左主干行冠狀動(dòng)脈旁路移植手術(shù)中遠(yuǎn)期效果分析

王文瑞 高長(zhǎng)青 肖蒼松 王 剛 王 嶸 吳 揚(yáng) 王加利

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左主干行冠狀動(dòng)脈旁路移植手術(shù)中遠(yuǎn)期效果分析

王文瑞 高長(zhǎng)青 肖蒼松 王 剛 王 嶸 吳 揚(yáng) 王加利

目的 總結(jié)2002～2008年行冠狀動(dòng)脈旁路移植手術(shù)的冠心病左主干患者遠(yuǎn)期橋血管通暢率。方法 2002～2008年冠心病左主干患者行冠狀動(dòng)脈旁路移植術(shù)共73例，男性57例，女性16例，患者年齡65.7±8.1歲。包括心肌梗死31例、左心室室壁瘤11例，合并瓣膜病變4例，術(shù)前使用主動(dòng)脈氣囊反搏(IABP)5例。行急診冠狀動(dòng)脈旁路移植術(shù)共5例，冠狀動(dòng)脈旁路移植術(shù)+瓣膜置換術(shù)共4例，冠狀動(dòng)脈旁路移植術(shù)+室壁瘤切除并左心室成形術(shù)共6例，機(jī)器人冠狀動(dòng)脈旁路移植術(shù)1例。其中體外循環(huán)下手術(shù)65例，非體外循環(huán)手術(shù)8例。左乳內(nèi)動(dòng)脈與左前降支吻合,大隱靜脈與靶血管吻合，靜脈吻合口超過兩個(gè)(含)時(shí)做序貫吻合。術(shù)后隨訪行冠狀動(dòng)脈64-CT或冠狀動(dòng)脈造影復(fù)查橋血管通暢率。結(jié)果 術(shù)后死亡2例(病死率2.7%)，死因分別為惡性心律失常和多器官衰竭。痊愈出院71例，隨訪患者53例，失訪18例，隨訪率74.6%，隨訪時(shí)間4個(gè)月～11年,平均隨訪時(shí)間73.2±30.2個(gè)月。隨訪期間死亡8例，其中3例為心源性死亡，心源性病死率5.7%，余者為其他疾病死亡。10例再發(fā)心絞痛，2例心肌梗死，2例腦梗死。 39例患者行橋血管CT或造影，動(dòng)脈橋通暢率97.4%，靜脈橋通暢率82.8%。結(jié)論 冠心病左主干患者病情重，行冠狀動(dòng)脈旁路移植術(shù)可有效改善冠脈血運(yùn)，遠(yuǎn)期效果良好。

左主干 冠狀動(dòng)脈旁路移植術(shù) 通暢率

左主干是左冠狀動(dòng)脈系統(tǒng)的起始部分，當(dāng)其出現(xiàn)狹窄時(shí)，易出現(xiàn)心室顫動(dòng)、心臟驟停等嚴(yán)重并發(fā)癥，因而引起心血管外科醫(yī)生的高度重視[1]。隨著醫(yī)療設(shè)備和技術(shù)的發(fā)展，目前內(nèi)科介入和外科手術(shù)的方法均可治療左主干疾病，達(dá)到再血管化的目的。但國(guó)外的隨機(jī)對(duì)照試驗(yàn)薈萃分析結(jié)果和注冊(cè)治療的研究結(jié)果均顯示冠狀動(dòng)脈旁路移植術(shù)(CABG)是左主干狹窄的“標(biāo)準(zhǔn)治療”[2，3]?，F(xiàn)將筆者科室2002～2008年因冠狀動(dòng)脈左主干狹窄而行冠狀動(dòng)脈旁路移植術(shù)患者的隨訪資料總結(jié)如下。

