冠状动脉旁路移植术治疗年龄≤40岁冠心病患者术后中期疗效分析

宋 凯 陆树洋 孙晓宁 张红强 陈金淼 胡 馗 洪 涛 丁文军 夏利民 王春生

(复旦大学附属中山医院心外科 上海 200032 )

冠状动脉旁路移植术治疗年龄≤40岁冠心病患者术后中期疗效分析

宋 凯▲陆树洋▲孙晓宁 张红强 陈金淼 胡 馗 洪 涛 丁文军 夏利民 王春生△

(复旦大学附属中山医院心外科 上海 200032 )

目的 探讨年龄≤40岁冠心病患者的临床特点、外科治疗经验及冠状动脉旁路移植术后的中期疗效。方法 2009年1月至2015年12月复旦大学附属中山医院单中心诊断为冠心病且年龄≤40岁于心脏外科行手术治疗的患者共12例,其中男性10例,女性2例,平均年龄(37.9±2.5)岁(32～40)岁。该组病例临床特点包括,有高血压病史5例,糖尿病史3例,高脂血症病史4例,有吸烟史8例,术前心梗病史7例,3支主干中不少于1支全闭6例,2例反复行PCI术,分别植入支架5枚和3枚。回顾性分析患者的临床资料、外科手术治疗情况及随访结果。结果 围手术期及随访期间均无死亡。采用双侧乳内动脉联合桡动脉全动脉化冠状动脉旁路术6例,双侧乳内动脉联合大隐静脉冠状动脉旁路术2例,左侧乳内动脉联合大隐静脉冠状动脉旁路术4例。非体外下冠状动脉旁路术9例,体外循环辅助下冠状动脉旁路术3例。平均随访时间(47.8±24.3)个月,随访过程中1例术后5年静脉桥出现再狭窄,于心内科行经皮冠状动脉介入术,其余11例随访心功能恢复至Ⅰ～Ⅱ级。结论 年轻冠心病患者(年龄≤40岁)因心功能代偿良好一般发病较隐匿,临床诊断时冠脉病变较严重。冠状动脉旁路术预后良好,手术中远期疗效满意。

冠状动脉旁路移植术; 冠心病; 手术策略

近年来,随着人们生活水平的提高和饮食结构的变化年轻冠心病患者有增多的趋势,内科经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)技术的应用,可以一定程度上治疗大部分冠心病患者[1-2]。然而,对于严重的冠状动脉三支病变、反复支架植入后再狭窄的冠心病患者,冠状动脉旁路移植术仍然是治疗冠心病最为有效的方法[3]。外科的冠状动脉搭桥术最常用的桥血管的选择包括:乳内动脉和大隐静脉,这两种桥血管的10年通畅率分别在84%和41%～53%[4-5]。对于年龄低于40岁的年轻冠心病患者这一特殊群体,冠心病再血管化的选择策略显得尤为重要,直接关系到患者的远期再次手术和生存质量。现回顾性分析和总结复旦大学附属中山医院心外科中心年龄≤40岁的冠心病患者资料,探讨该人群的临床特点、外科治疗经验及冠状动脉旁路移植术后的中远期疗效。

资 料 和 方 法

2009年1月至2015年12月,共收治12例年龄≤40岁的冠心病患者在我科行冠状动脉旁路移植术;其中男性10例,女性2例;年龄32～40岁,平均(37.9±2.5)岁。所有患者术前均行冠状动脉造影检查确诊为冠心病,多支血管病变。该组病例临床特点包括:有高血压病史5例,糖尿病史3例,高脂血症病史4例,有吸烟史8例,术前心梗病史7例,冠状动脉3支主干血管中不少于1支全闭6例。2例患者术前曾反复行PCI术,分别植入支架5枚和3枚。

