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Surgical Treatment for Chronic Total Occlusion of Coronary Artery with Offpump Coronary Artery Bypass Grafting

Objective To investigate the surgical therapy for chronic total occlusion (CTO) of coronary artery with offpump coronary artery bypass grafting (OPCAB). Methods From Aug. 1999 to Oct. 2007, 696 patients with 853 totally occluded coronary arteries (127 coronary arteries lack of opacification while the other 726 arteries with reverse flow showed by coronary angiography) underwent OPCAB. A total of 2 231 grafts were constructed including 136 placed to coronary endarterectomy (CE) targets and 28 arterialized middle cardiac veins. Blood flow was detected during operation in 26 coronary arteries with no opacification in preoperative angiography, while no blood flow was detected in 63 coronary arteries with opacification in preoperative angiography. Cardiopulmonary bypass was applied in 15 cases because of a poor hemodynamics and 6 of which were assisted with intraaortic balloon pump(IABP). Results All patients survived the operation. 6 died in hospital because of low cardiac output (2 cases), renal failure (2 cases), perioperative cardiac infarction (1 case) or cerebrovascular accident (1 case). Stress ulceration occurred in one case, mediastinal infection occurred in another case after operation. Both were treated medically and recovered. 692 patients were followed up and the rate of flup was 99.42%(685/686)， with 4 withdrawal. Freedom from cardiac angina was 99.85%(685/686) and cardiac functional grading (NYHA) was Ⅰ-Ⅱ. Conclusion OPCAB can be well performed in patients with chronic total occlusion of coronary arteries. The ralue of coronary angiography for evaluating totally occluded coronary artery is limited, and endoscope or intravascular ultrasound techniques may be helpful.

冠状动脉旁路移植术治疗左主干分叉病变

目的 探讨冠状动脉左主干分叉病变的外科治疗方法，总结其临床经验。 方法 1999年3月至2008年4月我院共收治29例冠状动脉左主干分叉病变患者，在体外循环心脏不停跳下行冠状动脉旁路移植术(CABG)，观察体外循环时间、术后呼吸机辅助时间、 ICU时间、住院时间、围术期以及随访情况。 结果 体外循环时间为482±15.5 min，术后呼吸机辅助时间14.2±4.6 h，住ICU时间3.3±0.8 d，住院时间18.0±2.7 d，无围术期心肌梗死发生。本组患者随访7～98个月 (29.0±19.2个月)，25例心绞痛症状完全消失，2例心绞痛症状缓解，3例于术后3年、4年和8年分别死于脑血管病变、心脏骤停及肺癌。超声心动图检查提示:左心室收缩功能获得不同程度的改善。 结论 冠状动脉左主干分叉病变应用体外循环心脏不停跳CABG可以取得良好的治疗效果。

