非体外循环下机器人冠状动脉旁路移植手术的麻醉管理

目的 总结非体外循环机器人冠状动脉旁路移植手术中的麻醉技术.方法 2007年1月至2011年3月共完成机器人心脏跳动下冠状动脉旁路移植手术163例,其中62例全机器人冠状动脉旁路移植手术,101例机器人辅助肋间小切口冠状动脉旁路移植手术.麻醉均采用全麻,左侧双腔气管插管.结果 术中单肺通气和CO2气胸引起动脉氧分压(PaO2)和静脉氧饱和度显著降低,163例患者中有17例出现低氧,SpO2降至0.92.使用5～15 cmH2O的持续气道正压后,PaO2从(59±12)mm Hg升至(115±23)mm Hg(P<0.05).CO2气胸开始阶段平均动脉压和心脏指数明显降低,同时伴有平均肺动脉压增高、心率加快,经快速补液和使用血管活性药得以纠正.术后(7.5±3.1)h拔管,ICU停留平均21h.1例因肺部感染在ICU治疗3天;1例行二次手术止血.全部患者术后住院4～7天.结论 非体外循环机器人冠状动脉旁路移植手术中的单肺通气和CO2气胸对患者循环和呼吸功能的影响是麻醉管理的关键.心脏外科医师和麻醉医师要熟练掌握单肺通气和CO2气胸的相关技术知识,恰当处理术中缺氧和血流动力学波动.

Abstract：

Objective Anesthesia for endoscopic robotic coronary artery bypass grafting surgery on beating heart to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one lung ventilation ( OLV ) and intrathoracic inflation of CO2 with positive pressure (CO2 pneumothorax) is crucial. Methods Between February 2007 and January 2011, 163 patients underwent robotically assisted coronary artery bypass surgery on beating heart using the da Vinci S Surgical System. Of them, 62 patients underwent totally endoscopic coronary artery bypass grafting ( TECAB). Other 101 patients underwent robotically assisted endoscopic atraumatic coronary artery bypass ( ENDOACAB) in which the left internal mammary artery was harvested robotically and direct anastomosis via a small left anterior thoractomy incision. Results PaO2 and SvO2 after initiate of OLV and CO2 pneumothorax showed a significant decrease. Meanwhile, the SpO2 decreased to 0.92 in 17 of the 163 patients.In these patients, application of CPAP setting 5-15 cmH2O to the collapsed lung resulted in an increase in PaO2 from (59 ±12) mmHg to (115 ±23) mmHg (P < 0.05). At the beginning of CO2 pneumothorax the most dramatic fall in MAP and CI was showed with an increase in MPAP and HR. The hemodynamie compromise was counteracted by transfusion and inotropes/ vasopressors. Postoperatively, the average extubation time was (7. 5 ±3. 1) hours, and median ICU length of stay was 21 hours. One patient remained in the ICU for 3 days for treatment of a postoperative pneumonia. One patient who had underwent ENDOACAB were reexplored for bleeding in the left anterior thoracotomy incision. All patients were discharged home 4 to 7 days after surgery. Conclusion Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.     

非体外循环与体外循环冠状动脉旁路移植血管中远期通畅率比较

目的 比较非体外循环不停跳与体外循环冠状动脉旁路移植手术后中远期移植血管的通畅率.方法 对同一术者行冠状动脉旁路移植手术后5年以上病例50例.按手术方式分为两组.第1组采用传统体外循环下进行冠状动脉旁路移植(体外循环组,25例);第2组采用非体外循环不停跳技术进行冠状动脉旁路移植(非体外循环组,25例).对所有病例进行冠状动脉造影随访,比较两组移植血管的通畅情况.结果 两组均男21例,女4例.第1组手术年龄(55.4±8.9)岁;随访70～110个月,平均(86.52±12.48)个月;移植血管共83支,其中动脉移植血管41支,静脉移植血管42支,平均移植血管(3.32±0.63)支/例;随访移植血管通畅61支,狭窄6支,闭塞16支,动脉移植物通畅率为78.05%,静脉通畅率69.05%,总通畅率73.49%.第2组手术年龄(58.2±9.09)岁;移植血管共65支,其中动脉移植血管31支,静脉移植血管34支,平均移植血管(2.52±0.71)支/例,随访64～99个月,平均(82.68±12.48)个月;随访移植血管通畅47支,狭窄4支,闭塞14支,动脉移植物通畅率为74.19%,静脉通畅率70.59%,总通畅率72.31%.结论 非体外循环不停跳冠状动脉旁路移植手术移植血管中远期通畅率与传统体外循环手术一致,均可达到较好的中远期疗效.

