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北京大学人民医院陈彧等研究提示:预定CABG策略与实际完成的手术策略在方式、靶血管位置及血管桥选择存在差别

2018-12-26 xujing 中国循环杂志

CABG 策略的制定是手术成功的关键,北京大学人民医院心脏中心陈彧等研究发现,基于冠脉造影预先制定的 CABG 手术策略与实际完成的手术策略会存在一定的差别,与医生年资无关。


CABG 策略的制定是手术成功的关键,北京大学人民医院心脏中心陈彧等研究发现,基于冠脉造影预先制定的 CABG 手术策略与实际完成的手术策略会存在一定的差别,与医生年资无关。

这种差别表现在手术方式、靶血管位置以及血管桥材料选择三个方面。

CABG 主要包括 ONCAB 和 OPCAB 两种方式。当前国内很多单位都能开展这两种技术,手术方式的选择主要依赖外科医生的手术经验及治疗效果。

该研究数据显示,ONCAB 符合率最低,仅 52.9%。

研究者指出,在像北大人民医院以OPCAB 为主的单位,医生对于这种策略选择更有一致倾向性,而对于 ONCAB 的选择存在较大分歧;如有些严重血管病变患者,术前预计麻醉诱导后会出现循环不稳定,因此术前倾向选择体外循环,但术中可能循环尚可,接受而坚持在非体外循环下完成手术,还有一些患者术中发现主动脉严重钙化,无法行体外循环插管而转行 OPCAB。

靶血管位置的选择是手术方案制定的核心内容。本研究结果显示,不同靶血管位置的符合率不同。

左前降支符合率为 97.5%,符合率最高,主要与左前降支供血范围及再血管化治疗的重要意义相关。

而右冠脉系统符合率最低,仅为 82.5%,右冠脉系统常用的搭桥位置有右冠脉主干、后降支、左心室后支,在制定手术策略时,差别更加趋于显著,主要和病变位置相关。

目前第二根动脉桥的使用率仍偏低,本研究中,第二根动脉桥的使用率只有 13.2%,在术前制定的CABG 策略中,该比例更低,仅为 10.6%,目前大多数医生倾向于选择单侧乳内动脉加大隐静脉的策略,对于多动脉桥选择倾向小。

而且,本研究结果还显示,独立手术医生选择 CABG 策略时具有相对稳定性,受训医生经过培训后策略符合率逐渐提高并接近独立医生水平,CABG 策略研究对受训医生具有培训价值。

连续纳入 2016-06 至 2017-05 拟初次单纯行 CABG 的冠心病患者 287 例,由 9 位外科医生基于冠脉造影结果,独立制定术前预定策略,经全科讨论后确定基本手术方案,由独立手术者完成手术,术后记录实际手术策略,计算术前预定策略与实际手术策略的符合率。

9 名外科医生分为独立医生组(n=5)和受训医生组(n=4),对两组术者的策略符合率进行比较。

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    2019-01-04 日月
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    2018-12-28 衣带渐宽

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