劉 帥，高長(zhǎng)青，任崇雷，肖蒼松，王 嶸，吳 揚(yáng)

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冠心病合并頸動(dòng)脈狹窄患者冠狀動(dòng)脈旁路移植術(shù)后遠(yuǎn)期結(jié)果

劉 帥，高長(zhǎng)青*，任崇雷，肖蒼松，王 嶸，吳 揚(yáng)

（解放軍總醫(yī)院心血管外科，北京 100853）

分析不同術(shù)式（心臟停跳或不停跳）對(duì)行冠狀動(dòng)脈旁路移植術(shù)（CABG）后患者腦卒中發(fā)生率和生存率的影響。解放軍總醫(yī)院心血管外科2003年6月至2013年6月冠心病合并頸動(dòng)脈狹窄的159例患者，其中男118例，女41例，年齡為（67.0±7.5）歲，根據(jù)心臟是否停跳分為停跳（on-pump）組及不停跳（off-pump）組，并對(duì)兩組患者行CABG后的腦卒中發(fā)生率和生存率進(jìn)行回顧性分析。隨訪146例，隨訪率93.6%，隨訪時(shí)間6～120（46.3±25.3）個(gè)月，10例術(shù)后出現(xiàn)神經(jīng)系統(tǒng)癥狀，其中2例腦出血，8例腦梗死。17例死亡（4例腦部并發(fā)癥，1例食管癌，1例肺癌，11例為心源性），平均死亡時(shí)間為術(shù)后41（4～72）個(gè)月。停跳組患者術(shù)后腦卒中發(fā)生率及生存率與不停跳組相比差異無統(tǒng)計(jì)學(xué)意義（＞0.05）。心臟是否停跳對(duì)冠心病合并頸動(dòng)脈狹窄患者術(shù)后腦卒中發(fā)生率和生存率無明顯影響。

冠狀動(dòng)脈分流術(shù)；冠狀動(dòng)脈疾??；頸動(dòng)脈狹窄；卒中；停跳；不停跳

腦卒中是冠狀動(dòng)脈旁路移植術(shù)（coronary artery bypass grafting，CABG）后的嚴(yán)重并發(fā)癥之一，具有較高的致死率與致殘率，嚴(yán)重影響了患者的預(yù)后及生活質(zhì)量[1]。對(duì)于采用CABG治療冠心病的方法，目前存在3種意見：一種認(rèn)為心臟不停跳（off-pump）對(duì)冠心病患者更有益，具有更低的術(shù)后腦卒中發(fā)生率和死亡率[2?4]；一種認(rèn)為心臟停跳（on-pump）更有益[5,6]；還有一些研究認(rèn)為兩種術(shù)式的結(jié)果是一樣的[7?9]。所以究竟哪種方法更優(yōu)目前尚無定論，尤其是對(duì)于合并頸動(dòng)脈狹窄的冠心病患者應(yīng)該采取哪種手術(shù)方式的相關(guān)研究就更為罕見[10]。本文針對(duì)解放軍總醫(yī)院心血管外科冠心病合并頸動(dòng)脈狹窄的患者進(jìn)行統(tǒng)計(jì)和隨訪，并分析了不同術(shù)式對(duì)行CABG后患者腦卒中的發(fā)生率及生存率的影響。

1 對(duì)象與方法

1.1 研究對(duì)象

2003年6月至2013年6月解放軍總醫(yī)院心血管外科共有159例冠心病合并頸動(dòng)脈狹窄的患者行CABG，約占同期CABG總數(shù)的6.54%，其中男118例，女41例；年齡51～83歲（67.0±7.5）歲?；颊呔胁环€(wěn)定型心絞痛史，合并高血壓病100例（62.9%），2型糖尿病55例（34.6%），血脂異常27例（17.0%），有腦卒中病史42例（26.4%）?；颊呔泄跔顒?dòng)脈造影，提示：?jiǎn)沃Р∽?例，雙支病變16例，三支病變89例，左主干病變60例，合并室壁瘤3例、二尖瓣疾病4例、主動(dòng)脈瓣疾病3例、心包炎1例。心功能NYHA Ⅱ?Ⅳ級(jí)。所有患者術(shù)前常規(guī)行頸動(dòng)脈超聲檢查，根據(jù)美國(guó)超聲放射學(xué)會(huì)推薦的頸動(dòng)脈狹窄判斷標(biāo)準(zhǔn)：輕度狹窄（單側(cè)或雙側(cè)＜50%）12例（7.5%），中度狹窄（50%≤單側(cè)或雙側(cè)＜70%）89例（56.0%），重度狹窄（70%≤單側(cè)或雙側(cè)＜99%）55例（34.6%），完全閉塞3例（1.9%）。95例是在心臟停跳下完成的，64例是非停跳下完成的，兩組的基本資料詳見表1。