Abstract：

Objective Off-pump coronary artery bypass grafting (OPCAB) is used more widely in recent years in China. However, there is an argument on benefits and risks of off-pump surgery. Many studies shown that OPCAB had more benefits in short-term outcomes than conventional coronary artery bypass grafting(CCABG). But evidences from other studies suggested that OPCAB resulted in less long-term graft patency as compared with on-pump surgery. This study examined the longterm graft patency of OPCAB and CCABG performed by one surgeon. Methods 50 patients who had received surgical revascularization by a surgeon for more than 5 years were reviewed, 25 patients received conventional coronary artery bypass grafting ( group 1 ) and 25 patients received OPCAB ( group 2). All patients had angiograms for compareing the graft patency between the two groups. Results Among 25 patients in group 1,21 were male and 4 were female. The mean age of patients at surgery was (55.4 ±8.9) years. 15 cases had unstable angina, 16 patients had old myocardial infarction and 6 cases had diabetes.The ejection fraction (EF) was 0.58 ±0.14. The mean number of bypasses per patient was 3.32 ±0.63. Mean duration of operation was (3.58 ± 0. 82) hours. Mean follow-up duration was ( 86.52 ± 12.48) months. 83 grafts were evaluated for patency ( open vs. closed) and were graded by Fitzgibbon as grade A ( excellent graft), B ( impaired graft, with a stenosis of ≥50%, or a diameter less than 50% of the grafted artery), or O ( completely occluded). The graft patency was 73.49%, 61grafts were graded as Fitzgibbon A, 6 grafts as Fitzgibbon B and 16 grafts as Fitzgibbon 0. 25 patients were in group 2, 21males and 4 females. The mean age of patients at procedure was (58.2 ± 9.09) years, 11 patients had unstable angina, 13 patients had old myocardial infarction and 6 cases had diabetes. The ejection fraction (EF) was 0.59 ± 0. 14. Conclusion No 2011.03.013 difference in long-term graft patency was identified between on-pump and off-pump coronary artery bypass grafting. Off-pump oronary artery bypass grafting preformed by an experienced surgeon may gain similar long-term graft patency to that of conventional bypass.     

不同心肌血运重建方式治疗高龄冠心病三支病变患者的围术期结果

目的 比较机器人辅助微创"杂交"冠状动脉血运重建(hybrid coronary revascularization,HCR)、非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass,OPCAB)和经皮冠状动脉介入(percutaneous coronary interventio...     

400例机器人微创心脏手术入路

目的 分析机器人微创心脏手术手术入路及技术特点,总结选择手术入路的依据和不同手术入路的适用术式.方法 2007年1月至2011年3月,解放军总医院心血管外科使用"达芬奇S"全机器人手术系统,完成微创心脏手术400例.术中根据病种、手术计划及患者体形,于单侧胸壁开直径1cm的小孔 3～4个,并同机器人手臂系统连接.术者于控制台前遥拎器械完成手术.机械臂的位置、角度依据手术类型和术中要求作相应调整.超声引导下于右侧股动静脉及右侧颈内静脉插管建立体外循环.结果 右侧胸壁入路221例,用于房、室间隔缺损修补、二尖瓣手术、心房黏液瘤切除等体外循环下心内直视手术;左侧胸壁打孔178例,用于单侧或双侧内乳动脉游离、心脏不停跳下冠状动脉旁路移植术、心包疾病和纵隔肿瘤切除手术.1例患者因胸膜重度粘连改为正中开胸,其余患者均成功接受机器人微创心脏手术.术中无严重的机械臂碰撞、机械功能障碍而影响手术进程或导致术式转化.术后疼痛程度减轻,切口美观.结论 机器人微创心脏手术可安全的应用于常见心脏疾病的外科治疗,采用右侧或左侧胸壁打孔,手术入路应根据手术要求和患者的体形选择并作精确调整.

