Bonacchi M, Prifti E, Frati G, Leacche M, Salica A, Giunti G, Proietti P, Furci B, Miraldi F
Istituto di Chirurgia del Cuore e dei Grossi Vasi, Università degli Studi di Roma La Sapienza, Italy.
J Card Surg. 1999 Nov-Dec;14(6):408-16.
Total arterial myocardial revascularization (TAMR) is feasible because of the excellent long-term patency of the arterial conduits. We present five new surgical configurations for TAMR.
Between December 1998 and July 1999, 34 patients with triple vessel disease underwent TAMR. All patients were in CCS III or IV. Sketelonized internal mammary arteries (IMAs) were used. The surgical techniques for TAMR consisted of Y or T composite grafts constructed between the in situ RIMA and free LIMA graft or radial artery (RA) conduit in three different configurations. Other techniques uses included a T graft constructed between the RA conduit and free LIMA graft in two configurations. Twenty-six (76%) patients underwent contrast-enhanced TTE color Doppler before and after adenosine provocative test, and seven (20%) patients had postoperative coronary angiography.
Overall, 144 anastomoses (average number per patient, 4.2) were completed. One (2.9%) patient undergoing an inverted T graft technique died on postoperative day 2. Another patient (2.9%) undergoing the right Y graft technique using IMAs and RA suffered perioperative AMI due to RA conduit vasospasm. Contrast-enhanced TTE color Doppler before and after the adenosine provocative test and at 1 week postoperation revealed a coronary flow reserve (CFR) of 2.1 +/- 0.2 in the LIMA stem, and in the RIMA stem, a CFR of 2.3 +/- 0.3 (P < 0.007). In one patient undergoing the right Y graft technique using IMAs, we found only anomalous flow dynamic parameters of RIMA, suggesting a partial graft closure. The angiographic examination revealed a free LIMA graft closure. At 6 +/- 2.4 months after operation 33 patients were alive and free of angina. The IMAs stem evaluation by TTE color Doppler at follow-up revealed a 2.45 +/- 0.1 mm LIMA diameter and 2.6 +/- 0.2 mm RIMA diameter, which was more than early postoperative data of P < 0.001 and P < 0.007, respectively.
These data indicate that TAMR in young patients perhaps offers a better postoperative outcome and perhaps should be part of the surgical armamentarium. These techniques apply the "nontouch" principle and should be taken into consideration in patients with a heavily calcified aorta. Contrast-enhanced TTE color Doppler is a safe, accurate, and noninvasive test, which allows assessment of IMA patency and CFR evaluation. The flow reserve of the IMAs seems to be adequate for multiple coronary anastomoses.
由于动脉血管桥具有出色的长期通畅性，全动脉化心肌血运重建术（TAMR）是可行的。我们介绍了五种用于TAMR的新手术构型。
1998年12月至1999年7月期间，34例三支血管病变患者接受了TAMR。所有患者均为加拿大心血管学会（CCS）分级III级或IV级。使用了骨骼化的胸廓内动脉（IMA）。TAMR的手术技术包括在原位右胸廓内动脉（RIMA）与游离的左胸廓内动脉（LIMA）移植物或桡动脉（RA）血管桥之间构建Y型或T型复合移植物，共有三种不同构型。其他使用的技术包括在RA血管桥与游离的LIMA移植物之间构建T型移植物，共有两种构型。26例（76%）患者在腺苷激发试验前后接受了对比增强经胸超声心动图（TTE）彩色多普勒检查，7例（20%）患者进行了术后冠状动脉造影。
总体而言，共完成了144处吻合（平均每位患者4.2处）。1例（2.9%）接受倒T型移植物技术的患者于术后第2天死亡。另1例（2.9%）接受使用IMA和RA的右Y型移植物技术的患者因RA血管桥血管痉挛发生围手术期急性心肌梗死（AMI）。腺苷激发试验前后及术后1周的对比增强TTE彩色多普勒检查显示，LIMA主干的冠状动脉血流储备（CFR）为2.1±0.2，RIMA主干的CFR为2.3±0.3（P<0.007）。在1例接受使用IMA的右Y型移植物技术的患者中，我们仅发现RIMA的血流动力学参数异常，提示移植物部分闭塞。血管造影检查显示游离的LIMA移植物闭塞。术后6±2.4个月时，33例患者存活且无心绞痛。随访时通过TTE彩色多普勒对IMA主干的评估显示，LIMA直径为2.45±0.1mm，RIMA直径为2.6±0.2mm，分别比术后早期数据有显著增加（P<0.0
