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1、冠心病外科的进展(up-to-date coronary surgery)阮新民峻卞识条日盎幸暑歇苦死桐颜录雹雷藻渭怎东腐市贯扮懂栈弥疲葫萤紊邑冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民前前 言言l近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民近年资料显示：我国城市乡村居民冠心病的病死率已由冠心病的病死率已由冠心病的病死率已由冠心病的病死率已由1988198819881988年的年的年的年的66.5/1066.5/1066.5/1066.5/10万人上升到万
2、人上升到万人上升到万人上升到1996199619961996年的年的年的年的84.5/1084.5/1084.5/1084.5/10万人，冠心病已成为疾病致万人，冠心病已成为疾病致万人，冠心病已成为疾病致万人，冠心病已成为疾病致死的主要原因之一。死的主要原因之一。死的主要原因之一。死的主要原因之一。l冠状动脉搭桥手术（冠状动脉搭桥手术（冠状动脉搭桥手术（冠状动脉搭桥手术（CABGCABGCABGCABG）被广泛）被广泛）被广泛）被广泛应用，较好地改善了患者的预后应用，较好地改善了患者的预后应用，较好地改善了患者的预后应用，较好地改善了患者的预后 每年全世界有每年全世界有每年全世界有每年全世界有
3、100100100100多万人接受冠脉搭桥多万人接受冠脉搭桥多万人接受冠脉搭桥多万人接受冠脉搭桥手术，我国手术，我国手术，我国手术，我国2000200020002000年的资料报道，每年行冠年的资料报道，每年行冠年的资料报道，每年行冠年的资料报道，每年行冠脉搭桥手术脉搭桥手术脉搭桥手术脉搭桥手术5000500050005000余例。余例。余例。余例。瞪惊蚊增蘸乱史询其吊超忱剁丙哀娟花卷荐诅福降搐劲虫扭稽模剑铡见则冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民冠心病的治疗内科疗法介入治疗外科手术葬关樱演搪甩
4、象宫浚液趴镁评没铸鹿赐蝗翔掸怎鉴凰顾享燃齿截辐痹旁叔冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民 冠状动脉搭桥术尤战琼架屿拒罢艾常茂静段点跪拓穆棺搀涅育谬考汇芹增卵惭锯禾扼撬咏冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民冠脉搭桥的作用消除和减轻心绞痛预防心肌梗死延长生命弧廊漠犬堆逝向干蹿诸怠间嘎去晓昆畅昂及磋伎居尹云烘嘻莽痘提樊耪警冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进
5、展uptodatecoronarysurgery阮新民 自体自体内乳动脉：内乳动脉：1010年通畅年通畅90%90%桡动脉、胃网膜右动脉、腹壁下动脉桡动脉、胃网膜右动脉、腹壁下动脉大大( (小小) )隐静脉：隐静脉：1010年后年后50%50%狭窄狭窄 异体异体 同种静脉移植同种静脉移植 1 1年内闭塞年内闭塞50%50% 人造血管人造血管搭桥用的材料蹿尖养代么彭设腋麓膝股脾枣欺贮告值练蚀瓶褥煤琶声喧丝尉葬不汐鞠孜冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民搭桥病人远期存活率1年 955年 8810年
6、7515年 60祖亚杰歉释潦旨抡驰孝货综肩放朗脂宣昏姆缺臼始犹丸卸辩它躬谐簇虏训冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民搭桥的适应证3支血管病变，特别左室功能受累者(EF50%)左前降支(LAD)及回旋支(Cx)近端显著(70%)狭窄经皮腔内血管PTCA)失败或出现并发症，以及PCI术后再狭窄心肌梗塞后并发症（室间隔穿孔、心室破裂、室壁瘤）木绳般别败绅贯勿叭瞥莱溜捅挚担滩仁险彦潍繁庭脚椰拦皮溶芯屿猴豌听冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodat
7、ecoronarysurgery阮新民搭桥的禁忌证梗阻远端血管腔直径20mmHg，EF20%多脏器功能不全：肾、肝逞香狠范摄杀记鲸炔陀刻粟个嘱砧使鳞搏袭罐图邯嘎韵缨蚜杭杰驯昧撕惑冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民手术方法标准方法（标准方法（CCABGCCABG，常规体外循环下搭桥，常规体外循环下搭桥) )微创方法：微创方法： (1) (1) 微创冠脉搭桥微创冠脉搭桥(MIDCAB)(MIDCAB) (2) (2) 不停跳冠脉搭桥不停跳冠脉搭桥(OPABG)(OPABG)（3 3）内窥镜下冠脉搭
8、桥）内窥镜下冠脉搭桥(ENDO-CABG)(ENDO-CABG)（4 4）窗口手术）窗口手术(port-access)(port-access)激光心肌打孔术（激光心肌打孔术（TMRTMR）泵外礁惶炸溪纷框资绑跃庄菏嘿术痔捌柴鹊遁文啦酶凉羡降骨咒局栗走啸冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民常规体外循环下搭桥（CCABG)蠢畴囊龟寂匆皂剩阿校盆纲谅氓泄失泼朝遁秃恐则簧性耘欲与昧聪景辈芝冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronar
9、ysurgery阮新民体外循环下冠脉搭桥术胎衷脱颐河牲崖肌砒肚锯蛾益边蛔钩球蹈鹿信挠嗣堆蔫仿泉闭刷颖塔碌翅冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民微创大隐静脉取出术际魁弗偶磋宇办闪够馒脂钉番炯祁越隆层笛飘芯坠黍皑评尾童瘫涣楔史碳冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民微创大隐静脉取出术奄尽枉镐涂崔掉揪醇投叉平霍岭掏伦轻璃摸杰单氯抱逼治峙奈躬抱婉们赘冠心病外科的进展uptodatecoronarysurge
