左冠状动脉主干重建术治疗孤立性左冠状动脉主干狭窄

左冠状动脉主干重建术治疗孤立性左冠状动脉主干狭窄高长青朱朗标李伯君肖苍松作者单位：１００８５３解放军总医院心血管外科图１术前冠状动脉造影（左前斜位）示ＬＭＣＡ开口重度狭窄图２术前主动脉造影（左前斜位）示ＰＤＡ粗大图４术后冠状动脉造影（左前斜位ＬＭＣＡ...     

颈内动脉旁路移植、内膜剥脱同期冠状动脉旁路移植术一例

患者　女 ,6 3岁。因不稳定型心绞痛加重 15天伴左侧心力衰竭入院。冠状动脉造影示左前降支中段闭塞 ,左回旋支开口处 85 %狭窄 ,右冠状动脉开口处 90 %狭窄。因心绞痛发作频繁 ,未行心室造影。二维超声心动图检查示室壁运动异常 ,经颅多普勒超声检查示颅内血管多发性狭窄 ,颈动脉超声检查示双颈内动脉严重狭窄。脑血管造影示右颈内动脉近段85 %局限性狭窄 ,左颈内动脉长段串珠样改变 ,最窄处达95 % (图 1)。图 1　脑血管造影示左颈内动脉长段串珠样改变　　手术方法 :先用大隐静脉行左颈总动脉、颈内动脉的旁路端侧吻合 ,右侧行颈内动脉内…     

24岁冠心病患者行冠状动脉旁路移植术一例

患者女,24岁。心前区发作性憋痛6个月,加重2个月入院。入院查体：未见明显异常,血压112／70mmHg。心电图示：下壁、前壁导联ST段明显下移。冠状动脉造影显示：左主干（LM）远端99％局限性狭窄,左前降支（LAD）开口100％闭塞,回旋支（LCX）开口99％局限狭窄（图1A,箭头所示）,右冠状动脉（RCA）到LAD有丰富的侧枝循环形成（图1B,箭头所示）。超声心动图检查未见异常,左心室射血分数（LVEF）48％。血脂、血糖等化验检查均正常。     

左冠状动脉异常起源于肺动脉的诊断和外科治疗

目的总结先天性左冠状动脉异常起源于肺动脉的临床特点、诊断和外科治疗经验.方法1993年7月至2005年10月,外科治疗10例左冠状动脉异常起源于肺动脉病人,其中男5例,女5例;年龄13 d～40岁.术前均经超声心动图和心导管造影检查明确诊断.单纯左冠状动脉异常起源于肺动脉者3例,合并二尖瓣关闭不全6例,同时合并二尖瓣关闭不全及左心室心尖部室壁瘤1例.行异常冠状动脉结扎4例,在体外循环下行肺动脉内隧道成形术3例,升主动脉左冠状动脉开口植入术3例;同期行二尖瓣成形5例,室壁瘤切除1例.结果早期死亡1例.随访1个月～11年.1例因严重二尖瓣关闭不全而于第1次术后16个月再行二尖瓣置换术,余者无心肌缺血或梗死、残余分流和晚期死亡,心功能恢复到Ⅰ级.结论左冠状动脉异常起源于肺动脉者存在明显的血流动力学和心血管形态学改变,应尽早确诊、尽快手术治疗,适当的手术方法是取得良好外科手术疗效的关键.     

64层CT诊断冠状动脉狭窄的准确性:与常规血管造影比较

目的评价64层螺旋CT冠状动脉造影对冠状动脉明显狭窄诊断准确性和可行性。方法218例冠心病疑似患者在一周内进行了64层CT冠状动脉造影及常规血管造影,对冠状动脉的主干及主要分支进行诊断,以冠状动脉造影结果为金标准评价64层CT诊断冠状动脉狭窄的准确性。结果多层螺旋CT所显示的2592支冠状动脉中冠状动脉狭窄173处,正确诊断166处,漏诊7处,误诊28处,敏感性95.9%,特异性98.6%,阳性预测值90.2%,阴性预测值99.7%,准确率98.4%。结论64层螺旋CT对冠状动脉狭窄诊断有较高的准确性,可作为高危人群普查筛选的首选方法之一。     

