The Effect of Temporary Coronary Occlusion on the Myocardium during Coronary Artery Bypass Grafting without Cardiopulmonary Bypass

在施行無體外循環不停跳心臟冠狀動脈繞道術中暫時性冠狀動脈血流阻斷對心肌之影響

魏斯邁(Szu-Mai Wei) ； 林佳勳(Chia-Hsun Lin)

《輔仁醫學期刊》 10卷4期 (2012/12) Pp. 185-191

摘要

背景：無體外循環不停跳心臟冠狀動脈繞道手術，在目前低侵襲性術式的發展中已逐漸被認同與廣泛的被運用。但其術中需暫時性完全阻斷已狹窄的冠狀動脈血流，以利於操作血管之吻合，此步驟是否有對心肌造成傷害的可能性極須探討。方法：本院12位病患接受無體外循環不停跳心臟冠狀動脈繞道手術，術中全程以心電圖變化、經食道超音波觀察心室壁收縮能力及肺動脈導管監側壓力與心輸出量，術後以心肌旋轉蛋白－I（troponin-I）、肌酸磷化脢－同功脢MB（CK-MB）的變化與心電圖、超音波心室收縮比來評估心肌所受之影響。結果：所有病患於術中、術後之所有數據皆無達到診斷心肌梗塞的標準。術中因翻動心臟可能會引起短暫血壓與心輸出量的下降，但於恢復心臟位置後立即復原。術後一位病患心肌旋轉蛋白－I最高值為1.36 μg/L，但無心電圖變化或心室功能損害及任何臨床症狀。結論：無體外循環不停跳心臟冠狀動脈繞道手術可於病患安全施行，不會造成有意義的心肌損傷或心室收縮功能異常。雖然可測得心肌旋轉蛋白－I的升高值，代表手術中仍會造成輕微心肌損傷，但其最高數值尚未達到在使用體外循環與心肌麻痺液的冠狀動脈繞道術已建立的心肌梗塞診斷值。

關鍵字

冠狀動脈血流阻斷 ； 心肌缺氧 ； 無體外循環不停跳冠狀動脈繞道手術

並列摘要

Background and purpose: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) has gained acceptance as an effective and feasible procedure. However, the potential ischemic injury to the myocardium resulting from temporary coronary occlusion during the operation remains of great concern. Methods: Twelve patients underwent elective CABG without CPB, including 6 off-pump coronary artery bypass (OPCAB) and 6 minimally invasive direct coronary artery bypass (MIDCAB) procedures. Intraoperative transesophageal echocardiography (TEE) was carried out, and a Swan-Ganz pulmonary artery catheter was introduced for hemodynamic monitoring. Release of cardiac troponin-I (CTnI) and the creatine kinase MB isoenzyme (CK-MB) was measured before coronary occlusion, after completing the operation, and for the next 3 days. Changes in the electrocardiogram (ECG) and left ventricular ejection fraction (LVEF) on the echocardiogram were evaluated. Results: No patient had laboratory or electrocardiographic evidence of a myocardial infarction during or after the operation. Hemodynamic stability was maintained, except for temporary reversible decreases in cardiac output and arterial blood pressure which developed during the cardiac manipulation. Postoperatively, the cardiac markers were mildly elevated with the highest levels of CK-MB of 51 IU/L and of CTnI of 1.36 μg/L. The LVEF was not adversely affected. Conclusions: CABG without CPB support can be well tolerated with no significant myocardial damage or LVEF compromise. Although increased CTnI and CK-MB concentrations were found, indicating minor myocardial injury, none of the measurements exceeded the threshold value considered to be a perioperative myocardial infarction in patients who received CPB and cardioplegia.

並列關鍵字

coronary occlusion ； myocardial ischemia ； off-pump CABG