對(duì)象與方法

1.一般資料:2002年6月～2008年12月，筆者科室收治左主干狹窄>50%的患者共73例，其中男性57例，女性16例，患者平均年齡65.7±8.1歲。術(shù)前合并癥包括高血壓53例，高脂血癥46例，糖尿病25例，腦梗死9例，PCI術(shù)后6例，心肌梗死31例，左心室室壁瘤11例，合并瓣膜病變4例，冠脈造影顯示冠脈3支病變71例，雙支病變2例。術(shù)前使用主動(dòng)脈氣囊反搏(IABP)5例。術(shù)前心臟超聲檢查見左心室大小為46.0±6.2mm，平均射血分?jǐn)?shù)為54.4%±10.3%(表1)。

表1 左主干狹窄患者術(shù)前基本資料

2.術(shù)前處理：所有患者術(shù)前行冠狀動(dòng)脈造影確診后即停服抗血小板藥物，對(duì)于心絞痛頻繁發(fā)作、藥物控制無效、嚴(yán)重左主干狹窄者行急診手術(shù)。術(shù)前出現(xiàn)血流動(dòng)力學(xué)不穩(wěn)定者行主動(dòng)脈球囊反搏(intra-aortic balloon pumping,IABP)輔助循環(huán)并急診手術(shù)。

3.手術(shù)方法：全身麻醉下采用正中開胸或機(jī)器人微創(chuàng)小切口手術(shù)。對(duì)于正中開胸的患者，采用胸膜外帶蒂游離左乳內(nèi)動(dòng)脈技術(shù)，機(jī)器人手術(shù)則采用胸膜外全骨骼化游離乳內(nèi)動(dòng)脈。當(dāng)移植血管多于1支時(shí)，取大隱靜脈備用。所有乳內(nèi)動(dòng)脈與前降支吻合，大隱靜脈與其他靶血管吻合，吻合口在兩個(gè)以上時(shí)采用序貫吻合。血流動(dòng)力學(xué)穩(wěn)定的患者，行非體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)，術(shù)中血流動(dòng)力學(xué)不穩(wěn)定或者需同期行其他心臟手術(shù)的患者，則行體外循環(huán)下冠狀動(dòng)脈旁路移植術(shù)。對(duì)于有瓣膜病變的患者，先完成冠狀動(dòng)脈的吻合再處理瓣膜病變；對(duì)于室壁瘤的患者，先行室壁瘤切除左心室成形術(shù)，再行移植血管與冠狀動(dòng)脈靶血管的吻合。

4.術(shù)后隨訪：通過門診、住院以及電話隨訪，統(tǒng)計(jì)患者M(jìn)ACE事件發(fā)生情況，于術(shù)后5～12年行冠狀動(dòng)脈造影或者心臟64-CT冠狀動(dòng)脈重建，評(píng)價(jià)橋血管的通暢率,橋血管的評(píng)價(jià)指標(biāo)參考采用Fitzgibbon的標(biāo)準(zhǔn)，根據(jù)以下公式計(jì)算橋血管的通暢率：通暢率(%)=橋血管或吻合口總數(shù)-(橋血管或吻合口閉塞數(shù)目)/橋血管或吻合口總數(shù)×100%。

結(jié) 果

1.早期臨床結(jié)果：共有73例無保護(hù)左主干狹窄患者納入本研究，所有患者術(shù)前基本資料見表1。72例患者在全身麻醉下、正中胸骨切口入路進(jìn)行手術(shù)， 其中59例行單純體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)(包括5例急診手術(shù))，6例同時(shí)行左心室室壁瘤切除并左心室成形術(shù)，4例同時(shí)行行瓣膜置換術(shù)，3例患者行非體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)，1例患者行達(dá)芬奇機(jī)器人輔助下冠狀動(dòng)脈旁路移植術(shù)。6例患者與術(shù)前行IABP植入，3例于術(shù)中行IABP植入。上述所有患者乳內(nèi)動(dòng)脈均與前降支吻合，大隱靜脈與其他狹窄的冠脈吻合，1例機(jī)器人手術(shù)則采用HYBRID技術(shù)，即手術(shù)行前降支與乳內(nèi)動(dòng)脈的吻合，術(shù)后于狹窄的右冠植入支架1枚。術(shù)中乳內(nèi)動(dòng)脈橋血管血流量為28.8±16.2ml/min，靜脈橋血流量為49.6±23.2ml/min。術(shù)后住院期間2例患者死亡，死因分別為惡性心律失常及多器官衰竭。其余71例患者均康復(fù)出院。