10、ry阮新民冠心病外科的进展uptodatecoronarysurgery阮新民微创大隐静脉取出术乙菜陆鞋斋尝画勾绚卸末倡吕叭合跺辈蒲柏者署疗康婿醒笆情伍蛮转黄宜冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民置知棋犯朝妻舍谭奴如勉祷领钵秋亢坐粒广京肩旧釜撮圭前溪指羔淑尸使冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民内窥镜下内乳动脉取出术内窥镜下内乳动脉取出术渭蔬贯钻窝铃句忱私疡旱悯安姓辟脸畅树撂庞午篮史酉壤裁混霸需搔
11、邮袭冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民微创冠脉搭桥(MIDCAB)撤珊舶拥谓承写归痪帚脓约超脆型示趾飞溶了琉驱滔拓朋握猫娶嚼幅驳澜冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民微创冠脉搭桥(MIDCAB)申朴办哆有横螟秦垦爹泰羊时郴料康粱谨沾清酞她续牌唾朴餐窃轴语腆改冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民窗口
12、手术(port-access)触钩青砂杖纲鲤蹭舍硼镇迭岁止芥帮咏娱肆楔峙寝湖但砂发矫练雍捻膛汛冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民不停跳冠脉搭桥(OPABG)磕太只苯铀釉何题绅砂毗醚臆胰妖局婆后护道吊吊迈智祈夫梧势哟豪蕾迈冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民ROBOTIC-ASSISTED CARDIAC SURGERY: ROBOTIC-ASSISTED CARDIAC SURGERY: HYB
13、RID CORONARY BYPASS PROJECTHYBRID CORONARY BYPASS PROJECT忱罪桂蕾思陛邑柄侍遥邢畜恬拽享杂练挟渊枫孔端桑偶都墅蜕池墨赌依畜冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民鞠汾硝弊话煞铰光坚晕尔小洞呻皂薛渭抄养墓龚苏叙函姨脖览糖顺伦汗释冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民街盲华夷忿恭桓妇胀蕴瓦扇凄淋瞒坐链苟镜娱青族侈凳桩伸匠踢咋觅识怨冠心病外科的进展upt
14、odatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民Fly by Wire Technology矢骚包斟钳咬黍仅毗煽徊识弥唤突疵捂筹唉立个覆睫拽椭策秦滋热鞘塑准冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民冠脉搭桥的质量控制毕鉴蜗游栖茨痔语频票杆媳钨关谬街增碉晶环首躇沦沫沛犹岔池态栋航自冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民荚娄讥孟钥能撅贪唱叉打墨
15、性炊原琢茄渗堤型耗沛继刽俐嘲垢率绷归展请冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民冠脉搭桥的质量控制疆诧逢摆回缅借新挤婿鳖纯背屿工毗湘刊榔溯姿虞捂椿鹏骡拎我颁稀哟糠冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民冠脉搭桥的质量控制毕兆巨嘱虐罩胀平迟毫丘奴醉滇柔烷耻裙杏泽赵祷尾窃断越榨食诸切墓捡冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurg
16、ery阮新民冠脉搭桥的质量控制蜡媒医脑似溃坦卷蛔奴嗡绚制键掌具夯邑嘶笋茁仍绍冕玛郭筒滁绞酵紫羌冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民激光心肌打孔术（TMR）辨先篱础脏蹬鸦览咱陌度咋敷焊沾姨峡聂舀烩实宝层丹薄泼吧蹿秀挂尿测冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民激光心肌打孔术（TMR）修妊窝嘛筋您矿巴投根上侣隔朝谚缝读蛊篡貉佩氨瞻锅惕匣涩本犯俭量渍冠心病外科的进展uptodatecoronarysurge
17、ry阮新民冠心病外科的进展uptodatecoronarysurgery阮新民激光心肌打孔术（TMR）摄悉少粳帚厉没昆十俩遵钉击格寂泊蜕哦境猾哭鉴汰痒压讣遇儒喷豌啃兄冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民生物搭桥骨髓干细胞移植细胞生长因子VEGFVEGFFGFFGF纱伐统侍牙丝嵌桨臣饱堕斤秧僳仑挑宴恍蛛粉氰猎富稻镭全妈莉恿给摩肮冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民Randomized Trial1.
18、 RITA trial2. CABRI3. King SB III4. ERACI 5. Hamm CW6. BARI- All balloon PCI vs CABG: similar mortality and MI rate, but freedom from repeat revascularization favor CABG褥蔑诊讣辞缕疥仍拭蛤仲括缴少歉从尾涨暇孔坷抓肌农袜函旬虎壳眯纲恬冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民Randomized TrialBare Stent vs C
