非体外循环冠状动脉搭桥术的手术配合

【目的】总结非体外循环冠状动脉搭桥术的术中配合经验。【方法】36例行非体外循环冠状动脉搭桥手术（OPCABG）患者，术中控制血压、心率的变化，保证有效循环血量，应用心脏表面固定器及血管夹临时阻断，使吻合局部心肌相对静止，并使冠状动脉处于无血状态，术中注意手术环境的恒温、恒湿，合理配合手术。【结果】36例冠状动脉搭桥术均获成功，无严重心律失常、心肌缺血、心肌收缩无力等并发症发生；术后心绞痛症状明显改善，随访1个月至2年，无死亡病例．患者生活质量明显提高。【结论】高质量的术中配合对非体外循环下冠状动脉搭桥术具有积极的临床意义。     

非体外循环下行冠状动脉搭桥术的手术配合

非体外循环冠状动脉搭桥手术（OPCAB）是一种微创手术，已成为冠心病外科发展的一个趋势。我院从2003年4月以来，共行非体外循环心脏不停跳冠状动脉搭桥手术32例，取得满意疗效，手术过程顺利，无死亡病例，现将手术配合体会报道如下。     

体外循环和非体外循环下冠脉搭桥术的术中配合对比分析

目的 探讨体外循环和非体外循环下行冠状动脉搭桥手术的术中配合,为更好地配合冠脉搭桥手术提供理论依据.方法 选择我院在体外循环和非体外循环下行多支冠状动脉搭桥术共54例.其中体外循环15例,非体外循环39例.术中控制血压、心率的变化,保证有效循环血量.体外循环下冠脉搭桥是在心脏停止跳动后直接进行血管吻合,非体外循环利用心脏固定器和氧气吹管以及冠状动脉分流栓使吻合处的局部心肌处于相对静止和冠状动脉处于无血状态下做血管吻合.结果54例冠状动脉搭桥术均获成功,无一例死亡,术后2周均痊愈出院.结论 手术室护理人员应针对患者生理和心理特点,加强术中护理;熟悉手术经过,严格无菌观念,通过和手术医生、麻醉师、机组人员的密切配合以保证手术顺利完成.     

非体外循环冠状动脉搭桥术的临床观察及护理

目的 通过比较非体外循环心脏不停跳冠状动脉搭桥和体外循环下心脏停跳冠状动脉搭桥手术对血液动力学、术中出血量等的影响，评价非体外循环心脏不停跳冠状动脉搭桥术的优越性。方法 观察组21例，采用非体外循环心脏不停跳冠状动脉搭桥术；对照组208例，采用体外循环心脏停跳冠状动脉搭桥术。比较两组病人术中出血量、拔管时间、ICU停留时间、住院时间及术后心绞痛缓解率、肺部并发症发生率。结果 观察组可使血流动力学保持相对稳定，且术中出血量、手术时间、拔管时间、ICU停留时间及总住院时间均短于对照组。结果非体外循环冠状动脉搭桥手术术中出血少、手术时间短、ICU停留时间短、并发症少，有效缩短了病人的住院时间，减轻了护理工作量。     

非体外循环下全动脉冠状动脉搭桥术26例的手术配合

目的:探讨非体外循环下进行全动脉冠状动脉搭桥术的手术配合。方法:在非体外循环下行多支冠状动脉搭桥26例,利用器械使吻合处的局部心肌处于相对静止和冠状动脉处于无血状态下做血管吻合。结果:26例患者术中情况平稳,术后恢复良好,均康复出院。结论:此手术要求护士具备熟练的技术操作,特别是术前患者的心理护理、术中动脉分离及缝合的配合、手术温度的保持对手术的成功意义重大。     

8例胸腔镜辅助微创单支冠状动脉旁路移植术的手术配合

目的：探讨胸腔镜辅助下经胸壁小切口非体外循环冠状动脉旁路移植术的手术配合方法。方法：配合医师对8例患者在胸腔镜电视系统监测下经第4肋间前外侧小切口采集乳内动脉，经此小切口完成非体外循环不停跳冠状动脉旁路移植术。结果：8例患者均在胸腔镜电视系统监测下经第4肋间前外侧小切口采集乳内动脉，并经此小切口顺利完成非体外循环不停跳冠状动脉旁路移植术。结论：术前充分准备好各种必要物品、术中保证电视胸腔镜系统提供清晰术野、协助游离完好的乳内动脉、防止患者术中出现心律失常、心肌缺血是此手术得以顺利完成的关键。     