2.術(shù)后隨訪結(jié)果：成功隨訪患者53例，失訪18例，隨訪率74.6%，隨訪時(shí)間4個(gè)月～11年,平均隨訪時(shí)間73.2±30.2個(gè)月。隨訪期內(nèi)MACE事件發(fā)生情況見表2。隨訪期間10例患者再發(fā)心絞痛，2例心肌梗死，2例出現(xiàn)腦梗死，1例腦出血。 39例行橋血管CT或造影，動(dòng)脈橋血管通暢率97.4%，靜脈橋血管通暢率82.8%。隨訪期間共死亡8例，病死率15.1%，MACE.主要心血腦血管不良事件；TVR/TLR.靶血管/靶病變的再次血運(yùn)重建其中3例為心源性死亡，心源性病死率5.7%，余者為其他疾病死亡。隨訪期間患者Kaplan-Meier生存曲線見圖1。

表2 MACE事件發(fā)生情況

圖1 患者生存曲線圖

左主干狹窄是指血管病變侵犯了左主干管腔50%以上，80%的左主干患者都合并有多支冠狀動(dòng)脈病變[2]。由于左主干供應(yīng)心臟的70%血液,一旦左主干缺血或血流被阻斷,極易發(fā)生猝死、心力衰竭、心肌梗死及心源性休克，故而是冠心病患者中的高危人群[4,5]。對(duì)于此類患者，如合并其他冠狀動(dòng)脈分支血管病變，冠狀動(dòng)脈旁路移植術(shù)是一種生存優(yōu)勢(shì)頗佳的再血管化有效方法[6]。

近年來有文獻(xiàn)報(bào)道無保護(hù)的左主干狹窄行PCI的成功病例，并于冠狀動(dòng)脈旁路移植術(shù)進(jìn)行了對(duì)比。一項(xiàng)多中心研究報(bào)道了2240例左主干狹窄患者行PCI或CABG后5年隨訪結(jié)果,目標(biāo)血管的再血管化率PCI組高于CABG組，且差異有統(tǒng)計(jì)學(xué)意義[7]。但是少有對(duì)此類患者5～10年的隨訪。本研究重點(diǎn)收集了左主干狹窄患者行CABG后中遠(yuǎn)期生存情況以及橋血管的通暢率，發(fā)現(xiàn)乳內(nèi)動(dòng)脈只有1例閉塞，其余均通暢，說明乳內(nèi)動(dòng)脈遠(yuǎn)期通暢率效果理想，遠(yuǎn)期通暢率高于國(guó)內(nèi)報(bào)道的前降支PCI術(shù)后的通暢率。

LIMA作為CABG術(shù)的首選材料，已被世界公認(rèn)，常規(guī)使用LIMA與LAD吻合及大隱靜脈與其余冠脈吻合被認(rèn)為是標(biāo)準(zhǔn)的CABG術(shù)式[8，9]。本研究中所有患者均使用乳內(nèi)動(dòng)脈與前降支吻合，除1例患者術(shù)后3年乳內(nèi)動(dòng)脈閉塞，其余患者的動(dòng)脈橋血管均未見明顯狹窄，通暢率達(dá)97.4%，雖然國(guó)人乳內(nèi)動(dòng)脈偏細(xì)，但是在與前降支吻合后，通暢率并未與國(guó)外報(bào)道有所不同，這再次印證了乳內(nèi)動(dòng)脈橋遠(yuǎn)期通暢率高，是理想的搭橋血管[8]。

