Byrne J G, Karavas A N, Adams D H, Aklog L, Aranki S F, Filsoufi F, Cohn L H
Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts 02115, USA.
J Heart Valve Dis. 2001 Sep;10(5):584-90.
An alternative to avoid redo sternotomy in patients with patent left internal mammary artery-left anterior descending coronary artery (LIMA-LAD) grafts undergoing mitral valve surgery is right thoracotomy with moderate-deep hypothermia (approximately 20 degrees C) and fibrillatory arrest without aortic cross-clamping. Few reports exist which directly compare re-sternotomy and right thoracotomy.
Between July 1992 and February 2000, 47 patients (39 males, eight females; median age 66 years; range: 41-83 years; 41 in NYHA class III or IV) with patent LIMA-LAD grafts underwent mitral valve surgery. Thirty-seven patients were approached through a right thoracotomy with moderate-deep hypothermia (median 20 degrees C) and fibrillatory arrest (right thoracotomy group), and 10 were approached through a re-sternotomy, with aortic cross-clamping and cardioplegic arrest. The median ejection fraction was 42% (range: 20-71%). Univariate analysis was used to determine predictors of outcome, as well as to evaluate differences in characteristics between groups.
Operative mortality (OM) and perioperative myocardial infarction for the entire cohort was 11% and 10%, respectively, and there were no inter-group differences. No preoperative characteristics were associated with OM. Two LIMA-LAD graft injuries occurred in the re-sternotomy group compared with none in the right thoracotomy group (20% versus 0%, p = 0.04). Transfusion requirements were also greater in the redo sternotomy group (median 7 versus 2 packed red blood cell units, p = 0.04).
Right thoracotomy with moderate-deep hypothermia and fibrillatory arrest is the preferred approach for reoperative mitral valve surgery after coronary artery bypass grafting in the presence of patent LIMA-LAD grafts. These data suggest that this approach is associated with decreased incidence of LIMA-LAD graft injury, as well as reduced transfusion requirements.
对于接受二尖瓣手术且左乳内动脉-左前降支冠状动脉（LIMA-LAD）移植血管通畅的患者，避免再次开胸正中切口的一种替代方法是右胸切口，采用中度-深度低温（约20℃）和无主动脉阻断的颤动停搏。直接比较再次开胸正中切口和右胸切口的报告很少。
1992年7月至2000年2月期间，47例LIMA-LAD移植血管通畅的患者（39例男性，8例女性；年龄中位数66岁；范围：41-83岁；41例纽约心脏协会心功能分级为III或IV级）接受了二尖瓣手术。37例患者采用右胸切口，中度-深度低温（中位数20℃）和颤动停搏（右胸切口组），10例患者采用再次开胸正中切口，主动脉阻断和心脏停搏。射血分数中位数为42%（范围：20-71%）。采用单因素分析确定预后的预测因素，并评估组间特征差异。
整个队列的手术死亡率（OM）和围手术期心肌梗死发生率分别为11%和10%，组间无差异。术前特征与OM均无关联。再次开胸正中切口组发生2例LIMA-LAD移植血管损伤，而右胸切口组未发生（20%对0%，p = 0.04）。再次开胸正中切口组的输血需求量也更大（中位数7个对2个浓缩红细胞单位，p = 0.04）。
对于存在通畅LIMA-LAD移植血管的冠状动脉旁路移植术后再次二尖瓣手术，采用中度-深度低温和颤动停搏的右胸切口是首选方法。这些数据表明，该方法与LIMA-LAD移植血管损伤发生率降低以及输血需求量减少相关。
