不停跳冠脉搭桥心肌保护技术在瓣膜疾病合并冠心病手术中的应用

董桂福; 王宇航; 葛建军

doi:10.16766/j.cnki.issn.1674-4152.002133

不停跳冠脉搭桥心肌保护技术在瓣膜疾病合并冠心病手术中的应用

doi: 10.16766/j.cnki.issn.1674-4152.002133

1.
中国科学技术大学附属第一医院(安徽省立医院)心脏大血管外科，安徽合肥 230001
2.
苏州大学附属第一医院心脏大血管外科，江苏苏州 215006

基金项目:

安徽省科技重大专项项目 18030801132

详细信息

通讯作者:
葛建军，E-mail：SLgejianjun@outlook.com

中图分类号: R654.3 R542.5 R541.4
计量
- 文章访问数: 159
- HTML全文浏览量: 57
- PDF下载量: 5
- 被引次数: 0
出版历程
- 收稿日期: 2021-04-20
- 网络出版日期: 2022-02-15

Application analysis of myocardial protection technique for off-pump coronary artery bypass grafting in the operation of valve disease combined with coronary heart disease

1.
Department of Cardiac Surgery, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China

摘要

摘要: 目的介绍不停跳冠脉搭桥心肌保护技术在瓣膜疾病合并冠心病手术中的应用。方法观察2017年1月—2020年7月就诊于中国科学技术大学附属第一医院心脏外科的瓣膜病合并冠心病的149例患者，应用不停跳冠脉搭桥心肌保护技术行瓣膜置换合并冠脉搭桥术的手术效果和相关并发症。对于搭桥+主动脉瓣膜/双瓣膜置换术，经左、右冠状动脉开口直接灌注+经静脉桥血管灌注，然后行心脏瓣膜置换术，缝合主动脉切口+静脉桥血管吻合。对于搭桥+二尖瓣膜置换手术，将静脉桥血管吻合至主动脉，降温阻断后，行主动脉根部灌注和二尖瓣膜置换。结果 149例手术患者中，主瓣+搭桥49例，二尖瓣+搭桥83例，双瓣+搭桥17例，单支冠脉病变需搭桥54例，2支病变55例，3支病变40例。术后住院期间死亡10例，术后有4例发生永久性脑卒中，有28例发生急性肾功能不全需透析治疗，有18例机械通气时间>24 h。结论对于冠心病合并瓣膜病的患者，在冠状动脉搭桥合并瓣膜手术中应用不停跳冠脉搭桥心肌保护技术具有操作简单、手术效果满意、术后并发症少及临床效果满意等优点。
- 冠心病合并瓣膜病 /
- 不停跳冠脉搭桥心肌保护技术 /
- 瓣膜置换 /
- 冠脉搭桥 /
- 术后住院死亡
Abstract: Objective To introduce the application of myocardial protection technique for off-pump coronary artery bypass grafting (OPCABG) in the operation of valve disease complicated with coronary heart disease. Methods The effect and related complications of valve replacement combined with coronary artery bypass grafting using myocardial protection technique for OPCABG in patients with valvular disease complicated with coronary heart disease treated in the Department of Cardiac Surgery of the First Affiliated Hospital of China University of science and technology from January 2017 to July 2020. For bypass surgery+aortic valve replacement surgery, the direct perfusion through the left and right coronary artery orifices and transvenous graft perfusion were firstly performed, and then heart valve replacement surgery was taken and the anastomosis of aortic incision and vascular graft was sutured. For bypass surgery+mitral valve replacement surgery, the vascular graft was anastomosed with the pathological target vessel under the circulatory beating heart, and the vascular graft was anastomosed with the aorta. After the aorta was cooled and blocked, the aortic root perfusion and the mitral valve replacement were performed. Results Among the 149 patients, 49 patients taken aortic valve replacement+bypass surgery, 83 taken mitral valve replacement+bypass surgery, 17 taken double valves replacement+bypass surgery, 54 had a single pathological branch of coronary artery which required bypass surgery, 55 had two pathological branches of coronary artery which required bypass surgery, and 40 had three pathological branches of coronary artery requiring bypass surgery. Ten patients died during postoperative hospitalization, 4 suffered permanent stroke after surgery, 28 suffered acute renal insufficiency and required dialysis treatment, and 18 taken mechanical ventilation for more than 24 hours. Conclusion For patients with coronary heart disease combined with valvular diseases, the myocardial protection technique for OPCABG in coronary artery bypass surgery combined with valve surgery is easy to operate, causing less postoperative complications and bringing satisfactory surgical results and clinical effects.

