Lin J C, Fisher D L, Szwerc M F, Magovern J A
Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA.
Ann Thorac Surg. 2000 Oct;70(4):1350-4. doi: 10.1016/s0003-4975(00)01720-3.
An objective method for determining intraoperative graft patency is an essential part of minimally invasive direct coronary artery bypass. This study compares angiography and Doppler methods for graft analysis during minimally invasive direct coronary artery bypass and presents long-term outcome in a cohort of patients.
Between March and October 1997, 35 patients had elective minimally invasive direct coronary artery bypass procedures in which the left internal mammary artery was anastomosed to the left anterior descending coronary artery. Immediate graft patency was determined with intraoperative angiography using selective injection of the left internal mammary artery from a femoral approach and with Doppler flow analysis using a 1-mm, 20-MHz Doppler probe placed directly on the graft.
There was immediate perfect patency with brisk flow in 91% of patients (32 of 35). A normal Doppler study, defined as a diastolic predominant pattern with a diastolic flow velocity of greater than 15 cm/second, was found in all patients with normal angiograms. All patients with abnormal angiograms also had abnormal Doppler flow. Thus, Doppler analysis was 100% accurate for confirming graft patency and for detecting failed grafts. All abnormal grafts were successfully revised, which allowed 100% early patency. Operative mortality was 2.8% (1 of 35) and there have been no late deaths at a follow-up of more than 2 years. One patient required angioplasty of the anastomosis (1 of 34, 2.9%), but none have required subsequent surgical intervention.
Objective analysis of graft flow in the operating room is necessary to achieve 100% early graft patency with minimally invasive direct coronary artery bypass operations. Doppler analysis is the preferred initial method, because it is safe, accurate, and rapid.
确定术中移植物通畅性的客观方法是微创直接冠状动脉旁路移植术的重要组成部分。本研究比较了微创直接冠状动脉旁路移植术中用于移植物分析的血管造影和多普勒方法，并报告了一组患者的长期结果。
1997年3月至10月期间，35例患者接受了择期微创直接冠状动脉旁路移植手术，将左乳内动脉吻合至左前降支冠状动脉。术中通过经股动脉途径选择性注射左乳内动脉进行血管造影以及使用直接置于移植物上的1毫米、20兆赫多普勒探头进行多普勒血流分析来确定移植物即刻通畅情况。
91%的患者（35例中的32例）移植物即刻完全通畅且血流活跃。在所有血管造影正常的患者中均发现多普勒检查结果正常，即舒张期为主型，舒张期血流速度大于15厘米/秒。所有血管造影异常的患者多普勒血流也异常。因此，多普勒分析在确认移植物通畅和检测移植物失败方面的准确率为100%。所有异常移植物均成功修复，实现了移植物100%的早期通畅。手术死亡率为2.8%（35例中的1例），在超过2年的随访中无晚期死亡病例。1例患者需要对吻合口进行血管成形术（34例中的1例，2.9%），但后续均无需手术干预。
在微创直接冠状动脉旁路移植手术中，为实现移植物早期100%通畅，有必要在手术室对移植物血流进行客观分析。多普勒分析是首选的初始方法，因为它安全、准确且快速。