Abstract：

Objective Subject To summary the port placement and system set-up for robotic minimally invasive heart surgery using da Vinci S system in China. Methods 400 patients accepted selective robotic minimally invasive heart surgery from January 2007 to January 2011. We conducted a retrospective review of port placement and system set-up for all the surgeries. During the surgery 3-4 ports were made in the lateral thoracic wall and the position of ports were modulated according to the types of diseases, the procedure and patients' habitus. The surgeon completed the procedure before the surgeon console.The arms of da Vinci S system was adjusted according to surgery procedure. Results The right lateral ports were suitable for the intracardiac operation with extracorporeal circulation. And the left lateral ports can be used in the inner thoracic artery harvesting and coronary bypass graft on beating heart. Except for 1 case changed to sternotomy because of sever pleural adhesions,no arms collision and mechanical malfunction during the surgery that leaded to surgical conversion. Conclusion Robotic minimally invasive heart surgery can be safely applied to partial cardiac surgeries. The port position and system set-up should be adjusted according to the habitus of patients and surgical requirement.     

全机器人心脏不停跳下房间隔缺损修补术

目的 总结使用"达芬奇S"(da Vinci S)机器人手术系统,心脏不停跳下房间隔缺损修补或房间隔缺损修补+三尖瓣成形术的经验体会.方法 2009年3月至2010年12月,使用da Vinic S机器人系统,心脏不停跳下完成继发孔型房间隔缺损修补或房间隔缺损修补+三尖瓣成形术40例.患者女23例,男17例;年龄平均(38±13)岁.房间隔缺损直径为1.5～3.5 cm,平均(2.8±1.3)cm,无右向左分流,伴有或不伴有三尖瓣重度关闭不全.手术经股动、静脉及右侧颈内静脉插管建立体外循环.于右侧胸壁打直径为0.8 cm的器械臂孔3个,直径为2 cm工作孔1个,术中不阻断升主动脉,经内窥镜套管持续给予二氧化碳,心脏跳动下,术者于操作台前遥控机器人进行房间隔缺损修补,三尖瓣重度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损22例,心包补片修补房间隔缺损18例,同期三尖瓣成形9例.术中食管超声评估修补及三尖瓣成形效果.对比不停跳与心脏停跳下全机器人房间隔缺损修补术的手术时间及体外循环时间.结果 所有患者均成功接受全机器人心脏不停跳下房间隔缺损修补术或房间隔缺损修补+三尖瓣成形术,无体循环气体栓子及残余分流等并发症.不停跳组的手术时间、机器人使用时间或体外循环时间少于停跳组.结论 机器人心脏不停跳下房间隔缺损修补术无需阻断升主动脉,简化了全机器人手术过程,手术效果安全可靠.

Abstract：

Objective To Summary the first 40 cases underwent robotic atrial septal defect (ASD) closure or atrial septal defect closure combined bicuspid valve plasty (TVP) using "da Vinci S" surgical System on beating heart. Methods 40 cases of atrial septal defect or combined sever tricuspid valve regurgitation were repaired using "da Vinic S" surgical system on beating heart from March 2009 to December 2010 in cardiovascular department of PLA general hospital. The average age was (38 ± 13) yeas old. 23 cases were female and 17 cases were male. All patients were ostium atrial septal defect with or without pulmonary hypertension. The atrial defect diameter was 1.5 -3.5 cm, and the mean diameter was(2. 8 ±1.3)cm. 9 patients had sever tricuspid valve regurgitation. Without sternotomy, the extracorporeal circulation was established through groin artery,groin vein and internal jugular vein cannulation with the guidance of transeophageal echocardiography. 3 ports of 8 mm and 1 working port of 2 cm were made in the right chest wall. After "da Vinci S" syetem was set up, with the assistant of bed-side surgeon, the surgeon completed the atrial septal defect closure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization. During the operation, without cardioplegia administrated and aortic occlusion, the procedure was completed through right atriotomy. The pleural space was insufflated with carbon dioxide to avoid the air embolism. The direct suturing was used in 22 cases and pericardial patch were used in 18 cases. 9 patients accepted concurrent De Vega tricuspid valve plasty. The transesophageal echocardiography were used to evaluate the result of atrial defect closure or tricuspid valve repair. The operation time, robotic using time and cardiopulmonary time were compared with totally robotic atrial defect repair in arrested heart. Results All cases were accomplished successfully without complication. There was no residual shunt and air embolism. The operation time, robotic using time and cardiopulmonary time were less than the arrested group. Conclusion Robotic atrial septal defect closure or combined tricuspid valve repair on beating heart can avoid aortic ocllusion and can be utilized effectively and safely.     

