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153例非體外循環冠狀動脈旁路移植術

目的　總結 15 3例非體外循環冠狀動脈旁路移植術患者無手術死亡的治療經驗。　方法　回顧性分析近4年來 15 3例非體外循環冠狀動脈旁路移植術的臨床資料、手術方法、手術結果。　結果　全組無手術死亡。每例平均移植旁路血管 3.1支 ,全組無圍手術期心肌梗死、呼吸衰竭、肝腎功能衰竭等并發癥 ,14 1例患者術后 4～ 6小時拔除氣管內插管 ,86例患者未輸庫血 ,術后心絞痛均消失。所有患者均獲隨訪 ,隨訪時間 2～ 4 2個月 ,無晚期死亡。1例患者于術后 1年 6個月出現活動后胸悶、心絞痛 ,其余患者癥狀均消失 ,活動量明顯增加 ,心功能改善。　結論　非體外循環冠狀動脈旁路移植術安全、有效 ,術后并發癥少 ,正確掌握其手術適應證、手術技巧和圍術期處理 ,是確保手術療效的關鍵。

Usher綜合征一例

同種異體原位心臟移植六例

目的總結6例行原位心臟移植術患者的外科治療經驗。方法采用Shumway和Stanford方法行心臟移植,供心保護采用經主動脈根部灌注4℃心臟停搏液;術后免疫抑制治療采用環孢素A、驍悉和強的松聯合治療,根據血環孢素A濃度及心內膜活檢調整環孢素A用量。結果6例患者均康復,無手術及術后死亡,術后未發生超急性或急性排斥反應。結論受者-供者選擇、供心保護、吻合技術、合理應用免疫抑制劑和圍術期并發癥的處理是手術成功的關鍵。

Surgical Treatment for Patients with Diffused Coronary Artery Disease

Objective To summarize the early outcomes and clinic al experience of off-pump coronary artery bypass grafting (off-pump CABG) afte r off-pump coronary endarterectomy (CE) for patients with diffused coronary art ery disease. Methods From May 2003 to November 2006，83 patients with diffu sed coronary artery disease underwent CE without cardiopulmonary bypass and off-pump CABG. There were 61 males and 22 females with age ranged from 55 to 80 ye ars (65±7 years). There were 7 patients in Canadian Cardiac Society(CCS) an gina classⅡ,20 patients in class Ⅲ,and 56 patients in class Ⅳ. 36(43.4%) pat ients had history of myocardial infarction. Coronary angiogram revealed th at 5 patients had double vessels disease, and other 78 patients had triple ves s els disease with 16 left main stem disease. The left ventricular ejection fract ion(LVEF) ranged from 25% to 65% (51%±16%). One hundred and ten endarter e ctomies were performed in 83 patients totally which included 67 in left anterior descending artery(LAD)，9 in circumflex artery and 34 in right coronary artery . Twenty patients received onlay venous patch after CE in LAD and then grafte d by internal mammary artery (IMA) on the patch. There were 83 left IMA, 2 radia l arteries, others were great saphenous veins, the mean number of grafts was 3.9 ±1.2. Results There was no death in all patients. Intraoper ative graft flowmeter was used to check the flow in the grafts before chest cl osure. One hundred and one (92%) out of 110 grafts after CE showed a satisfactor y grafts flow(22±16ml/min) intraoperatively. Four patients had perioperative myocardial infarctions but none had hemodynamic changes. All patients discharged uneventfully. Seventyfive patients (90.4%) had 8 to 50 months followup with no angi na reoccurrence. Eight patients had coronary angiogram from 3 to 29 months af ter operation with all patent grafts to the CE coronaries. Conclusion Off-pump CABG with coronary endarterectomy is feasible and achieves surgical revascularization in patients with diffuse cor onary artery disease.

