中华胸心血管外科杂志
中華胸心血管外科雜誌
중화흉심혈관외과잡지
Chinese Journal of Thoracic and Cardiovascular Surgery
2010年
5期
329-331
,共3页
高杰%苏丕雄%刘岩%张希涛%安向光
高傑%囌丕雄%劉巖%張希濤%安嚮光
고걸%소비웅%류암%장희도%안향광
冠状动脉疾病%甲状腺功能减退症%冠状动脉分流术
冠狀動脈疾病%甲狀腺功能減退癥%冠狀動脈分流術
관상동맥질병%갑상선공능감퇴증%관상동맥분류술
Coronary disease%Coronary artery bypass%Hypothyroidism
目的 探讨冠心病(CAD)合并甲状腺功能低下(甲低)病人的冠状动脉旁路移植术(CABG)围术期外科处理的临床效果.方法 2002年9月至2009年6月,1347例CABG中21例(A组)合并甲低需要甲状腺激素替代治疗,男6例,女15例;平均(60.4±14.2)岁.体外循环下手术4例(包括心脏停跳手术1例),非体外循环下CABG 17例.术前均口服左旋甲状腺素,FT3、FT4、TSH、TT3、TT4明显改善后手术.同期对照20例甲状腺功能正常CABG者(B组),其中4例体外循环下CABG.观察两组术前、术中、术后甲状腺功能指标以及近端吻合时血流动力学指标.结果 围术期应用放射免疫法甲状腺激素水平检测,非体外循环下手术者,A组17例FT3术前及术中水平为[(1.39±0.36)pg/ml对(1.29±0.32)pg/ml]、B组16例为[(2.28±0.36)pg/ml对(2.19±0.34)pg/ml];体外循环下手术者,A组4例FT3术前及术中水平为[(1.53±0.51)pg/ml对(0.85±0.40)pg/ml]、B组4例为[(2.08±0.24)pg/ml对(1.96±0.26)pg/ml].A、B两组术中心排指数[(2.7±1.4)L·min-1·m-2对(2.8±1.5)L·min-1·m-2,P=0.53].A组1例重度甲低病人体外循环下心脏停跳手术后因心脏复跳困难死亡,20例生存者均为心脏不停跳方式手术者,其中17例为非体外循环手术,术后随访2～30个月均有心功能改善,射血分数(EF)由术前0.48±0.17增加至术后0.55±0.21.B组均生存.两组间术中血流动力学、手术预后、住院时间[(12.2±4.7)天对(10.1±3.9)天]、呼吸机辅助[(17.6±9.1)h对(15.1±13.7)h],差异无统计学意义.结论 冠心病合并甲低病人,术前准备充分,采用心脏不停跳手术方式较安全,非体外循环下手术对病人FT3激素水平影响较小;围术期甲状腺素治疗是关键;重度甲低病人体外循环下手术风险大.
目的 探討冠心病(CAD)閤併甲狀腺功能低下(甲低)病人的冠狀動脈徬路移植術(CABG)圍術期外科處理的臨床效果.方法 2002年9月至2009年6月,1347例CABG中21例(A組)閤併甲低需要甲狀腺激素替代治療,男6例,女15例;平均(60.4±14.2)歲.體外循環下手術4例(包括心髒停跳手術1例),非體外循環下CABG 17例.術前均口服左鏇甲狀腺素,FT3、FT4、TSH、TT3、TT4明顯改善後手術.同期對照20例甲狀腺功能正常CABG者(B組),其中4例體外循環下CABG.觀察兩組術前、術中、術後甲狀腺功能指標以及近耑吻閤時血流動力學指標.結果 圍術期應用放射免疫法甲狀腺激素水平檢測,非體外循環下手術者,A組17例FT3術前及術中水平為[(1.39±0.36)pg/ml對(1.29±0.32)pg/ml]、B組16例為[(2.28±0.36)pg/ml對(2.19±0.34)pg/ml];體外循環下手術者,A組4例FT3術前及術中水平為[(1.53±0.51)pg/ml對(0.85±0.40)pg/ml]、B組4例為[(2.08±0.24)pg/ml對(1.96±0.26)pg/ml].A、B兩組術中心排指數[(2.7±1.4)L·min-1·m-2對(2.8±1.5)L·min-1·m-2,P=0.53].A組1例重度甲低病人體外循環下心髒停跳手術後因心髒複跳睏難死亡,20例生存者均為心髒不停跳方式手術者,其中17例為非體外循環手術,術後隨訪2～30箇月均有心功能改善,射血分數(EF)由術前0.48±0.17增加至術後0.55±0.21.B組均生存.兩組間術中血流動力學、手術預後、住院時間[(12.2±4.7)天對(10.1±3.9)天]、呼吸機輔助[(17.6±9.1)h對(15.1±13.7)h],差異無統計學意義.結論 冠心病閤併甲低病人,術前準備充分,採用心髒不停跳手術方式較安全,非體外循環下手術對病人FT3激素水平影響較小;圍術期甲狀腺素治療是關鍵;重度甲低病人體外循環下手術風險大.
