机器人辅助的微创冠状动脉旁路移植术

目的：介绍机器人辅助的微创冠状动脉旁路移植手术。方法：应用da Vinci机器人系统取左乳内动脉,然后经左胸第2肋间小切口在体外循环下行冠状动脉旁路移植术。结果：本组34例患者无围术期死亡和心肌梗死;术后有4例发生低心排血量综合征,2例发生急性肾功能不全。结论：机器人辅助的微创冠状动脉旁路移植术是一种安全可靠的手术方法,可以减轻术后疼痛和促进术后恢复。     

胸主动脉瘤合并冠心病的外科治疗

目的探讨行胸主动脉瘤置换同期行冠状动脉旁路移植术的安全性及其对预后的影响。方法1982年5月至2004年10月我院收治67例胸主动脉瘤患者,其中同时行冠状动脉旁路移植术者24例：行降主动脉置换+冠状动脉旁路移植术9例,升主动脉置换+冠状动脉旁路移植术15例。将其术后结果与同期仅行胸主动脉置换者进行对比。结果同期行冠状动脉旁路移植术者总病死率为13%(3/24),同期行降主动脉置换+冠状动脉旁路移植术者虽因心肺转流和选择性脑灌注使手术时间显著延长[(278±54)与(188±59)min,t=5．397,P＜0．05],但术后并发症发生率、3年生存率和3年无心脏意外率与单纯行胸主动脉置换术者比较,差异无统计学意义(P＞0．05)。结论同期胸主动脉瘤置换+冠状动脉旁路移植术安全可靠,有助于防止因冠心病而致术后远期发生心脏意外。     

经左胸后外侧切口进行非体外循环下二次冠状动脉旁路移植术的临床运用

目的总结经左胸后外侧切口实施二次冠状动脉旁路移植术的临床应用与特点。方法我院自2014年7月～2016年3月共实施经左胸后外侧切口实施二次冠状动脉旁路移植术2例,使用普通肋骨撑开器,经左第五肋间进胸。从心尖部逐渐向心包内游离,分离原有初次手术造成的粘连面。合理暴露靶血管并判断选取远端吻合区域,使用大隐静脉或者小隐静脉作为血管桥,游离下肺韧带,侧壁钳夹取降主动脉为近端吻合口,从而进行二次冠脉血运重建。结果 2例均成功实施非体外循环心脏跳动下的冠状动脉旁路移植术,远端吻合口2～3个,平均手术时间182分钟。无住院死亡病例。目前随访尚无死亡及并发症报道。结论经左胸后外侧切口实施二次冠状动脉旁路移植术对某些二次开胸的冠心病病人是安全实用的选择,非体外循环方式下进行此类手术是可行的。     

胸主动脉瘤合并冠心病同期外科治疗(附15例报告)

目的 总结胸主动脉手术同期行冠状动脉旁路移植术的经验。方法1999年6月至2002年7月，胸主动脉瘤手术同期行冠状动脉旁路移植术15例，均为男性；年龄40～66岁，平均57．2岁；体重60～89kg，平均70．2kg。病种包括主动脉根部瘤5例、升主动脉瘤2例、弓部瘤3例、主动脉夹层5例。经胸骨正中切口在全麻低温体外循环下手术14例；左外侧切口非体外循环下冠状动脉旁路移植同期股股转流降主动脉置换术1例。结果术后早期30d内死亡1例，随访1～36个月，无远期死亡，无再次手术及冠心病相关事件发生。结论胸主动脉置换术与冠状动脉旁路移植术能够安全同期进行，同期冠心病的再血管化对预防冠心病相关事件的发生有积极作用。     

非体外循环下冠状动脉旁路移植术

目的 报告微创非体外循环冠状动脉旁路移植术(OPCABG),探讨其手术指征及外科处理要点。方法 回顾性总结5例OPCABG的临床资料。结果 5例顺利完成非体外循环冠状动脉旁路移植术。随访3～4个月,无死亡,无明显心绞痛及心肌缺血表现。结论 对于选择的患者,OPCABG安全、经济、有效,是一种值得推广的微创心脏手术方法。     

