Murphy E S, Rösch J, Rahimtoola S H
Am J Cardiol. 1977 Apr;39(4):505-9. doi: 10.1016/s0002-9149(77)80158-6.
Myocardial infarction during aortic valve replacement has previously been reported to result from obstruction of a branch of the left main coronary artery by the perfusion cannula. Patients with a dominant left coronary arterial system may be at greater risk. To assess the frequency and significance of a dominant left coronary arterial system the coronary angiograms of 75 consecutive patients more than 34 years of age with isolated aortic stenosis were studied and compared with those of a control group of 150 patients. Among the patients with aortic stenosis, 19 (25 percent) had left dominance, 9 (12 percent) a balanced circulation and 47 (63 percent) a dominant right coronary arterial system. Among control patients, 14 (9 percent) had left dominance 18 (12 percent) a balanced system and 118 (79 percent) right dominance. The increased prevalence of left dominance in patients with aortic stenosis was significant (P less than 0.005). Among patients with aortic stenosis, the left main coronary artery was shorter (P less than 0.01) in those with left dominance (6.2 +/- 1.3 mm [mean +/- standard error]) than in those with right dominance (9.9 +/- 0.7). Sixty-nine patients with aortic stenosis underwent aortic valve replacement. Perioperative myocardial infarction occurred in 4 of 15 (26.7 percent) of those with left dominance and in 4 of 54 (7.4 percent) of those with right dominance or a balanced circulation (P less than 0.05). Perioperative myocardial infarction occurred in all three patients with left dominance and obstructive coronary artery disease. The increased prevalence of a dominant left coronary arterial system in aortic stenosis suggests that this may be part of a developmental complex. Patients with left dominance have a shorter left main coronary artery than patients with right dominance. They also have an increased risk of perioperative myocardial infarction if there is associated obstructive coronary artery disease. Preoperative information about the coronary arterial anatomy and extent of coronary artery disease may be helpful in planning the use of coronary perfusion and other myocardial preservation techniques during surgery in order to reduce the incidence of myocardial infarction.
此前有报道称，主动脉瓣置换术中的心肌梗死是由灌注插管阻塞左主冠状动脉的一个分支所致。左冠状动脉系统占优势的患者可能风险更高。为评估左冠状动脉系统占优势的频率及意义，对75例年龄超过34岁、孤立性主动脉瓣狭窄的连续患者的冠状动脉造影进行了研究，并与150例对照组患者的造影结果进行比较。在主动脉瓣狭窄患者中，19例（25%）为左优势型，9例（12%）为均衡循环型，47例（63%）为右冠状动脉系统占优势型。在对照组患者中，14例（9%）为左优势型，18例（12%）为均衡系统型，118例（79%）为右优势型。主动脉瓣狭窄患者中左优势型的患病率增加具有显著性（P<0.005）。在主动脉瓣狭窄患者中，左优势型患者的左主冠状动脉较短（P<0.01）（6.2±1.3mm[均值±标准误]），而右优势型患者为（9.9±0.7）。69例主动脉瓣狭窄患者接受了主动脉瓣置换术。左优势型患者中15例有4例（26.7%）发生围手术期心肌梗死，右优势型或均衡循环型患者中54例有4例（7.4%）发生围手术期心肌梗死（P<0.05）。3例左优势型且患有阻塞性冠状动脉疾病的患者均发生了围手术期心肌梗死。主动脉瓣狭窄患者中左冠状动脉系统占优势的患病率增加表明，这可能是发育复合体的一部分。左优势型患者的左主冠状动脉比右优势型患者短。如果伴有阻塞性冠状动脉疾病，他们发生围手术期心肌梗死的风险也会增加。术前有关冠状动脉解剖结构和冠状动脉疾病范围的信息，可能有助于在手术中规划冠状动脉灌注及其他心肌保护技术的应用，以降低心肌梗死的发生率。
