Bonatti J, Nagele G, Hangler H, Danzmayr M, Mueller L, Rieger M, Bodner G, Laufer G
Department of Cardiac Surgery,Innsbruck University Hospital, Innsbruck, Austria.
Heart Surg Forum. 2002;5 Suppl 4:S272-81.
Crossclamping a severely atherosclerotic ascending aorta carries a significant risk of stroke in coronary artery bypass grafting. Besides other techniques aortic no touch concepts are increasingly applied for management of this problem.
Out of 407 patients undergoing epiaortic scanning during coronary artery bypass grafting 38 (9.3%) exhibited severe ascending aortic atherosclerosis. 22 of these patients (18 male, 4 female, age 72 (57-79) years, Parsonnet Score 11 (0-18), Euro Score 8 (2-13), McSPI Stroke Risk Index 6 (1-30) %) were operated on using a beating heart and aortic no touch technique. All patients received at least one internal mammary artery (IMA) in situ graft and additional extraanatomical bypass conduits: venous Y-graft from the IMA (n=14), arterial Y-graft from the IMA (n=3), vein graft from the axillary artery (n=3), vein graft from the IMA stump (n=2), vein graft from the innominate artery (n=2).
No stroke occurred. The rate of perioperative myocardial infarction (CKMB rt; 50 U/l) was 5/22. Median ICU length of stay was 54 (15-1245) h. Hospital mortality was 2/22. Pre- and postoperative angina class (CCSC) were 3.3 +/- 0.9 and 1.4 +/- 0.9 respectively (p<0.001). After a median follow up period of 8 months 3 deaths, one stroke, and one myocardial infarction occurred. On 3D multislice CT scan reconstructions which were performed in 13 patients during the first postoperative year all IMA grafts to the LAD and 11 out of 13 extraanatomical vein grafts were shown to be patent.
Performance of beating heart extraanatomical coronary artery bypass grafts for management of a heavily diseased ascending aorta can result in a very low stroke rate despite a considerable stroke risk. The complexity of the procedures may be reflected by a relatively high rate of perioperative myocardial infarctions. Perioperative mortality as well as short term patency of extraanatomical bypass grafts seem to be acceptable.
在冠状动脉旁路移植术中，对严重动脉粥样硬化的升主动脉进行交叉钳夹会带来显著的中风风险。除了其他技术外，主动脉非接触概念越来越多地应用于该问题的处理。
在407例行冠状动脉旁路移植术并接受主动脉超声扫描的患者中，38例（9.3%）表现为严重的升主动脉粥样硬化。其中22例患者（18例男性，4例女性，年龄72（57 - 79）岁，Parsonnet评分11（0 - 18），欧洲评分8（2 - 13），McSPI中风风险指数6（1 - 30）%）采用心脏跳动和主动脉非接触技术进行手术。所有患者至少接受了一根原位胸廓内动脉（IMA）移植以及额外的解剖外旁路血管：来自IMA的静脉Y型移植（n = 14）、来自IMA的动脉Y型移植（n = 3）、来自腋动脉的静脉移植（n = 3）、来自IMA残端的静脉移植（n = 2）、来自无名动脉的静脉移植（n = 2）。
未发生中风。围手术期心肌梗死（CKMB rt；50 U/l）发生率为5/22。重症监护病房（ICU）中位住院时间为54（15 - 1245）小时。医院死亡率为2/22。术前和术后心绞痛分级（CCSC）分别为3.3±0.9和1.4±0.9（p<0.001）。中位随访8个月后，发生3例死亡、1例中风和1例心肌梗死。在术后第一年对13例患者进行的三维多层CT扫描重建显示，所有至左前降支的IMA移植血管以及13根解剖外静脉移植血管中的11根通畅。
尽管存在相当大的中风风险，但对于严重病变的升主动脉，采用心脏跳动的解剖外冠状动脉旁路移植术可使中风发生率非常低。围手术期心肌梗死发生率相对较高可能反映了手术的复杂性。围手术期死亡率以及解剖外旁路移植血管的短期通畅率似乎是可以接受的。