非体外循环下冠状动脉搭桥手术的护理配合方法及要点

目的探讨非体外循环下冠状动脉搭桥手术的配合方法和要点。方法总结分析我院356例非体外循环下冠状动脉搭桥手术的术中配合过程。结果 356例非体外循环下冠状动脉搭桥手术均顺利完成,未发生配合失误影响手术事件,无严重并发症发生。讨论非体外循环冠状动脉搭桥术要求护士操作技术熟练,理论基础扎实,提前备齐特殊用具,熟悉手术步骤,配合娴熟,保证手术顺利完成。     

非体外循环冠状动脉搭桥术的手术配合及体会

非体外循环冠状动脉搭桥术(OPCAB)，即是在没有体外循环支持下在跳动的心脏上行主动脉和冠状动脉搭桥术，与传统的体外循环冠状动脉搭桥术（CABG）相比，具有缩短手术时间，减少住院和ICC停留时间，避免了体外循环给人体造成的不良影响及相关并发症。减化了操作，降低医疗费用等诸多优点，而倍受关注。我院自2002年5月21日～2002年11月11日开展OPCAB手术26例，术后桥通畅率100%，现将手术配合和体会报道如下。     

非体外循环冠状动脉旁路移植术的手术配合

总结了60例非体外循环冠状动脉旁路移植术的手术配合措施,包括术前准备、器械护士和巡回护士在术中的护理配合、术后器械的清洗、保养.认为良好的手术配合能保证非体外循环冠状动脉旁路移植术的治疗效果.     

非体外循环冠状动脉旁路移植术治疗心肌桥13例分析

目的:探讨非体外循环冠状动脉旁路移植术治疗心肌桥的临床效果.方法:2004年4月-2009年1月狭窄程度Noble分级在3级以上的13例心肌桥患者,均接受非体外循环冠状动脉旁路移植术治疗.采用Genzyme心脏血管稳定器,心脏不停跳下切开心肌桥远端(冠状动脉钻出心肌处)心肌表面脂肪组织,取左内乳动脉搭桥至心肌桥远端.结果:13例患者均顺利完成手术.术后随访6～50个月,均无心绞痛发作,患者生活质量满意.结论:非体外循环冠状动脉旁路移植术是治疗Noble3级以上心肌桥的有效方法.     

Coronary reoperation with and without cardiopulmonary bypass

Summary Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB. From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66±9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67±8 years). Perioperative overall mortality rate was 3.6% (n=7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p=0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity. Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p<0.01). The average number of grafts was significantly higher in the on pump group (2.8±0.78 versus 1.6±0.6; p=0.04). Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50±16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44±13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p=0.92). On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.     

Effects of off-pump coronary artery bypass grafting on patient outcome.

BACKGROUND: Cardiopulmonary bypass (CPB) is associated with postoperative myocardial stunning, hypothermia, formation of microemboli, and systemic inflammatory response syndrome, all of which may prolong recovery from coronary artery bypass grafting (CABG) surgery. This study sought to compare outcomes in patients undergoing CABG off pump versus on pump. METHODS: Outcomes, including mortality and several morbidities, were reviewed in 1,623 on-pump patients and 683 off-pump patients. Morbidities assessed included postoperative bleeding, incidence of multiorgan dysfunction, and neurologic complications. Chi-square and t-test analysis were used to determine statistical significance. RESULTS: Mortality was 42% lower in the off-pump group than the on-pump group. Both critical care and total hospital length of stay were significantly shorter in the off-pump group. The incidence of postoperative bleeding requiring transfusion or a return to the operating room was reduced by 29% in the off-pump group and the incidence of multiorgan dysfunction was reduced by 31%. The off-pump patients also presented a significantly lower incidence of cerebral vascular accidents and seizures than on-pump patients. CONCLUSIONS: We conclude that there is an association between improved patient outcome and off-pump CABG surgery. The outcomes of this study show a statistically significant decrease in mortality, critical care length of stay, total hospital stay, incidence of bleeding requiring transfusion or return to the operating room, amount of blood transfused, incidence of multiorgan dysfunction, cerebral vascular accidents, and seizures in off-pump patients when compared with on-pump patients. Such results support the use of myocardial revascularization off pump as an alternative to CABG surgery on pump. CABG surgery off pump may allow a better postoperative clinical course in patients who are candidates for the procedure.     