1.2 手術(shù)方法

159例均單純行CABG，未進(jìn)行頸動(dòng)脈干預(yù)，其中95例采用心臟停跳術(shù)式，64例采用心臟不停跳術(shù)式，內(nèi)包括2例行機(jī)器人不開胸全內(nèi)鏡（非體外循環(huán)）冠狀動(dòng)脈旁路移植術(shù)（totally endoscopic coronary artery bypass graft，TECABG），5例行機(jī)器人乳內(nèi)動(dòng)脈（internal mammary arteries）游離、小切口直接（心臟跳動(dòng)下）冠狀動(dòng)脈旁路移植術(shù)（minimally invasive direct coronary artery bypass graft，MIDCABG），機(jī)器人手術(shù)均為全麻下右側(cè)單肺通氣后于左側(cè)胸腔入路，TECABG為全內(nèi)鏡下行CABG，MIDCABG在左第四肋間前外側(cè)小切口（約6cm）進(jìn)胸，直視下行CABG。其余均為胸骨正中切口，常規(guī)游離左胸廓乳內(nèi)動(dòng)脈，off-pump CABG借助于冠狀動(dòng)脈內(nèi)分流器和心臟固定器，on-pump CABG借助于體外循環(huán)機(jī)及阻斷鉗完成手術(shù)。關(guān)胸前常規(guī)行“血管橋”血流量測(cè)定。在完成遠(yuǎn)端吻合后，經(jīng)右心房、房間隔暴露并處理二尖瓣或切開主動(dòng)脈處理主動(dòng)脈瓣；合并室壁瘤者，切除瘤體后，采用“三明治”法或左心室內(nèi)補(bǔ)片法修補(bǔ)。

表1 冠心病合并頸動(dòng)脈狹窄患者基本資料

BMI: body mass index; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease; PCI: percutaneous coronary intervention; IMA: internal maxillary artery; LAD: left anterior descending coronary artery; MBP: mean blood pressure. 1mmHg＝0.133kPa

1.3 隨 訪

出院后采取住院、門診或電話隨訪，隨訪時(shí)間6～120個(gè)月，觀察指標(biāo)主要包括：死亡、心肌梗死、腦卒中。

1.4 統(tǒng)計(jì)學(xué)處理

采用SPSS13.0統(tǒng)計(jì)學(xué)軟件進(jìn)行分析，繪制腦卒中及死亡率與隨訪時(shí)間的關(guān)系趨勢(shì)圖。＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

2.1 手術(shù)結(jié)果

64例行off-pump CABG，95例行on-pump CABG，其中3例同期行室壁瘤切除術(shù)、2例行二尖瓣置換術(shù)、2例行二尖瓣成形術(shù)、3例行主動(dòng)脈瓣置換術(shù)、1例行心包剝脫術(shù)。停跳組平均冠狀動(dòng)脈搭橋（2.9±0.7）支，術(shù)中平均動(dòng)脈壓（60.4±6.9）mmHg（1mmHg＝0.133kPa）；不停跳組平均冠狀動(dòng)脈搭橋（2.4±0.6）支，術(shù)中平均動(dòng)脈壓（70.6±6.9）mmHg。住院期間術(shù)后兩組共出現(xiàn)腦梗死2例，死亡3例（1例肺部感染，1例腦出血，1例橋血管出血）。余156例康復(fù)出院。

2.2 隨 訪

146例（93.6%）患者得到隨訪，隨訪期間8例出現(xiàn)腦梗死，2例出現(xiàn)腦出血，共有17例患者死亡（4例腦卒中，1例食管癌，1例肺癌，余均為心源性）。