HTML全文

表 1 149例行瓣膜置换联合冠状动脉搭桥术患者临床基线资料

组别	例数	年龄(x ±s，岁)	BMI (x ±s)	性别[例(%)]		吸烟史[例(%)]		高脂血症[例(%)]
组别	例数	年龄(x ±s，岁)	BMI (x ±s)	男性	女性	无	有	无	有
主瓣+搭桥	49	64.7±7.9	23.3±3.5	38(77.6)	11(22.4)	16(32.7)	33(67.3)	35(71.4)	14(28.6)
二尖瓣+搭桥	83	62.5±7.7	23.6±3.9	48(57.8)	35(42.2)	15(18.3)	67(81.7)	69(83.1)	14(16.9)
双瓣+搭桥	17	62.2±13.9	23.6±2.2	7(41.2)	10(58.8)	2(11.8)	15(88.2)	12(70.6)	5(29.4)
统计量		1.093^a	0.133^a	8.798^b		4.881^b		3.035^b
P值		0.338	0.875	0.012		0.087		0.219

组别	例数	高血压[例(%)]		糖尿病[例(%)]		慢性肾功能不全[例(%)]		慢性阻塞性肺疾病[例(%)]
组别	例数	无	有	无	有	无	有	无	有
主瓣+搭桥	49	19(38.8)	30(61.2)	41(83.7)	8(16.3)	47(95.9)	2(4.1)	49(100.0)	0(0.0)
二尖瓣+搭桥	83	42(50.6)	41(49.4)	70(84.3)	13(15.7)	73(88.0)	10(12.0)	77(92.8)	6 (7.2)
双瓣+搭桥	17	9(52.9)	8(47.1)	14(82.4)	3(17.6)	14(82.4)	3(17.6)	14(82.4)	3(17.6)
统计量		2.004^b		0.044^b		3.378^b		7.392^b
P值		0.367		0.978		0.185		0.025
注：^a为F值，^b为χ²值。

下载: 导出CSV

表 2 149例行瓣膜置换联合冠状动脉搭桥术患者术后资料[例(%)]

组别	例数	死亡		脑卒中		急性肾功能衰竭		延长机械通气时间>24 h
组别	例数	无	有	无	有	无	有	无	有
主瓣+搭桥	49	44(89.8)	5(10.2)	47(95.9)	2(4.1)	41(83.7)	8(16.3)	43(87.8)	6(12.2)
二尖瓣+搭桥	83	81(97.6)	2(2.4)	82(98.8)	1(1.2)	68(81.9)	15(18.1)	72(86.7)	11(13.3)
双瓣+搭桥	17	14(82.4)	3(17.6)	16(94.1)	1(5.9)	12(70.6)	5(29.4)	16(94.1)	1(5.9)
χ²值		6.655		1.727		1.479		0.724
P值		0.036		0.422		0.477		0.696

组别	例数	纵隔感染		术后出血二次手术				延长监护室监护时间>48 h
组别	例数	无	有	无		有		无	有
主瓣+搭桥	49	49(100.0)	0(0.0)	46(93.9)		3(6.1)		36(73.5)	13(26.5)
二尖瓣+搭桥	83	82(98.8)	1(1.2)	80(96.4)		3(3.6)		63(75.9)	20(24.1)
双瓣+搭桥	17	17(100.0)	0(0.0)	16(94.1)		1(5.9)		12(70.6)	5(29.4)
χ²值		0.801		0.493				0.250
P值		0.670		0.782				0.882

下载: 导出CSV

参考文献(18)