목적 탐토관심병(CAD)합병갑상선공능저하(갑저)병인적관상동맥방로이식술(CABG)위술기외과처리적림상효과.방법 2002년9월지2009년6월,1347례CABG중21례(A조)합병갑저수요갑상선격소체대치료,남6례,녀15례;평균(60.4±14.2)세.체외순배하수술4례(포괄심장정도수술1례),비체외순배하CABG 17례.술전균구복좌선갑상선소,FT3、FT4、TSH、TT3、TT4명현개선후수술.동기대조20례갑상선공능정상CABG자(B조),기중4례체외순배하CABG.관찰량조술전、술중、술후갑상선공능지표이급근단문합시혈류동역학지표.결과 위술기응용방사면역법갑상선격소수평검측,비체외순배하수술자,A조17례FT3술전급술중수평위[(1.39±0.36)pg/ml대(1.29±0.32)pg/ml]、B조16례위[(2.28±0.36)pg/ml대(2.19±0.34)pg/ml];체외순배하수술자,A조4례FT3술전급술중수평위[(1.53±0.51)pg/ml대(0.85±0.40)pg/ml]、B조4례위[(2.08±0.24)pg/ml대(1.96±0.26)pg/ml].A、B량조술중심배지수[(2.7±1.4)L·min-1·m-2대(2.8±1.5)L·min-1·m-2,P=0.53].A조1례중도갑저병인체외순배하심장정도수술후인심장복도곤난사망,20례생존자균위심장불정도방식수술자,기중17례위비체외순배수술,술후수방2～30개월균유심공능개선,사혈분수(EF)유술전0.48±0.17증가지술후0.55±0.21.B조균생존.량조간술중혈류동역학、수술예후、주원시간[(12.2±4.7)천대(10.1±3.9)천]、호흡궤보조[(17.6±9.1)h대(15.1±13.7)h],차이무통계학의의.결론 관심병합병갑저병인,술전준비충분,채용심장불정도수술방식교안전,비체외순배하수술대병인FT3격소수평영향교소;위술기갑상선소치료시관건;중도갑저병인체외순배하수술풍험대.
Objective Hypothyroidism may have adverse effects on the post-operative outcomes. We evaluated the outcomes of coronary artery bypass grafting (CABG) in patients who had both coronary artery disease (CAD) and hypothyroidism.Methods Among 1347 patients undergoing CABG between September 2002 and June 2009, hypothyroidism was diagnosed in 21 patients (Group A, with 6 men and 15 women) and treated with thyroxin replacement therapy. The average age of patients in group A was(60.4 ± 10.2). Hypothyroidism was identified with tests for thyroid functions. CABG in 4 patients was performed with extracorporeal circulation, three of them received on-pump beating heart CABG, and in 17 patients was performed with off pump CABG( OPCAB). CABG was performed following the improvement of FT3, FT4 and TSH with the use of levothyroxine for all patients in group A Twenty patients with CAD in the absence of hypothyroidism ( group B) served as control, 4 of these patients underwent CABG with extracorporeal circulation. Data of thyroid function and hemodynamics pre-, post- and during operation were analyzed. Results Serum thyroid hormones, such as FT3, were measured with sensitive and specific radioimmunoassays peri-operatively. In the patients receiving CABG without extraorporeal circulation, the mean serum FT3 concentrations were ( 1. 39 ± 0. 36 ) pg/ml pre-operatively and ( 1.29 ± 0. 32 ) pg/ml post-operatively ( P = 0.18 ) for 17 cases in group A, and were (2.28 ±0.36)pg/ml and (2.19 ±0.34) pg/ml respectively (P =0.24)for 16 cases in Group B. In the patients receiving CABG with extracorporeal circulation, the mean serum FT3 concentrations were( 1.53 ±0.51 )pg/ml pre-operatively and (0.85 ± 0.40) pg/ml post-operatively ( P = 0. 04 ) for 4 cases in group A, and were ( 2.08 ± 0.24) pg/ml vs. ( 1.96 ±0. 26) pg/ml ( P = 0. 26 ) for 4 cases in group B. The CIs of patients in group A and group B were ( 2.7 ± 1.4)L · min-1 · m-2 vs. (2.8 ±1.5) L · min-1 · m-2, P=0.53). One patients with severe hypothyroidism and underwent CABG with extracorporeal circulation in Group A died of refractory bradycardia after failure in heart resuscitation. Twenty survivors in group A underwent coronary artery bypass on-beating heart. All survivors had improvement in cardiac function during 2to 30 months of follow-up, their preoperative ejection fraction (EF) was 0.48 ± 0.17 and follow-up EF was 0.55 ± 0. 21. All 20 patients in group B were alive. There was no significant difference between group A and B in hemodynamics, prognosis, duration of hospitalization [( 12.2 ±4.7 ) day vs. ( 10. 1 ± 3.9 ) day, P = 0.17], time to extubation [( 17.6 ± 9. 1 ) h vs.(15.1 ± 13.7) h, P =0.12]. Conclusion CABG in patients with both CAD and hypothyroidism is relatively safe. Proper peri-operative nanagement, combined with on-beating heart techniques of CABG, may decrease the operation risks. Off pump CABG had little effect on serum concentrations of FT3. Peri-operative thyroid replacement therapy was critical for patients with hypothyroidism. Patients with severe hypothyroidism who underwent CABG with extracorporeal circulation were at high risk.
