Perrault L, Carrier M, Cartier R, Leclerc Y, Hébert Y, Diaz O S, Pelletier C
Department of Surgery, Montreal Heart Institute, Quebec.
Can J Cardiol. 1991 Dec;7(10):427-30.
Reoperation ('redo') for coronary artery disease shows a significant increase in morbidity and mortality compared to primary surgery. Some technical approaches have been advocated to decrease myocardial injury, presumably due to coronary artery embolization from atheromatous vein grafts. From 1984 to 1989, 321 'redo' operations were performed at the Montreal Heart Institute. Patients with patent and atherosclerotic vein grafts at preoperative coronary angiography (239 patients) were compared to those with normal or occluded grafts (82 patients). Perioperative myocardial infarction and death rates were 19% and 13%, respectively. They were particularly high among patients with three or more patent and atherosclerotic vein grafts at reoperation (32% and 29%, respectively). Among the 239 patients with patent atherosclerotic grafts, the results of three different surgical techniques were studied retrospectively. A first group of 66 patients had early ligation of patent atheromatous grafts before cardioplegia was administered by antegrade infusion during single aortic clamping for coronary anastomoses, and maintained for the confection of aortic anastomoses. In a second group of 35 patients, early ligation of diseased graft, antegrade cardioplegic delivery, and partial aortic cross clamping for aortic anastomoses of vein grafts was done. In the third group of 138 patients, venous grafts were not interrupted before antegrade cardioplegic infusion and partial aortic cross clamping for aortic anastomoses of vein grafts was used. No significant difference in hospital mortality or perioperative myocardial infarction rate was observed between the three groups of patients. Thus, the modified techniques so far recommended for repeat coronary artery bypass grafting, such as early ligation of patent atherosclerotic grafts, have failed to improve the early results of 'redo' operations.
与初次手术相比，冠心病再次手术（“redo”手术）的发病率和死亡率显著增加。有人主张采用一些技术方法来减少心肌损伤，推测这是由于动脉粥样硬化静脉移植物导致冠状动脉栓塞所致。1984年至1989年期间，蒙特利尔心脏研究所进行了321例“redo”手术。将术前冠状动脉造影显示静脉移植物通畅且有动脉粥样硬化的患者（239例）与静脉移植物正常或闭塞的患者（82例）进行比较。围手术期心肌梗死率和死亡率分别为19%和13%。在再次手术时存在三个或更多通畅且有动脉粥样硬化静脉移植物的患者中，这些比率尤其高（分别为32%和29%）。在239例有动脉粥样硬化通畅移植物的患者中，对三种不同手术技术的结果进行了回顾性研究。第一组66例患者在单次主动脉阻断进行冠状动脉吻合期间通过顺行灌注给予心脏停搏液之前，早期结扎了通畅的动脉粥样硬化移植物，并在进行主动脉吻合时维持该状态。第二组35例患者进行了病变移植物的早期结扎、顺行心脏停搏液灌注以及静脉移植物主动脉吻合时的部分主动脉阻断。第三组138例患者在顺行心脏停搏液灌注之前未中断静脉移植物，并采用了静脉移植物主动脉吻合时的部分主动脉阻断。三组患者之间在医院死亡率或围手术期心肌梗死率方面未观察到显著差异。因此，目前推荐的用于重复冠状动脉搭桥术的改良技术，如早期结扎通畅的动脉粥样硬化移植物，未能改善“redo”手术的早期结果。