[1]	楚天舒, 葛建军, 赵智伟. 不停跳冠脉搭桥心肌保护技术在冠脉搭桥合并瓣膜手术中的应用[J]. 安徽医科大学学报, 2016, 51(6): 897-899. https://www.cnki.com.cn/Article/CJFDTOTAL-YIKE201606031.htm
[2]	殷恩智, 田伟臣, 李刚, 等. 同期行冠状动脉旁路移植和心脏瓣膜置换术治疗冠心病合并心脏瓣膜病的临床研究[J]. 现代生物医学进展, 2014, 14(10): 1890-1892. https://www.cnki.com.cn/Article/CJFDTOTAL-SWCX201410021.htm
[3]	王领, 刘学刚, 李海慧, 等. 单操作孔全胸腔镜心脏不停跳技术在心内直视手术中的应用[J]. 中华全科医学, 2021, 19(3): 362-364, 445. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202103007.htm
[4]	RAHHAB Z, EL FAQUIR N, TCHETCHE D, et al. Expanding the indications for transcatheter aortic valve implantation[J]. Nat Rev Cardiol, 2020, 17(2): 75-84. doi: 10.1038/s41569-019-0254-6
[5]	BARBANTI M, BUCCHERI S, CAPODANNO D, et al. Transcatheter or surgical treatment of severe aortic stenosis and coronary artery disease: A comparative analysis from the Italian OBSERVANT study[J]. Int J Cardiol, 2018, 270: 102-106. doi: 10.1016/j.ijcard.2018.06.011
[6]	THALJI N M, SURI R M, DALY R C, et al. The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: Implications for revascularization in the transcatheter era[J]. J Thorac Cardiovasc Surg, 2015, 149(2): 451-460. doi: 10.1016/j.jtcvs.2014.08.073
[7]	ZHANG Y, WANG D, LIU Y, et al. Surgical management of severe ischaemic mitral regurgitation[J]. Heart Lung Circ, 2018, 27(4): 517-523. doi: 10.1016/j.hlc.2017.04.005
[8]	ROGERS C A, CAPOUN R, SCOTT L J, et al. Shortening cardioplegic arrest time in patients undergoing combined coronary and valve surgery: Results from a multicentre randomized controlled trial: the SCAT trial[J]. Eur J Cardiothorac Surg, 2017, 52(2): 288-296. doi: 10.1093/ejcts/ezx087
[9]	DAVARPASAND T, HOSSEINSABET A, JALALI A. Concomitant coronary artery bypass graft and aortic and mitral valve replacement for rheumatic heart disease: Short- and mid-term outcomes[J]. Interact Cardiovasc Thorac Surg, 2015, 21(3): 322-328. doi: 10.1093/icvts/ivv132
[10]	张金辉, 蔡淑女. 右美托咪定全程泵注对体外循环下心脏瓣膜置换术患者的心肌保护作用[J]. 中华全科医学, 2020, 18(5): 752-756. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202005014.htm
[11]	孟金金, 刁文杰, 刘学刚, 等. 70岁以上高龄冠心病患者27例外科手术临床分析[J]. 中华全科医学, 2019, 17(11): 1818-1820. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201911008.htm
[12]	MONGERO L B, TESDAHL E A, STAMMERS A H, et al. A BMI >35 does not protect patients undergoing cardiac bypass surgery from red blood cell transfusion[J]. Perfusion, 2017, 32(1): 20-26. doi: 10.1177/0267659116652213
[13]	RANUCCI M, DE VINCENTⅡS C, MENICANTI L, et al. A gender-based analysis of the obesity paradox in cardiac surgery: Height for women, weight for men?[J]. Eur J Cardiothorac Surg, 2019, 56(1): 72-78. doi: 10.1093/ejcts/ezy454
[14]	DIELEMAN J M, PEELEN L M, COULSON T G, et al. Age and other perioperative risk factors for postoperative systemic inflammatory response syndrome after cardiac surgery[J]. Br J Anaesth, 2017, 119(4): 637-644. doi: 10.1093/bja/aex239
[15]	ARONEY N, PATTERSON T, ALLEN C, et al. Neurocognitive Status after aortic valve replacement: Differences between TAVI and surgery[J]. J Clin Med, 2021, 10(8): 1789. doi: 10.3390/jcm10081789
[16]	RANKIN J S, BADHWAR V, HE X, et al. The society of thoracic surgeons mitral valve repair/replacement plus coronary artery bypass grafting composite score: A report of the society of thoracic surgeons quality measurement task force[J]. Ann Thorac Surg, 2017, 103(5): 1475-1481. doi: 10.1016/j.athoracsur.2016.09.035
[17]	HARTRUMPF M, KUEHNEL R, ALBES J M. The obesity paradox is still there: A risk analysis of over 15 000 cardiosurgical patients based on body mass index[J]. Interact Cardiovasc Thorac Surg, 2017, 25(1): 18-24. doi: 10.1093/icvts/ivx058
[18]	SØNDERGAARD L, POPMA J J, REARDON M J, et al. Comparison of a complete percutaneous versus surgical approach to aortic valve replacement and revascularization in patients at intermediate surgical risk[J]. Circulation, 2019, 140(16): 1296-1305. doi: 10.1161/CIRCULATIONAHA.118.039564