Czerny Martin, Zimpfer Daniel, Kilo Juliane, Gottardi Roman, Dunkler Daniela, Wolner Ernst, Grimm Michael
Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria.
Ann Thorac Surg. 2003 Mar;75(3):847-52. doi: 10.1016/s0003-4975(02)04652-0.
We compared our experience of minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass (CPB) with the standard procedure of total dissection of the heart and complete revascularization with CPB in patients who had elective reoperative coronary artery bypass grafting (redo-CABG).
We analyzed recurrence of angina and clinical outcome in 118 patients who had elective redo-CABG between January 1995 and April 2002. Seventy-four patients had redo-CABG with CPB, and 44 patients had redo-CABG without CPB.
Perioperative outcome was comparable with regard to morbidity and mortality rates. At follow-up, the mean Canadian Cardiovascular Society score was 1.3 +/- 0.6 in patients who had redo-CABG with CPB and 1.7 +/- 0.8 in patients who had redo-CABG without CPB (p = 0.02). At follow-up, patients who had redo-CABG without CPB had a higher rate of recurrence of angina (log rank = 0.001) and higher use of nitrates (p = 0.015). Target vessel revascularization was an independent predictor of recurrence of angina in younger patients (< 75 years; p = 0.012) but not in the elderly (> or = 75 years; p = 0.142).
In elective redo-CABG patients, minimal tissue dissection and target vessel revascularization without cardiopulmonary bypass did not add significant benefit with regard to perioperative morbidity and mortality. The unsatisfactory relief of symptoms does not seem to justify target vessel revascularization by a less invasive approach. Therefore, this technique should be offered exclusively to patients at high risk with complete revascularization using CPB, such as the elderly.
我们将在择期再次冠状动脉旁路移植术（redo-CABG）患者中，采用非体外循环（CPB）进行最小化组织分离和靶血管血运重建的经验，与采用CPB进行心脏全部分离和完全血运重建的标准手术方法进行了比较。
我们分析了1995年1月至2002年4月期间118例行择期redo-CABG患者的心绞痛复发情况和临床结局。74例患者采用CPB进行redo-CABG，44例患者采用非CPB进行redo-CABG。
围手术期结局在发病率和死亡率方面具有可比性。随访时，采用CPB进行redo-CABG的患者加拿大心血管学会平均评分为1.3±0.6，采用非CPB进行redo-CABG的患者为1.7±0.8（p = 0.02）。随访时，采用非CPB进行redo-CABG的患者心绞痛复发率更高（对数秩检验= 0.001），硝酸盐类药物使用率更高（p = 0.015）。靶血管血运重建是年轻患者（<75岁；p = 0.012）心绞痛复发的独立预测因素，但在老年患者（≥75岁；p = 0.142）中并非如此。
在择期redo-CABG患者中，非体外循环下的最小化组织分离和靶血管血运重建在围手术期发病率和死亡率方面并未带来显著益处。症状缓解不令人满意似乎无法证明通过侵入性较小的方法进行靶血管血运重建是合理的。因此，这种技术应仅提供给使用CPB进行完全血运重建的高危患者，如老年患者。