Treatment of Coronary Heart Diseases and Carotid Arteriostenosis Through Offpump Coronary Artery Bypass Grafting Combined with Carotid Endarterectomy

Objective To investigate the effect of combined carotid endarterectomy (CEA) and offpump coronary artery bypass grafting (OPCAB) on patients with carotid arteriostenosis and coronary heart diseases. Methods A total of 121 consecutive patients with carotid arteriostenosis and coronary artery diseases underwent CEA and OPCAB between January 2003 and December 2009 in Nanjing First Hospital of Nanjing Medical University. There were 81 males and 40 females, with their ages ranged from 62 to 72 years (67.2±4.5 years). All patients had 3vessel coronary artery lesions, and there were 3 cases of left main coronary artery lesion. Unilateral carotid arteriostenosis (≥50%) occurred in 95 patients, and bilateral (≥50%) in 26 patients. The occurrence of stroke, myocardial infarction, angina pectoris and other complications after operation was observed, and followup was carried out. Results All patients underwent unilateral CEA including 50 on the right side and 71 left. The mean block time of carotid artery in CEA was 20.5±7.0 minutes. The average number of distal grafts per patient in OPCAB was 2.9±0.3. None of the patients had stroke or myocardial infarction and no perioperative death occurred. Eightyseven patients felt well in terms of their neuropsycho symptoms; 32 felt no change; and 2 worsened. Follow-up was done for all the patients with a follow-up rate of 100%. The mean time of the follow-up was 67.5±12.5 months. During this period, none of the patients manifested stroke, myocardial infarction or neuropsycho symptoms. Conclusion Concomitant OPCAB and CEA is a safe and effective procedure in patients with carotid arteriostenosis and coronary artery diseases. It can reduce the rate of postoperative stroke significantly. However, longterm outcome of the procedure needs operative experience accumulation, longterm follow-up and observation, and serious research and illumination.

68例特發性黃斑裂孔患眼內界膜及視網膜前膜的超微結構

非體外循環下冠狀動脈旁路移植術

目的 探討和評價微創非體外循環冠狀動脈旁路移植術(OPCAB)的臨床效果. 方法 38例OPCAB患者中左冠狀動脈主干病變 4例, 1支血管病變10例,2支14例,3支10例,均經胸骨正中切口行 OPCAB,每例移植血管1～5支,平均移植血管2.42支.應用左乳內動脈38支,大隱靜脈54支. 結果 全組無手術死亡,36例順利完成手術,2例轉為心肺轉流術下冠狀動脈旁路移植術.38例均在手術后2～12小時,平均4.9±2.6小時順利拔除氣管內插管.全組均順利康復,15例手術后1個月內恢復了原工作. 結論對有適應證的患者,OPCAB是一項安全有效的術式.

Off-pump Coronary Artery Bypass Grafting for the Treatment of Left Main with Three-vessel Coronary Disease

Objective To summarize experience in surgery about off-pump coronary artery bypass grafting(OPCAB)for the treatment of left main with three-vessel coronary disease. Methods OPCAB were perfomed in 33 patients of left main with three-vessel coronary disease. The left internal mammary artery(LIMA) was used to be the graft vessel to anastomose with left anterior descending. The saphenous vein was used to be the graft vessel to anastomose with left circumflex coronary artery, right coronary artery/posterior descend artery, diagonal branch, obtuse marginal branch. Results There was no operative death.The average number of grafting was 3.4 per case.There was no perioperative myocardial infarction, respiratory or hepatic or renal failure and other serious complications.Blood transfusion was not needed in 33% of cases.The angina pectoris was free after operation in all cases. Conclusions OPCAB is safe and effective for the treatment of left main with three-vessel coronary disease. The injuries were minimal. Preoperative preparation, using of intra-aortic balloon counterpulsation, operative matching, techniques and to create a skill and swift team for meet an emergency are the key factors to assure surgical outcome.

