Mickleborough L L, Maruyama H, Takagi Y, Mohamed S, Sun Z, Ebisuzaki L
Department of Surgery, University of Toronto, Ontario, Canada.
Circulation. 1995 Nov 1;92(9 Suppl):II73-9. doi: 10.1161/01.cir.92.9.73.
In patients with coronary artery disease and poor ventricular function (ejection fraction, < 20%), bypass grafting remains a surgical challenge. This study evaluates experience with isolated revascularization in such patients.
In 79 consecutive patients (69 men, 10 women; average age, 59 +/- 9 years), preoperative ejection fraction was 18 +/- 5%. Indications for surgery were congestive heart failure (CHF) in 5 of 79 patients (6%), CHF and angina in 19 (24%), angina in 41 (52%), ventricular arrhythmias (VAs) in 8 (10%), and critical anatomy in 6 (8%). Some patients had prior VAs (23 of 79; 29%) or mitral regurgitation (18; 23%) and required emergent surgery (25; 32%). At surgery, temperature mapping ensured adequate distribution of antegrade cold cardioplegia, with 3.6 +/- 0.7 grafts per patient, including left internal mammary artery graft in 60 of 79 (76%) and endarterectomy in 14 (18%). Hospital mortality was 3.8%. Perioperative support included intra-aortic balloon pump in 18 of 79 (23%) and drugs for VAs in 28 (35%). Morbidity included myocardial infarction in 2 of 79 (2.5%) and stroke in 2 (2.5%). During follow-up, there were 19 late deaths. Actuarial survival was 94%, 82%, and 68% at 1, 2, and 5 years, respectively, and was similar in patients with severe angina, CHF, mitral regurgitation, or VAs. Freedom from sudden death was 100%, 98%, and 91% at 1, 2, and 5 years, respectively. Among survivors, angina improved in 84% and heart failure improved in 26%.
These data support bypass graft surgery in patients with severe LV dysfunction. With careful cardioplegic techniques, hospital mortality was low (3.8%). Long-term survival is encouraging, with good relief of symptoms in most patients. Perioperative VAs are frequent but respond to medical treatment, with only 23% of patients discharged on antiarrhythmic drugs. Five-year freedom from sudden death is 91%, with only 3 late sudden deaths in this series.
在冠状动脉疾病且心室功能较差（射血分数＜20%）的患者中，冠状动脉搭桥术仍是一项外科挑战。本研究评估了此类患者单纯血运重建的经验。
连续纳入79例患者（69例男性，10例女性；平均年龄59±9岁），术前射血分数为18±5%。手术指征为：79例患者中有5例（6%）为充血性心力衰竭（CHF），19例（24%）为CHF合并心绞痛，41例（52%）为心绞痛，8例（10%）为室性心律失常（VA），6例（8%）为严重解剖结构病变。部分患者既往有VA（79例中的23例；29%）或二尖瓣反流（18例；23%），并需要急诊手术（25例；32%）。手术时，温度监测确保了顺行冷停搏液的充分分布，每位患者平均植入3.6±0.7支移植血管，其中79例中有60例（76%）植入了左乳内动脉移植血管，14例（18%）进行了动脉内膜切除术。医院死亡率为3.8%。围手术期支持包括79例中的18例（23%）使用主动脉内球囊反搏，28例（35%）使用治疗VA的药物。并发症包括79例中的2例（2.5%）发生心肌梗死，2例（2.5%）发生中风。随访期间，有19例晚期死亡。1年、2年和5年的精算生存率分别为94%、82%和68%，在严重心绞痛患者、CHF患者、二尖瓣反流患者或VA患者中相似。1年、2年和5年无猝死生存率分别为100%、98%和91%。在幸存者中，84%的心绞痛症状改善，26%的心力衰竭症状改善。
这些数据支持在严重左心室功能不全患者中进行冠状动脉搭桥手术。采用谨慎的停搏技术，医院死亡率较低（3.8%）。长期生存率令人鼓舞，大多数患者症状得到良好缓解。围手术期VA很常见，但对药物治疗有反应，只有23%的患者出院时服用抗心律失常药物。5年无猝死生存率为91%，本系列中仅有3例晚期猝死。
