Grinda J M, Zegdi R, Couetil J P, Chauvaud S, Deloche A, Fabiani J N, Carpentier A
Service de chirurgie cardiaque, hôpital Broussais, Université Paris VI.
Arch Mal Coeur Vaiss. 1998 Oct;91(10):1229-34.
The authors performed 184 coronary reoperations (172 redux, 12 tridux) between January 1986 and december 1995 in 177 patients (165 men, 12 women) with an average age at surgery of 62.9 +/- 7.6 years. The average interval between the surgical procedures was 9.5 +/- 4.5 years. The symptoms were recurrent angina, stable in 44%, unstable in 51%, and cardiac failure, 7%. Graft dysfunction was the cause in 94.5% of cases with progression of atheroma of the native coronary vessels in only 5.6% of cases. At reoperation 389 bypass procedures were performed (venous 39.5%, arterial 60.5%) (2.1 +/- 0.6 per patient) with 10 associated procedures (3 mitral valvuloplasties, 2 left ventricular aneurysmectomy, 3 aortic valve replacements, 1 replacement of the ascending aorta, 1 carotid endarteriectomy). The operative mortality was 10.9%. The causes of the 20 deaths were myocardial infarction (7), left ventricular failure (8), arrhythmias (2), mediastinitis (1) and multi-organ failure (2). The risk factors for death were: the date of surgery (19% before 1991 and 8% after: p = 0.03), age (18% after 60 years, 2% before: p = 0.015), the interval between the surgical procedures (33% after 15 years, p = 0.02), anterograde cardioplegic injection alone (15% versus 4.5% when mixed antero and retrograde perfusion was used: p = 0.02). The morbidity was 28% (52/184 patients); 132 patients (72%) had uncomplicated postoperative courses. The incidence of repeat coronary artery surgery is in constant progression. Improved medico-surgical management should continue to reduce the mortality which is still high.
1986年1月至1995年12月期间，作者对177例患者（165例男性，12例女性）进行了184例冠状动脉再次手术（172例二次手术，12例三次手术），手术时平均年龄为62.9±7.6岁。两次手术之间的平均间隔时间为9.5±4.5年。症状为复发性心绞痛，其中稳定型占44%，不稳定型占51%，心力衰竭占7%。94.5%的病例病因是移植血管功能障碍，只有5.6%的病例是原冠状动脉血管粥样硬化进展。再次手术时进行了389次搭桥手术（静脉搭桥占39.5%，动脉搭桥占60.5%）（每位患者2.1±0.6次），同时进行了10例相关手术（3例二尖瓣成形术，2例左心室室壁瘤切除术，3例主动脉瓣置换术，1例升主动脉置换术，1例颈动脉内膜切除术）。手术死亡率为10.9%。20例死亡的原因是心肌梗死（7例）、左心室衰竭（8例）、心律失常（2例）、纵隔炎（1例）和多器官功能衰竭（2例）。死亡的危险因素有：手术日期（1991年之前为19%，之后为8%：p = 0.03）、年龄（60岁之后为18%，之前为2%：p = 0.015）、两次手术之间的间隔时间（15年之后为33%，p = 0.02）、仅采用顺行心脏停搏液注射（采用顺行和逆行混合灌注时为4.5%，前者为15%：p = 0.02）。发病率为28%（184例患者中的52例）；132例患者（72%）术后病程无并发症。冠状动脉再次手术的发生率持续上升。改善药物和手术管理应继续降低仍然较高的死亡率。
