摘要
【目的】应用经食管多普勒超声(TEE)与心导管技术同步定量研究非体外循环冠状动脉旁路移植术(OPCAB)治疗心肌缺血前后左室整体功能的变化。【方法】选取42例行OPCAB患者，冠状动脉造影显示：左主干(LM)病变1例、单支长病变1例、双支病变12例，三支及三支以上病变28例，心功能Ⅱ级29例，心功能Ⅲ级12例，心功能Ⅳ级1例。所有患者均已排除合并有瓣膜病、房颤及传导阻滞患者，并排除因各种原因术中改行常规冠状动脉旁路移植术(cCABG)患者。所有患者均行常规TEE连续检测，测量肺静脉(PVF)、二尖瓣(MVF)和冠状窦(CSF)血流频谱、左室收缩(ESV)和舒张末期(EDV)容量，左室心搏量(SV)，左室心输出量(CO)、心脏指数(CI)和左室射血分数(LVEF)等参数，同步心导管测量中心静脉压(CVP)、肺动脉楔嵌压(PCWP)和肺动脉平均压(PAP)。对所有测量参数结果进行OPCAB术前术后对比研究，并对TEE与心导管同步测量所得参数进行相关分析。【结果】①各测量参数OPCAB术前后对比结果：MVF舒张早期峰值血流速度(MVe)、MVe速度时间积分(VTImve)、PVF收缩期前向波峰值血流速度(PVs)、舒张早期前向波峰值血流速度(PVd)、PVs速度时间积分(VTIpvs)、PVd速度时间积分(VTIpvd)、CSF收缩期前向波峰值血流速度(CSs)、舒张早期前向波峰值血流速度(CSd)、CSs速度时间积分(VTIcss)、CSd速度时间积分(VTIcsd)、LVEF、CO、CI、SV等较术前有明显增加(P＜0.05～0.0001)；MVF舒张晚期峰值血流速度(MVa)、MVa速度时间积分(VTImva)、MVe减速时间(MVedt)、PVF舒张晚期逆向波峰值血流速度(PVa)、PVa速度时间积分(VTIpva)、PVa减速时间(PVadt)、EDV、ESV、PAP、PCWP等有明显降低(P＜0.05～0.001)；PVa持续时间(PVat)与MVa持续时间(MVat)之差(Tpvat-mvat)、PVadt与MVa减速时间(MVadt)之差(Tpvadt-mvadt)等较术前有明显增加(P＜0.01～0.0001)；余参数间差别无统计学意义。②TEE与心导管测量间相关分析结果：MVe、MVat、MVe／MVa、PVa、VTIpva、PVadt、Tpvadt-mvadt、Tpvat-mvat与PCWP有正相关，其中PAP、PVa、VTIpva、Tpvadt-mvadt、Tpvat-mvat与其相关性最好(r=0.64～0.86，P＜0.001)；与MVedt、MVadt呈负相关(r=-0.35～-0.58，P＜0.001-0.05)；CVP与CSa、VTIcsa有很好的相关性(r=0.69～0.78，P＜0.001)。【结论】①TEE术中测量到的MVF、PVF及EDV、ESV、LVEF、SV、CO、CI可准确反映左室收缩和舒张功能；②TEE术中测量指标
中文摘要
与心导管所测有创压间有良好相关性，其中PVa、VTIpva、Tpvat一mvat、Tpvadt一mvadi
能准确反映和估测PCWP;③TEE通过测量CSF反映冠脉循环的变化，提示冠脉再
通;④OPCAB通过挽救存活心肌、改善左室重构、避免缺血再灌注损伤和心肌顿抑，
使左室收缩和舒张功能术后即刻就有明显提高;⑤rEE为定量评价OPCAB提供了
可靠的技术，尤其应用于冠脉外科术中监测和手术评价。
Objective To investigate the changes of left ventricular global function quantitatively before and after off-pump coronary artery bypass(OPCAB) treating myocardial ischemia simultaneously using transesophageal Doppler echocardiography(TEE) and cardiac catheterization. Methods 42 patients determining to accept OPCAB were enrolled among whom there was 1 patient with 1 lesion in left main coronary artery, 1 patient with a long lesion in right coronary artery, 12 patients with 2 lesions and 28 patients with 3 or more lesions in coronary artery proved by coronary angiography. All patients were deficient in cardiac function among whom there were 28 patients with NYHAII class, 12 patients with NYHA III class and 1 patient with NYHA IV class and the patients with mitrial valve stenosis and severe regurgitation, atrial fibrillation, atrioventricular block and those changed to conventional coronary artery byoass(cCABG) for all kinds of causes were excluded. Pulmonary vein flow(PVF), mitral valve flow(MVF), coronary si
nus flow(CSF), end-diastolic volume(EDV), end-systolic(ESV), stroke volume(SV), cardiac output(CO), cardiac index(CI) and left ventricular ejection fraction(LVEF) were measured by TEE before and after OPCAB. At the same time pulmonary capillary wedge pressure(PCWP), pulmonary artery pressure(PAP) and central vein pressure(CVP) were detected during OPCAB by cardiac catheter simultaneously. All the measurements were compared between pre- and immediately post-OPCAB and were correlation-analyzed with indices measured by cardiac catheter. Results (1)MVe, VTImve, PVs, PVd, VTIpvs, VTIpvd, CSs, CSd, VTIcss, VTIcsd, LVEF, CO, CI, SV, Tpvat-mvat and Tpvadt-mvadt had increased significantly (P<0.05~0.0001) and Mva, VTImva, MVedt, Pva, VTIpva, PVadt. EDV, ESV, PAP and PCWP had decreased obviously (P<0.05~0.001) post-OPCAB. There was no significant difference in other indices between pre- and post-OPCAB. (2)PCWP was highly correlated with MVat, MVe/Mva, Pva, VTIpva, PVadt, Tpvadt-mvadt and Tpvat-mvat, among which the co
rrelations between PCWP and Pva, VTIpva, Tpvadt-mvadt and Tpvat-mvat were better than others (r=0.64~0.86, P<0.001). There was poor negative correlation between PCWP and MVedt and MVadt(r= -0.35--0.58, P<0.001-0.05) and good positive correlation between CVP and CSa,
VTIcsa too(r=0.69~0.78, P<0.001). Conclusions (1)MVF, PVF, EDV, ESV, LVEF, SV, CO and CI measured by TEE can accurately reflect left ventricular diastolic and systolic function and the changes of cardiac pressure. (1)Measurements detected by TEE highly correlated with the pressures measured by cardiac catheter and PVa. VTIpva, Tpvat-mvat and Tpvadt-mvadt can be used to calculate and reflect PCWP. (3)Revascularizaton of coronary artery can be assessed by detection of CSF. (4)OPCAB can improve left ventricular performance significantly immediately after the procedure, which perhaps attributes to left ventricular remodeling, saving viable myocardium and avoiding ischemia-reperfusion injury and myocardial stunning. (5)TEE is a reliable technology to assess OPCAB. especially in the supervision and evaluation during coronary artery surgery,
引文
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