大隱靜脈是行冠狀動(dòng)脈旁路移植術(shù)的理想靜脈材料，近年來對(duì)靜脈橋通暢率的研究顯示靜脈橋通暢率雖不及動(dòng)脈橋，但遠(yuǎn)期通暢率亦能保持較高水平。且大隱靜脈有獲取容易，血管口徑大等特點(diǎn)，故而一直在冠狀動(dòng)脈旁路移植術(shù)中使用。本研究中遠(yuǎn)期靜脈橋血管通暢率達(dá)到82.8%，這與筆者獲取大隱靜脈的方式有一定關(guān)系。在游離大隱靜脈時(shí)，筆者采用no touch技術(shù)，盡量少或者不接觸靜脈血管壁，減少對(duì)靜脈的牽拉，避免了血管內(nèi)皮的損傷[10]。國(guó)外的相關(guān)研究也顯示此種游離大隱靜脈的方式8.5年的通暢率可達(dá)90%，高于傳統(tǒng)游離的大隱靜脈76%的通暢率[11]?？傊笾鞲苫颊咝泄诿}搭橋術(shù)后，不論何種橋血管材料，中遠(yuǎn)期通暢率都能保持較高水平，說明冠狀動(dòng)脈旁路移植術(shù)是治療左主干的有效手段，對(duì)于左主干合并多支血管病變患者，外科手術(shù)不失為一種很好的治療方法。

本研究為非前瞻性研究,且樣本量小,不能完全代表左主干患者搭橋術(shù)后的整體狀況,且靶血管的質(zhì)量和內(nèi)徑、失訪患者中的橋血管情況及死亡病例等因素未納入本分析中，是本研究的不足，尚需進(jìn)一步研究和完善，以便得出更加客觀的結(jié)果。

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(修回日期：2015-03-11)

A Mid to Long Term Results of Patients with Left Main Disease Undergoing Coronary Artery Bypass Grafting.

WangWenrui,GaoChangqing,XiaoCangsong,etal.

InstituteofCardiacSurgeryofChinesePLA,DepartmentofCardiovascularSurgeryofChinesePLAGeneralHospital,Beijing100853,China

Objective To summary the long-term graft patency and the follow-up outcome of coronary artery bypass grafting in left main disease. Methods Seventy three patients

CABG including 57 male and 16 female patients with a mean age of 65.7±8.1 years. Indications for the patients included myocardial infarction (31 cases), left ventricular aneurysm(11 cases), valve disease(4 cases). Five patients were preoperatively supported by intra-aortic balloon pumping (IABP). 5 patients received emergency coronary artery bypass grafting (ECABG). Four patients were with valve replacement, Five patients were with left ventricular aneurysm operation,and 1 patient were with totally endoscopic coronary artery bypass (TECAB). Sixty five on-pump operation were performed and 8 patients received off-pump surgery. The left internal mammary artery(LIMA) was routinely anastomosed to left anterior descending arter (LAD) and great saphenous vein (GSV) to other target vessels in a segmental or sequential anastomosis. The graft patency was evaluated by 64-CT scan or angiography. Results two patients died of arrhythmia and multiple organ failure after surgery respectively. The left 71 patients were discharged. 53 patients received follow-up successfully. The follow-up rate was 74.6%. The follow-up period ranged from 4 month to 11 year with a mean time of 73.2±30.2 month. Eight patients died during follow-up period. Three of them were cardiac death. The other 5 were died of non-cardiac disease. Ten patients had recurrence of angina. Two patients had myocardial infarction. 2 patients had cerebral infarction. Thirty nine patients received 64-CT or angiography. The LIMA-LAD patency was 97.4%, and the GSV graft patency was 82.8%. Conclusion Proper indication and timing for LM disease were essential for optimal results. CABG was safe and efficacious for patients suffered from LM disease. The mid to long-term results were satisfied.

Left main coronary artery; Coronary artery bypass grafting; Patency

100853 北京，中國(guó)人民解放軍總醫(yī)院心血管外科

高長(zhǎng)青，電子信箱:gaochangq@126.com

R654.33;R654.27

A DOI 10.11969/j.issn.1673-548X.2015.10.020

2015-02-26)