Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery - Technical Aspects

極少侵犯性的冠狀動脈繞道手術－技術層面

陳復銓(Robert Fu-Chean Chen) ； 林俊龍(Chin-Lon Lin) ； 趙盛豐(Sheng-Feng Chao) ； 賴嘉珀(Cha-Po Lai) ； 王志鴻(Ji-Hung Wang) ； 曾文賓(Wen-Ping Tseng)

《慈濟醫學雜誌》 10卷4期 (1998/12) Pp. 279-284

https://doi.org/10.6440/TZUCMJ.199812.0279

摘要

傳統式，在心臟停止下，利用心肺機體外循環施行心臟的冠狀動脈繞道手術已被公開認為是有效的，但是體外循環的副作用，如凝血酵素被破壞所引起的大量出血，全身性的發炎反應，較長的加護病房及住院天數，並且很大的醫療經濟負擔是不可忽視的。
我們慈濟醫院在18個月內有12個病人在心臟還跳動下，無須心肺機體外循環，嘗試施行心臟冠狀動脈繞道手術，方法是從左前胸，大約只8公分長，第四肋間進入胸腔並打開心包膜，將左內乳動脈接至心臟的左前下肢冠狀動脈，手術中經麻醉醫師小心的使用藥物，使心臟減速。
在這12個病人中，有9個順利完成，且平均開刀後第一天離開加護病房，第四天出院，預後良好。其中兩個病人，因為冠狀動脈鈣化，及太深入心肌而改為傳統式利用心臟停止及心肺體外循環，雖然也都順利完成，但他們個別於術後第13天及15天才出院。
總結，極少侵犯性的冠狀動脈繞道手術，在團隊的合作下，麻醉醫師的配合，順利完成，不過很重要的是要謹慎的選擇適當的病人。

關鍵字

冠動脈繞道手術 ； 心肺體外循環 ； 內乳動脈 ； 小左前開胸手術

並列摘要

Minimally invasive direct coronary artery bypass surgery without cardiopulmonary bypass is gaining popularity for the surgical revascularization of patients with selected coronary artery disease. The most frequent procedure is left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass graft using left anterior small thoracotomy (LAST) incision. The LIMA can be dissected under direct vision or through video-assisted device.
Recently, we used minimally invasive direct coronary artery bypass (MIDCAB) surgery on the beating heart without cardiopulmonary bypass for single – or double – vessel coronary artery disease patients.
Twelve patients with symptomatic coronary artery disease were included in this study. These patients underwent attempted MIDCAB surgery. A LAST incision, about 8 cm long, was made in the fourth intercostals space and the fourth intercostals cartilage was excised (third cartilage also, if needed). The LIMA was mobilized for about 6 cm under direct vision. End to side, LIMA to LAD coronary artery anastomosis was performed for nine patients with single vessel LAD disease and median sternotomy with a vein graft was performed for one patient with double-vessed disease. These ten patients all underwent MIDCAB on beating hearts without cardiopulmonary bypass.
Of the twelve study patients, two required conversion to traditional approach median sterotomy with cardiopulmonary bypass, one patient for intramyocardial and the other because of calcified LAD.
In conclusion, MIDCAB surgery can be performed with success under careful patient selection.

並列關鍵字

Left anterior small thoracotomy ； cardiopulmonary bypass ； coronary artery bypass graft ； internal mammary artery