左冠状动脉异常起源于肺动脉的外科治疗

１例患左冠状动脉异常起源于动脉的７岁女孩，行左冠状动脉的重建术获得成功。因异常起源的左冠状动脉源于肺脉的主干左后侧，右冠状主干较，不能直接植入升主动脉；病儿年龄小，大隐静脉和其他自体血管难以利用，故采用人工血管左冠状动脉旁路架桥术。术后病儿恢复顺利，研室功能正常，心血管造景证实人工血管桥和左冠状动脉 通畅、无狭窄或扭曲。作者认为，在左冠状动脉异常起源于肺动脉的病人，当左冠状动脉不能直接植入升主动脉     

高频超声检查对呕吐查因婴儿患者的诊断价值

【摘要】〓目的〓探讨高频超声检查技术在婴儿呕吐病因诊断中的临床价值。方法〓对94例呕吐婴儿患者胃肠超声诊断资料进行回顾性分析。结果〓44例外科疾病中,经手术病理证实,其中30例先天性肥厚性幽门狭窄,11例十二指肠梗阻(5例闭锁,3例狭窄,3例先天性肠旋转不良),3例幽门闭锁。术前超声诊断41例,诊断率为93.18%。其余50例属内科疾病,其中40例为胃食管反流、10例为幽门痉挛。内科疾病经治疗后均短期内复查超声明确诊断,并与上消化道造影检查结果相对照,超声诊断率98%。结论〓超声检查无创、安全、简便、重复性好,对查找婴幼儿呕吐病因可作为常规首选筛查手段。     

前上纵隔恶性肿瘤姑息切除并冠状动脉旁路移植一例

患者,男,69岁,左前胸痛伴左肩放射痛频繁发作1年。查体:桶状胸,左肺呼吸音减弱。胸部X线:左侧膈肌麻痹。胸部CT:前上纵隔占位,有中心液化和环形钙化。肺功能:重度通气功能减损。心电图:Ⅲ、AVF导联不典型Q波。冠状动脉造影:右冠状动脉后三叉病变,狭窄80%;左冠状动脉前降支近端、主干及四条分支均狭窄,约85%;回旋支中段及远段两处80%狭窄。造影诊断:冠心病,三支病变。术前诊断:(1)冠心病;不稳定性心绞痛。(2)前上纵隔肿瘤。2006年12月行纵隔肿瘤切除并冠状动脉旁路移植术(CABG)。胸骨正中切口,见左前上纵隔有一10cm×8cm×8cm不规则肿瘤…     

左冠状动脉起源肺动脉主干1例

病儿　女 ,16岁。活动后心慌 ,气短半年。胸骨左缘2、3肋间可触及收缩期震颤 ,可闻及 4/ＶＩ级收缩期吹风样杂音。Ｘ线胸片示肺血轻度增多。心脏超声检查示左、右冠状动脉严重扩张迂曲 ,左冠窦内未见冠状动脉开口。升主动脉根部造影及右冠状动脉造影示左右冠脉及其分支严重迂曲扩张 ,造影剂从右冠状动脉经过怒张的交通支进入左冠状动脉后汇入肺动脉主干 (图 1)。诊断 :左冠状动脉异位起源于肺动脉主干。1997年 12月行中低温体外循环心脏直视手术。术中见左、右冠状动脉动脉及其分支均严重迂曲怒张 ,右冠状动脉开口于升主动脉根部 ,左冠状动…     

八例先天性冠状动脉瘘的外科治疗

我院自2003年1月至2006年7月,共诊治先天性冠状动脉瘘8例,效果良好,现将其治疗经验进行总结。1临床资料与方法1.1一般资料本组共8例,男4例,女4例;年龄2～14岁。有心悸、胸闷病史3例,无明显症状5例。心前区闻及2/6～4/6级连续性杂音5例,舒张期杂音1例,收缩期杂音2例。胸部X线片显示:所有患者均有不同程度的肺血增多,心胸比率0.46～0.64。行超声心动图检查8例,其中7例显示冠状动脉瘘起源、扩张迂曲程度和瘘入心腔的部位,明确诊断。心血管造影提示左右冠状动脉交汇成囊性扩张漏入右心室1例,CT检查提示合并动脉导管未闭,且有多个漏口漏入右心…     

Use of multidetector computed tomography for evaluating coronary artery disease in patients undergoing dialysis

