Jegaden O, Bontemps L, de Gevigney G, Chatel C, Itti R, Mikaeloff P
Department of Cardio-vascular Surgery, Cardiovascular hospital, Cl Bernard University, Lyon, France.
Eur J Cardiothorac Surg. 1999 Aug;16(2):131-4. doi: 10.1016/s1010-7940(99)00160-8.
To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries.
Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients.
During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy.
Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.
评估使用双侧乳内动脉（IMA）和胃网膜动脉（GEA）进行外科血管重建术为心肌提供的血流供应情况。
对122例（平均年龄61±9岁）仅使用IMA和GEA进行冠状动脉旁路移植术（CABG）的患者，在未接受药物治疗的情况下，通过运动铊心肌闪烁显像进行了为期两年的评估。通常，右侧IMA用于绕过左前降支冠状动脉，左侧IMA在需要时作为序贯移植物绕过对角支和边缘动脉。50例患者中GEA用于绕过右冠状动脉（RCA），72例患者中GEA用于绕过其后分支。
在最大或次最大运动应激试验期间，119例患者（98%）无症状，26例患者（21%）出现中度缺血性心电图改变，这些改变与血管重建不完全以及使用GEA绕过RCA相关（P<0.01）。三分之一的患者在运动后再分布时出现中度缺血性铊缺损（前壁10例；侧壁2例；下壁28例）。铊闪烁显像检测到的无症状性残余心肌缺血与心电图改变和血管重建不完全相关（P<0.001）；当GEA绕过RCA时，下壁铊缺损更常见（P<0.05）。然而，26%的患者尽管血管重建完全仍有残余缺血，并且在至少18%的GEA病例和8%的右侧IMA病例中，在最大运动水平时动脉移植物血流不足，导致铊闪烁显像检测到无症状性残余心肌缺血。
使用双侧IMA和GEA进行心肌血管重建术在大多数情况下可提供令人满意的心肌灌注；然而，三分之一的患者检测到无症状性残余心肌缺血，这与血管重建不完全以及可能由于动脉移植物直径小导致的血流供应不足有关。
