chmidt DH,Blau F,Hellman C,et al. Isoproterenol-induced flow response inmammary and bypass grafts. J Thorac Cardiovasc Surg,1980,80:319-326.
[9] Hcdgson J,Singh AK,Drew TM,et al. Evaluation of postoperative flow reserve ininternal mammary artery bypass grafts. J Am Coll Cardiol,1986,7:32-37.
[10] Johnson AN,Kron IL,Watson DD,et al. Evaluation of postoperative flowreserve in internal mammary artery by-pass grafts. J Thorac CardiocascSurg,1986,92:822-826.
[11] Akasaka T,Yoshikawa J,Yoshida K,et al.Flow capacity of internal mammarygrafts:Early restriction and later improvement assessed by Doppler guidewaire.J Am Coll Cardiol,1995,25:640-647.
[12] Rastan AJ,Eckenstein JI, Hentschel B, et al. Emergency coronary arterybypass graft surgery for acute coronary syndrome: beating heart versusconventional cardioplegic cardiac arrest strategies[J]. Cirulation,2006,114(Suppl 1): 1477-1485.
[13] Mizutani S, Matsuura A, Miyahara K,et al On-pump beating-heart coronaryartery bypass a propensity analysis[J]. Ann Thorac Sufg, 2007,83(4):1386-1373.
[14] Miyahara K, Matsuura A, Takemura H,et al On-pump beating-heart coronaryartery bypass grafting after acute myocardial infarction has lower mortalityand morbidity[J]. J Thorac Cardiovasc Surg,2008,135(3): 521-526.
[15] Hirotani T,Kameda T,Knmamoto T,et al. Should arterial grafts be used forurgent Coronary artery bypass surery. Kyoby-Geka,2000,53(1) : 69-73.
[1]言翊光，王东进，武忠等，31例急诊冠脉搭桥分析，中国医药导报，2009，6（19）：71-72。
[2].Lee DC,OZ MC,Weinborg AD, et al. Optimal timing of revasoularization:trausmaral versusnontransmaral acute myocardial infraction. Ann Thorac Sur,2001,71(4):1198-1204
[3].ACC/AHA 2004 Cuideline Update for Coronary Artery Bypass Craft Surgery.Summary article [J].Circulation,2004,(110):1168-1176.
[4]王强，姜楠，王联群，急诊冠状动脉搭桥术的临床应用，天津医药，2007，35（10）：792-793。
[5]梅运清，汤楚中，吴明荣，21例急诊冠状动脉旁路移植术的临床应用，中华急诊医学杂志，2005，14（3）：251-252。
[6].He GW et al, Arterial grafts for coronary artery bypass surgery. A testbookfor cardiovascular clinicians and reaschers. Published in 1999;.
[7].Weisz D，Hamby RI，Aintablian A，et al. Late coronary bypass graft flow. Quantitativeassessment by roentgendensitometry. Ann Thorac Surg,1979,28:429-435.
[8]牛兆倬，池一凡，侯文明，急诊冠状动脉旁路移植手术22例经验总结。心肺血管杂志，2009，28：18-20。
[9].Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg, 2003, 75 :1400-1405
[10]胡盛寿，黄方炯。冠心病外笠治疗学。北京：科学出版社，2003。
[11].Fomaro G,Porando MD,Paroai F,et al. Short intermediate form clinical outcomein patients with cardiogenic shock beated with aortic counter pulsation. GLtalCardial ,1996,26(12):1385-1399.
[12].Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg,2003,75:1400-1405.
[13].Chmidt DH,Blau F,Hellman C,et al. Isoproterenol-induced flow response inmammary and bypass grafts. J Thorac Cardiovasc Surg,1980,80:319-326.
[14].Landoni g, Pappalardo F, Crescenzi G, et al . The outcome of patients requiringemergency conversion from off-pump to on-pump coronary artery bypass grafting[J],Eur J Anaesthesiol.2007,24(4):317-322.
