Byrne J G, Aklog L, Adams D H, Cohn L H, Aranki S F
Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Ann Thorac Surg. 2001 Jan;71(1):196-200. doi: 10.1016/s0003-4975(00)02182-2.
Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integrating the currently available newer technologies for each patient indication.
Between October 1991 and October 1999, 50 consecutive patients underwent reoperative CABG through a left thoracotomy. Age was 65 +/- 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 +/- 13. In 36 patients (72%) the left internal mammary artery had been placed to the left anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery-left anterior descending coronary artery graft was patent. The mean duration from previous CABG was 8.0 +/- 4.8 years. Three approaches were used: (1) conventional cardiopulmonary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%).
The off-pump CABG technique was used in the majority of recent patients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hemodynamic instability. When cardiopulmonary bypass was used its duration was 122 +/- 59 minutes and mean temperature on bypass was 24 degrees +/- 6 degrees C. In the 4 patients in whom the Heartport system was used, the median endoaortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were performed to an anterolateral coronary target. There were 3 of 50 (6%) operative deaths, 2 in the conventional group and 1 in the endoaortic balloon occlusion group. The mean length of stay in the 47 survivors was 7.8 +/- 3.9 days (median, 7 days).
Reoperative CABG by left thoracotomy remains a challenging operation. Several techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon's armamentarium to allow a tailored approach for each operation based on patient indications.
经左胸切口进行再次冠状动脉旁路移植术（CABG）是一项具有挑战性的手术，没有一种占主导地位的方法。我们为这一困难的患者群体制定了一种量身定制的策略，根据每位患者的具体情况整合当前可用的更新技术。
1991年10月至1999年10月，连续50例患者经左胸切口进行再次CABG。年龄为65±9岁，40例（80%）为男性，术前射血分数为40±13。在36例患者（72%）中，初次CABG时左乳内动脉已被吻合至左前降支冠状动脉，在这36例患者中的25例（70%），该左乳内动脉-左前降支冠状动脉移植血管通畅。距上次CABG的平均时间为8.0±4.8年。采用了三种方法：（1）使用颤动或循环停止的传统体外循环（n = 33，66%）；（2）Heartport主动脉内球囊阻断（n = 4，8%）；（3）非体外循环心脏跳动技术（n = 13，26%）。
大多数近期患者采用了非体外循环CABG技术，1例（7.7%）因血流动力学不稳定而转为体外循环。使用体外循环时，其持续时间为122±59分钟，体外循环期间的平均体温为24℃±6℃。在使用Heartport系统的4例患者中，主动脉内阻断的中位持续时间为49分钟。每位患者平均接受1.4根移植血管。70例患者中的60例（89%）在冠状动脉前外侧目标处进行了远端吻合。50例患者中有3例（6%）手术死亡，传统组2例，主动脉内球囊阻断组1例。47例幸存者的平均住院时间为7.8±3.9天（中位数，7天）。
经左胸切口进行再次CABG仍然是一项具有挑战性的手术。包括非体外循环CABG、传统体外循环、循环停止和主动脉内球囊阻断在内的几种技术，应纳入外科医生的技术储备，以便根据患者情况为每台手术采用量身定制的方法。