升主动脉替换联合三分支支架血管术中置入治疗急性A型主动脉夹层

目的 总结升主动脉人工血管替换联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层的初步经验.方法 2008年6月至2009年9月20例急性A型主动脉夹层病人接受了升主动脉人工血管替换和三分支支架血管置入术.体外循环鼻咽温度降至20℃时,停止下半身灌注,经无名动脉近端升主动脉横断切口,将三分支支架血管置入主动脉弓和近端胸降主动脉真腔内,并将其分支支架血管依次置入左锁骨下动脉、左颈总动脉和无名动脉.将主干支架血管的近端与无名动脉近端的升主动脉切口重建后与替换近端升主动脉的人工血管端端吻合.结果 所有病人术中均顺利地置入三分支支架血管,平均体外循环(163.2±19.2)min,主动脉阻断(89.4±10.0)min,低流量选择性脑灌注和下半身缺血(32.7±6.6)min.术后出现短暂性神智障碍1例,急性肾功能衰竭1例.20例均治愈出院.术后3个月电子束CT检查结果示,主干支架血管及分支支架血管通畅、无扭曲;支架血管置入部位夹层假腔闭合;16例远端胸降主动脉夹层假腔闭合.结论 三分支支架血管术中置入是简化急性主动脉夹层者主动脉弓重建、提高手术安全性的一种有效方法.主要适应证为弓内内膜无破口而需主动脉弓重建的急性A型主动脉夹层病人.支架血管大小、分支支架血管间的距离选择和放置过程中避免内膜损伤是术中三分支支架血管成功放置的关键.

Abstract：

Objective To report the primary experience of open placement of triple-branched stent graft for acute Stanford type A aortic dissection. Methods Between June 2008 and September 2009, 20 well-selected patients with acute Stanford type A aortic dissection underwent open placement of triple-branched stent graft for total arch reconstruction. When core cooling to a 20℃ nasophageal temperature, perfusion to the lower body was discontinued and the ascending aorta was transected at the base of the innominate artery. Through a transverse incision, the triple-branched stent graft was inserted into the true lumen of the arch and descending aorta, and each side arm of the stent graft was positioned one by one into the arch branches.The transected stump of the ascending aorta was reconstructed by inner proximal stent-free dacron tube of the main graft and outer teflon felt, and subsequently continuous anastomosis to the 1-branched dacron tube graft was made. Results Open placement of triple-branched stent graft was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and lower body arrest time were (163.2 ±19.2) min, (89.4 ±10.0) min and (32. 7 ±6. 6)min, respectively. Transient postoperative neurological dysfunction was observed in 1 patient and acute renal failure in 1 patient. All patients were discharged from the hospital. Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened without distortion. In the vascular stent implantation site the dissected false lumen was eliminated. The false lumen of the descending aorta distal to the stent graft was closed with thrombus in 16 cases. Conclusion Open placement of triple-branched stent graft is a new effective technique for total arch reconstruction in acute type A aortic dissection. Patients have the indications of the extensive primary repair of the thoracic aorta without primary intimal tears in the arch may be the best candidates for this new technique. The size of the stent graft, the distances between two neighboring side arm grafts and the prevention of the intimal trauma during the placement are crucial for successful open placement of triple-branched stent graft.     

