Doty J R, Salazar J D, Fonger J D, Walinsky P L, Sussman M S, Salomon N W
Division of Cardiac Surgery, Johns Hopkins and Sinai Hospital of Baltimore, MD 21287, USA.
Eur J Cardiothorac Surg. 1998 Jun;13(6):641-9. doi: 10.1016/s1010-7940(98)00086-4.
Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits.
Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization.
Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0-39).
Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.
微创直接冠状动脉旁路移植术（MIDCAB）是在直视下进行，无需开胸或体外循环。该技术用于再次手术的患者，通过各种切口使心脏的一个或两个区域血管再通。乳内动脉、胃网膜动脉、桡动脉或大隐静脉用作移植血管。
经小前外侧开胸切口用乳内动脉移植到冠状动脉前壁靶点。经上腹部正中小切口用胃网膜动脉移植到冠状动脉下壁靶点。经后外侧开胸切口用桡动脉或大隐静脉移植到冠状动脉侧壁靶点。部分肝素化后，通过局部冠状动脉阻断和稳定来促进吻合。移植血管随访包括门诊多普勒检查和选择性再次导管插入术。
1994年1月至1997年8月，81例患者接受再次手术的MIDCAB移植术。21例患者（25.9%）进行了乳内动脉移植，39例（48.2%）进行了胃网膜动脉移植，21例（25.9%）进行了桡动脉或大隐静脉侧壁移植。有9例早期死亡（4例心脏相关，5例非心脏相关），5例晚期死亡（3例心脏相关，2例非心脏相关），其余患者中有9例发生心肌梗死。16例患者接受了再次导管插入术；有1例移植血管闭塞，2例移植血管狭窄，8例吻合口狭窄。术后平均住院时间为3.8天。在平均7.8个月（范围0 - 39个月）的随访中，90%（55/61）的患者无症状。
再次手术的MIDCAB移植术避免了再次开胸、主动脉操作和体外循环的风险。该技术的早期通畅率为94%，其中包括8例术后接受基于导管的干预的患者。与传统冠状动脉旁路移植术相比，再次手术的MIDCAB移植术的室上性心律失常和输血发生率较低，但在死亡率、中风或心肌梗死方面没有优势。这3年的经验表明，虽然再次手术的MIDCAB移植术可以有效地使心脏局部区域血管再通，但应仔细选择患者以尽量降低手术风险。