主动脉缩窄合并冠心病一例

原发性心脏肿瘤的外科治疗

目的 总结原发性心脏肿瘤的外科治疗经验，以提高手术疗效。 方法 回顾性分析1980年6月至2008年12月中国医科大学附属第一医院收治的263例原发性心脏肿瘤患者的临床资料，其中男90例，女173例；年龄10～79岁（41±13岁）。良性肿瘤241例，其中良性粘液瘤240例，纤维瘤1例；恶性肿瘤22例，其中恶性粘液瘤7例，恶性间皮瘤4例，血管肉瘤5例，横纹肌肉瘤1例，肺动脉内膜肉瘤1例，平滑肌肉瘤1例，炎症性恶性纤维组织细胞瘤1例，恶性淋巴瘤1例，滑膜肉瘤1例。手术完整摘除肿瘤252例（恶性肿瘤11例），局部切除肿瘤5例（均为恶性肿瘤），开胸探查取病理活组织检查6例（均为恶性肿瘤）。同期行冠状动脉旁路移植术（CABG）5例，二尖瓣置换术5例，二尖瓣成形术4例，三尖瓣成形术9例，三尖瓣生物瓣置换术1例，主动脉根部及肺动脉成形术1例，肺动脉瓣置换术1例，肺动脉主干及左右肺动脉人工血管加肺动脉瓣置换术1例，肺动脉切开取栓术1例，经股动脉取瘤栓术5例。 结果 围术期死亡7例（良性粘液瘤6例、恶性粘液瘤1例），其中术中不能停体外循环2例，术后发生低心排血量、心室颤动3例，呼吸、循环衰竭1例，大面积脑出血1例；其余患者无并发症发生。随访247例（良性肿瘤229例，恶性肿瘤18例），随访时间3个月～28年，失访9例（良性肿瘤6例、恶性肿瘤3例）。随访期间良性粘液瘤复发4例，均再次手术治疗；良性肿瘤患者死亡13例（心源性猝死6例、脑卒中2例、肺癌1例、不明原因4例），其余216例均生存。随访期间恶性肿瘤患者死亡15例，术后生存时间为1～4年，死于肿瘤复发或转移11例，心力衰竭和恶病质各2例。 结论 原发性心脏肿瘤一经确诊应尽早手术治疗，良性肿瘤手术效果好，恶性肿瘤术中应尽量切除肿瘤。

Comparative Study between Offpump and Onpump Coronary Artery Bypass Grafting in the Patients of Multivessel Coronary Disease Below 70 Years Old

Abstract: Objective To compare the therapeutic effects between offpump coronary artery bypass grafting (off-pump CABG) and onpump coronary artery bypass grafting (on-pump CABG) in the patients of multivessel coronary disease below 70 years old, in order to decide on the best surgery method. Methods From June 2007 to June 2009, 196 patients below the age of 70 underwent coronary artery bypass grafting (CABG), including 152 male patients and 44 female patients. The average age was 55.00 years old, ranging from 46 to 69 years. The patients were divided into two groups according to the methods of operation. There were 94 patients in the off-pump CABG group including 2 patients who were converted to the onpump CABG surgery because of the unstable hemodynamics. The other 102 patients were in the onpump CABG group. The type and number of the vessel grafts, the quantity of blood transfusion, intubation duration, length of stay in hospital, complications during perioperative period and mortality were compared between the two groups. Results In the offpump CABG group, 2 patients were converted to onpump CABG surgery because of the unstable hemodynamics, and 1 of them died from multiple organ failure. In the onpump CABG group, 2 patients died from severe low output syndrome and sudden heart arrest respectively. No significant difference was found in the vessel grafting materials, perioperative complications and mortality between the two groups (Pgt;0.05), while the number of anastomosis (3.22±0.65 vs. 4.52±1.11, t=9.807, P=0.000), the [CM(159mm]quantity of blood transfusion (312.57±305.26 ml vs. 744.86±279.37 ml, t=10.317, P=0.000),the intubation duration (10.71±5.32 h vs.17.12±4.67 h, t=8.683, P=0.000) and the length of stay in hospital (17.75±3.04 d vs. 21.24±6.46 d, t=4.782,P=0.000) in the off-pump CABG group were significantly lower or shorter than those in the on-pump CABG group. A total of 93 patients in the off-pump CABG group and 100 patients in the on-pump CABG group were followed up with the time periods ranging from 2 to 26 months. All patients survived without angina. Conclusion There is no significant difference in the early clinical therapeutic effects between off-pump CABG and onpump CABG in the patients of multivessel coronary disease below 70 years old, but revascularization in the on-pump CABG patients is better. So far, offpump CABG cannot replace on-pump CABG and more clinical trails are needed for evaluation of the longterm prognosis.

