von Segesser L K
Service de chirurgie cardio-vasculaire, Centre hospitalier universitaire vaudois, Lausanne.
Schweiz Med Wochenschr. 1997 Dec 13;127(50):2084-90.
There are a number of surgical alternatives to repeat artery bypass grafting, which is the primary treatment for recurrent severe myocardial ischemia. In patients with endstage coronary artery disease unsuitable for repeat bypass procedures, orthotopic heart transplantation is now well established. However, the increasing donor shortage limits this option to relatively few patients, a fact well documented by longer waiting lists despite less stringent donor criteria. Hence, other surgical therapies, which may at this time be underused, should be explored. In addition to mechanical circulatory support by means of implantable blood pumps which are now available with wearable drivers and rechargeable batteries, mention should be made of surgical left ventricular volume reduction and reverse remodeling, transmyocardial laser revascularization (TMR), and dynamic cardiomyoplasty. The mechanisms that explain the beneficial effects of the three latter procedures are not fully understood. But it may be speculated for these procedures that Laplace and Starling laws play a major role in the sometimes spectacular recovery. It is probably due to the complexity of the procedures mentioned, the severe condition of the patients, the high risk of a proactive attitude under such circumstances, and the significant cost, that the number of these alternative procedures performed is still rather low despite the fact that the results are similar to those of transplantation. However, careful individual evaluation is of prime importance for better results. The presence or absence of symptoms is certainly a major issue for the decision-making process. If the left ventricular ejection fraction is preserved, transmyocardial laser revascularisation may relieve angina. Dynamic cardiomyoplasty may be appropriate if the left ventricular ejection fraction is low, provided the heart is not too big and that there is neither too much mitral regurgitation nor major arrhythmia. If the left ventricle is very big and major mitral regurgitation is present, volume reduction giving transventricular access to the mitral valve can be evaluated. A decision-making tree is proposed.
对于复发性严重心肌缺血的主要治疗方法——再次动脉搭桥术，有多种手术替代方案。对于终末期冠状动脉疾病且不适合再次搭桥手术的患者，原位心脏移植目前已得到广泛应用。然而，供体短缺问题日益严重，使得这一选择仅适用于相对较少的患者，尽管放宽了供体标准，但等待名单变长这一事实充分证明了这一点。因此，应探索其他目前可能未得到充分应用的手术治疗方法。除了借助现已配备可穿戴驱动器和可充电电池的植入式血泵进行机械循环支持外，还应提及手术性左心室容积减小和逆向重塑、经皮心肌激光血运重建术（TMR）以及动力性心肌成形术。后三种手术有益效果的机制尚未完全明确。但可以推测，对于这些手术，拉普拉斯定律和斯塔林定律在有时显著的恢复过程中起主要作用。可能是由于上述手术的复杂性、患者的严重病情、在这种情况下积极态度带来的高风险以及高昂的费用，尽管这些替代手术的结果与移植手术相似，但其实施数量仍然相当少。然而，进行仔细的个体评估对于取得更好的结果至关重要。症状的有无无疑是决策过程中的一个主要问题。如果左心室射血分数得以保留，经皮心肌激光血运重建术可能会缓解心绞痛。如果左心室射血分数较低，且心脏不过大、不存在过多二尖瓣反流和严重心律失常，动力性心肌成形术可能是合适的。如果左心室非常大且存在严重二尖瓣反流，可以考虑进行容积减小手术，经心室途径进入二尖瓣进行评估。本文提出了一个决策树。