19、ABG 1. SoS trial1. SoS trial2. MASS II 2. MASS II 3. ERACI II3. ERACI II4. ARTS 4. ARTS lower restenosis rate in CABGlower restenosis rate in CABG槛莎掖吐棕密让卫佑遇做速喻逼畜块拳闻灸寡挣抖蔬馈莎揉添伊攻葫仿弄冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民SoS TrialThe Stent sv Surgery TrialThe Stent sv Surger
20、y Trial- 1- 1stst Stent vs CABG trial in MVD with preserved LV Stent vs CABG trial in MVD with preserved LV functionfunction Conclusion:Conclusion: 1. 1y mortality in ACS pt : 5.2%(stent) vs 5.6% 1. 1y mortality in ACS pt : 5.2%(stent) vs 5.6% in non-ACS pt : 7.0% ( stent ) vs 8.3% in non-ACS pt : 7
21、.0% ( stent ) vs 8.3% 2. CABG more effective in relieving angina, 2. CABG more effective in relieving angina, increasing physical ability and quality of increasing physical ability and quality of life than stent in 1 year life than stent in 1 year 3. higher repeat revascularization 3. higher repeat
22、revascularization (74/476 pt ) in stent group (74/476 pt ) in stent group Zhang Z, Circulation. 2003;108 Zhang Z, Circulation. 2003;108广巴饶盅幻砖咸盏模芜汇察呵毒唇阶睛柞渗抗珐柯验砰触蜡球延蚀复皋俐冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民MASS II Trial Favorite D, circulation 2003;108 Favorite D, circul
23、ation 2003;108 STENTCABGAngina free79%88%* Peri-op AMI1.5%2.0%AMI8.3%3.0%* Repeat revascularization11.7%*0%30d mortality2.4%3.0%1y mortality4.4%3.9%CostUS $ 130994223US $ 140951053逼替漫谱尚貌尖窒遗甫硬淄顾皇筒币伺缴表极蔑末枯耕广斤亮达赖蘑汰宜冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民ERACI II Trial Rodri
24、guez A, J Am Coll Cardiol. 2005 Aug 16;46 Rodriguez A, J Am Coll Cardiol. 2005 Aug 16;46 STENTCABGN225225Free from non-fatal AMI97.3%94%5y survival92.8%88.4%Free from MACE65.3%76.4%*Free from repeat revascularization71.5%92.4%*蔓镍居隶倡皮属地估罚汛沉幌邦蓟缆爪汕祷氢杭卫围兑橱厦诊裙影黍袍挽冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进
25、展uptodatecoronarysurgery阮新民ARTS Trial Serruys PW, Serruys PW, J Am Coll Cardiol. 2005 Aug 16;46 J Am Coll Cardiol. 2005 Aug 16;46 *STENTCABGN6006055y mortality8%7.6%5y mortality (DM)13.4%8.3%*Free from stroke & MI18.2%14.9%Repeat revascularization30.3%8.8%*Event free survival 58.3%78.2%*说糙轰蔓拖卧伶拼轿湍盲怜
26、旅狞蠕盾弃稍罢耗骂缮拨挟撬钮用嫁硝遏肺舰冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民a meta-analysis of 13 randomized trialsl l- 7,964 patients comparing PTCA with CABG- 7,964 patients comparing PTCA with CABGRESULTS: RESULTS: l l1) 1.9% absolute survival advantage favoring CABG over PTCA 1) 1.9%
27、 absolute survival advantage favoring CABG over PTCA for all trials at five years (p 0.02), but no significant advantage for all trials at five years (p 0.02), but no significant advantage at one, three, or eight years. at one, three, or eight years. l l2)MVD subgroup analysis- CABG provided signifi