[15].Isomura T, Hoshino J. Fukada Y. et al .Surgical treatment for ischemic heartdisease[J]. Kyobu Geka,2009,62(1):4-8,
[16].Tahalele P,Parasmon A,Puruhito,et al.Surgical repair of an impending ruptureof left ventricular(LV) aneurysm with off-septal perforation and rupture ofpapillary muscle after acute myocardial infarction. Ann Thorac CardiovascSurg,2000,6(6):401-404.
[17].Hirotani T,Kameda T,Knmamoto T,et al. Should arterial grafts be used forurgent Coronary artery bypass surgery. Kyobu-Geka,2000,53(1):69-73.
[18].Narin C, Ozkara A, Soylu A, Ege E,The effect of coronary revascularizationon new-onset complete atrioventricular block due to acute coronary syndrome. HeartSurg Forum. 2009 Jan;12(1):E30-4.
[19].Chew DP, Mahaffey KW, White HD, Coronary artery bypass surgery in patientswith acute coronary syndromes is difficult to predict.Am Heart J. 2008May;155(5):841-7. Epub 2008 Feb 21.
[20].Bjessmo S, Svenarud P, Tran PK.Long-term survival after surgery for acutecoronary syndromes in relation to perioperative troponin T release and angina class-a prospective study in 200 patients.Thorac Cardiovasc Surg. 2009 Apr;57(3):148-52.Epub 2009 Mar 27.
[21].Osswald BR, Knipp S, Wiese I, Jakob HG.Massive alterations of the leftinternal thoracic artery late after repair for aortic coarctation. Ann Thorac Surg.2009 Feb;87(2):634-6.
[22]万峰等。急诊冠状动脉旁路移植手术。北京医学，2006,26,119-122.
[2] Taggart DP. Thomas B. Ferguson Lecture. Coronary artery bypass grafting isstill the best treatment for multivessel and left main disease,but patientsneed to know. Ann Thorac Surg.2006 Dec;82(6):1966-75.
[3] ACC/AHA 2004 guideline update for coronary artery bypass graft surgery.Sunnaryarticle [J]. Circulation,2004,(110):1168-1176
[4]牛兆倬，池一凡，侯文明，等。急诊冠状动脉旁路移植手术22例经验总结。心肺血管病杂志，2009，28：18-20。
[5] Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg, 2003,75 :1400-1405
[6] He GW et al, Arterial grafts for coronary artery bypass surgery. A testbookfor cardiovascular clinicians and reaschers. Published in 1999;
[7] Weisz D,Hamby RI,Aintablian A,et al. Late coronary bypass graft flow.Quantitative assessment by roentgendensitometry. Ann ThoracSurg,1979,28:429-435.
[8] Chmidt DH,Blau F,Hellman C,et al. Isoproterenol-induced flow response inmammary and bypass grafts. J Thorac Cardiovasc Surg,1980,80:319-326.
[9] Hcdgson J,Singh AK,Drew TM,et al. Evaluation of postoperative flow reserve ininternal mammary artery bypass grafts. J Am Coll Cardiol,1986,7:32-37.
[10] Johnson AN,Kron IL,Watson DD,et al. Evaluation of postoperative flowreserve in internal mammary artery by-pass grafts. J Thorac CardiocascSurg,1986,92:822-826.
[11] Akasaka T,Yoshikawa J,Yoshida K,et al.Flow capacity of internal mammarygrafts:Early restriction and later improvement assessed by Doppler guidewaire.J Am Coll Cardiol,1995,25:640-647.
[12] Rastan AJ,Eckenstein JI, Hentschel B, et al. Emergency coronary arterybypass graft surgery for acute coronary syndrome: beating heart versusconventional cardioplegic cardiac arrest strategies[J]. Cirulation,2006,114(Suppl 1): 1477-1485.
[13] Mizutani S, Matsuura A, Miyahara K,et al On-pump beating-heart coronaryartery bypass a propensity analysis[J]. Ann Thorac Sufg, 2007,83(4):1386-1373.
[14] Miyahara K, Matsuura A, Takemura H,et al On-pump beating-heart coronaryartery bypass grafting after acute myocardial infarction has lower mortalityand morbidity[J]. J Thorac Cardiovasc Surg,2008,135(3): 521-526.
[15] Hirotani T,Kameda T,Knmamoto T,et al. Should arterial grafts be used forurgent Coronary artery bypass surery. Kyoby-Geka,2000,53(1) : 69-73.