本组病例行冠状动脉旁路术的手术指征为:严重的左主干病变,主干血管慢性完全性闭塞,冠脉三支主干血管弥漫性病变,反复内科PCI治疗失败者。冠状动脉旁路移植策略包括:双侧乳内动脉联合桡动脉全动脉化冠状动脉旁路术6例,双侧乳内动脉联合大隐静脉冠状动脉旁路术2例,左侧乳内动脉联合大隐静脉冠状动脉旁路术4例。非体外循环辅助下冠状动脉旁路术9例,体外循环辅助下冠状动脉旁路术3例。

所有病例均采用全麻气管插管,传统正中开胸方法进胸。乳内动脉、桡动脉、大隐静脉桥血管的制备均由高年资经验丰富的主治医师完成,充分保证桥血管的获取质量。采用单独1根原位左乳内动脉或右乳内动脉充分再血管化前降支,保证前降支的血液供应,若联合使用大隐静脉桥血管,则采用2根静脉桥近段吻合于升主动脉,分别再血管化左冠系统和右冠系统病变血管。

结 果

围手术期及随访期间均无因心血管事件发生死亡。本组病例中患者再血管化的手术策略见表1,采用双侧乳内动脉联合桡动脉全动脉化冠状动脉旁路术6例,双侧乳内动脉联合大隐静脉冠状动脉旁路术2例,左侧乳内动脉联合大隐静脉冠状动脉旁路术4例。所有病例均采用单独1根原位左乳内动脉或原位右乳内动脉充分再血管化前降支。左乳内动脉联合大隐静脉的4例患者中有3例选择静脉桥再血管化左冠系统及右冠系统,采用2个近段分别端侧吻合方法(患者2,5,11)。平均随访时间(47.8±24.3)个月,随访过程中1例术后5年冠脉CT造影提示回旋支静脉桥血管出现再狭窄,于我院心内科行冠状动脉造影术,术中于桥血管上植入支架2枚,手术顺利,其余11例随访无不良心血管事件发生,冠状动脉CT造影桥血管显影良好,心功能恢复至Ⅰ～Ⅱ级。

表1 本组病例再血管化策略

LIMA:Left internal mammary artery;RIMA:Right internal mammary artery;LRA:Left radial artery;VG:Venous graft;AO:Aorta;OM:Obtuse marginal branch;D:Diagonal branch;PDA:Posterior descending artery;RCA:Right coronary artery;PL:Posterior branch of left ventricle;LAD:Left anterior lescending.

讨 论

近年来,随着人们物质生活水平的改善,冠心病的发病率有增高的趋势,发病个体亦不再局限于中老年人群,年轻人罹患冠心病亦有增加的趋势。回顾性分析2009年1月至2015年12月期间在我中心诊断为冠心病且年龄≤40岁于心脏外科行手术治疗的患者资料,不难发现这部分年轻冠心病患者有其临床发病特点。首先,冠心病高危因素突出[4],如具有吸烟史高达66.7%,高血压病史41.7%,高血脂病史33.3%,糖尿病史25%,可见高血压、糖尿病、高血脂等与冠心病密切相关的疾病已不再是中老年人群的专属。其次,病变严重,发病隐匿[5]。本组病例中有一半以上(58.3%)的患者有心梗病史,有50%的患者冠脉3支主干中至少存在1支主干血管完全性闭塞。我们认为,由于该群体整体年龄较轻,心肌储备及心功能代偿能力较强,早期患者症状不明显或不典型,待出现症状,心功能失代偿时就诊,一旦明确诊断时常常病情较严重。

