Allen B S, Rosenkranz E, Buckberg G D, Davtyan H, Laks H, Tillisch J, Drinkwater D C
Department of Surgery, UCLA Medical Center 90024-1741.
J Thorac Cardiovasc Surg. 1989 Nov;98(5 Pt 1):691-702; discussion 702-3.
Eighty consecutive patients receiving maximum inotropic and intraaortic balloon support underwent emergency coronary artery bypass grafting 3.4 +/- 1 days (mean +/- standard error) after infarction for severe left ventricular power failure (stroke work index less than 25 gm-m, left atrial pressure greater than 20 mm Hg). All underwent induction of cardioplegia with a 37 degrees C glutamate/aspartate blood cardioplegic solution, multidose cold (4 degrees C) replenishment, and warm reperfusate. Viable areas were grafted first to ensure cardioplegic distribution. Left ventricular power failure was reversed in 94% of patients; 75 of 80 patients had discontinuation of inotropic drugs and intraaortic balloon support. The early mortality rate (less than 30 days) was only 7% (3/45) with early operation (less than 18 hours) and rose to 31% (11/35, p less than 0.05) if operation was delayed more than 18 hours. Six of 14 early deaths were due to progression of preoperative organ failure despite reversal of shock. Eighteen of 66 early survivors died of end-stage heart failure (21/80), a 26% late mortality rate. Nonsurvivors (early and late) had a higher incidence of extending versus evolving infarction (33/64 versus 2/16, p less than 0.05), a longer delay from shock to operation (11/45 versus 24/35, p less than 0.05), more preoperative organ failure (9/9 versus 26/71, p less than 0.05), and a greater incidence of previous infarction (22/43 versus 13/37, p greater than 0.05). Thirty of 45 late survivors (67%) remain physically active. We conclude that left ventricular power failure should be considered a medical/surgical emergency that necessitates prompt angiography and can be reversed in selected patients. Postoperative mortality (early and late) is due principally to delay of operation leading to progression of preoperative organ failure or progression of underlying cardiac disease if infarction becomes established.
80例接受最大剂量强心药物及主动脉内球囊支持治疗的患者，因严重左心室功能衰竭（每搏功指数小于25gm-m，左心房压大于20mmHg），在心肌梗死后3.4±1天（均值±标准误）接受了急诊冠状动脉搭桥术。所有患者均采用37℃的谷氨酸/天冬氨酸血液停搏液诱导心脏停搏，多剂量冷（4℃）补充，以及温血再灌注液。首先对存活心肌区域进行搭桥，以确保停搏液分布。94%的患者左心室功能衰竭得到逆转；80例患者中有75例停用了强心药物及主动脉内球囊支持。早期手术（小于18小时）的早期死亡率（小于30天）仅为7%（3/45），若手术延迟超过18小时，死亡率则升至31%（11/35，p小于0.05）。14例早期死亡患者中有6例是由于尽管休克已逆转，但术前器官功能衰竭仍在进展。66例早期存活者中有18例死于终末期心力衰竭（21/80），晚期死亡率为26%。非存活者（早期和晚期）与进展性梗死相比，扩展性梗死的发生率更高（33/64对2/16，p小于0.05），从休克到手术的延迟时间更长（11/45对24/35，p小于0.05），术前器官功能衰竭更多（9/9对26/71，p小于0.05），既往心肌梗死的发生率更高（22/43对13/37，p大于0.05）。45例晚期存活者中有30例（67%）身体活动良好。我们得出结论，左心室功能衰竭应被视为一种内科/外科急症，需要及时进行血管造影，并且在部分患者中可以逆转。术后死亡率（早期和晚期）主要是由于手术延迟导致术前器官功能衰竭进展，或者如果梗死已确立，则是由于基础心脏病进展。
