Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA.
J Thorac Cardiovasc Surg. 2012 Nov;144(5):1036-40. doi: 10.1016/j.jtcvs.2012.07.057. Epub 2012 Aug 20.
Management of a patent left internal thoracic artery graft during reoperation is controversial. The "no-dissection" technique avoids dissection and clamping of the left internal thoracic artery graft, and myocardial protection is achieved using adjunctive systemic hypothermia and hyperkalemia. We compared the postoperative outcomes after isolated reoperative aortic valve replacement in patients with previous coronary artery bypass grafting with a patent left internal thoracic artery graft using a no-dissection technique with the outcomes of patients with previous coronary artery bypass grafting without a left internal thoracic artery graft.
The outcomes were analyzed for patients who underwent isolated reoperative aortic valve replacement with previous coronary artery bypass grafting from January 1, 2002, to June, 30, 2011. Patency of the left internal thoracic artery was confirmed using either coronary angiography or computed tomography angiography. The patent left internal thoracic artery group did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalemia. The no left internal thoracic artery group underwent isolated aortic valve replacement with previous coronary artery bypass grafting but had no left internal thoracic artery graft.
A total 174 patients were identified for the patent left internal thoracic artery group and 26 for the no left internal thoracic artery group. The perfusion and crossclamp times were similar. No differences were seen between the 2 groups in operative mortality (6.9% vs 7.7%, P = 1.00). The complication rates were similar, and the peak creatine kinase-MB values within 24 hours of surgery were not significantly different between the 2 groups (median, 27.4 vs 29 μ/mL; P = .72).
Reoperative aortic valve replacement in patients with previous coronary artery bypass grafting and a patent left internal thoracic artery graft can be performed safely without dissection or clamping of the left internal thoracic artery using systemic hyperkalemia and hypothermia. We believe this method prevents unnecessary injury during dissection of the left internal thoracic artery graft.
在再次手术中，处理通畅的左内乳动脉移植物存在争议。“不解剖”技术避免了对左内乳动脉移植物的解剖和夹闭，通过辅助全身低温和高钾血症实现心肌保护。我们比较了使用不解剖技术处理既往冠状动脉旁路移植术（CABG）且通畅的左内乳动脉移植物的患者与既往 CABG 且无左内乳动脉移植物的患者在孤立再次主动脉瓣置换术（reoperative aortic valve replacement，ROAVR）后的术后结果。
分析了 2002 年 1 月 1 日至 2011 年 6 月 30 日接受 ROAVR 且既往 CABG 的患者的结局。使用冠状动脉造影或计算机断层血管造影术（computed tomography angiography，CTA）确认左内乳动脉通畅。左内乳动脉通畅组未进行左内乳动脉移植物的解剖或夹闭，通过全身低温和高钾血症获得心肌保护。无左内乳动脉组进行了既往 CABG 但无左内乳动脉移植物的 ROAVR。
左内乳动脉通畅组共 174 例患者，无左内乳动脉组 26 例患者。灌注和体外循环时间相似。2 组之间的手术死亡率无差异（6.9% vs 7.7%，P = 1.00）。并发症发生率相似，2 组间术后 24 小时内肌酸激酶同工酶-MB 的峰值无显著差异（中位数，27.4 vs 29 μ/mL；P =.72）。
在既往 CABG 且通畅的左内乳动脉移植物患者中，可安全地进行 ROAVR，无需对左内乳动脉移植物进行解剖或夹闭，使用全身高钾血症和低温。我们认为，这种方法可防止在左内乳动脉移植物解剖过程中造成不必要的损伤。
