Fabricius A M, Gerber W, Hanke M, Garbade J, Autschbach R, Mohr F W
Division of Cardiovascular Surgery, Herzzentrum University of Leipzig, Leipzig, Germany.
Eur J Cardiothorac Surg. 2001 Jun;19(6):853-8. doi: 10.1016/s1010-7940(01)00692-3.
To assess the impact of immediate angiography in patients with defined clinical and laboratory criteria of perioperative myocardial infarction after coronary artery bypass operation.
Between January 1999 and December 1999 2052 patients underwent coronary artery bypass grafting in our institution. Out of this cohort 131 (6.4%) patients met the criteria of perioperative myocardial ischemia, which was defined as: (a) increase in the isoenzyme ratio of creatinine phosphokinase (CK/CK-MB] above 10%; (b) ischemic electrocardiographic episodes (defined as a new onset of elevated ST-segment change lasting at least 1 min and involving a shift from baseline of greater than or equal to 0.1 mV of ST-depression and a new association of a postoperative Q; (c) recurrent episodes of, or sustained ventricular tachyarrhythmia as well as ventricular fibrillation; (d) hemodynamic deterioration despite adequate inotropic support.
Angiography was performed in 108 patients (5.3%, group A) whereas 23 patients (1.1%, group B) were immediately re-operated due to severely compromised hemodynamics. Angiographic results in group A showed regular grafts in 45 patients (2.2%); 63 patients (3.1%) had either an occlusion (n=41), incorrect anastomosis (n=29), graft stenosis (n=14), graft spasm (n=6), displaced graft (n=6), poor distal run-off (n=5) or incomplete revascularization (n=2). In group A 43 patients underwent a re-operation (34 patients) or an early angioplasty (nine patients). Due to poor coronary artery status no intervention was performed in the remaining 20 patients with angiographic findings. Operative findings in group B showed graft occlusion in ten patients (43.5%), incorrect anastomosis in five patients (21.7%), bleeding, stretched graft, venous graft spasm and displaced graft in one patient (4.3%) each, and no patho-morphological finding in 4 patients (17.4%). Thirty-day mortality rate was ten patients in group A (9.3%), all of them with angiographic findings, as opposed to nine patients (39.1%) in group B.
ST-change and elevated CK/CK-MB enzyme ratio is highly indicative for possible graft failure and should be followed early angiographic control to assess the need for reintervention.
评估即时血管造影术对符合冠状动脉搭桥手术后围手术期心肌梗死特定临床和实验室标准患者的影响。
1999年1月至1999年12月期间，2052例患者在我院接受冠状动脉搭桥手术。在这一队列中，131例（6.4%）患者符合围手术期心肌缺血标准，其定义为：（a）肌酸磷酸激酶同工酶比值（CK/CK-MB）升高超过10%；（b）缺血性心电图发作（定义为新出现的ST段抬高改变持续至少1分钟，ST段压低从基线偏移大于或等于0.1 mV，以及术后新出现的Q波）；（c）室性心动过速或持续性室性心律失常以及心室颤动的反复发作；（d）尽管给予了足够的正性肌力支持，但血流动力学仍恶化。
108例患者（5.3%，A组）进行了血管造影，而23例患者（1.1%，B组）因严重血流动力学受损立即再次手术。A组血管造影结果显示正常移植血管45例（2.2%）；63例患者（3.1%）存在移植血管闭塞（n = 41）、吻合错误（n = 29）、移植血管狭窄（n = 14）、移植血管痉挛（n = 6）、移植血管移位（n = 6）、远端血流不佳（n = 5）或血运重建不完全（n = 2）。A组中43例患者接受了再次手术（34例）或早期血管成形术（9例）。由于冠状动脉状况不佳，其余20例有血管造影结果的患者未进行干预。B组手术发现10例患者（43.5%）移植血管闭塞，5例患者（21.7%）吻合错误，1例患者（4.3%）分别出现出血、移植血管拉伸、静脉移植血管痉挛和移植血管移位，4例患者（17.4%）未发现病理形态学改变。A组30天死亡率为10例患者（9.3%），均有血管造影结果，而B组为9例患者（39.1%）。
ST段改变和CK/CK-MB酶比值升高高度提示可能存在移植血管失败，应尽早进行血管造影检查以评估是否需要再次干预。
