Chavanon Olivier, Durand Michel, Hacini Rachid, Bouvaist Hélène, Noirclerc Marianne, Ayad Tarek, Blin Dominique
Department of Cardiac Surgery, Grenoble University Hospital, France.
Ann Thorac Surg. 2002 Feb;73(2):499-504. doi: 10.1016/s0003-4975(01)03335-5.
Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease.
From January 1995 to July 2000, 171 consecutive patients were reviewed in a prospective database. Ninety-one patients underwent coronary artery bypass grafting without cardiopulmonary bypass (group A), and 80 patients were operated on under cardiopulmonary bypass with aortic cross-clamp and cardioplegia (group B).
Patient data were similar in both groups except for the Euroscore (mean; 3.4+/-6.1, group A versus 2.5+/-4.5, group B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection fraction (mean, 54.6%+/-15.8%, group A versus 63.1%+/-12.7%, group B; p < 0.001). Severe aortic calcification was present in 6 group A patients, versus no patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to cardiopulmonary bypass occurred in 1 patient, who was excluded from the study. Bleeding was higher in group A (852.6+/-288 mL versus 712.4+/-274 mL, p < 0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. Myocardial infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon pump was used in 2 patients (group B). One patient died (group A) and 1 had an embolic stroke (group B). After discharge, 2 more patients died (group A, day 91; group B day 141), and 1 patient suffered an embolic stroke (group B). One patient in each group presented with dysfunction of the gastroepiploic artery graft requiring successful percutaneous transluminal angioplasty on the right posterolateral artery.
These results suggest that off-pump coronary artery bypass grafting using the left internal thoracic artery and gastroepiploic artery is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta.
全动脉化和非体外循环血管重建术在冠状动脉旁路移植术中的应用日益广泛。本研究描述了我们在一组双支血管病变患者中，通过正中胸骨切开术，在有或无体外循环的情况下，单独使用左胸廓内动脉和胃网膜动脉的经验。
1995年1月至2000年7月，对前瞻性数据库中的171例连续患者进行回顾。91例患者接受非体外循环冠状动脉旁路移植术（A组），80例患者在体外循环下使用主动脉交叉钳夹和心脏停搏液进行手术（B组）。
除欧洲心脏手术风险评估系统评分（平均值；A组为3.4±6.1，B组为2.5±4.5；欧洲心脏手术风险评估系统评分>6：A组为26.4%，B组为10%；p<0.05）和射血分数（平均值，A组为54.6%±15.8%，B组为63.1%±12.7%；p<0.001）外，两组患者数据相似。A组有6例患者存在严重主动脉钙化，而B组无患者有此情况。A组手术时间较短（185分钟对213分钟，p<0.0001），远端吻合口较少（2.26个对2.5个，p<0.05）。1例患者转为体外循环，该患者被排除在研究之外。A组出血较多（852.6±288毫升对712.4±274毫升，p<0.05），但两组输血情况相似。两组房颤、术后使用正性肌力药物支持及住院时间相似。A组心肌梗死发生率较低（1例对4例）。B组有2例患者术后使用主动脉内球囊泵。1例患者死亡（A组），1例发生栓塞性中风（B组）。出院后，又有2例患者死亡（A组，第91天；B组，第141天），1例患者发生栓塞性中风（B组）。每组各有1例患者出现胃网膜动脉移植物功能障碍，需要对右后外侧动脉成功进行经皮腔内血管成形术。
这些结果表明，即使在高危患者中，使用左胸廓内动脉和胃网膜动脉进行非体外循环冠状动脉旁路移植术也是安全的。这种方法允许对主动脉采用绝对的非接触技术。
