Beyersdorf F, Mitrev Z, Sarai K, Eckel L, Klepzig H, Maul F D, Ihnken K, Satter P
Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University, Frankfurt, Germany.
J Thorac Cardiovasc Surg. 1993 Jul;106(1):137-48.
Between 1977 and 1992 a total of 163 consecutive patients underwent emergency coronary artery bypass grafting after acute coronary occlusion (94% after failed angioplasty). Patients were divided into four groups according to the method used for myocardial protection. The crystalloid cardioplegia group included 30 patients operated on from 1977 to 1980; the hypothermic fibrillation group included 60 patients (1980 to 1986); the blood cardioplegia group included 36 patients (1986 to 1989); and the blood cardioplegia with controlled reperfusion group included 37 patients (1989 to 1992). Preoperative data, ischemic time interval, collateral blood flow, intraoperative data, regional wall motion, global ejection fraction, myocardial infarct-specific electrocardiographic changes, enzyme release, rhythm disturbances, mortality, prevalence of intraaortic balloon pumping, and inotropic support were assessed in this retrospective study. Our data indicate that the current spectrum of patients undergoing emergency coronary artery bypass grafting after acute coronary occlusion are at a significantly higher risk compared with those 15 years ago, that is, increase in age (53 +/- 1 versus 59 +/- 2 years; p < 0.05), three-vessel disease (38% versus 3%; p = 0.004), acute occlusion of the left main coronary artery (11% versus 0%; p = 0.02), preoperative cardiogenic shock (35% versus 3%; p = 0.007), prevalence of acute two-vessel occlusion (22% versus 3%; p = 0.05), prevalence of previous infarction (59% versus 23%; p = 0.04), and duration of ischemia (3.0 +/- 0.2 versus 4.1 +/- 0.3 hours; p < 0.05). Despite the increase in patients with severely compromised ventricular function during recent years, the overall hospital mortality decreased to 5% (2/37) when maximal protection of the ischemic and remote myocardium was performed (preoperative intraaortic balloon pump, combined antegrade/retrograde substrate-enriched blood cardioplegia, warm induction, controlled reperfusion, prolonged vented bypass). Single-vessel disease was always associated with a low mortality, whereas mortality could be reduced with controlled blood cardioplegia in patients with multivessel disease (6%) and cardiogenic shock (15%). The immediate return of regional contractility in the previously ischemic area after controlled reperfusion might serve as an explanation for these favorable results. After unmodified blood reperfusion, normokinesis or slight hypokinesis occurs in only 34% to 46% in the early postoperative period (1 to 4 weeks) in comparison with 86% after controlled blood cardioplegia reperfusion (p < 0.05). We conclude that there is a significant increase in risk factors in patients undergoing emergency coronary artery bypass grafting and that improved methods of intraoperative myocardial protection are needed for these compromised patients.
1977年至1992年间，共有163例连续性患者在急性冠状动脉闭塞后接受了急诊冠状动脉旁路移植术（血管成形术失败后接受该手术的患者占94%）。根据心肌保护方法，患者被分为四组。晶体停搏液组包括1977年至1980年接受手术的30例患者；低温颤动组包括60例患者（1980年至1986年）；血液停搏液组包括36例患者（1986年至1989年）；血液停搏液联合控制性再灌注组包括37例患者（1989年至1992年）。在这项回顾性研究中，对术前数据、缺血时间间隔、侧支血流、术中数据、局部室壁运动、整体射血分数、心肌梗死特异性心电图变化、酶释放、心律失常、死亡率、主动脉内球囊反搏的发生率以及正性肌力支持进行了评估。我们的数据表明，与15年前相比，目前急性冠状动脉闭塞后接受急诊冠状动脉旁路移植术的患者风险显著更高，即年龄增加（53±1岁对59±2岁；p<0.05）、三支血管病变（38%对3%；p = 0.004）、左主干冠状动脉急性闭塞（11%对0%；p = 0.02）、术前心源性休克（35%对3%；p = 0.007）、急性双支血管闭塞的发生率（22%对3%；p = 0.05）、既往梗死的发生率（59%对23%；p = 0.04）以及缺血持续时间（3.0±0.2小时对4.1±0.3小时；p<0.05）。尽管近年来心室功能严重受损患者有所增加，但当对缺血和远隔心肌进行最大程度保护时（术前主动脉内球囊反搏、顺行/逆行联合富含底物的血液停搏液、温诱导、控制性再灌注、延长的带通气旁路），总体医院死亡率降至了5%（2/37）。单支血管病变总是与低死亡率相关，而在多支血管病变患者（6%）和心源性休克患者（15%）中，控制性血液停搏液可降低死亡率。控制性再灌注后先前缺血区域局部收缩力的立即恢复可能是这些良好结果的一个解释。与控制性血液停搏液再灌注后86%的患者相比，未改良的血液再灌注后，术后早期（1至4周）仅34%至46%的患者出现正常运动或轻度运动减弱（p<0.05）。我们得出结论，接受急诊冠状动脉旁路移植术的患者风险因素显著增加，对于这些病情严重的患者，需要改进术中心肌保护方法。