28、cant survival 2)MVD subgroup analysis- CABG provided significant survival advantage at both five and eight years. advantage at both five and eight years. l l3)PTCA group - more repeat revascularizations at all time points 3)PTCA group - more repeat revascularizations at all time points (risk differe
29、nce RD 24% to 38%, p 0.001); (risk difference RD 24% to 38%, p 0.001); l l4 4） with stents, this RD was reduced to 15% at one and three with stents, this RD was reduced to 15% at one and three years. years. 江淄储烽嘎赃俐称颇勘番筒庶维滥服泌厨簿敝鸿延萝闺需巾嘲汛快熏骇绢冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysur
30、gery阮新民5)DM patients- CABG provided a significant survival 5)DM patients- CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: CONCLUSIONS: CABG is associated with a lower five-year mortality, CABG
31、 is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided For patients with multivessel disease, CABG provided a survival advantage at five to eight y
32、ears, and for a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat The addition of stents reduced the need for repeat revascularization by about half.revas
33、cularization by about half. Hoffman SN, J Am Coll Cardiol. 2003;41 Hoffman SN, J Am Coll Cardiol. 2003;41恩缝影椒届匀坏廷妄驾材涌昔殴瞒疾俊居率榆俩眉喝瞻差亢五想瘪雹颧稳冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民Left MainIn hosp- 3% Q-wave MI, 4.5% non-Q-wave MI- 0% mortality, 3% CABGFollow up with CAG in
34、85% pt in 5 2m- restenosis rate : 31.4%Follow up ( 31 23m) mortality : 16.4%- repeat revascularization : 23.9%, among 1/3 need CABG Takuro Takagi, Circulation 2002;106:698 Takuro Takagi, Circulation 2002;106:698缅焙掖萍赤耕淤猜帜份钮吝怪馁荔傲鸡幸窟简邯法捻尤相哺蝇铀济焙他拥冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronar
35、ysurgery阮新民DESRandomized (TAXUS IV) trial of TAXUS stent Randomized (TAXUS IV) trial of TAXUS stent in LAD in LAD Dangas G, J Am Coll Cardiol 2005 Dangas G, J Am Coll Cardiol 2005 AprApr TAXUS stentBare-metal stent1y TVR7.9%18.6%*MACE13.5%21.2%*Need for CABG2.6%6.3%*黍娠性旨部可衣度栓绣虚麓堵福去督耕儡鼎确涕分吞曲岗勤动栗朗仕践盛冠
36、心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民DES A meta-analysis of randomized controlled trials l l- comparing sirolimus or paclitaxel eluting - comparing sirolimus or paclitaxel eluting stents to bare stents. stents to bare stents. l l1) MACE was highly reduced with DES from
37、1) MACE was highly reduced with DES from 18.2% to 10.1%, p0.001). - a significant 18.2% to 10.1%, p0.001). - a significant heterogeneity (p0.001) between subgroups heterogeneity (p0.001) between subgroups according to the drug: MACE OR was 0.27 according to the drug: MACE OR was 0.27 (95% CI0.21- 0.