冠状动脉旁路移植术后早期紧急再次手术

目的 探讨冠状动脉旁路移植(CABG)术后围术期急性心肌缺血的病因和外科治疗.方法 2001年1月至2009年1月,28例CABG术后早期进行了紧急再次手术.其中男18例,女10例.平均年龄54岁.主要病因包括早期移植物栓塞、乳内动脉(IMA)异常、靶血管吻合口异常,桡动脉(RA)痉挛、心肌血管化不完全.首次手术到再次手术时间间隔1～48 h,平均8 h.紧急再次手术中仅2例选择非体外循环不停跳手术,余均在体外循环心脏停跳下CABG.再次手术包括:对异常移植物尽可能去除,选择重新吻合或远端加一旁路血管.对RA持续痉挛者拆除后用静脉再次行旁路手术.再次手术中给予充分再血管化.结果 手术死亡2例.术后1～14天死亡8例.16例术后放置主动脉内球囊反搏(IABP)辅助,其中2例同时进行体外膜式氧合器(ECMO)辅助,2例同时选择左心辅助装置(LVAD).18例生存者均无严重并发症.结论 CABG术后早期急性严重心肌缺血病死率高.早期诊断和及时外科处理可以提高生存率.强调术前、术后预防的重要性.

Abstract：

Objective To explore the cause of acute myocardial ischemia early after coronary artery bapass graft (CABG) and surgical management on it. Methods From 2001 to 2009, 28 patients underwent urgent reoperation early after CABG due to acute myocardial ischemia. The incidence of reoperation is about 0.02%. The cause of reoperation inclouded early graft occlusion (10 cases) ,IMA damage or injury during harvesting(9 cases), inexactitude distal anastomosis(2 cases)and radial artery spasm(4 cases). The mean interval time between two operations was 8 hours. Reoperation was done under offpump bypass in 2 patients and on-bypass used in other patients. Unsatisfactoey graft were substituted with new graft material and thrombotic was removed. If LIMA was the reson for myocardial ischemia, an additional vein graft was inserted. The spasm radial artery were substituted with new vein graft. Completely revascularization was used in re-do CABG. Results Two patients died during reoperation. 8 patients was died between 1 day and 14 days after reoperation. IABP was used in 16 patients,which 2 patients received ECMO suppord and 2 patient received LVAD suppord at mean time. Conclusion There have very high mortality in acute myocardial ischemia early after CABG. The early diagnosis and correct surgical management can improve the rates of survival. The active prevent should be emphasized during the first CABG.     

非体外循环冠状动脉旁路移植术的病理生理与麻醉处理

冠状动脉旁路移植术(coronary artery bypass grafting,CABG)是常见的心脏手术.非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass,OPCABG)最早于1964年在圣彼得堡完成,但很快随着体外循环(cardiopulmonary bypass,CPB)技术及心脏停跳液的发展而被弃之不用.     

再次冠状动脉旁路移植术42例临床分析

目的 总结再次冠状动脉旁路移植术(CABG)的临床特点及手术效果.方法 对2002年1月至2010年12月连续收治的42例CABG术后患者行再次CABG.其中男性29例,女性13例;年龄46～78岁,平均(61.2±2.1)岁.非体外循环CABG患者31例,心肺转流下CABG患者11例,同期分别行主动脉瓣置换术及主动脉根部替换+右半主动脉弓置换术各1例.结果 全组死亡3例,1例因术中右心室破裂死亡,1例因术后心力衰竭死亡,1例发生肾功能衰竭导致多器官功能衰竭死亡,围手术期病死率为4.8%.其余40例术后呼吸机辅助呼吸时间9～27 h,平均(17±7)h.术后心绞痛均消失,围手术期无心肌梗死发生,顺利恢复出院.术中接受主动脉内球囊反搏6例.术后随访38例,随访时间6～54个月,均无心绞痛发作;12例复查冠状动脉CTA,显示移植血管均通畅.结论 随着手术技巧和围手术期管理的改进,合理采用各种技术,再次冠状动脉旁路移植术可以取得满意疗效.

