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首页> 外文期刊>Journal of cardiac surgery. >Myocardial infarction in coronary bypass surgery using on-pump, beating heart technique with pressure- and volume-controlled coronary perfusion.
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Myocardial infarction in coronary bypass surgery using on-pump, beating heart technique with pressure- and volume-controlled coronary perfusion.

机译：冠状动脉搭桥手术中的心肌梗塞，使用泵，搏动心脏技术和压力和体积控制的冠状动脉灌注。

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BACKGROUND: Even with the current aerobic techniques in myocardial protection, perioperative myocardial infarction can still occur. In this study, we sought to find out whether there is a method-specific mechanism of ischemic injury in coronary bypass surgery using an on-pump beating heart technique. For this reason, we investigated localization and the extent of myocardial infarction in correlation to the severity of coronary artery stenosis. We discuss strategies for reduction of infarction incidence. METHODS: 34 patients, who after isolated coronary bypass procedure developed non-Q or Q wave infarction were selected for the study. In 12 of 34 patients (group A) beating heart technique and in 22 of 34 patients (group B) cardioplegic arrest was used for myocardial protection. The study was conducted retrospectively and included patients with stable, unstable, and postinfarction angina without preoperative enzymatic evidence of ischemic injury and with technically noncomplicated coronary bypass grafting. Excluded from the study were emergency and redo procedures. In group A, in all instances, the left anterior descending artery was grafted as the last vessel and while distal anastomoses were constructed, coronary perfusion was maintained by using a perfusion catheter. RESULTS: Most patients in both groups had triple-vessel disease (10 of 12 patients group A; 17 of 22 patients group B), all patients received complete revascularization; 7 of 12 patients in group A and 5 of 22 patients in group B had significant or critical left main stem stenosis. In group A, 11 infarctions occurred in LAD-(12 stenotic), 1 in CX-(11 stenotic), and 1 in RCA-(11 stenotic) supply area, four were Q wave infarctions. In group B, eight infarctions occurred in LAD (22 stenotic), four in CX (17 stenotic), and 14 in RCA (20 stenotic) supply area, eight were Q wave infarctions. In group A, the infarction incidence in the LAD area was 10-times higher than in CX and RCA areas. In group B, the infarction incidence in the RCA area was 2- and 3-times higher than in the LAD and CX areas, respectively. In both groups no correlation between infarction incidence and severity of stenosis was observed. CONCLUSIONS: Using an on-pump beating heart technique, higher coronary perfusion pressures, avoidance of extreme upward retraction of the heart during revascularization of the CX-branch, as well as choosing the revascularization of the LAD as the first vessel, could possibly contribute to better myocardial protection. In hearts arrested with cardioplegic solution, the right ventricle is probably more susceptible to ischemic injury, especially when RCA is poorly collateralized. For adequate protection, choosing the revascularization of the RCA as the first vessel with immediate repeated cardioplegia via a RCA graft, higher perfusion pressures and antegrade with retrograde cardioplegia delivery, may be advantageous.
机译：背景：即使采用目前的心肌保护有氧技术，围手术期心肌梗塞仍可能发生。在这项研究中，我们试图找出使用泵浦跳动心脏技术在冠状动脉搭桥手术中是否存在特定方法的缺血性损伤机制。因此，我们调查了冠状动脉狭窄程度与心肌梗塞的定位和程度有关。我们讨论了减少梗死发生率的策略。方法：选择经独立冠状动脉搭桥手术后发生非Q或Q波梗死的34例患者。 34例患者（A组）中有12例（A组）和34例患者（B组）中的22例，使用了心脏停搏来保护心肌。这项研究是回顾性研究，纳入了稳定，不稳定和梗塞后心绞痛的患者，这些患者没有术前酶学证据表明的缺血性损伤，并且在技术上并不复杂。该研究排除了紧急和重做程序。在所有情况下，在A组中，将左前降支动脉移植为最后一个血管，并在构建远端吻合的同时，使用灌注导管维持冠状动脉灌注。结果：两组的大多数患者均患有三支血管疾病（A组12例，其中10例; B组22例，其中17例），所有患者均已完全血运重建。 A组12例中有7例，B组22例中有5例具有明显或严重的左主干狭窄。在A组中，LAD-（12狭窄）发生11例梗塞，CX-（11狭窄）发生1例，RCA-（11狭窄）供应区发生1例，其中4例为Q波梗死。在B组中，LAD（22例狭窄）发生了八次梗死，CX（17例狭窄）发生了四次梗塞，RCA（20例狭窄）发生了14次，Q波梗死。在A组中，LAD地区的梗死发生率比CX和RCA地区高10倍。在B组中，RCA地区的梗死发生率分别比LAD和CX地区高2到3倍。两组均未观察到梗塞发生率与狭窄程度之间的相关性。结论：使用泵跳动心脏技术，更高的冠状动脉灌注压力，避免在CX分支血运重建过程中心脏极度向上收缩以及选择LAD的血运重建作为第一血管，可能有助于更好的心肌保护。在以心脏停搏液停搏的心脏中，右心室更容易受到缺血性损伤，尤其是当RCA的侧支不良时。为了获得足够的保护，选择RCA的血运重建作为第一个通过RCA移植物立即重复出现心脏停搏，更高的灌注压力和逆行心脏停搏顺行的血管可能是有利的。

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