主动脉内球囊反搏辅助下非体外循环冠状动脉旁路移植术

目的　探讨主动脉内球囊反搏 (IABP)辅助下行非体外循环冠状动脉旁路移植术 (OPCAB)的治疗经验。方法　回顾性分析近二年来 7例高危冠心病患者在IABP辅助下行OPCAB的临床资料、手术资料 ,并监测应用IABP前后血流动力学指标。结果　全组患者在IABP支持下手术顺利 ,心绞痛均消失 ,无围手术期死亡 ;应用IABP辅助时间平均 32 6h ,无明显IABP并发症 ,术后并发低心排 1例 ,应用IABP后血流动力学指标明显改善。结论　IABP在OPCAB中具有积极的治疗作用 ,改善心功能 ,稳定血流动力学 ,保证手术成功 ,尤其是抢救重危患者具有非常重要的意义     

Clinical outcomes of on-pump coronary bypass using heparin-bonded circuits and reduced anti-coagulation compare favorably with off-pump approach

Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), or off pump, has gained popularity by avoiding the postoperative morbidity related to the use of CPB. Previously, we have demonstrated that CABG done on pump using heparin-bonded cardiopulmonary bypass circuits (HBC) with a lower anti-coagulation protocol (LAP) attenuates these effects, reduces homologous blood product requirement, and improves clinical outcome when compared with conventional CPB circuits. Our purpose in this study was to compare off-pump CABG clinical outcomes to on-pump CABG using HBC with LAP. We retrospectively analysed preoperative and postoperative variables of all primary CABG (n=1214) performed at this institution from 1 January 1997 to 28 July 2000. These patients were divided into the on-pump (n=1152) and off-pump groups (n=62). HBC with LAP were used in all on-pump CABG cases. There was no statistical difference in preoperative comorbid risk factors except percentage of females (on pump, 30% vs. off pump, 44%; p=0.02) and body surface area (on pump, 1.94 +/- 0.25 ml vs. off pump, 1.85 +/- 0.22 ml; p=0.02). There was no difference in intraoperative and postoperative complications, risk-adjusted mortality, total blood product usage, or length of stay. The mean number of distal anastomoses performed was significantly different (on pump, 3.5 +/- 0.82 vs. off pump 1.8 +/- 0.82; p < 0.001). Despite similar preoperative risk factors, clinical outcomes and homologous blood requirements were not statistically different between the off-pump and on-pump groups. These endpoints should not be the only criteria to justify performing off-pump CABG.     

术中改变非体外循环冠脉搭桥术式的原因探讨

目的：探讨非体外循环冠脉搭桥术中被迫改变为体外循环下施术的原因和处理、预防措施。方法：1999年3月－2001年3月不完全统计OPCAB手术143例，术中23例出现严重影响手术继续进行的心律失常、血压波动，其中6例（3％）术中被迫转变为体外循环下施术，其直接原因是：①不能转复的严重心律失常（房颤并室上速1例，室速、室颤3例）。②不能耐受显露靶血管搬动心脏而出现持续性血压下降（2例）。结果：肾急转变为体外循环下完成手术。无手术死亡和术后早期严重并发症发生。结论：术前准备不充分，手术适应症选择不当和术中对意外情况处理欠妥与发生术中被迫改变术式的直接原因有关。     

自体心包管道在冠脉搭桥术中应用的研究

目的采用实验犬的心包片制作心包管道替代冠脉搭桥术中的传统移植血管，希望为冠脉搭桥提供一种理想的血管替代物。方法随机选用杂种成年犬10头，雌雄不限，氯氨酮20mg／kg肌内注射麻醉诱导，行气管插管后机控呼吸，静脉注射氯氨酮和万可松分别维持麻醉和肌松。在非体外循环下所有犬开胸后取心包片制作心包管道行主动脉与右冠脉主干搭桥，术毕止血、膨肺、关胸。实验犬清醒后脱机，拔除气管插管，饲养至实验结束。记录实验犬的早期存活率，采用电磁血流量计测量搭桥前后心包管道的血流通畅度，观察大体及H-E染色光镜下心包管道的病理变化。结果实验犬的早期死亡率为10％，心包管道的血流通畅，冠脉搭桥术前后实验犬右冠脉的血流量变化无统计学意义，P〉0．05，心包管道的组织学形态改变良好。结论在非体外循环下采用心包管道替代传统的移植血管行冠脉搭桥创伤小，实验犬存活率高，冠脉血供效果令人满意，有希望成为理想的血管移植替代物。     