Abstract：

Objective To determine the clinical characteristics and outcomes of redo CABG.Methods The outcomes of 42 consecutive patients who underwent redo CABG from January 2002 to December 2010 was analyzed.There were 29 males and 13 females,aging from 46 to 78 years old with a mean of(61.2 ± 2.1)years.Off-pump CABG was applied for 31 patients and on-pump CABG for 11 patients.There were 1 patient underwent concomitant aortic valve replacement and 1 patient underwent aortic root and right aortic arch replacement respectively.Results Three patients died of right ventricle rupture,heart failure and multiple system organ failure respectively and the perioperative mortality rate was 4.8%.The post-operatively mechanical ventilation time varied from 9 to 27 h with a mean of(17 ±7)h.There was no residual angina and perioperative myocardial infarction in the remaining patients who were all discharged uneventfully.Intraoperative 6 patients had accepted intraaortic balloon counterpulsation.During the followup from 6 months to 4.5 years for 38 patients,which showed no evidence of recurrent angina and postoperative coronary CT angiography in 12 patients showed the patency of grafts is good.Conclusion Satisfactory outcome of redo coronary artery bypass grafting can be achieved if proper indication were choosed and reasonable management were performed.     

机器人系统行心房黏液瘤切除术40例

目的 总结机器人二尖瓣置换术的临床应用,以评估其安全性及有效性.方法 2008年6月至2011年4月,20例患者接受机器人二尖瓣置换术,男7例,女13例;年龄32～65岁,平均(44.7±9.8)岁.术前心功能Ⅰ～Ⅱ级16例,Ⅲ级4例.15例合并房颤.股动、静脉及右侧颈内静脉插管建立体外循环.右侧胸壁打直径为0.8cm的器械臂孔3个,直径为1.5～2.5cm工作孔1个,术者于三维成像系统下遥控微创器械完成二尖瓣置换.术中食管超声引导建立体外循环并评估手术效果.术后常规进行随访.结果 无手术死亡及术中术式转化.机器人二尖瓣置换平均体外循环(137.1±21.9)min,主动脉阻断(99.3±17.4)min.随访(12.1±6.6)个月,未见瓣周漏等并发症.结论 机器人系统可安全、有效地完成二尖瓣置换,术后近期效果良好.

Abstract：

Objective To determine the safety and efficacy of robotic mitral valvereplacement using da Vinci S system.Methods From August 2008 to April 2011, over 400 cases of robotic cardiac surgery have been completed in Chinese PLA general hospital, in which 20 patients with isolated mitral valve stenosis underwent robotic mitral replacement, including 7 male and 13 female patients with a mean age of (44.7 ±9.8) years (ranging from 32 to 65 years). 16 patients had a NYHA class Ⅰ～Ⅱ heart function and 4 patients were NYHA class Ⅲ. Fifteen patients were concomitant with atiral fibrillation. Surgery approach was achieved through 4 right chest ports with femoral perfusion and Chitwood aortic occlusion. Antegrade cold blood cardioplegia was administered directly via chest for myocardial protection. The transesophageal echocardiography was used intraoperatively to estimate the surgical results. Results All patients had successful valve replacement including mechanical and tissue valve replacement. There was no conversion to a median sternotomy. The mean cardiopulmonary bypass and arrested heart time were(137.1 ±21.9) minutes and (99.3 ±17.4) minutes. Echocardiographic follow-up in all patients revealed no complications. Conclusion Robotic mitral valve replacement is safe and efficacious in the patients with isolated mitral valve disease.     

机器人非体外循环冠状动脉旁路移植与支架置入杂交手术

目的 总结"达芬奇S"(da Vinic S)机器人下非体外循环冠状动脉旁路移植与支架置入杂交手术技术特点和优势.方法 2007年1～8月使用da Vinic S机器人系统,完成非体外循环冠状动脉旁路移植共42例,其中10例因双支冠脉病变,在机器人旁路手术后行支架置入术.病人平均年龄为(62.3±12.1)岁,其中男8例,女2例.病人冠状动脉造影均显示严重的前降支病变,并合并有回旋支或右冠状动脉的局限性狭窄.所有病人肺功能良好,无胸膜炎和左侧胸腔手术史.机器人手术过程中无需正中开胸,仅左侧胸壁打直径为1 cm的器械臂孔3个,术者于da Vinic S系统的操作台前、三维成像系统下遥控机器人全程游离乳内动脉;其中4例直接行全机器人非体外行循环下冠状动脉旁路移植术(TECAB),另6例于左侧胸壁第4肋间作6～8cm的小切口,在心脏跳动下行乳内动脉和前降支的吻合(SVST).术后1周左右经股动脉常规行回旋支或右冠状动脉支架置入术.置入术中行乳内动脉造影评价再血管化效果.结果 病人术后恢复顺利,并成功接受支架置入术,乳内动脉旁路血管通畅,无并发症发生.结论 应用机器人微创冠脉旁路手术和支架置入杂交手术治疗冠心病,可最大限度的减小手术创伤并实现完全再血管化.     

