Coronary Artery Bypass Grafting Combined With Valve Surgery

Objective: To summary and analysis the clinical data, perioperativemanagement, controversy in treatment and recent years` research progressionof valvular heart disease combined with coronary artery disease.Method: Analyzing retrospectively the clinical data, surgical treatment of6 patients who underwent coronary artery bypass grafting (CABG) associatedwith heart valve surgery in our hospital from March,2002 to January, 2005Clinic data: The whole group involve 6 patients ,including 5 males,1female. Age 43 ～64 years old, (mean age :54.8 ±8.6) .Body weight 51 ～78 kg.(mean weight :64.4 ±13.4 kg).2 patients had a history of rheumaticheart disease for many years, and have angina pectoris in recent years; other 4patients mainly complained about the symptoms of cardiac ischemiacombining valvular disease. All patients had coronary artery angiography toconfirm the coronary arteries` pathological changes. In addition, 4 patients hadangina pectoris , 1 had myocardial infarction ,1 patient had hypertension , 2patients suffer from atrium fibberation ,1 patient was diagnosed infectiveendocarditis, and adenovirus, coxsackievirus infection, hem development haddetected viridans streptococci infection, operation was performed after 2months` anti-infection treatment and had no fever. preoperativeechocardiography indicated: left ventricle ejection fraction( LVEF):39% ～80%(57.3% ±15.1%), left ventricle end diastole diameter(LVEDD):35~68mm(50.8mm±10.9mm),left atrium end diastole diameter(LAEDD):39～49 mm .(44.0 mm ±4.8 mm ).preoperative coronary artery angiographymanifested that 1 had single-vessel disease ,1 double-vessel diseases , 4 hadtriple-vessel diseases including 1 patent who had three segmental stenonsis,and 3 patients who had diffuse stenonis combined with segmental stenonsis , 4patients` degree of steontic were 50%～70%, 2 patients` stenotic degree were71%～90%. preoperative cardic function was:classⅡin 3 patients, classⅢin 2 patients, class Ⅳin 1 patient.( NYHA) . Surgical techniques :operations were performed under the conditions ofwhole body anaesthesia, hypothermia(28 ℃±2 ℃)and cardiopulmonarybypass (CPB) .The CPB time was 168 ～257 min(mean time:207 min ±44min), and the duration of aortic cross-clamping time was 106～162 min.(meantime:137 min ±24 min). Heart was exposed through a median sternotomy. theleft internal mammary arteries(LIMAs),and saphenous veins (SVs) wereharvest for grafting. Establishing CPB, aortic was cross-clamped andcold-blood cardioplegia including 4 ℃cold crystal liquid and 4:1coldoxygenation hem(10～15℃)were intermittently antegrade perfused(15 ～20)ml/ kg every 30 minutes to maintain cardic arrest and myocardial protection.For patients who had been diagnosed mitral valve disease preoperatively, rightatrium and atrial septum incisions were made to examine mitral valve, Forpatients who had aortic valve pathological changes or cardiac arresting wasnot satisfying, as early as possible cutting open aorta perfused cardioplegiadirectly through left,right coronary artery sinus. then beginning aortic valvereplacement(AVR) ,mitral valve replacement(MVR) ,or mitral valveplasty(MVP).MVR was underwent with 2-0 Prolene thread (Ethicon) andcontinuous suture method to immobilization artificial valve,AVR wasperformed with the same thread but interrupted suture method. There were nopostoperative complications such as perivalvular leakage or valve annulus toreetc.The LIMA was grafted to the left anterior descending artery (LAD) anddistal anastomoses of the saphanous vein (SV) to the target vessels wereperformed. Proximal ananstomsis of the SV to the aorta was finally finishedon beating heart. Totally, 12 grafts were applied as bypasses, the bypasses vessels includeSVs, LIMAs .Among them 2 patients received single graft,2 patients receiveddouble-graft , 2 patients received triple-graft. 5 patients received LIMA –LADbypasses.3 patients realized complete revascularization, other 3 patients couldnot be completely revascularized because of coronary arteries` diffuse lesionand distal diameter<1 mm. MVP were performed in 3 patients, 2 of themreceived quadrangular leaflet resection plus annuloplasty, 1 receivededge-to-egde repaire (double-orifice technique), CABG was performed withMVR in 2 patients, with AVR+MVR in 1 patient, at the same time 3 patientsreceived tricuspid valve plasty( TVP), among them Kay method 2 patients, Devaga method 1 patient. In our group, Rheumatic heart disease was present in 2 patients withpathological changes either in leaflet or chordae tendineae, both of themreceived valve replacements, one is MVR, the other is AVR+MVR(DVR).theetiology of other 4 patients were all ischemic mitral valve regurgitation ,one ofthem was anterior leaflet prolapse, double-orifice technique was performed torepair mitral valve .3 patients suffered rupture of posterior leaflet `s chordaetendineae, 2 of them received quadrangular leaflet resection plus annuloplastywith pericardium ,1 received MVR. Results: There were no operation death. Dopamine were used with thedosage of 5-10μg.kg-1.min-1.glonoin with the dosage of 0.1-0.5μg.kg-1.min-1 .the mean time of using mechanical ventilator was 36h , the mean ICU staytime was 5d . the mean time of postoperative hospitalization stay is 35d.complications were as follows: respiratory dysfunction in 1 patient, and thesame person also suffered infection of the wound, kidney dysfunction in 1patient. No complications occurred in other patients.1 patients died at the 35thday after operation , the reason of death were anticoagulant overdose ,infectious shock. this patient had been diagnosed infective endocarditis, andadenovirus, coxsackie virus infection, hem development had detected viridansstreptococci infection, operation was performed after 2 months` anti-infectiontreatment and had no fever.; The survivors remained in good conditions duringa period of 6 ～18 months follow -up. postoperitive cardic functionwas:classⅠin 3 patients, class Ⅱin 2 patients,( NYHA).the cardiac function ofthem improved obviously, they all have the ability of taking care of themself.1patient still need drug to alliviate angina pectoris. After mitral valve plasty ,the area of mitral regurgitation was reduced dramatically. Conclusion 1 ,patients who suffered from valvular heart diseasecombined with coronary artery disease usually had complicatedpathophysiological changes, require high surgical technique to operation, andhave to endure long myocardial ischemic period during the operation .with ahigh early and late mortality .the perioperative managements have itselfcharacteristics, we should earnestly improve and evaluate patients`cardiacfunction preoperatively, carefully research the influence of the changing ofcardiac preload and afterload, fully estimate patients condition and operationrisk; management carefully after operation according to pathophysiologicalchanges. 2,In recent years, the research directions of coronary artery disease...