IABP輔助下非體外循環冠狀動脈旁路移植術治療冠心病合并嚴重左心室功能不全

目的 總結嚴重左心室功能低下的冠心病患者行主動脈內球囊反搏(IABP)輔助下非體外循環冠狀動脈旁路移植術（offpump CABG）的臨床經驗，以提高手術的成功率。 方法 66例嚴重左心室功能低下的冠心病患者，男48例，女18例；年齡68.4±10.3歲；左心室射血分數（LVEF）29.6%±5.3%。所有患者均在選擇性IABP輔助下行offpump CABG。根據IABP置入的時間不同，將66例患者分為兩組，術前IABP置入組：34例，于術前麻醉誘導后置入IABP；術后IABP置入組：32例，在手術完成后置入IABP。回顧分析其臨床資料、手術資料、手術結果。結果  66例患者中每例移植血管3.4±0.7支，采用乳內動脈（IMA）66例，且全部吻合于左前降支，采用大隱靜脈（SV）64例，橈動脈（RA）5例，吻合于除左前降支以外的所有冠狀動脈。于術后15~48 h均順利停用IABP；圍術期死亡1例，于術后29 d發生低心排血量綜合征合并腎功能衰竭，死于多器官功能衰竭。所有患者應用IABP后血流動力學和血氣指標明顯改善，連續心排血量（CCO）、心臟指數（CI）、混合靜脈血氧飽和度（SvO2）、有創動脈收縮壓（SABP）、有創平均動脈壓（MABP）較術前明顯升高，而毛細血管楔壓（PCWP）較術前明顯降低（Plt;0.05）。術前置入IABP組術后住ICU時間、室性心律失常和低心排血量發生率短于或低于術后置入組（Plt;0.05）。隨訪60例，隨訪時間1個月~3年，失訪5 例。隨訪期間無心絞痛復發，無心肌梗死發生，心功能分級（NYHA）Ⅰ~Ⅱ級51例，Ⅲ級9例。無晚期死亡。 結論 合理使用IABP，使嚴重左心室功能低下的冠心病患者施行off-pump CABG有良好的近期效果，該方法是可行的。

Clinical Application of Re-do Coronary Artery Bypass Grafting

Objective To summarize and analyze the clinical experience and surgical results of re-do coronary artery bypass grafting (Re-CABG) for reconvert coronary artery disease. Methods Eighteen patients who underwent Re-CABG in this hospital between June 2001 and December 2006 were analyzed. There were 15 males and 3 females aged from 65 to 78 years old. Seven patients were in class III angina(CCS) and 11 patients were in class IV. Coronary artery angiography showed stenosis or occlusion of great saphenous vein grafts in 16 patients, occlusion of left internal mammary artery(LIMA) grafts in 2 patients and new significant stenosis of the native coronary artery in 6 patients. All Re-CABG were done through re-sternotomy. Fifteen patients underwent cardiopulmonary bypass (CPB for their Re-CABG and 3 patients underwent off-pump Re-CABG. The concomitant procedures included left ventricular aneurysmectomy in 1 patient, mitral valve repair in 3 patients, combined aortic and mitral valve replacement and carotid endarterectomy in 1 patient. Bilateral IMA were used in 4 patients, LIMA in 12 patients, radial artery in 3 patients, and the rest of the grafts consisted of great and lesser saphenous vein. Results In on-pump Re-CABG, the aortic cross clamp time was 57±26min (range 45 to 112 min), the CPB time was 78±24min (range 66 to 140 min).The mean number of distal anastomosis per patient was 3.11(range 1 to 5). Intraoperative flow study of the grafts by Medi-Stim Butterfly showed a mean flow rate of 27.0±12.5 ml/min with pulsatility index( PI)less than 4.2. Intra-aortic balloon pump (IABP) was used in 1 patient who underwent concomitant aortic and mitral valve replacement and carotid endarterectomy. Post-operatively this patient developed renal failure and expired 6 days later. There was no residual angina and peri-operative myocardial infarction in the remain 17 patients.The post-operatively mechanical ventilation time varied from 5 to 15 hours, chest drainage varied from 290 to 1 040ml. Seventeen patients were discharged uneventfully. Follow-up from 6 months to 4.5years in 17 patients showed no evidence of recurrent angina. Postoperative coronary artery angiography in 4 patients showed patent grafts. Conclusion Re-CABG can be performed as safely and effectively as primary CABG in spite of the fact that it is more demanding. Selecting the proper target vessels, satisfactory blood flow of grafts, complete revascularization and proper peri-operative management are all key factors to a successful Re-CABG.