主动脉手术同期冠状动脉旁路移植术97例

目的 总结行主动脉手术同期行冠状动脉旁路移植术的临床经验.方法 回顾分析2009年1月至2011年12月,97例同期行主动脉手术和冠状动脉旁路移植术患者的临床资料.男88例,女9例;年龄(57.6±9.5)岁.其中,真性动脉瘤63例,主动脉夹层25例,主动脉狭窄及闭塞性病变7例,主动脉溃疡2例.诊断冠状动脉病变依靠术前冠状动脉造影、术前冠状动脉计算机体层摄影血管成像(CTA)检查和术中探查3种方式.术前确诊冠状动脉病变的比例分别为,真性动脉瘤组93.7％(59/63例),主动脉夹层组40.0％(10/25例),主动脉溃疡和狭窄闭塞组均为100.0％.结果 术前未明确冠状动脉病变者行主动脉手术同期合并抢救性冠状动脉旁路移植术,术前明明确冠状动脉病变的患者同期行常规冠状动脉移植术.两种情况各死亡3例.Fisher精确检验P=0.078,差异有统计学意义.结论 对主动脉病变患者,术前尽可能常规行冠状动脉造影检查或冠状动脉CTA检查,主动脉手术同期合并常规冠状动脉旁路移植手术安全、可靠.     

冠状动脉肌桥的外科治疗

目的探讨外科手术治疗冠状动脉肌桥(myocardial bridge,MB)的适应证、手术方法、安全性及手术效果等。方法症状性冠状动脉肌桥病人30例,均施行外科手术治疗。诊断明确后首先给予药物治疗,症状控制不佳者选择外科手术。外科手术方式包括冠状动脉旁路移植术和肌桥松解术,行微创左胸小切口非体外循环下肌桥松解术5例,行冠状动脉旁路移植术25例,其中20例行胸腔镜下微创非体外循环下冠状动脉旁路移植术。结果全组无死亡病例, 30例病人术后胸痛、胸闷症状均有改善,无严重并发症。术后随访1～60个月,无严重心绞痛发生,无心肌梗死、死亡病例,无再次手术病例。结论外科手术治疗药物不能控制症状的冠状动脉肌桥效果较好,其安全性高、近中期疗效可靠。     

电视内镜下获取大隐静脉在冠状动脉旁路移植术中的应用

目的 探讨冠状动脉旁路移植术(CABG)中应用微创电视内镜下获取大隐静脉的手术要点和临床效果.方法 自2001年1月至2008年12月212例患者接受CABG,按照获取大隐静脉的方法分为两组:内镜组72例,传统组140例.比较分析两组患者的手术资料和术后并发症等情况.结果 内镜组获取静脉的时间与传统组比较差异无统计学意...     

胸骨下段小切口行非体外循环冠状动脉旁路移植术

目的探讨胸骨下段小切口在非体外循环冠状动脉旁路移植术中应用的效果。方法回顾性分析2012年6月至2014年12月前降支单支病变的冠心病患者行胸骨下段小切口非体外循环冠状动脉旁路移植术19例的临床资料,其中男11例、女8例,年龄59.6(44～68)岁。所有患者均游离左乳内动脉与前降支吻合,其中1例因术中探查见第一对角支近端明显粥样斑块且对角支粗大,遂向上延长切口,全胸骨打开,游离大隐静脉行对角支搭桥,近端吻合于升主动脉,术后1、3、6、12个月进行随访。结果其中1例术中转为常规胸骨正中切口手术,其余18例手术胸骨下段小切口完成,术中血流动力学稳定,无围术期急性心肌梗死及死亡病例,无乳内动脉损伤、无吻合口漏血及恶性心律失常发生,无大出血、二次开胸止血及切口感染等并发症出现,术后住院4～6 d,监护室入住时间、呼吸机辅助通气时间及住院费用均较常规开胸手术明显降低,术后随访期间无心绞痛复发病例。结论胸骨下段小切口行非体外循环冠状动脉旁路移植术,创伤较小,安全可靠;而且是一种操作相对简单,容易掌握及可灵活应变的小切口微创手术,尤其适合于初学小切口冠状动脉旁路移植术术者。     

