Budde Ricardo P J, Bakker Patricia F A, Gründeman Paul F, Borst Cornelius
Heart Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands.
Surg Endosc. 2009 Mar;23(3):467-76. doi: 10.1007/s00464-008-0082-y. Epub 2008 Sep 20.
In open-chest coronary artery bypass grafting (CABG), the surgeon faces several intraoperative challenges: (1) to locate the target coronary artery, (2) to select the optimal anastomotic site, and (3) to assess the quality of the graft and distal anastomosis. Endoscopically, these three diagnostic aims are particularly challenging.
We reviewed the literature on the intraoperative application of high-frequency (6.5-15 MHz) epicardial ultrasound (ECUS) in CABG to aid in these challenges.
Overall, ECUS was used in 628 patients to visualize and assess 912 (segments of) coronary arteries, as well as 418 grafts and distal anastomoses. In 96 cases, ECUS successfully located a coronary artery that was buried in the epicardial and/or myocardial tissue. In 37/155 (24%) imaged anastomotic sites, an alternative site free of pathology was selected. For quality assessment of the coronary anastomosis, experimental validation of ECUS included 218 anastomoses in ex vivo and animal models. ECUS showed high sensitivity (0.98) and specificity (1.00) for detection of anastomotic construction errors in 120 ex vivo anastomoses. In 418 grafts and distal anastomoses evaluated in patients, irregularities leading to revision were detected in 8 (1.9%) anastomoses and minor irregularities in an additional 23 (5.5%) anastomoses. However, little is known about the effect on long-term patency of specific anastomotic abnormalities revealed by ECUS. Scanning of arteries and anastomoses required several minutes. Current size ultrasound probes allowed successful experimental robot-assisted endoscopic application of ECUS.
CABG may be facilitated and improved in several ways by intraoperative high-frequency epicardial ultrasound scanning. Totally endoscopic CABG may benefit from ultrasound diagnostics in particular.
在开胸冠状动脉旁路移植术（CABG）中，外科医生面临着几个术中挑战：（1）定位目标冠状动脉，（2）选择最佳吻合部位，以及（3）评估移植物和远端吻合口的质量。在内镜检查中，这三个诊断目标尤其具有挑战性。
我们回顾了关于高频（6.5 - 15 MHz）心外膜超声（ECUS）在CABG术中应用以应对这些挑战的文献。
总体而言，ECUS应用于628例患者，以可视化和评估912条冠状动脉（节段）以及418个移植物和远端吻合口。在96例病例中，ECUS成功定位了一条埋于心外膜和/或心肌组织中的冠状动脉。在155个成像的吻合部位中的37个（24%），选择了无病变的替代部位。对于冠状动脉吻合口的质量评估，ECUS的实验验证包括在离体和动物模型中的218个吻合口。在120个离体吻合口中，ECUS检测吻合口构建错误的敏感性高（0.98），特异性高（1.00）。在对患者评估的418个移植物和远端吻合口中，8个（1.9%）吻合口检测到导致修正的不规则情况，另外23个（5.5%）吻合口检测到轻微不规则情况。然而，关于ECUS揭示的特定吻合口异常对长期通畅性的影响知之甚少。动脉和吻合口扫描需要几分钟。当前尺寸的超声探头允许ECUS成功地应用于实验性机器人辅助内镜检查。
术中高频心外膜超声扫描可在多个方面促进和改善CABG。完全内镜下CABG尤其可能受益于超声诊断。