左主干完全闭塞的外科治疗

目的 探讨冠状动脉左主干完全闭塞的外科治疗方法，总结其临床经验。 方法 1998年3月～2006年11月我院共收治6例冠状动脉左主干完全闭塞患者，在体外循环心脏不停跳下行冠状动脉旁路移植术（CABG），观察体外循环时间、术后呼吸机辅助时间、ICU时间、住院时间、围术期以及随访情况。 结果 体外循环时间为88.2±15.5min，术后呼吸机辅助时间14.2±4.6h，住ICU时间3.3±0.8d，住院时间18.0±2.7d，无围术期心肌梗死发生。6例均随访，随访时间29.0±19.2个月,心绞痛症状均消失，无1例死亡。超声心动图检查提示左心室收缩功能得到不同程度的改善。 结论 冠状动脉左主干完全闭塞患者施行体外循环心脏不停跳CABG，可以取得良好的临床疗效。

Minimally Invasive Mitral Valve Replacement Combined with Atrial Fibrillation Radiofrequency Ablation via Right Minithoracotomy

ObjectiveTo summarize clinical advantages and outcomes of minimally invasive mitral valve replacement (MVR) combined with atrial fibrillation (AF) radiofrequency ablation via right minithoracotomy. MethodsEight patients with mitral valve disease and AF who received surgical therapy in the First Hospital of China Medical University between October 2009 and October 2012 were included in the study. There were 4 males and 4 females with their age of 34-67 (52.4±17.5) years. All the patients underwent minimally invasive MVR combined with AF radiofrequency ablation via right minithoracotomy. Clinical outcomes were summarized. ResultsThere was no in-hospital death or conversion to conventional sternotomy in this group. Two patients received biological valve replacement and 6 patients received mechanical prosthesis. Operation time was 207.9±18.1 minutes, cardiopulmonary bypass time was 81.7±23.9 minutes, and chest drainage amount was 126.7±34.5 ml. AF recurred in 1 patient on the 3rd postoperative day. All the patients were in sinus rhythm at discharge. These patients were followed up for 18.3±7.4 months. During follow-up, 1 patient had AF recurrence. Seven patients were in NYHA class Ⅰ, and 1 patients was in NYHA class Ⅱ. ConclusionMinimally invasive MVR combined with AF radiofrequency ablation via right minithoracotomy can achieve satisfactory clinical results and esthetic appearance, and is a good choice for patients with mitral valve disease and AF.

心脏恶液质瓣膜病患者的外科治疗

80岁以上老年患者行非体外循环冠状动脉旁路移植术16例

连续性肾脏替代疗法改善合并慢性肾脏病冠状动脉旁路移植术患者的预后

目的 总结连续性静脉静脉血液透析滤过（CVVHDF）在冠心病合并慢性肾功能不全患者施行冠状动脉旁路移植术（CABG）后的应用经验。 方法 1998年8月至2008年2月对我院收治的14例冠心病合并慢性肾功能不全患者（其中2例术前因肾功能衰竭行规律透析治疗，12例合并肾功能不全未透析治疗）行CABG，术后应用CVVHDF，观察CVVHDF对患者的心率、中心静脉压、平均动脉压、动脉血氧分压、肾功能变化以及围术期和预后情况。 结果 14例患者中10例在体外循环下完成手术，4例在非体外循环下完成手术，术后均进行CVVHDF，透析6 h后患者心率由106.07±8.84次/分下降为95.64±8.44次/分，中心静脉压由22.64±2.90 cm H2O降为12.71±2.95 cm H2O，肌酐由467.21±103.38 μmol/L降为358.50±91.27 μmol/L，尿素氮由20.29±4.32 mmol/L降为14.29±3.17 mmol/L，较未透析时明显下降；而平均动脉压由62.79±4.84 mm Hg升高到71.93±7.52 mm Hg，动脉血氧分压由68.71±11.21 mm Hg升高到78.71±11.14 mm Hg，较未透析时明显升高。死亡2例，2例放弃治疗，其余10例患者中有4例改为内科规律透析治疗，6例肾功能恢复至术前水平，出院后尿量恢复未再行透析治疗。术后随访36.90±29.06个月，心绞痛症状均消失，生活质量明显提高。 结论 CVVHDF是改善冠心病合并肾功能不全患者施行CABG预后的有效方法，早期的透析可以取得较好的疗效。