Folliguet T, Temkine J, Dibie A, Slama M, Philippe F, Le Bret E, Carbognani D, Bichel T, Laborde F
Département cardio-vasculaire, Institut Mutualiste Montsouris, Paris.
Arch Mal Coeur Vaiss. 1998 Oct;91(10):1235-42.
Coronary revascularization without cardiopulmonary bypass is evolving as an important technique. From January 1988 to September 1997, 224 patients underwent consecutively coronary artery bypass grafting without cardiopulmonary bypass in our institution. Indications for this type of revascularization were essentially: patients with a single coronary lesion and patients which presented an increased risk for extra-corporeal circulation. Follow-up was complete. The majority of patients were men (176) and the median age was 62 years. Most patients were in CCS III and IV (79%). Unstable angina was found in 19%, 4% had a recent trans mural infarction (< or = 48 hr), and 36% had an older infarct (> 48 hr). 8% were operated in emergency, 29% presented a restenosis following angioplasty, with 4% having a complication from angioplasty, and 0.8% were operated in cardiogenic shock. Redo surgery was seen in 4% of patients. 12% of patients had an ejection fraction less than 30%, 47% an ejection fraction between 30 et 49%, and 40% patients an ejection fraction greater than 50%. Mean Parsonnet score was 10. 185 patients (82.5%) underwent single bypass, and 39 patients (17%) multiple bypasses. Ten patients (4.4%) underwent hybrid revascularization with primarily surgical grafting followed by angioplasty. Postoperative outcome included: myocardial infarction in 16 patients (7.1%), 8 patients (3.5%) were reoperated for tamponade or bleeding, 2 patients (0.8%) developed a mediastinitis, and 1 patient (0.4%) had a neurological event. Hospital mortality was 4% (9 patients). Univariate and multivariate analysis identified two risks factors: age greater than 70 (OR 4.2, CI 1-18.4), and an ejection fraction less than 30% (OR 5, CI 1.2-21.6). Survival was 99.1% at 1 year, 94% at 3 years and 83.2% at 7 years. Post operative angina occurred in 33 patients, linked to a coronary anastomosis dysfunction in 9 patients (4.1%). A significant reduction of cost was found, compared to patients operated with extra-corporeal circulation. We conclude that coronary revascularization without cardiopulmonary bypass can provide satisfactory results, for patients with single coronary lesion, or for patients with an increased risk and multiple coronary lesions.
非体外循环冠状动脉血运重建术正逐渐发展成为一项重要技术。1988年1月至1997年9月，我院共有224例患者连续接受了非体外循环冠状动脉旁路移植术。这类血运重建术的适应症主要为：单一冠状动脉病变患者以及体外循环风险增加的患者。随访完整。大多数患者为男性（176例），中位年龄为62岁。大多数患者处于加拿大心血管学会（CCS）分级的III级和IV级（79%）。19%的患者有不稳定型心绞痛，4%的患者近期发生透壁心肌梗死（≤48小时），36%的患者有陈旧性心肌梗死（>48小时）。8%的患者为急诊手术，29%的患者在血管成形术后出现再狭窄，其中4%的患者发生血管成形术相关并发症，0.8%的患者在心源性休克状态下接受手术。4%的患者接受了再次手术。12%的患者射血分数低于30%，47%的患者射血分数在30%至49%之间，40%的患者射血分数大于50%。平均Parsonnet评分为10分。185例患者（82.5%）接受了单支血管搭桥，39例患者（17%）接受了多支血管搭桥。10例患者（4.4%）接受了杂交血运重建术，主要为外科血管移植，随后进行血管成形术。术后结果包括：16例患者（7.1%）发生心肌梗死，8例患者（3.5%）因心包填塞或出血接受再次手术，2例患者（0.8%）发生纵隔炎，1例患者（0.4%）出现神经系统事件。住院死亡率为4%（9例患者）。单因素和多因素分析确定了两个危险因素：年龄大于70岁（比值比4.2，可信区间1 - 18.4）和射血分数低于30%（比值比5，可信区间1.2 - 21.6）。1年生存率为99.1%，3年生存率为94%，7年生存率为83.2%。33例患者术后发生心绞痛，其中9例患者（4.1%）与冠状动脉吻合口功能障碍有关。与接受体外循环手术的患者相比，费用显著降低。我们得出结论，非体外循环冠状动脉血运重建术可为单一冠状动脉病变患者或风险增加及多支冠状动脉病变患者提供满意的结果。
