Robinson M C, Gross D R, Zeman W, Stedje-Larsen E
Department of Surgery, College of Medicine, University of Kentucky, Lexington.
J Card Surg. 1995 Sep;10(5):529-36. doi: 10.1111/j.1540-8191.1995.tb00628.x.
The benefit of internal mammary artery (IMA) grafting as a long-lasting intervention for coronary artery disease is well recognized. However, largely because they are less invasive, catheter based alternatives are frequently chosen, particularly to treat single or double vessel disease. To retain the advantages of the IMA graft, and to offset the invasiveness of conventional coronary artery bypass grafting, we developed a new minimally invasive method using an anterior mediastinotomy for treating left anterior descending (LAD) or right coronary artery disease, or both. Feasibility studies using 16 pigs and a human cadaver led to approval by the Institutional Review Board for use of this procedure to treat six patients (four men, two women; mean age, 63.8 +/- 13.6 [SD] yrs) who granted informed consent. Pedicle dissection of the IMA, using video assisted thoracoscopy if necessary, was made through a 2- to 3-inch horizontal anterior mediastinotomy. The underlying LAD artery was grafted during femoral vessel cardiopulmonary bypass, with cooling to 30 degrees C, induced ventricular fibrillation, and left ventricular venting if required. Transesophageal echocardiography performed after bypass showed that two patients maintained normal wall motion and four had improvement from the original impairment. One patient suffered a recurrence of angina 4 weeks after the procedure; recatheterization showed an acutely angled IMA, subsequently corrected by balloon angioplasty. The results of follow-up dobutamine echocardiographic stress tests were negative in all patients. With this minimally invasive approach, the procedure should provide the benefits of IMA grafting with shorter hospital stay, more rapid recovery, and less overall cost.
乳内动脉（IMA）移植作为一种治疗冠状动脉疾病的长效干预措施，其益处已得到广泛认可。然而，主要由于侵入性较小，基于导管的替代方法经常被选用，特别是用于治疗单支或双支血管病变。为了保留IMA移植的优势，并抵消传统冠状动脉旁路移植术的侵入性，我们开发了一种新的微创方法，即通过前纵隔切开术治疗左前降支（LAD）或右冠状动脉疾病，或两者皆治。使用16头猪和1具人体尸体进行的可行性研究，促使机构审查委员会批准使用该程序治疗6例患者（4名男性，2名女性；平均年龄63.8±13.6[标准差]岁），这些患者均已签署知情同意书。必要时使用电视辅助胸腔镜，通过2至3英寸的水平前纵隔切开术进行IMA蒂部解剖。在股血管体外循环期间，将体温降至30℃，诱发心室颤动，并在必要时进行左心室引流，在此期间对下方的LAD动脉进行移植。旁路术后经食管超声心动图检查显示，2例患者的室壁运动保持正常，4例患者较术前有所改善。1例患者术后4周心绞痛复发；再次导管检查显示IMA呈锐角，随后通过球囊血管成形术纠正。所有患者的随访多巴酚丁胺超声心动图负荷试验结果均为阴性。采用这种微创方法，该手术应能提供IMA移植的益处，同时缩短住院时间，更快康复，总体费用更低。
