CAJ | 학술논문

目的研究非体外循环冠状动脉旁路移植术(CABG)的术中手术策略在吻合不同部位靶血管时对血流动力学的影响,探讨非体外循环CABG术中稳定血流动力学的措施.方法 2005年3月至2007年3月进行手术治疗的67例冠状动脉粥样硬化性心脏病患者,男性45例,女性22例,年龄44～81岁,均为严重三支病变.所有患者均先作左胸廓内动脉一前降支(LIMA-LAD)吻合,再作钝缘支(OM)及后降支(PDA)的序贯吻合.根据吻合的顺序不同将患者分为三组:组Ⅰ吻合顺序为PDA-OM-主动脉(Ao),共22例;组Ⅱ吻合顺序为Ao-PDA-OM,共14例;组Ⅲ为Ao-OM-PDA,共31例.以LIMA-LAD吻合前的血流动力学指标为基础值,在LAD吻合时及吻合后、PDA吻合时、OM吻合时各时间点测定血流动力学指标,并与基础值相比较.结果 67例患者均顺利施行了非体外循环CABG,无手术死亡.行LIMA-LAD吻合时,各项血流动力学指标变化不显著.LIMA-LAD完成后,各项指标显著改善.吻合OM时,组Ⅰ、组Ⅲ的心率(HR)、中心静脉压(CVP)显著升高(P＜0.05),平均动脉压(MAP)、心指数(CI)、左室做功指数(LVSWI)及右室做功指数(RVSWI)均显著降低(P＜0.05),但组Ⅱ上述指标变化均不显著(P＞0.05).吻合PDA时,组Ⅰ、组Ⅱ的HR、CVP均显著升高(P＜0.05),MAP、CI、LVSWI及RVSWI均显著降低(P＜0.05),但组Ⅲ上述指标变化不显著(P＞0.05).结论先吻合桥血管的近端,再序贯吻合靶血管,这样的手术策略有利于非体外循环CABG时完成显露、吻合困难的OM、PDA部位的手术.
목적 연구비체외순배관상동맥방로이식술(CABG)적술중수술책략재문합불동부위파혈관시대혈류동역학적영향,탐토비체외순배CABG술중은정혈류동역학적조시.방법 2005년3월지2007년3월진행수술치료적67례관상동맥죽양경화성심장병환자,남성45례,녀성22례,년령44～81세,균위엄중삼지병변.소유환자균선작좌흉곽내동맥일전강지(LIMA-LAD)문합,재작둔연지(OM)급후강지(PDA)적서관문합.근거문합적순서불동장환자분위삼조:조Ⅰ문합순서위PDA-OM-주동맥(Ao),공22례;조Ⅱ문합순서위Ao-PDA-OM,공14례;조Ⅲ위Ao-OM-PDA,공31례.이LIMA-LAD문합전적혈류동역학지표위기출치,재LAD문합시급문합후、PDA문합시、OM문합시각시간점측정혈류동역학지표,병여기출치상비교.결과 67례환자균순리시행료비체외순배CABG,무수술사망.행LIMA-LAD문합시,각항혈류동역학지표변화불현저.LIMA-LAD완성후,각항지표현저개선.문합OM시,조Ⅰ、조Ⅲ적심솔(HR)、중심정맥압(CVP)현저승고(P＜0.05),평균동맥압(MAP)、심지수(CI)、좌실주공지수(LVSWI)급우실주공지수(RVSWI)균현저강저(P＜0.05),단조Ⅱ상술지표변화균불현저(P＞0.05).문합PDA시,조Ⅰ、조Ⅱ적HR、CVP균현저승고(P＜0.05),MAP、CI、LVSWI급RVSWI균현저강저(P＜0.05),단조Ⅲ상술지표변화불현저(P＞0.05).결론 선문합교혈관적근단,재서관문합파혈관,저양적수술책략유리우비체외순배CABG시완성현로、문합곤난적OM、PDA부위적수술.
Objective To study the influence of anastomoses sequence on the hemodynamics in offpump coronary artery bypass grafting(CABG),and to investigate the strategy to stabilize the hemodynamics.Methods From March 2005 to March 2007,67 patients with serious triple-vessel coronary artery lesions(male 45,female 22)with a age range from 44 to 81 years old were enrolled for off-pump CABG.All the patients underwent left internal mammary artery-left anterior descending branch(LIMALAD)anastomose firstly,followed by the foreword anastomose of the other two vessels.According to the anastomose sequence of posterior descending branch(PDA)and obtuse marginal branch(OM),the patients were divided into three groups.Group Ⅰ(n=22)did the sequence of PDA-OM-aortic root(Ao).Group Ⅱ (n=14)did the sequence of Ao-PDA-OM.Group Ⅲ(n=31)did the sequence of Ao-OM-PDA.The hemodynamics markers,including heart rate(HR),central venous pressure(CVP),mean artery pressure (MAP),cardiac index(CI),left ventricular-stroke work index(LVSWI)and right ventricular stroke work index(RVSWI),were analyzed before LIMA-LAD anastomose to serve as baseline.And these markers were re-measured at LIMA-LAD anastomose,immediately after LIMA-LAD anastomose,at PDA anastomose and at OM anastomose.Results All the patients survived after off-pump CABG. Compared with the baseline,there were no significant hemodynamic changes when doing LIMA-LAD anastomose.When the anastomose finished,the hemodynamic indices improved significantly.When performing OM anastomose,HR and CVP increased significantly,and MAP,CI,LVSWI and RVSWI decreased remarkably in group Ⅰ and group Ⅲ,while there were no significant changes of MAP,CI and RVSWI in group Ⅱ. When performing PDA anastomose,HR and CVP increased significantly,and MAP,CI,LVSWI and RVSWI decreased remarkably in group Ⅰ and group Ⅱ,while there were no significant hemodynamic changes in group Ⅲ except HR.Conclusion Proximal anastomose first when performing off-pump CABG,followed by distal anastomoses of target vessels is beneficial to those who have hard exposure and difficult anastomose of OM and PDA.