Aim: Cardiovascular disease is the most common cause of death in patients undergoing dialysis. The accuracy of multidetector computed tomography (MDCT) for detecting coronary disease has not been determined, and little information is available regarding the performance of MDCT in patients undergoing dialysis. Methods: Twenty‐nine patients undergoing dialysis were analyzed and MDCT and coronary angiography (CAng) were performed consecutively. The coronary arteries were divided into four segments for analysis. We compared the significant stenosis lesions (≥50% luminal narrowing) identified by MDCT with those found by CAng. The total coronary artery calcium (CAC) score was determined by summing the individual lesion scores from each of the coronary branches. Results: One hundred and sixteen coronary artery branches in 29 patients were analyzed. The sensitivity, specificity, and positive and negative predictive values of MDCT for detecting significant coronary artery stenosis (≥50% stenosis) were 68%, 94%, 71% and 93%, respectively. The CAC scores were significantly higher in subjects with coronary artery disease (CAD) (514.0 ± 493.6 vs 254.3 ± 375.3, P = 0.05). The severe CAC score (>500) was related to the presence of significant CAD (P = 0.05) and the sensitivity and specificity for detecting significant CAD were 50% and 80%, respectively. Conclusion: MDCT is a useful and non‐invasive approach for detecting or excluding CAD in patients undergoing dialysis.     

采用双冠状动脉导丝法建立先天性心脏病介入治疗复杂路径轨道

目的探讨以双冠状动脉导丝法建立先天性心脏病(简称先心病)介入治疗复杂路径轨道的价值。方法回顾性分析12例应用双冠状动脉导丝法建立介入治疗轨道的先心病患儿的临床资料,其中肺动脉闭锁伴室间隔缺损(PA/VSD)矫治术后肺动脉狭窄5例,法洛四联症(TOF)矫治术后肺动脉狭窄1例,大动脉转位(TGA)术后肺动脉狭窄1例,粗大体肺侧支(MAPCAs)3例,复杂型肺动静脉瘘1例及左冠状动脉回旋支-右心房瘘1例;分析先心病介入治疗复杂路径特点。结果采用双冠状动脉导丝均成功建立输送轨道。对PA/VSD矫治术后肺动脉狭窄、TOF术后肺动脉狭窄、TGA术后肺动脉狭窄患儿成功进行球囊扩张,对MAPCAs、复杂型肺动静脉瘘及左冠状动脉回旋支-右心房瘘患儿均封堵成功,未出现瓣膜损伤、血管损伤、心包填塞及死亡等严重并发症。结论以双冠状动脉导丝法建立先心病介入治疗复杂路径轨道方法安全、有效,可调控性强,能提供足够支撑力通过纡曲段,有利于提高介入治疗成功率,值得临床推广应用。     

Frequency of Left Atrial Myxoma with Concomitant Coronary Artery Disease

Purpose: Simultaneous coronary artery bypass grafting with a resection of left atrial myxoma has been rarely reported. The ages and the symptoms of patients who have left atrial myxomas and coronary artery disease are similar. In this report, we present our cases of left atrial myxoma with concomitant coronary artery disease who were all treated surgically. Methods: Between September 1998 and January 2001, 11 patients were surgically treated after being diagnosed to have left atrial myxoma. Routine coronary angiography was performed on all patients preoperatively. In four patients concomitant coronary artery disease was identified. At surgery we performed coronary artery bypass grafting after a resection of left atrial myxoma in three patients. Results: All patients were weaned from cardiopulmonary bypass without any difficulty. The postoperative course was uneventful. The follow-up period was 17 ± 10 months (range 3–32 months). All patients were symptom-free and no recurrence of myxoma was detected. Conclusion: Based on our experience, cardiovascular surgeons should be aware of the concomitance of these diseases. It is therefore recommended that coronary angiography should be performed on all patients who present with left atrial myxomas. Received: November 5, 2001 / Accepted: September 3, 2002 Reprint requests to: N. Erdil This paper was presented at the World Society of Cardio-thoracic Surgeons 11th World Congress in Sao Paulo, Brazil (August 12–15, 2001)     

Fewer centers will increase quality and safety in cardiothoracic transplantation

Objective—It is not clear whether the severity of coronary artery disease as assessed on angiography has an impact on the postoperative outcome after coronary artery bypass surgery (CABG).

Design—The angiographic status of 15 coronary arteries/segments of 2233 patients who underwent isolated on‐pump CABG was graded according to the following criteria: 1?=?no stenosis; 2?=?stenosis <50%; 3?=?stenosis of 50–69%; 4?=?stenosis of 70–89%; 5?=?stenosis of 90–99%; 6?=?vessel occlusion; and 7?=?vessel is not visualized.

