Calafiore A M, Di Giammarco G, Teodori G, Mazzei V, Vitolla G
Department of Cardiac Surgery, G. D'Annunzio University, San Camillo de' Lellis Hospital, Via C. Forlanini 50, 66100 Chieti, Italy.
Heart Surg Forum. 1998;1(1):20-5.
Coronary artery bypass grafting (CABG) without the heart lung machine has been possible for easily accessible targets such as the anterior descending or proximal right coronary. Until now technical difficulty in reaching lateral and inferior wall targets imposed significant barriers to multivessel off-pump grafting. To expand the potential for off-pump CABG the authors have devised new exposure and stabilization techniques suitable for all target vessels. In this report we relate our experience with these new techniques and demonstrate that multivessel coronary bypass can be safely performed without cardiopulmonary bypass (CPB).
From February 8, 1993 to December 16, 1997 a total of 280 patients underwent myocardial revascularization on the beating heart via median sternotomy. Until May 20, 1997 only patients with high preoperative risk factors for CPB were considered for this approach (Group A; N = 122). After this date any patients with favorable anatomy were included (Group B; N = 158) and were subsequently compared with patients operated on using CPB during the same time interval (Group C; N = 114). In Group B patients lateral and/or inferior wall targets were exposed by means of 4 cloth slings (2 through the transverse sinus and 2 behind the inferior vena cava) and by positioning the patients in Trendelenburg with rightward rotation of the table. Regional stabilization of the target artery was obtained with a commercial stabilizing foot plate.
Thirty day hospital mortality was only 2 patients (1.6%) in Group A, 3 patients (1.9%) in Group B, and 3 patients (2.6%) in Group C (NS). Postoperative complications were low in both Group A and B. When Group B was compared with a similar cohort in whom CPB was used (Group C), there were statistically significant improvements in ICU and hospital stay demonstrated when CPB was not used (16.8+/-10.7 vs 26.3+/-38.6 hours respectively; p = 0.007, and 4.1+/-1.5 vs 5.5+/-2.4 days respectively, p<0.001). Angiographic followup was available for 78 patients in Groups A and B with a global patency rate (all grafts) of 98.6%, including a patency rate of 96.7% for 60 grafts to obtuse marginal branches of the circumflex).
Multivessel CABG without CPB is possible with results similar to those obtained with pump-oxygenator support using simple exposure and stabilization techniques.
对于易于接近的目标血管，如前降支或右冠状动脉近端，不使用心肺机进行冠状动脉旁路移植术（CABG）已成为可能。到目前为止，到达侧壁和下壁目标血管的技术难度对多支血管非体外循环移植术构成了重大障碍。为了扩大非体外循环CABG的可能性，作者设计了适用于所有目标血管的新暴露和稳定技术。在本报告中，我们介绍了我们使用这些新技术的经验，并证明多支血管冠状动脉旁路移植术可以在不使用心肺转流（CPB）的情况下安全进行。
从1993年2月8日至1997年12月16日，共有280例患者通过正中胸骨切开术在跳动的心脏上进行心肌血运重建。直到1997年5月20日，仅将具有CPB术前高风险因素的患者纳入该方法（A组；N = 122）。在此日期之后，任何解剖结构合适的患者均被纳入（B组；N = 158），随后与同期使用CPB进行手术的患者（C组；N = 114）进行比较。在B组患者中，通过4条布带（2条穿过横窦和2条在下腔静脉后方）并将患者置于头低脚高位且手术台向右旋转来暴露侧壁和/或下壁目标血管。使用商用稳定脚板实现目标动脉的局部稳定。
A组30天医院死亡率仅2例（1.6%），B组3例（1.9%），C组3例（2.6%）（无统计学差异）。A组和B组的术后并发症均较低。当将B组与使用CPB的类似队列（C组）进行比较时，未使用CPB时在重症监护病房（ICU）停留时间和住院时间有统计学上的显著改善（分别为16.8±10.7小时对26.3±38.6小时；p = 0.007，以及分别为4.1±1.5天对5.5±2.4天，p<0.001）。A组和B组的78例患者进行了血管造影随访，总体通畅率（所有移植物）为98.6%，包括60条至回旋支钝缘支移植物的通畅率为96.7%。
使用简单的暴露和稳定技术，不使用CPB进行多支血管CABG是可行 的，其结果与使用体外循环支持获得的结果相似。