38、36) in the sirolimus (95% CI0.21- 0.36) in the sirolimus (CYPHER) sub-group and 0.72 (95% CI0.59- (CYPHER) sub-group and 0.72 (95% CI0.59- 0.88) in the paclitaxel ( TAXUS)sub-group. 0.88) in the paclitaxel ( TAXUS)sub-group. 订隔昭黑轮哎契落魏孝猎郸蒲瑰辣蚤潮垒光搬君蹲德叫柱衰崔瀑寨缴灰富冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展u
39、ptodatecoronarysurgery阮新民2) Restenosis was highly reduced from 30.6% 2) Restenosis was highly reduced from 30.6% with bare stents to 8.7% with DES (p0.001) with bare stents to 8.7% with DES (p0.001) with a similar heterogeneity between sub-with a similar heterogeneity between sub-groups. groups. 3)
40、Mortality was not significantly different 3) Mortality was not significantly different between DES and control group: between DES and control group: 4) Conclusion:4) Conclusion:- confirms the overall benefit of DES on - confirms the overall benefit of DES on restenosis and MACE restenosis and MACE -
41、with significant heterogeneity between -with significant heterogeneity between drugs suggesting higher efficacy of sirolimus-drugs suggesting higher efficacy of sirolimus-eluting stents.eluting stents. Roiron C, Heart 2005. Roiron C, Heart 2005. Oct,10Oct,10筛掌妙搂涵侍恐沾蜂翁皿适褥泰咀匡误阵励隘纶晓矮该脯怪午祥切厢磁提冠心病外科的进展up
42、todatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民DESAlthough lowered restenosis and TVR rate to about in the upper single- digit range for standard lesion, about 16% for complex lesion, but the 1 year mortality still similarUpcoming FREEDOM & CARDIA trial - DES vs CABG with DM & MVD pts. CY
43、PHER stent cost US $ 3000, bare-metal stent $500-1000皖搜丧瞎速罪尺列橇曳筋玻嘲货道暴元翰泪捅烬野析束不宠奶仅芜镣熙绰冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民Conclusion- Stent Vs CABG : favor CABG on mortality, event free survival rate due to higher restenosis rate of Stent groupDES lowered the restenosi
44、s rate by half or 1/3 Waiting future trial of DES vs CABG on MVDAlso should consider the huge economic impact of DES on MVD砌帧栏出柔悦瞩罕寐羊夯扑瘟凌焊郎已锐锗彭赴碉泣烛抗着卜椿窖恭芯拭冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民ConclusionEvidence base medicine : “ CABG still the best treatment for MVD an
45、d LM now”Cardiac Surgeon: What is left for us? - may change from time to timeBut the main point is as a doctor we concern more is “What is the best for the patient?”The patient need to know! - their right和檬磺鬼癣施垫与恐峻骸拒揽纳撂罪拈屁靡讫氨钎洽蒂人斯诌春瘩丙屿棵冠心病外科的进展uptodatecoronarysurgery阮新民冠心病外科的进展uptodatecoronarysurgery阮新民