Results—Thirty‐seven patients (1.7%) died during the in‐hospital stay and 108 (4.8%) developed postoperatively low cardiac output syndrome. Multivariate analysis showed that along with other risk factors the overall coronary angiographic score was predictive of postoperative death (p?=?0.03; OR: 1.027, 95% CI: 1.003–1.052) and of low cardiac output syndrome (p?=?0.04; OR: 1.172, 95% CI: 1.010–1.218). The status of the proximal segment of the left circumflex coronary artery, the diagonal arteries and the left obtuse marginal arteries was most closely associated with adverse postoperative outcome.

Conclusion—The angiographic status of coronary arteries has an impact on the immediate outcome after CABG.     

Acute myocardial infarction due to left main coronary artery occlusion

OBJECTIVE: Acute myocardial infarction due to left main coronary artery occlusion remains catastrophic and mostly fatal due to severe cardiogenic shock and arrhythmia. METHODS: We studied 13 patients undergoing coronary artery bypass grafting for acute myocardial infarction due to left main coronary artery occlusion to clarify the optimal management of these difficult patients. RESULTS: In-hospital mortality was 46.2% (6/13). Revascularization was achieved by catheter intervention followed by bypass surgery in 7, and bypass surgery alone in 6. Two bypass surgery patients without catheter intervention had collateral flow to the left coronary artery, with the right coronary artery dominant. The time from onset to recanalization in the survival group was significantly shorter than in the early death group. CONCLUSIONS: Emergency intervention to preserve left ventricular function or right coronary artery dominant and collateral blood flow to left coronary arteries is important for improving the prognosis of patients with acute myocardial infarction due to left main coronary artery occlusion. If residual left main coronary artery stenosis is significant or other proximal coronary stenosis exists after catheter intervention, early coronary bypass surgery may improve long-term survival.     

左冠状动脉主干血管成形术

目的介绍单一性左冠状动脉主干狭窄的外科手术方法.方法回顾性总结采用血管补片成形术治疗单一性左冠状动脉主干病变的手术结果.结果本组8例患者均存活,无围手术期心肌梗死等严重并发症发生,平均随访时间5年4个月;其中1例患者于术后6个月因心绞痛复发而行冠状动脉旁路移植术,术后无并发症发生;其余患者心绞痛症状均完全消失,并参与正常活动.结论冠状动脉主干血管成形术可作为单一性左冠状动脉主干狭窄的外科手术方式之一,但不宜用于病变血管处有管壁严重钙化的患者.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

Similar survival 15 years after coronary artery surgery irrespective of left main stem stenosis

Abstract

Objectives. To evaluate 15-year survival after coronary artery bypass grafting (CABG) in relation to grade left main stenosis (LMS) and right coronary artery (RCA) obstruction. Design. Coronary angiographic findings were prospectively collected in 977 patients who had CABG for stable angina during 1994–1995 and were included in the Swedish Coronary Revascularization – Swedish Council of Technology Assessment study. Results. Significant LMS was present in one fifth of the patients and significant RCA obstruction was found in 61% of those with LMS and in 68% of patients without LMS. The patients were categorized as no LMS (Group I), LMS without RCA obstruction (Group II) or significant LMS with significant right coronary artery (RCA) obstruction (Group III). Early mortality did not differ in the three groups and was 1.2, 1.2% and 0.8% in group I, II and III, respectively. Corresponding survival at 15 years was similar 51%, 47% and 47%, respectively. In multivariable analysis older age, smoking, severe angina, positive stress test, hypertension, diabetes mellitus and ejection fraction < 50% were risk factors for death at 15 years. Conclusions. Death 15 years after CABG correlated to clinical variables but was not predicted from presence of LMS with or without significant associated RCA obstruction.     

Coronary artery dissection following aortic valve replacement. How can one deal with this rare yet life‐threatening complication?

Coronary artery dissection following its cannulation for cardioplegia administration as a result of aortic valve replacement (AVR) is a rare but nevertheless life‐threatening complication. The three cases of a patient suffering from aortic stenosis illustrated below focus on the issue of how to identify and treat the dissected artery. In all of the patients who had undergone AVR diagnosed was a periprocedural myocardial infarction. Angiography revealed the dissection of the left main in two of the patients, while in the third one that of the right coronary artery. In the case of local dissection, angiography was sufficient to identify the true lumen, whereas in a dissection encompassing the whole of the coronary tree it was necessary to either find the coronary artery not involved in the dissection or to perform intravascular ultrasound imaging. After true lumen identification, the entry of dissection was stented with the optimal angiographic result.     

Coronary artery spasm after off-pump coronary artery bypass grafting

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.