Woś S, Bachowski R, Ceglarek W, Domaradzki W, Matuszewski M, Kucewicz E
2nd Department of Cardiac Surgery, Silesian Medical School, Katowice, Poland.
Eur J Cardiothorac Surg. 1998 Oct;14 Suppl 1:S38-42. doi: 10.1016/s1010-7940(98)00102-x.
This study was undertaken to assess our experience with the first 50 patients who underwent CABG without cardiopulmonary bypass. In seven patients left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting was performed through a short left anterior thoracotomy. In 43 other patients median sternotomy was used. Primary CABG was performed in 48 patients; there were two reoperations. Eleven patients had unstable angina. Three patients had left ventricular ejection fraction (LVEF) equal to or lower than 25%. One patient had carcinoma of the right lung coexisting with unstable angina and underwent also right lower lobectomy. In each patient the clinical course, 12-lead ECG, transthoracic echocardiography and the serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT), aspartate aminotransferase (AspAT) were assessed. The need for inotropic or intraaortic balloon counterpulsation (IABP) support and blood transfusion was also recorded. There were three deaths, all in the sternotomy group (6%). A patient with systemic lupus erythemetodes (SLE) died of postoperative MI due to graft thrombosis. Another patient who was found to have porcelain aorta and had LIMA-LAD grafting as a rescue procedure died of MI with low cardiac output. The third patient with unstable angina and ejection fraction of 30% developed postoperative MI with ventricular arrhythmia. One patient with LIMA-LAD graft in whom percutaneous translaminal coronary angioplasty (PTCA) had been abandoned because of coronary spasm developed acute myocardial ischaemia 5 h postoperatively. He had a vein graft placed to LAD in cardiopulmonary bypass, his further course was uneventful. Six patients had IABP support. Nine patients needed inotropic support. Ten patients received blood transfusion. Twelve-lead ECG did not show acute ischaemia or MI, apart from the above described cases. Echocardiographic check showed improved IVS contractility in three patients and better apex motion in one case. In the other survivors the echocardiographic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels did not exceed 200 IU/ml. One patient from the mini-thoracotomy group had recurrent angina 2 months after the procedure. His left internal mammary artery (LIMA) graft was occluded; we replaced it with a vein graft. All 47 survivors remain asymptomatic, with the mean follow-up time of 6 months. Coronary surgery without cardiopulmonary bypass seems a valuable alternative for high-risk patients.
本研究旨在评估我们对首批50例接受非体外循环冠状动脉旁路移植术（CABG）患者的经验。7例患者通过左前胸部小切口进行了左乳内动脉至左前降支动脉（LIMA-LAD）移植。其他43例患者采用正中胸骨切开术。48例患者进行了初次CABG；2例为再次手术。11例患者有不稳定型心绞痛。3例患者的左心室射血分数（LVEF）等于或低于25%。1例右肺癌症患者合并不稳定型心绞痛，还接受了右下肺叶切除术。对每例患者的临床病程、12导联心电图、经胸超声心动图以及肌酸激酶（CPK）、丙氨酸转氨酶（ALAT）、天冬氨酸转氨酶（AspAT）的血清水平进行了评估。还记录了是否需要使用正性肌力药物或主动脉内球囊反搏（IABP）支持以及输血情况。有3例死亡，均在胸骨切开术组（6%）。1例系统性红斑狼疮（SLE）患者因移植血管血栓形成死于术后心肌梗死。另1例发现有瓷化主动脉且作为挽救性手术进行了LIMA-LAD移植的患者死于心肌梗死伴低心排血量。第3例不稳定型心绞痛且射血分数为30%的患者术后发生心肌梗死并伴有室性心律失常。1例接受LIMA-LAD移植的患者因冠状动脉痉挛放弃了经皮腔内冠状动脉成形术（PTCA），术后5小时发生急性心肌缺血。他在体外循环下进行了LAD静脉移植，后续病程平稳。6例患者接受了IABP支持。9例患者需要正性肌力支持。10例患者接受了输血。除上述病例外，12导联心电图未显示急性缺血或心肌梗死。超声心动图检查显示3例患者的室间隔收缩力改善，1例患者的心尖运动改善。其他幸存者的超声心动图表现与手术前相同。所有幸存者的ALAT和AspAT血清水平均正常，CPK水平未超过200 IU/ml。小切口手术组的1例患者术后2个月出现复发性心绞痛。其左乳内动脉（LIMA）移植血管闭塞；我们用静脉移植血管进行了替换。所有47例幸存者均无症状，平均随访时间为6个月。非体外循环冠状动脉手术似乎是高危患者的一种有价值的选择。