大隐静脉顺行序贯式吻合技术在冠状动脉旁路移植术中的应用

目的总结冠状动脉粥样硬化性心脏病患者在非体外循环下应用大隐静脉顺行序贯式吻合技术行冠状动脉旁路移植术的治疗效果。方法 2013年1月至2015年6月,连续116例冠状动脉粥样硬化性心脏病患者在我院非体外循环下行顺行序贯式冠状动脉旁路移植术,其中男63例,女53例,平均年龄42~80(64.26±9.67)岁。采用左乳内动脉搭桥左前降支,其余各支靶血管以大隐静脉行顺行序贯式搭桥,首先吻合大隐静脉与升主动脉近端,再顺行序贯吻合对角支、回旋支、钝缘支、左室后支、后降支。结果全组患者无死亡,无围术期心肌梗死。桥血管吻合数目共436个,平均(3.75±0.53)个/例。术后低心排血量综合征3例,经给予血管活性药物联合应用主动脉内球囊反搏(IABP)治疗后痊愈。迟发性心脏压塞1例,急性肾功能衰竭1例,均治愈,患者心绞痛症状均消失,活动量明显增加而无明显不适。结论冠状动脉粥样硬化性心脏病在非体外循环下采用顺行序贯式吻合技术行冠状动脉旁路移植术,可减少主动脉吻合口,节约桥血管长度,缩短手术时间,并可最快恢复心脏供血,是一种安全、有效的冠状动脉手术技术。     

Cardiopulmonary bypass recommendations in adults: the northern New England experience

Using a regional cardiopulmonary bypass (CPB) registry, we compared the practice of CPB at eight northern New England institutions to recently published recommendations. We examined CPB practice among 3597 adult patients undergoing isolated coronary artery bypass grafting surgery from January 2004 to June 2005. Registry variables were used to compare regional CPB practice to recommendations on topics of neurologic protection (pH management, avoidance of hyperthermia, minimizing return of pericardial suction blood, aortic assessment, arterial line filtration), maintenance of euglycemia, reduction of hemodilution, and attenuation of the inflammatory response. We report overall regional practice (regional minimum, maximum). All centers used alpha-stat pH management and arterial line filters. Avoidance of hyperthermia (temperature < 37degrees C) was achieved during 23.4% of procedures (regional minimum, 1.5%; maximum, 83.2%). Minimizing return of pericardial suction blood was achieved in 23.7% of cases (0.7%, 93.6%). Aortic assessment was performed during 45.7% of procedures (1.3%, 98.9%). Maintenance of euglycemia (< 200 mg/dL) was accomplished in 82.7% (57.1%, 97.9%) of cases. Hemodilution (hematocrit < 23% on CPB) was lower for men 32.4% (20.6%, 52.3%) than women 77.9% (64.7% 88.9%). Men were less likely to receive red blood cell transfusions in the operating room (11.0%; 1.8%, 20.9%) than women (54.6%; 30.1%, 70.6%). In an effort to attenuate the inflammatory response, surface coated circuits were used in 83.3% of procedures (8.8%, 100%). During this time, gaps existed between regional CPB practice and recently published recommendations. We continue to prospectively measure CPB practice relating to these recommendations to monitor and improve the care provided to our patients.     

Long-term evaluation of EC-IC bypass patency

Summary The EC-IC Bypass Study Group could not detect any benefit from surgery compared to medical management in the prevention of stroke in 1985 [15]. During the past years surgical revascularization was re-evaluated and considered as an appropriate treatment for a small subgroup of patients with recurrent focal cerebral ischaemia and impaired haemodynamics. This retrospective study examines the long-term benefit and patency rate of bypass.We present a follow-up of 5.6 years of 47 patients, all of whom underwent byupass surgery after 1985. Forty patients suffered recurring transient ischaemic attacks due to uni- or bilateral internal carotid artery occlusion. Examination included neurologic status, TCD with CO₂ or Diamox challenge, angiography, CT and SPECT scans.Neurological improvement was seen in 23% of patients with better results after early surgery, a worsening in 22% suffering further ischaemic events on a postoperative average of 2.8 years. Patency rate for vein graft material was 50%, for the STA-MCA procedure 91%. Occlusion of the vein graft occurred on an average after 1.4 years, other anastomosis after 2.7 years.We conclude that only few patients derived long-term benefit from EC-IC bypasses. Functioning of the bypass worsens over time, suggesting a role for surgery predominantly in the first year of ischaemic events due to insufficient collateral supply. Actual indications for bypass surgery may be patients with failure of maximal medical therapy and progressive ischaemia and haemodynamic compromise.     

