Jegaden O, Eker A, Montagna P, Ossette J, Rossi R, Revel D, Saint-Pierre A, Itti R, Mikaeloff P
Department of Cardiovascular Surgery, Hôpital cardiologique Louis Pradel, BP Lyon-Monchat, France.
Eur J Cardiothorac Surg. 1995;9(10):575-80; discussion 581. doi: 10.1016/s1010-7940(05)80009-0.
From January 1990 to February 1994, 400 patients (mean age 59 +/- 9 years) underwent myocardial revascularization using the right gastroepiploic artery (GEA) to bypass the right coronary artery trunk or branches. They represented 40% of all patients undergoing isolated coronary surgery during the same period, from 19% in 1990 to 54% in 1994. Left ventricular function was normal in 32% of patients, moderately impaired in 62% and severely impaired in 6%. The GEA was used alone in six patients, associated with one internal mammary artery (IMA) in 111 patients (two arterial grafts, 2.2 +/- 0.4 anastomoses) and with both IMAs in 283 patients (three arterial grafts, 3.4 +/- 0.6 anastomoses); no vein graft was used. The rate of complete myocardial revascularization was 79%. Early mortality was 1.7% and influenced by left ventricular ejection fraction (P < 0.05). Complications occurred in 37 patients: myocardial infarction 4%, intra-aortic balloon pump 0.5%, reoperation for bleeding 0.5%, mediastinitis 0.25%. Early (15th postoperative day) angiographic control of the GEA graft was performed in 104 patients operated from January 1990 to December 1991 and the patency rate was 92%; anomalies of GEA were three occlusions, five stenoses, three competitive flow, no string or slender sign. Early functional results (3 +/- 1 months postoperatively) were studied in 192 patients during exercise test with medical treatment: 99% were symptom-free and 14% had electrocardiographic (ECG) ischemic modification significantly correlated with incomplete revascularization (P < 0.01). The 2- and 4-year actuarial survival rate was 96.7 +/- 1.9%. The rate of late cardiac events was 2% patient/year; Angioplasty for GEA graft failure was required in four patients. A 2-year postoperative functional assessment without medical treatment was performed during exercise test in 66 patients who had received three arterial grafts: 98% were symptom-free and 26% had ECG ischemic modification significantly correlated with incomplete revascularization (P < 0.01); during the same procedure, thallium myocardial scintigraphy was obtained in 50 patients: 18 patients (36%) had asymptomatic ischemic defects on exercise significantly correlated with incomplete revascularization and ECG ischemic changes (P < 0.01). However, posterior thallium defects demonstrated limited GEA flow at the maximum level of exercise in at least 8% of patients. Myocardial revascularization using the GEA can be achieved with minimal operative risk and offers satisfactory functional results and midterm survival rate.
1990年1月至1994年2月，400例患者（平均年龄59±9岁）接受了使用右胃网膜动脉（GEA）绕过右冠状动脉主干或分支的心肌血运重建术。他们占同期接受单纯冠状动脉手术患者的40%，从1990年的19%增至1994年的54%。32%的患者左心室功能正常，62%中度受损，6%重度受损。6例患者单独使用GEA，111例患者将GEA与一根乳内动脉（IMA）联合使用（两根动脉移植物，2.2±0.4处吻合），283例患者将GEA与两根IMA联合使用（三根动脉移植物，3.4±0.6处吻合）；未使用静脉移植物。完全心肌血运重建率为79%。早期死亡率为1.7%，受左心室射血分数影响（P<0.05）。37例患者出现并发症：心肌梗死4%，主动脉内球囊反搏0.5%，因出血再次手术0.5%，纵隔炎0.25%。对1990年1月至1991年12月接受手术的104例患者在术后第15天进行了GEA移植物的早期血管造影检查，通畅率为92%；GEA异常情况为3处闭塞、5处狭窄、3处竞争血流，无条索或纤细征。对192例患者术后3±1个月进行运动试验并接受药物治疗时的早期功能结果进行了研究：99%无症状，14%有心电图（ECG）缺血性改变，与血运重建不完全显著相关（P<0.01）。2年和4年的精算生存率为96.7±1.9%。晚期心脏事件发生率为2%患者/年；4例患者因GEA移植物失败需要进行血管成形术。对66例接受三根动脉移植物的患者在术后2年进行了无药物治疗的运动试验功能评估：98%无症状，26%有ECG缺血性改变，与血运重建不完全显著相关（P<0.01）；在同一检查过程中，对50例患者进行了铊心肌闪烁显像：18例患者（36%）在运动时有无症状性缺血缺损，与血运重建不完全及ECG缺血性改变显著相关（P<0.01）。然而，至少8%的患者在运动最大负荷时后铊缺损显示GEA血流受限。使用GEA进行心肌血运重建可在最小手术风险下实现，并提供满意的功能结果和中期生存率。