2.3 不同術(shù)式的患者術(shù)后再發(fā)腦卒中風(fēng)險(xiǎn)及生存率的關(guān)系

停跳組患者術(shù)后腦卒中發(fā)生率及生存率與不停跳組相比差異無統(tǒng)計(jì)學(xué)意義（＝0.388，＝0.765），詳見圖1，圖2。

3 討 論

我科資料顯示心臟是否停跳對(duì)冠心病合并頸動(dòng)脈狹窄患者術(shù)后腦卒中發(fā)生率和生存率無明顯影響。（1）目前認(rèn)為，CABG術(shù)后腦卒中的獨(dú)立危險(xiǎn)因素包括高齡、不穩(wěn)定型心絞痛、周圍血管病、慢性阻塞性肺疾病、再次手術(shù)、糖尿病、頸動(dòng)脈病變等[11,12]。本研究中兩組患者的上述情況均無明顯差異。（2）有研究表明，術(shù)前腦梗死也是術(shù)后發(fā)生腦卒中的危險(xiǎn)因素之一，其術(shù)后蘇醒時(shí)間、ICU及住院時(shí)間均延長(zhǎng)；術(shù)后譫妄、腦卒中及二次插管的發(fā)生率較術(shù)前無腦梗死的患者高[13]。但本研究中停跳組術(shù)前合并腦梗死有26例（27.3%），不停跳組有16例（25.0%），值為0.740，差異無統(tǒng)計(jì)學(xué)意義。（3）CABG術(shù)中平均血壓的高低對(duì)于術(shù)后腦卒中的發(fā)生是有一定影響的，尤其是對(duì)合并頸動(dòng)脈狹窄的冠心病患者。本研究中停跳組術(shù)中最低平均血壓（60.4±6.9）mmHg，不停跳組血壓最低時(shí)為近端吻合側(cè)壁鉗鉗夾主動(dòng)脈，當(dāng)時(shí)平均血壓是（70.6±6.9）mmHg，值為0.592，兩組的平均血壓均＞60mmHg，且差異無統(tǒng)計(jì)學(xué)意義。

圖1 停跳組與不停跳組患者術(shù)后腦卒中發(fā)生率與隨訪時(shí)間的關(guān)系

Figure 1 Relationship postoperative cerebral complications with follow-up duration between on-pump and off-pump procedures

圖2 停跳組與不停跳組患者生存率與隨訪時(shí)間的關(guān)系

Figure 2 Relationship of postoperative mortality with follow-up duration between on-pump and off-pump procedures

雖然本組研究中停跳組患者術(shù)后腦卒中發(fā)生率及生存率與不停跳組相比差異無統(tǒng)計(jì)學(xué)意義，但由圖1和圖2可得知，停跳組術(shù)后腦中風(fēng)發(fā)生率和死亡率整體趨勢(shì)均低于不停跳組，因本組例數(shù)較少，并且為回顧性研究，結(jié)果僅供參考和討論，至于哪種術(shù)式更適合于冠心病合并頸動(dòng)脈狹窄的患者，仍需大樣本多中心的前瞻性研究。

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（編輯: 李菁竹）

Long-term outcome of patients with coronary heart diseases and carotid arteriostenosis after coronary artery bypass surgery

LIU Shuai, GAO Chang-Qing*, REN Chong-Lei, XIAO Cang-Song, WANG Rong, WU Yang

(Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing 100853, China)

To investigate the effect of on-pump and off-pump procedures on postoperative cerebral complications and survival rate after coronary artery bypass grafting (CABG).From June 2003 to June 2013, a total of 159 patients [(67.0±7.5) years old, 118 males and 41 females] with carotid arteriostenosis and coronary heart diseases, accepted isolated CABG in our department. They were divided into on-pump group (＝95) and off-pump group (＝64). The prevalence of postoperative cerebral complications and the survival rate after CABG were compared and retrospectively analyzed.Follow-up was done for 146 patients with a rate of 93.6%, and a duration of (46.3±25.3) months, ranging from 6 to 120 months. Ten patients had neurological symptoms, including 2 of cerebral hemorrhage and 8 of stroke. Seventeen patients died during the follow-up (4 due to cerebral complications, 1 esophagus cancer, 1 lung cancer, and 11 cardiogenic reasons) within average 41 months postoperatively (ranging from 4 to 72 months). There was no statistical difference in prevalence of postoperative cerebral complications and the survival rate between on-pump and off-pump groups (＞0.05).On-pump and off-pump procedures have no significant difference in the effect on postoperative cerebral complications and survival rate in the patients with carotid arteriostenosis and coronary heart diseases.

coronary artery bypass; coronary disease; carotid stenosis; stroke; on-pump; off-pump

(BWS11J030).

R654.33; R543.3; R543.4

A

10.3724/SP.J.1264.2014.00081

2014?03?28;

2014?04?04

全軍醫(yī)學(xué)科技“十二五”重點(diǎn)項(xiàng)目（BWS11J030）

高長(zhǎng)青, E-mail: gaochq301@yahoo.com