关于年轻冠心病患者外科手术策略的选择,目前已有大量文献支持采用全动脉化冠状动脉旁路术,动脉桥血管远期通畅率高于静脉桥血管[6-7]。然而,有文献报道,一项随访长达16年的研究结果提示采用无触碰技术获取的大隐静脉桥血管远期通畅率与乳内动脉相当[8]。这充分说明了桥血管的获取质量可能是决定桥血管远期通畅率至关重要的因素。本组病例中全动脉化冠状动脉旁路术6例,6例联合使用大隐静脉桥血管。远期随访结果提示1例,回旋支再血管化静脉桥发生狭窄,至心内科行冠状动脉造影,同期植入2枚支架。本中心的经验,在联合使用静脉桥血管的病例中,若回旋支与右冠系统均需要再血管化,为保证远端血运,我们均采用2个近段吻合至升主动脉,采用端侧吻合方法,尽量避免采用序贯法。这可能也是本组病例远期随访效果较好的一个因素。全动脉化冠状动脉旁路动脉桥血管的选择,没有太多争议,目前最常用的包括双侧乳内动脉、桡动脉(Allen试验阴性),若无特殊情况,胃网膜右动脉应用较少。我们认为,对于年轻冠心病患者推荐首选全动脉化搭桥,若动脉桥不具备条件,尽可能采用无触碰技术提高静脉桥血管质量,远期亦有望获得良好的结果。当然,桥血管远期通畅率的影响因素很多,除了本身桥血管种类的选择,术后的抗血小板及针对冠心病高危因素的治疗亦是影响的重要方面。本组病例患者在随访过程中,依从性良好,能规律随访,遵医嘱执行治疗方案。

因此,通过总结我中心行冠状动脉旁路术的年轻冠心病患者(年龄≤40岁)临床资料,我们得出年轻患者心功能代偿良好,发病较隐匿,临床诊断时冠脉病变较严重,临床做到早期发现、早期诊断、早期治疗至关重要。外科冠状动脉旁路术手术技术确切,疗效及预后良好,手术中远期疗效满意,对于严重冠脉三支病变患者是一种理想的治疗方案。

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Mid-term outcome of coronary artery bypass graft surgery in patients aged≤40 years with coronary heart disease

SONG Kai▲, LU Shu-yang▲, SUN Xiao-ning, ZHANG Hong-qiang, CHEN Jin-miao,HU Kui, HONG Tao, DING Wen-jun, XIA Li-min, WANG Chun-sheng△

(DepartmentofCardiacSurgery,ZhongshanHospital,FudanUniversity,Shanghai200032,China)

Objective To investigate the clinical characteristics,surgical experience and mid-term outcome of coronary artery bypass graft surgery in patients aged ≤ 40 years. Methods From Jan.,2009 to Dec.,2015,12 patients with median age of (37.9±2.5) years (range 32-40 years,10 males) were diagnosed with coronary artery disease and underwent coronary artery bypass graft surgery at Zhongshan Hospital,Fudan University.The clinical characteristics included five cases with hypertension,three cases with diabetes mellitus,four cases with hyperlipemia,eight cases with smoking history,seven cases with myocardial infarction.Six cases had at least one branch totally occluded.Two cases once underwent percutaneous coronary intervention surgery and implanted with five and three stents respectively.The perioperative data and follow-up results were retrospectively analysed.Results There was no in-hospital death and no death during follow-up period.Surgical techniques included bilateral internal mammary arteries combined with radial artery were operated in six cases,bilateral internal mammary arteries combined with great saphenous vein in two cases,left internal mammary arteries combined with great saphenous vein in four cases,off-pump in nine cases and on-pump in three cases.The mean follow-up time was (47.8±24.3) months.During the follow-up one case suffered with saphenous vein graft restenosis 5 years after the surgery and underwent percutaneous coronary intervention.Other cases were all alive and assessed New York Heart Association’s function class Ⅰ-Ⅱ. Conclusions Younger patients usually suffer with severe coronary artery disease when diagnosed because they often have excellent compensative capacity and the pathogenesis is concealed.The mid-term results of coronary artery bypass graft surgery in patients aged≤40 years are satisfactory.

coronary artery bypass graft surgery; coronary heart disease; surgical strategy

国家自然科学基金青年项目(81501595)

R654.2

A

10.3969/j.issn.1672-8467.2017.04.013

2016-10-15;编辑:沈玲)

▲SONG Kai and LU Shu-yang contributed equally to this work

△Corresponding author E-mail:wang.chunsheng@zs-hospital.sh.cn

*This work was supported by the Youth Program of National Natural Science Foundation of China (81501595).