Mohl W, Simon P, Neumann F, Moidl R, Chevtchik O, Zweytick B, Kupilik N, Wolner E
Klinische Abteilung für Herz-Thoraxchirurgie, Universitätsklinik für Chirurgie, Allgemeines Krankenhaus der Stadt Wien, Vienna, Austria.
Eur J Cardiothorac Surg. 1998 Jan;13(1):27-35. doi: 10.1016/s1010-7940(97)00282-0.
Severe ischemic injury in the first few hours following primary revascularization necessitates acute reoperation. To study the effect of emergency coronary artery bypass grafting, we followed 18 patients for up to 8 years, relating their changes of global and regional myocardial function during the acute event and after secondary revascularization to final outcome.
A total of 16 patients with coronary artery bypass grafting (CABG) and 2 PTCA were treated for coronary heart disease between 1989 and 1993 and experienced life-threatening ischemic events (94% cardiogenic shock, 39% ventricular fibrillation, 67% ischemic electrocardiograph (ECG) changes) within 2.3+/-1.6 h after primary revascularization. Reoperation was carried out 1.0+/-1.3 h after the occurrence of acute ischemia. Serial echoes were obtained during the acute event and after reoperation as well as during the follow-up period.
Of the 18 patients, 8 are currently alive, 5 died within 30 days and 4 within the 1st year. There was one late death 5 years after surgery. Global and regional wall motion was evaluated using short axis views of transesophageal echoes taken during the acute event and after secondary revascularization, and compared with transthoracic echoes in long-term survivors up to 5 years after surgery. During the acute event left ventricular ejection fraction (LVEF) was reduced in 83% of the patients and improved significantly after reoperation (chi2 = 11.74, df= 2, P < 0.01). As to regional wall motion, 50% of the segments in non-revascularized areas remained abnormal. Regional wall motion after reoperation was significantly better in the surviving patients compared with patients dying in the post-operative course (chi2 = 6.23, df= 1, P < 0.05). The revascularization score ( > 75%) of abnormal contracting segments during the acute ischemic event was a significant determinant for long-term survival.
We conclude that patient outcome is determined by the severity of regional wall motion abnormality during the acute ischemic event, the aggressiveness of the attempt to revascularize these perfusion territories and their improvement after revision. Long-term survival reflects, therefore, the extent of emergency revascularization and therefore the ability to identify ischemic perfusion territories for surgical strategy planning.
初次血运重建后的最初几个小时内发生的严重缺血性损伤需要进行急诊再次手术。为研究急诊冠状动脉旁路移植术的效果，我们对18例患者进行了长达8年的随访，将他们在急性事件期间及二次血运重建后的整体和局部心肌功能变化与最终结局相关联。
1989年至1993年间，共有16例行冠状动脉旁路移植术（CABG）的患者和2例行经皮冠状动脉腔内血管成形术（PTCA）的患者因冠心病接受治疗，并在初次血运重建后2.3±1.6小时内发生危及生命的缺血事件（94%发生心源性休克，39%发生心室颤动，67%出现缺血性心电图（ECG）改变）。急性缺血发生后1.0±1.3小时进行再次手术。在急性事件期间、再次手术后以及随访期间获取系列超声心动图。
18例患者中，8例目前仍存活，5例在30天内死亡，4例在第1年内死亡。术后5年有1例晚期死亡。使用急性事件期间及二次血运重建后经食管超声心动图的短轴视图评估整体和局部室壁运动，并与术后长达5年的长期存活者的经胸超声心动图进行比较。在急性事件期间，83%的患者左心室射血分数（LVEF）降低，再次手术后显著改善（χ2 = 11.74，自由度 = 2，P < 0.01）。至于局部室壁运动，未进行血运重建区域50%的节段仍异常。存活患者再次手术后的局部室壁运动明显优于术后病程中死亡的患者（χ2 = 6.23，自由度 = 1，P < 0.05）。急性缺血事件期间异常收缩节段的血运重建评分（> 75%）是长期存活的重要决定因素。
我们得出结论，患者的结局取决于急性缺血事件期间局部室壁运动异常的严重程度、对这些灌注区域进行血运重建的积极程度以及再次手术后的改善情况。因此，长期存活反映了急诊血运重建的程度，从而反映了为手术策略规划识别缺血灌注区域的能力。
