Diegeler A, Falk V, Krähling K, Matin M, Walther T, Autschbach R, Battelini R, Mohr F W
Clinic of Cardiac Surgery, University of Leipzig, Heartcenter, Germany.
Eur J Cardiothorac Surg. 1998 Oct;14 Suppl 1:S13-9. doi: 10.1016/s1010-7940(98)00098-0.
The aim of this study was to compare four different techniques for less-invasive coronary artery bypass surgery with and without cardiopulmonary bypass (CPB) in terms of feasibility as well as in terms of the intra- and postoperative course.
One hundred and fourteen patients were divided into four groups, according to the surgical technique. Group I: minithoracotomy, internal thoracic artery (ITA) harvesting and anastomosis under direct vision using cardiopulmonary bypass (CPB) on the fibrillating heart (n = 31). Group II: sternotomy and beating heart without CPB (n = 13). Group III: MIDCAB with CPB and cardioplegic cardiac arrest using endo-aortic balloon-occlusion, Port Access system (n = 9). Group IV: MIDCAB on the beating heart without CPB (n = 61). In total, 104 single and ten double graft procedures were performed using the radial artery T-graft technique in seven cases (groups III and IV).
Harvesting of the ITA graft took 41+/-16.2 min in group I and could be reduced to 31+/-8.3 min in group IV by the use of a specially-designed retractor. Complications were: death (n = 1, group I), myocardial infarction, (n = 1, group I), early occlusion of the graft (n = 1, group IV), early stenosis of the anastomosis (n = 2, groups I and IV), late stenosis of the anastomosis (n = 1, group IV), thrombosis of the femoral vein (n = 1, group III). Postoperative ventilation, ICU and hospital stay were similar among groups.
Based on our results, the following strategy has been developed: MIDCAB without CPB is the preferred technique for one-vessel graft procedures to the left anterior descendens (LAD) or RCA. The Port Access system (with CPB) is reserved as a second option for young patients requiring multiple-vessel grafting to the left coronary circulation (LAD/CX) and as a backup to avoid conversion. Sternotomy and an off-pump technique is used for single-vessel or multiple-vessel graft procedures in selected patients (emergency procedure, acute myocardial infarction, in the very obese).
本研究旨在比较四种不同的微创冠状动脉搭桥手术技术，这些技术在有或没有体外循环（CPB）的情况下，从可行性以及术中和术后过程方面进行比较。
114例患者根据手术技术分为四组。第一组：小切口开胸，直视下获取胸廓内动脉（ITA）并在心脏颤动时使用体外循环（CPB）进行吻合（n = 31）。第二组：胸骨切开术且心脏跳动下不使用CPB（n = 13）。第三组：采用Port Access系统，在体外循环和主动脉内球囊阻断下进行心脏停搏的微创冠状动脉搭桥术（MIDCAB）（n = 9）。第四组：心脏跳动下不使用CPB的微创冠状动脉搭桥术（MIDCAB）（n = 61）。总共进行了104例单支血管和10例双支血管移植手术，其中7例（第三组和第四组）采用桡动脉T型移植技术。
第一组获取ITA移植物耗时41±16.2分钟，而第四组通过使用专门设计的牵开器可将时间缩短至31±8.3分钟。并发症包括：死亡（1例，第一组）、心肌梗死（1例，第一组）、移植物早期闭塞（1例，第四组）、吻合口早期狭窄（2例，第一组和第四组）、吻合口晚期狭窄（1例，第四组）、股静脉血栓形成（1例，第三组）。各组术后通气、重症监护病房（ICU）停留时间和住院时间相似。
基于我们的结果，制定了以下策略：对于左前降支（LAD）或右冠状动脉（RCA）的单支血管移植手术，首选不使用CPB的微创冠状动脉搭桥术。Port Access系统（使用CPB）作为需要对左冠状动脉循环（LAD/回旋支（CX））进行多支血管移植的年轻患者的第二选择，并作为避免中转的备用方案。胸骨切开术和非体外循环技术用于特定患者（急诊手术、急性心肌梗死、极度肥胖患者）的单支血管或多支血管移植手术。