[1]言翊光，王东进，武忠等，31例急诊冠脉搭桥分析，中国医药导报，2009，6（19）：71-72。
[2].Lee DC,OZ MC,Weinborg AD, et al. Optimal timing of revasoularization:trausmaral versusnontransmaral acute myocardial infraction. Ann Thorac Sur,2001,71(4):1198-1204
[3].ACC/AHA 2004 Cuideline Update for Coronary Artery Bypass Craft Surgery.Summary article [J].Circulation,2004,(110):1168-1176.
[4]王强，姜楠，王联群，急诊冠状动脉搭桥术的临床应用，天津医药，2007，35（10）：792-793。
[5]梅运清，汤楚中，吴明荣，21例急诊冠状动脉旁路移植术的临床应用，中华急诊医学杂志，2005，14（3）：251-252。
[6].He GW et al, Arterial grafts for coronary artery bypass surgery. A testbookfor cardiovascular clinicians and reaschers. Published in 1999;.
[7].Weisz D，Hamby RI，Aintablian A，et al. Late coronary bypass graft flow. Quantitativeassessment by roentgendensitometry. Ann Thorac Surg,1979,28:429-435.
[8]牛兆倬，池一凡，侯文明，急诊冠状动脉旁路移植手术22例经验总结。心肺血管杂志，2009，28：18-20。
[9].Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg, 2003, 75 :1400-1405
[10]胡盛寿，黄方炯。冠心病外笠治疗学。北京：科学出版社，2003。
[11].Fomaro G,Porando MD,Paroai F,et al. Short intermediate form clinical outcomein patients with cardiogenic shock beated with aortic counter pulsation. GLtalCardial ,1996,26(12):1385-1399.
[12].Barakate MS,Bannon PG,Hughes CF,et al. Emergery surgery after unsuccessfulangioplasty:a review of 15 years' experience. Ann Thorac Surg,2003,75:1400-1405.
[13].Chmidt DH,Blau F,Hellman C,et al. Isoproterenol-induced flow response inmammary and bypass grafts. J Thorac Cardiovasc Surg,1980,80:319-326.
[14].Landoni g, Pappalardo F, Crescenzi G, et al . The outcome of patients requiringemergency conversion from off-pump to on-pump coronary artery bypass grafting[J],Eur J Anaesthesiol.2007,24(4):317-322.
[15].Isomura T, Hoshino J. Fukada Y. et al .Surgical treatment for ischemic heartdisease[J]. Kyobu Geka,2009,62(1):4-8,
[16].Tahalele P,Parasmon A,Puruhito,et al.Surgical repair of an impending ruptureof left ventricular(LV) aneurysm with off-septal perforation and rupture ofpapillary muscle after acute myocardial infarction. Ann Thorac CardiovascSurg,2000,6(6):401-404.
[17].Hirotani T,Kameda T,Knmamoto T,et al. Should arterial grafts be used forurgent Coronary artery bypass surgery. Kyobu-Geka,2000,53(1):69-73.
[18].Narin C, Ozkara A, Soylu A, Ege E,The effect of coronary revascularizationon new-onset complete atrioventricular block due to acute coronary syndrome. HeartSurg Forum. 2009 Jan;12(1):E30-4.
[19].Chew DP, Mahaffey KW, White HD, Coronary artery bypass surgery in patientswith acute coronary syndromes is difficult to predict.Am Heart J. 2008May;155(5):841-7. Epub 2008 Feb 21.
[20].Bjessmo S, Svenarud P, Tran PK.Long-term survival after surgery for acutecoronary syndromes in relation to perioperative troponin T release and angina class-a prospective study in 200 patients.Thorac Cardiovasc Surg. 2009 Apr;57(3):148-52.Epub 2009 Mar 27.
[21].Osswald BR, Knipp S, Wiese I, Jakob HG.Massive alterations of the leftinternal thoracic artery late after repair for aortic coarctation. Ann Thorac Surg.2009 Feb;87(2):634-6.
[22]万峰等。急诊冠状动脉旁路移植手术。北京医学，2006,26,119-122.