Darwazah Ahmad K, Abu Sham'a Raed A H, Yasin Izzedein H
Department of Cardiac Surgery, Makassed Hopital, Mount of Olives, Jerusalem, Israel.
J Card Surg. 2007 Jan-Feb;22(1):69-72. doi: 10.1111/j.1540-8191.2006.00347.x.
Management of patients with severely impaired left ventricular function (LVF) associated with diffusely atheromatous coronary artery disease is a real dilemma. Coronary revascularization can be done only after endarterectomy to facilitate anastomosis. The aim of the present work is to present our experience and see whether performing endarterectomy during off-pump bypass can be of any benefit.
Five patients with a mean ejection fraction of 27 +/- 4.5 underwent coronary revascularization facilitated by endarterectomy using off-pump technique. There were three males and two females with a mean age of 64.4 +/- 7.4 years. All patients were in NYHA class III or IV. Close endarterectomy was done to left anterior descending artery (LAD), right coronary artery (RCA), and intermediate artery.
All patients survived the procedure. A total of seven closed endarterectomies were performed. Five of these were done on LAD and the other two were done on RCA and intermediate artery. Two patients (40%) received inotropic support. One patient had perioperative infarction (20%). Mean follow-up period was 14.2 months +/- 19.7 (range, 1 month to 48 months). All patients were free of angina according to Canadian Cardiovascular Society and were in class NYHA I or II except one, who was in class III. Postoperative catheterization showed that all bypasses to endarterectomized arteries were patent. Patency rate was 83.4%. The mean postoperative ejection fraction was 29.8 +/- 6.9, which was not significantly different from preoperative one (p= 0.12).
Performing endarterectomy on beating heart in patients with compromised left ventricle is not an easy task. But it can be done with difficulty. Although the procedure is associated with high incidence of infarction, our early results, follow-up clinical status, and graft patency justify its use among patients with compromised left ventricular function who were previously considered inoperable.
对于患有严重左心室功能受损（LVF）且伴有弥漫性动脉粥样硬化性冠状动脉疾病的患者，治疗是一个真正的难题。只有在动脉内膜切除术后才能进行冠状动脉血运重建，以利于吻合。本研究的目的是介绍我们的经验，并探讨在非体外循环搭桥手术期间进行动脉内膜切除术是否有益。
5例平均射血分数为27±4.5的患者采用非体外循环技术，通过动脉内膜切除术辅助进行冠状动脉血运重建。其中男性3例，女性2例，平均年龄64.4±7.4岁。所有患者均为纽约心脏协会（NYHA）Ⅲ级或Ⅳ级。对左前降支（LAD）、右冠状动脉（RCA）和中间动脉进行了严密的动脉内膜切除术。
所有患者均手术成功。共进行了7例严密的动脉内膜切除术。其中5例在LAD进行，另外2例在RCA和中间动脉进行。2例患者（40%）接受了强心支持。1例患者发生围手术期梗死（20%）。平均随访期为14.2个月±19.7（范围1个月至48个月）。根据加拿大心血管学会标准，所有患者均无心绞痛，除1例为NYHAⅢ级外，其余均为NYHAⅠ级或Ⅱ级。术后导管检查显示，所有至动脉内膜切除动脉的搭桥血管均通畅。通畅率为83.4%。术后平均射血分数为29.8±6.9，与术前相比无显著差异（p = 0.12）。
对左心室功能受损的患者在心脏跳动时进行动脉内膜切除术并非易事。但困难情况下仍可完成。尽管该手术梗死发生率较高，但我们的早期结果、随访临床状况及移植血管通畅情况证明，对于先前被认为无法手术的左心室功能受损患者，该手术是合理可行的。
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