稍微来介绍一下我们对于心脏外科最常听到的手术-冠状动脉绕道手术.

几乎每个人都有听过冠状动脉绕道手术,也都知道当心肌梗塞时(AMI)不失为另一种选择,但是可能很多人都不是很清楚绕道手术(CABG)本身的适应症是什么?首先先讲较为人讨论的CABG for emergent condition,根据2011 ACCF_AHA guildline,当AMI后产生postinfarction mechenical complication: 1) Ventricular septal rupture, 或是 2) Mitral valve insufficiency--通常为papillary muscle inafction/rutpure, 甚至产生3) Free wall rupture. 以上都为emergent CABG的 indication.此外,还有一种情形也是符合emergent CABG：当病人因为心肌梗塞而产生cardiogenic shock时,不管发生时间的长短,都应该尽快做紧急的CABG「class Ib」.最后当病人因为AMI而变成Vf时（ventricular fibrillation）也是需要进行紧急的CABG「class Ic」

当一些紧急的情况下冠状动脉绕道手术的适应症都介绍完后,我们来看一下elective CABG的适应症吧:

I. Chronic stable angina (Canadian class I/II)-- usually mean reversible ischemia status of coronary vessels
   a. It is usually well relieved by CABG, even though not permanently so; it can also be favorably influenced by modern medical treatment, and under many circumstances by PCI 
   b. Depend on all the patient-specific risk factors for unfavorable outcome events in patients with ischemic heart disease
(通常这类的病人,预后算相对好的,对于CABG, PCI, 甚至medical Tx的反应都不错; 所以CABG在这里的indicaiton就变成是一个individual clinical decision)
@当然特别说一下,一般来说,1SD(sigle vessel disease)的病人是不建议做CABG的
＃Canadian class的简介：他是一个对于angina的分期
    --> class I : Angina only during strenuous physical activity
    --> class II: Angina only during physical activity (简单来说就是运动更容易有症状,譬如稍微剧烈就不行了)
    --> class III: Angina within daily activity
    --> class IV : Angina at rest

   c.  2 SD : two vessel diseases
      1. CABG is not routinely indicated with mild angina
      2. CABG is indicated when P-LAD was involved or impaired LV function
  (这类的病人,一般来说PCI的预后不比CABG差,但是当lesion involves P-LAD时,或者是EF很差的病人CABG的优势就出来了)

   d. 3 SD: three vessel diseases
      1. P-LAD involve : CABG (2 SD伴随P-LAD都已经是CABG比较好了,3 SD当然也是)
      2. P-LAD no=> LV
                          * If LV dysfunction: CABG (though similar survival to medical Tx, CABG showed better prognosis)--这里必须强调一点,EF差确实常常是CABG的indication但是太差却又不适合开刀(CABG become uncertain when EF<30%)
                          * If LV good: CABG/PCI similar to medical Tx (如果LV function是好的,那么CABG和PCI的效果是差不多的)

II. Chronic stable angina (Canadian class III/IV)--真对于这类的病人,尽管medical Tx可能是有效的,但是intervention的介入还是需要的(Despite optimal medical treatment, intervention is usually advisable)

  a. 1 SD: PCI was recommened (though no mortality benefit, increase freedom from angina)

      * If proximal LAD or EF<50% was the case : 我们会建议CABG(因为做PCI会比CABG约3倍的机会产生 recurrent angina; 5倍的机会需要再一次intervention)
   b. 2 SD: CABG was recommened, 尤其是对P-LAD or renal dysfunction的病人(此时CABG的功效虽然没有比PCI突出很多,但是5年内的reintervention却明显下降很多)
   c. 3 SD: 
      1. P-LAD involve: CABG (基本上本身是3 VD又伴随P-LAD当然需要CABG)
      2. P-LAD no=> LV
                          * If LV dysfunction: CABG (predominant survival benefit)--However, risks and benefit of CABG become more uncertain when
                             EF<30%
                          * If LV good: CABG
       (若P-LAD并没有涉及到,则需要看LV的功能如何,如果EF功能很差,则建议CABG--除非EF差到<30%; 若LV功能是好的,其实也是建议CABG)

III. 讲完stable angina后,我们该来看一下unstable angina CABG的地位了,以下将是CABG的indication:
    *这类的病人,medical treatment initially是一定要的,而internvention介入的时间点并不需要emergent,urgent即可.除非有hemodynamic unstable等情形才需要emergent surgery.

   a. 1 SD or double vessel disease with/without P-LAD
   b. 3 vessel disease or double vessel disease + DM/EF<50% +(involve P-LAD): CABG
      * If 2 SD with P-LAD only without DM/EF<50%: CABG(PCI is an alternative)
      * If 2 SD without P-LAD: PCI initally try
(3 VD当然一定是CABG; 然而2 VD又伴随DM/EF<50%且同时有P-LAD时也是CABG; 若2 VD同时有P-LAD但是并没有DM/EF<50%时 ,CABG还是indication,但是PCI也是一种选择; 若2 VD并没有伴随P-LAD时, PCI是可以先试试看)

看完后,刚开始可能有一点痛苦,仔细消化后应该会渐入佳境,辛苦大家了

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