影响非体外循环冠脉搭桥手术的原因探讨

目的　探讨非体外循环冠脉搭桥术被迫改变为体外循环下施术的原因和处理、预防措施。方法　 1999～2 0 0 1年不完全统计 OPCAB手术 143例 ,术中 2 3例出现严重影响手术继续进行的心律失常、血压波动 ,其中 6例 (3% )术中被迫转变为体外循环下施术 ,其直接原因是 :1不能转复的严重心律失常 (4例 )。 2不能耐受显露靶血管牵拉心脏而出现持续性血压下降 (2例 )。结果　紧急转变为体外循环下完成手术。无手术死亡和术后早期严重并发症发生。结论　术前准备不充分、手术适应证选择不当和术中对意外情况处理欠妥与发生术中被迫改变术式有关     

快通道心脏外科技术应用于非体外循环冠脉搭桥术的护理研究

目的探讨快通道心脏外科技术行非体外循环冠状动脉旁路移植术(OPCABG)患者的护理特点。方法 32例OPCABG患者,其中16例术后手术室内即刻拔除气管内插管,16例术后常规机械辅助通气,比较两组患者围手术期资料,探讨护理的特点。结果两组一般临床资料除高血压、左室射血分数因素外其他因素构成比相同,无统计学差异。两组无手术死亡。与对照组相比,快通道组ICU时间缩短、术后住院时间缩短。结论快通道心脏外科技术应用于OPCABG是安全有效,呼吸系统管理和术后镇痛是术后护理的重点。     

降低高龄冠状动脉旁路移植手术风险的研究

目的探讨降低高龄病人冠状动脉旁路移植术（CABG）风险的方法。方法回顾分析2004年11月～2006年11月在我院行CABG的41例年龄大于70岁病人的临床资料，其中行On—pump手术32例，Off-pump手术9例。On—pump手术采用顺逆灌冷氧合血心肌保护法。40例术中使用左侧乳内动脉与大隐静脉做旁路移植材料，行乳内动脉与前降支吻合、大隐静脉与其余病变冠状动脉吻合。围手术期应用预防性治疗方案。结果1例病人术后2周突发腹膜后出血，经抢救无效死亡。余均治愈出院，术后心绞痛缓解。术后哮喘发作2例，房颤4例，上消化道大出血1例，脑栓塞致左侧肢体偏瘫1例。结论综合性治疗措施可有效降低高龄冠CABG手术风险。     

Learning by doing in CABG surgery

This study provides empiric confirmation of the widely held belief that coronary artery bypass graft (CABG) surgery has become quicker over time as clinical and organizational improvements diffuse across hospitals. Based on a two-stage cluster sample of 74 hospitals performing CABG surgery in 1984, data on skin-to-skin procedure and pump times were analyzed for 2,784 Medicare-eligible cases over the 1972-84 period. Using multivariate regression analysis to adjust for patient characteristics and number of grafts, we found that CABG skin-to-skin times fell an average of 36.5% during the first 12 years of hospital experience while cardiopulmonary pump times fell 28.2%. Rates of decline averaged 4.5-5.4% annually initially, but tapered off to 1.5% by the twelfth year of experience. Extrapolating over a 20-year period, gains in skin-to-skin times are projected to reach 42%, resulting in nearly a halving of surgical times. Our findings have implications both for physician reimbursement and patient outcomes. Medicare CABG prevailing fees do not reflect these gains in efficiency and could be reduced substantially. Alternatively, efficient, high-volume hospitals could be identified for inclusion in a Medicare "CABG PPO" so that society might share in the productivity gains. Finally, recent research showing better outcomes in high-volume institutions may be partially explained by their shorter procedure times, which should reduce operative complications.