Ferguson T B, Muhlbaier L H, Salai D L, Wechsler A S
Department of Surgery, Duke University Medical Center, Durham, NC 27710.
J Thorac Cardiovasc Surg. 1988 May;95(5):761-72.
Emergency coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty can be performed with acceptable complication rates. Recently, however, a new class of patients with unsuccessful angioplasty has evolved with the use of thrombolytic therapy and emergent angioplasty as treatment for developing acute myocardial infarction. The efficacy of surgical intervention after failure of angioplasty in this setting has not been demonstrated. This report compares the results of coronary bypass done emergently after either failed elective or failed emergent angioplasty. Between March 1984 and September 1986; 1350 angioplasty procedures were performed at our institution, 393 for acute myocardial infarction. Of the 111 patients who came to operation, 42 had had unsuccessful elective angioplasty and 69 unsuccessful angioplasty done in the clinical setting of an evolving acute myocardial infarction detected by electrocardiographic criteria. Twenty-one of the 42 patients having unsuccessful elective angioplasty (group I) and 32 of the 69 with unsuccessful emergent angioplasty (group II) underwent emergency coronary artery bypass grafting. A retrospective nonparametric statistical comparison of the two groups was performed. Age, preoperative ejection fraction, distribution of vessels undergoing angioplasty, and number of vessels bypassed were not statistically different. All group II patients received thrombolytic therapy, and a reperfusion catheter was used in over half the patients in each group. Three group I and six group II patients required a preoperative balloon pump, and half the patients in each group required postoperative inotropic support. One patient in group I (4.7%) and two patients in group II (6.2%) died (no significant difference). Only five patients in group I (23.8%) and 11 in group II (34.3%) had enzymatic and electrocardiographic evidence of an acute myocardial infarction at discharge. Six patients in group II (15.6%) required reexploration for bleeding, versus none in group I (p = 0.04). Nonhemorrhagic complication rates, mean in-patient and acute care days, total hospital charges, and blood product utilization rates were not statistically different. These data indicate that emergency coronary artery bypass grafting can be performed when necessary in the setting of failed emergent percutaneous transluminal coronary angioplasty with results comparable to coronary bypass after failed elective angioplasty.
择期经皮腔内冠状动脉成形术失败后行急诊冠状动脉旁路移植术，其并发症发生率可接受。然而，近年来，随着溶栓治疗和急诊血管成形术被用于治疗急性心肌梗死，一类血管成形术失败的新患者群体出现了。在此情况下，血管成形术失败后手术干预的疗效尚未得到证实。本报告比较了择期血管成形术失败或急诊血管成形术失败后急诊冠状动脉旁路移植术的结果。1984年3月至1986年9月期间，我们机构共进行了1350例血管成形术，其中393例用于急性心肌梗死。在111例接受手术的患者中，42例择期血管成形术失败，69例在心电图提示急性心肌梗死进展的临床情况下血管成形术失败。42例择期血管成形术失败的患者（I组）中有21例，69例急诊血管成形术失败的患者（II组）中有32例接受了急诊冠状动脉旁路移植术。对两组进行了回顾性非参数统计比较。两组患者的年龄、术前射血分数、接受血管成形术的血管分布以及旁路移植的血管数量无统计学差异。II组所有患者均接受了溶栓治疗，每组半数以上患者使用了再灌注导管。I组3例患者和II组6例患者术前需要球囊泵支持，每组半数患者术后需要强心支持。I组1例患者（4.7%）和II组2例患者（6.2%）死亡（无显著差异）。出院时，I组仅5例患者（23.8%）、II组11例患者（34.3%）有急性心肌梗死的酶学和心电图证据。II组6例患者（15.6%）因出血需要再次手术探查，I组无患者需要（p = 0.04）。非出血性并发症发生率、平均住院天数和急性护理天数、总住院费用以及血液制品使用率无统计学差异。这些数据表明，在急诊经皮腔内冠状动脉成形术失败的情况下，必要时可进行急诊冠状动脉旁路移植术，其结果与择期血管成形术失败后冠状动脉旁路移植术相当。