Early results of off-pump coronary artery bypass

Objective: The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not. Methods: OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003. Results: The mean number of bypass grafts was 2.43 ±0.82 in the OPCAB group and 2.70±0.71 in the CCAB group (p=0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p=0.822). Conclusion: Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.     

Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m². Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.     

Infrageniculate thin-walled PTFE bypass: Preliminary study of 53 cases

Between May 1, 1983 and May 1, 1985, 53 patients whose mean age was 75 years, and who presented with rest pain or ischemic changes had infrageniculate insertion of femoropopliteal or femorotibial thin-walled polytetrafluoroethylene (PTFE-TW) bypasses. Occlusive atherosclerotic disease was present in all patients. Postoperative follow-up ranged from 6 to 30 months. One patient died in the immediate post-operative period whereas 15 others died later during follow-up. There was one case of prosthetic sepsis. No anastomotic aneurysms occurred. Actuarial analysis of overall patency rates in significant population samples showed that 88% and 68% of bypasses were functional at one month and two years, respectively. The overall rate of early amputation was 17%. Overall limb salvage was 67% at 30 months. In patients over 75, 85% of bypasses were patent at one year whereas life expectancy for one year in this same group of patients was 49%. Although this is a preliminary study, results obtained with this new material suggest that an average gain of 20% in patency rates can be expected compared to those recorded with standard PTFE prostheses. The PTFE-TW vascular prosthesis may be the material of first choice for the geriatric patient in order to promote early hospital discharge and return to the home environment. Even though long-term patency rates of venous grafts are better, we believe that the use of PTFE-TW prostheses in elderly patients with limited life expectancy may be preferred.     

Combined aortobifemoral and femoropopliteal bypass in the management of patients with extensive atherosclerosis

Certain patients have atherosclerosis in both aortoillac and femoropopliteal segments of the arterial tree and thus do not have a good result from reconstruction of the aortoiliac segment. No method has been developed to identify these patients and we do not know whether, by combining a femoropopliteal bypass with an aortobifemoral bypass, the results can be improved. We present a series of 153 patients with severe multilevel occlusive disease treated by simultaneous reconstruction and followed for up to 6.5 years. The cumulative patency of the femoropopliteal bypasses was 80% at four years. Functional and symptomatic improvement was excellent, and operative mortality was low when one considers the age and poor general condition of the patients.     

Unilateral iliac artery occlusive disease: A randomized multicenter trial examining direct revascularization versus crossover bypass

This randomized trial compared the patency of direct unilateral aorto- or iliofemoral prosthetic bypass with that of crossover femorofemoral or iliofemoral bypass in unilateral atheromatous occlusive disease of the iliac artery. Between May 1986 and March 1991, 143 patients were enrolled in this study (74 crossover and 69 direct revascularizations). Cardiovascular risk factors, preoperative symptoms, and atheromatous lesions were similar in both groups. Patients were followed by Duplex scanning with systolic pressure index measurements. Routine digital subtraction arteriograms were obtained postoperatively and separately, when hemodynamic anomalies developed. Mean follow-up was 22 months. One patient with direct revascularization died postoperatively. Primary patency of direct revascularizations was 89.8% at 48 months compared with 52% for crossover bypass. This difference was statistically significant. Secondary patency of direct and crossover revascularization at 48 months was 92.9% and 93.6%, respectively (not significant). Even though crossover bypasses seem attractive because of their technical simplicity and low morbidity, our results suggest that direct revascularizations are preferable in the young patient with no major operative risks, while crossover bypasses remain indicated in patients at risk.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 20–21 1991, Marseille, France.     

