Takemura T, Shimamura Y, Tsuda Y, Iwasa S, Agematsu K
Department of Cardiovascular Surgery, National Nagano Hospital, Ueda, Japan.
Kyobu Geka. 2003 Jul;56(8 Suppl):672-7.
From January 2001 to January 2003, we performed 25 emergency off-pump coronary artery bypass grafting (CABG) procedures for patients with acute myocardial infarction (AMI) or unstable angina pectoris. During the same period, we also performed 2 emergency on-pump beating CABG procedures for patients with left main coronary trunk (LMT) shock syndrome. For the present study, we evaluated the operative results of the 25 cases of emergency or urgent off-pump CABG. The patients were divided into 3 groups, those with acute AMI with cardiogenic shock (group 1; n = 8), acute myocardial infarction without shock (group 2; n = 8), and unstable angina (group 3; n = 9). There were no differences between groups 1 and 2 with regard to age, number of diseased vessels, and preoperative use of an intraaortic balloon pump, however, patients in group 1 had a higher number of completely obstructed coronary arteries. Patients in groups 1 and 2 underwent off-pump CABG within 3.5 hours after a coronary angiography or coronary intervention procedure, while those in group 3 underwent off-pump CABG within 2 days of coronary angiography. The mean number of grafts per patient was 1.8, 2.1, and 2.3 in groups 1, 2, and 3, respectively. One group 1 patient with an LMT lesion was transferred to on-pump beating CABG because of hemodynamic instability. The 30-day mortality rate was 38% (3 of 8) in group 1, whereas it was 0% in groups 2 and 3. Intubation time, ICU stay, and postoperative stay were similar among the 3 groups. An early angiographic study was undertaken in all surviving patients and the results demonstrated patency in all of the examined grafts. Although our results are limited, emergency off-pump CABG was found to be safe and feasible for AMI without cardiogenic shock or unstable myocardial ischemia. However, the outcome of this procedure for patients with preoperative cardiogenic shock was not satisfactory, therefore, a combination therapy of appropriate mechanical circulatory support, prior revascularization by catheter intervention, and emergency surgical revascularization are considered to improve survival of those patients.
2001年1月至2003年1月期间，我们为急性心肌梗死（AMI）或不稳定型心绞痛患者实施了25例急诊非体外循环冠状动脉旁路移植术（CABG）。同期，我们还为左主干冠状动脉（LMT）休克综合征患者实施了2例急诊体外循环心脏跳动中CABG手术。在本研究中，我们评估了25例急诊或紧急非体外循环CABG的手术结果。患者被分为3组，即急性AMI合并心源性休克组（第1组；n = 8）、无休克的急性心肌梗死组（第2组；n = 8）和不稳定型心绞痛组（第3组；n = 9）。第1组和第2组在年龄、病变血管数量和术前主动脉内球囊泵的使用方面无差异，然而，第1组患者完全阻塞的冠状动脉数量较多。第1组和第2组患者在冠状动脉造影或冠状动脉介入手术后3.5小时内接受非体外循环CABG，而第3组患者在冠状动脉造影后2天内接受非体外循环CABG。第1、2、3组患者平均每例移植血管数分别为1.8、2.1和2.3。1例第1组患有LMT病变的患者因血流动力学不稳定被转至体外循环心脏跳动中CABG。第1组30天死亡率为38%（8例中的3例），而第2组和第3组为0%。3组患者的插管时间、重症监护病房停留时间和术后住院时间相似。所有存活患者均进行了早期血管造影检查，结果显示所有检查的移植血管均通畅。尽管我们的结果有限，但发现急诊非体外循环CABG对于无心脏性休克的AMI或不稳定型心肌缺血患者是安全可行的。然而，该手术对于术前有心源性休克患者的结果并不令人满意，因此，考虑采用适当的机械循环支持、导管介入先行血运重建以及急诊手术血运重建的联合治疗来提高这些患者的生存率。
