“分站式”杂交冠状动脉血运重建术治疗73例冠状动脉多支血管病变临床中期随访结果分析

Abstract

目的：观察“分站式”杂交冠状动脉血运重建术（HCR）治疗冠状动脉多支血管病变中期随访结果，评价“分站式”HCR的可行性、安全性和疗效。<br> 方法：入选2012-01至2014-06因冠状动脉多支血管病变在我院行择期“分站式”HCR的患者共73例，其中男性50例（68.5%），女性23例（31.5%），平均年龄（61.1±10.7）岁，所有患者均为包括左前降支在内的多支病变。“分站式”HCR要点为：全麻双腔气管插管，左前胸第4或第5肋间小切口，直视下获取左乳内动脉，心脏跳动下完成左乳内动脉和左前降支的吻合。在小切口冠状动脉旁路移植术（CABG）术后3~7天，在介入导管室先行冠状动脉造影，观察左乳内动脉-左前降支旁路血管情况，证实其通畅后对非左前降支病变行经皮冠状动脉介入治疗（PCI）并置入支架。患者术后每年进行超声心动图、X线胸片和心电图检查，如患者出现心肌缺血表现，则进行冠状动脉增强计算机断层摄影术（CTA）或冠状动脉造影检查等。<br> 结果：本组患者均顺利施行“分站式”HCR，全组无手术死亡。外科手术时间（152.9±43.8）min，处理冠状动脉（2.6±0.5）支，术后总引流量（558.6±441.3）ml,输红细胞（0.8±1.9）U,机械通气时间（10.5±13.0）h。小切口CABG与PCI间隔时间（5.3±2.9）d,冠状动脉置入支架（1.6±0.7）枚。术后随访期间，主要不良心脑血管事件（MACCE）发生5例（6.8%），其中死亡1例（1.4%），再发心肌缺血3例（4.1%），需要接受CABG/PCI者1例（1.4%，因支架再狭窄，再次置入支架）。<br> 结论：“分站式”HCR是一种安全，有效的手术方式，其围手术期和中期随访结果满意，“分站式”HCR适合于左前降支严重病变无法接受PCI而右冠状动脉主干和（或）回旋支等非左前降支病变可以进行PCI的冠状动脉多支病变患者。

<br> Objective: To observe the midterm outcomes of“2-staged”hybrid coronary revascularization (HCR) for treating the patients with multi-vessel coronary artery disease (CAD) and to evaluate the feasibility, safety and effcacy of“2-staged”HCR. <br> Methods: A total of 73 relevant patients received elective “2-staged” HCR in our hospital from 2012-01 to 2014-06 were studied. There were 50 (68.5%) male and 23 (31.5%) female at the age of (61.1±10.7) years and all patients had multi coronary artery lesions including left anterior descending (LAD) artery. The key points of“2-staged”HCR were as follows:double-chamber intubation with general anesthesia, small incision between 4-5 ribs of left front thorax, take left internal mammary artery (LIMA) by direct view and make anastomosis of LIMA and LAD with heartbeat. At (3-5) days post-minimally invasive direct coronary artery bypass (MIDCAB), coronary angiography (CAG) was conducted to confirm that LIMA-LAD bypass vessel was unobstructed; then percutaneous coronary intervention (PCI) was performed in non-LAD coronary artery for stent implantation. Post-operative echocardiography, chest X-ray and ECG were examined in each year;coronary CTA or CAG would be taken if the patients with myocardial ischemia. <br> Results: All patients finished“2-staged”HCR smoothly and no operative death occurred. The average surgical time was (152.9±43.8) min and (2.6±0.5) coronary branches were treated, total post-operative drainage volume was (558.6±441.3) ml, red blood cell transfusion was (0.8±1.9) U, mechanical ventilation time was (10.5±13.0) h. The interval between MIDCAB and PCI was (5.3±2) days and (1.6±0.7) stents was implanted. During post-operative follow-up period, there 1 (1.4%) patient died, 3 (4.1%) with recurrent myocardial ischemia, 1 (1.4%) with in-stent restenosis and received PCI again, 4 (5.5%) with MACCE. <br> Conclusion: “2-staged”HCR is a safe and feasible operation with satisfactory peri-operative and mid-term outcomes;it is suitable for the patients with multi-vessel CAD including severe LAD lesions.