Oz M C, Argenziano M, Rose E A
Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Chest. 1997 Nov 5;112(5):1409-16. doi: 10.1378/chest.112.5.1409.
Although the use of small incisions is theoretically appealing, it has been argued that the true advantage of minimally invasive approaches to myocardial revascularization lies in the avoidance of cardiopulmonary bypass.
Of 25 patients referred for surgical revascularization of single-vessel coronary disease, 20 elected to undergo a minimally invasive coronary artery bypass grafting (MICABG) procedure, while 5 opted to have conventional surgery with cardiopulmonary bypass (CPB). Patients having MICABG underwent single-vessel revascularization without CPB, via limited anterior thoracotomy, hemisternotomy, or median sternotomy. Intraoperatively, hemodynamics, anastomotic time, and total operative time were recorded. Postoperatively, length of hospital stay, incidence of myocardial infarction, indexes of end-organ function, and morbidity rates were recorded. In addition, patient questionnaires were used to assess subjective end points such as postoperative pain, wound drainage, and quality of life.
Fifteen of 20 patients undergoing MICABG underwent revascularization without CPB, while 4 were converted to standard coronary artery bypass grafting with CPB due to technical reasons and 1 for intraoperative ventricular fibrillation. Patients undergoing MICABG had no perioperative myocardial infarctions, while those having CPB had two infarctions (20%). Furthermore, there were no differences in length of stay or postoperative morbidity among the various approaches, while the MICABG procedures, especially via median sternotomy, were associated with shorter operative times.
The advantage of MICABG lies mainly in the avoidance of CPB. Thus, we advocate that surgeons initially utilize the median sternotomy and limited skin incision for MICABG to assure adequate exposure, technical precision, and patient safety. After a reasonable level of technical proficiency and experience are attained, the limited anterior thoracotomy approach can be used.
尽管小切口的应用在理论上具有吸引力，但有人认为微创心肌血运重建方法的真正优势在于避免使用体外循环。
在25例因单支冠状动脉疾病而接受手术血运重建的患者中，20例选择接受微创冠状动脉旁路移植术（MICABG），而5例选择进行常规体外循环（CPB）手术。接受MICABG的患者通过有限前外侧开胸、半胸骨切开或正中胸骨切开，在不使用CPB的情况下进行单支血管血运重建。术中记录血流动力学、吻合时间和总手术时间。术后记录住院时间、心肌梗死发生率、终末器官功能指标和发病率。此外，使用患者问卷评估主观终点，如术后疼痛、伤口引流和生活质量。
20例接受MICABG的患者中有15例在不使用CPB的情况下完成血运重建，4例因技术原因转为标准体外循环冠状动脉旁路移植术，1例因术中室颤转为该术式。接受MICABG的患者围手术期无心肌梗死，而接受CPB的患者有2例梗死（20%）。此外，不同手术方式在住院时间或术后发病率方面无差异，而MICABG手术，尤其是通过正中胸骨切开的手术，手术时间较短。
MICABG的优势主要在于避免使用CPB。因此，我们主张外科医生最初在MICABG中采用正中胸骨切开和有限的皮肤切口，以确保充分暴露、技术精确性和患者安全。在达到合理的技术熟练程度和经验水平后，可以采用有限前外侧开胸手术。