Methodologies,Devices, and New Surgical Concepts: Novel System for Percutaneous Cardiopulmonary Bypass

Percutaneous cardiopulmonary bypass (PCPB) has recently come to the forefront of medicine as a technique for resuscitating and supporting patients in various clinical situations. Current systems utilize small-diameter cannulas to aspirate blood under high suction into the cardiopulmonary bypass circuit. Aspiration-based systems have several disadvantages including risk of air embolism, blood hemolysis, and cavitation. Additionally, they are suboptimal for use during open-heart surgical procedures. A system with a venous cannula that employs gravity drainage has been evaluated. Once advanced into position over a guide- wire, the stylet is removed, causing the basket near the end of the cannula to expand. Blood flows into the cannula from side holes and the basket region, which prevents the vessel wall or atrium from collapsing around the catheter and impeding venous drainage. Hemodynamic, hematologic, and histologic examinations were performed on eight anesthetized mongrel dogs during 2 h of PCPB. All animals exhibited adequate tissue perfusion and right and left heart decompression. All animals were successfully weaned from PCPB and after 30 min exhibited normal myocardial function. No ischemic changes were observed in the heart, lung, kidney, or liver by light and electron microscopy. We conclude that full PCPB can be satisfactorily achieved by using a novel percutaneous venous cannula and gravity drainage     

Paracorporeal Artificial Heart in Postoperative Heart Failure

A pneumatically driven artificial heart with a tubular silicone rubber membrane and disc valves was used for functional heart replacement in the paracorporeal mode. A fluidic drive system allows adjustment of the heart rate, positive and negative pressures and systole/diastole ratio.
Since August, 1977, the artificial heart has been used in four patients with refractory postoperative heart failure not responding to volume loading, pH and electrolyte correction, catecholamines and intraaortic balloon pumping. Large cannulae were placed in the atria and great vessels. The ventricles were fixed on the chest paracorporeally. The assist system was used as a left heart bypass in one patient and as a biventricular bypass in three other patients. After 48–72 hours, the ventricular function recovered in three patients, permitting removal of the artificial heart. One patient died of cerebral complications six weeks later; the other two recovered completely and were released in good condition.
Profound postoperative heart failure can be completely reversed by the use of the paracorporeal artificial heart; the advantage of the system lies in the simplicity of its implantation and removal.     

Sequential bypass for multisegmental occlusive disease

We evaluated the effectiveness of a sequential bypass for multisegmental occlusive disease. Forty-seven multiple bypass grafts were performed on 43 patients ranging in age from 55 to 83 years (mean: 70 years). The indications for operation included incapacitating claudication in 20 limbs, resting pain in 15, and nonhealing ulcers in 12. An anatomical arterial bypass was performed on 36 limbs, consisting of an aorto-femoro-popliteal bypass in 21 limbs, a femoro-popliteal-posterior tibial bypass in 8, an ilio-femoro-popliteal bypass in 4, an ilio-femoro-posterior tibial bypass in 2, and a femoro-popliteal-plantar bypass in 1. Similarly, an extra-anatomical arterial bypass was performed on 11 limbs, consisting of an axillo-femoro-popliteal bypass in 6, a crossover femoro-femoro-popliteal bypass in 3, an axillo-femoro-posterior tibial bypass in 1, and a crossover femoro-femoro-anterior tibial bypass in 1. The follow-up period ranged from 3 to 77 months (mean: 23 months). Twelve graft failures occurred, and 2 of them required major amputations. The cumulative graft patency rate was 85% at one year and 65% at 3 years. Arterial Doppler examination revealed a mean preoperative ankle-brachial index of 0.29±0.25. The early and late mean postoperative ankle-brachial indices, however, increased to 0.97±0.19 and 0.84±0.25, respectively. Midterm results have indicated that such multiple sequential bypass grafts are effective.Presented at the 8th Congress Asian Surgical Association, Fukuoka, Japan, March 10–13, 1991