Lutter G, Saurbier B, Nitzsche E, Kletzin F, Martin J, Schlensak C, Lutz C, Beyersdorf F
Department of Cardiovascular Surgery, Albert-Ludwigs-University, Freiburg, Germany.
Eur J Cardiothorac Surg. 1998 Jan;13(1):21-6. doi: 10.1016/s1010-7940(97)00298-4.
Does perioperative use of the intraaortic balloon pump (IABP) improve the postsurgical outcome of patients presenting with endstage coronary artery disease, unstable angina and low ejection fraction transferred for transmyocardial laser revascularization (TMLR)?
TMLR, as sole therapy combined with the perioperative use of an intraaortic balloon pump has been assessed in seven patients with endstage coronary artery disease, unstable angina and low ejection fraction (EF < 35%). Six out of seven patients had signs of congestive heart failure. These patients are compared with 23 patients with endstage coronary artery disease, stable angina and EF > 35%, who were treated with TMLR as sole therapy without the use of IABP. The creation of transmural channels was performed by a CO2-laser. All patients were evaluated by hybrid positron emission tomography (perfusion SPECT and viability PET) and ventriculography preoperatively. Echocardiography, clinical status and hemodynamic assessment by Swan Ganz catheter were performed perioperatively.
The perioperative mortality of this combined procedure (TMLR and IABP) was zero. Three out of seven patients had pneumonia with complete recovery. Swan Ganz catheter examinations showed deterioration of LV-function after TMLR intraoperatively and improvement after 2 h and further after 6 h on ICU (P < 0.05). In contrast, a decrease of LV-function in sole TMLR patients with an EF > 35%) has not been observed. Patients with EF < 35% needed the IABP for 2.3 days and moderate dose catecholamines for a mean of 3.0 days. The postoperative EF and resting wall motion score index (WMSI) of all analysed LV segments (evaluated by echocardiography) did not change compared to baseline (EF 31.3+/-2.6 preop. to 32.8+/-3.2 postop.; WMSI: 1.75+/-0.14 at baseline to 1.71+/-0.17 postop.). The average Canadian Angina Class at the time of discharge decreased from 4.0+/-0 (baseline) to 2.3+/-0.5 (P < 0.05) and the NYHA-Index from 3.9+/-0.3 to 2.7+/-0.5. No patient had signs of angina pectoris, whereas two patients still had signs of congestive heart failure.
The reported data support our concept to start IABP preoperatively in patients with reduced LV contractile reserve in order to provide cardiac support during the postoperative phase of reversible decline of LV-function induced by TMLR.
对于因终末期冠状动脉疾病、不稳定型心绞痛且射血分数低而转至心肌激光血运重建术（TMLR）治疗的患者，围手术期使用主动脉内球囊反搏（IABP）是否能改善术后结局？
对7例终末期冠状动脉疾病、不稳定型心绞痛且射血分数低（EF<35%）的患者进行了评估，TMLR作为唯一治疗方法并联合围手术期使用主动脉内球囊反搏。7例患者中有6例有充血性心力衰竭体征。将这些患者与23例终末期冠状动脉疾病、稳定型心绞痛且EF>35%的患者进行比较，后者接受TMLR作为唯一治疗方法且未使用IABP。经壁通道的创建通过二氧化碳激光进行。所有患者术前均通过混合正电子发射断层扫描（灌注单光子发射计算机断层扫描和存活心肌正电子发射断层扫描）和心室造影进行评估。围手术期进行超声心动图、临床状况评估以及通过 Swan Ganz 导管进行血流动力学评估。
这种联合手术（TMLR和IABP）的围手术期死亡率为零。7例患者中有3例发生肺炎，但均完全康复。Swan Ganz导管检查显示，TMLR术后左心室功能术中恶化，在重症监护病房（ICU）2小时后改善，并在6小时后进一步改善（P<0.05）。相比之下，未观察到EF>35%的单纯TMLR患者左心室功能下降。EF<35%的患者IABP使用2.3天，中等剂量儿茶酚胺平均使用3.0天。所有分析的左心室节段术后的射血分数和静息壁运动评分指数（通过超声心动图评估）与基线相比无变化（EF：术前31.3±2.6至术后32.8±3.2；WMSI：基线时1.75±0.14至术后1.71±0.17）。出院时加拿大心绞痛分级平均从4.0±0（基线）降至2.3±0.5（P<0.05），纽约心脏协会（NYHA）心功能分级从3.9±0.3降至2.7±0.5。无患者有心绞痛体征，而2例患者仍有充血性心力衰竭体征。
报告的数据支持我们的观点，即对于左心室收缩储备降低的患者，术前开始使用IABP，以便在TMLR引起的左心室功能可逆性下降的术后阶段提供心脏支持。