机器人非体外循环冠状动脉旁路移植术

目的 总结使用da Vinci S机器人系统完成的微创机器人非体外循环冠状动脉旁路移植术(CABG)的技术特点和临床效果.方法 2007年4月至2008年12月,共有56例患者接受微创机器人非体外循环CABG.所有患者术前均有心绞痛症状,冠状动脉造影显示严重的前降支病变,10例患者合并有回旋支或右冠状动脉病变.其中25例患者有心肌梗死病史.心功能(NYHA分级)Ⅱ级45例,Ⅲ级11例,平均射血分数为57%±11%.所有患者肺功能良好,无胸膜炎和左侧胸腔手术史.术前常规行64排CT检查双侧胸廓内动脉(ITA)的解剖情况.共采用三种术式:(1)机器人单侧或双侧ITA游离并同期小切口非体外循环CABG;(2)全机器人非体外循环CABG;(3)对合并有回旋支或右冠状动脉局限性狭窄的患者,接受上述两种术式的一种后行分站式支架置入杂交术.行单支或多支CABG时于左侧胸壁第4肋间做长6 cm的小切121,直视、心脏跳动下行ITA和前降支的吻合;行全机器人非体外循环CABG时无需胸壁切口.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受了上述手术.术中平均ITA桥血流量为(23.2±16.7)mL/min,无中转开放手术和手术死亡.ITA移植到前降支53例,双支桥3例,其中10例患者旁路移植后接受了回旋支或右冠状动脉的支架植入杂交术.术后复查未见桥血管狭窄或闭塞.结论 微创机器人非体外循环CABG手术效果确实、可靠,不破坏胸腔骨性结构、创伤小,是微创CABG的发展方向之一.     

全机器人胸廓内动脉游离非体外循环冠状动脉旁路移植术

目的总结全机器人下不开胸胸廓内动脉（IMA）游离心脏不停跳冠状动脉旁路移植术的初步经验。方法使用da Vinci S全机器人系统,完成胸廓内动脉游离心脏不停跳下冠状动脉旁路移植术15例。所有患者均有心绞痛症状,其中4例患者有心肌梗死病史,冠状动脉造影显示严重的前降支病变,2例患者对角支及回旋支亦有病变。手术过程中于左侧胸壁打直径为1cm的器械臂孔3个,医生于操作台前在三维成像系统下操控机器人进行胸廓内动脉的游离,其中13例行左侧胸廓内动脉游离,1例行双侧胸廓内动脉游离,1例行对侧胸廓内动脉游离。游离结束后,沿左胸前第4肋间行长度为6cm小切口开胸,13例于心脏跳动下行胸廓内动脉和前降支的吻合,2例同时吻合对角支或回旋支。其中1例是完全机器人不停跳下冠状动脉旁路移植术。结果所有患者均成功接受胸廓内动脉游离,无胸廓内动脉损伤及术式的转变。胸廓内动脉和前降支、对角支和回旋支吻合后桥血流良好。术中平均出血量80ml,平均ICU时间20h,术后恢复好。结论全机器人不开胸胸廓内动脉游离技术精细、安全,不停跳下冠状动脉移植术效果确实、可靠,术后效果良好。     

机器人微创非体外循环冠状动脉旁路移植术

目的 评价da Vincis机器人系统进行胸廓内动脉(IMA)游离、小切口非体外循环下冠状动脉旁路移植术的安全性和手术效果.方法 2007年1月到2011年3月,105例患者接受机器人IMA游离、小切口非体外循环下冠状动脉旁路移植术.其中男性77例,女性28例,年龄33～77岁,平均(59±10)岁.患者术前行64排CT检查评估IMA质量,2例患者左LIMA纤细或走行异常弃用.术者于操作台前、三维成像系统下遥控机器人游离IMA并完成动脉桥与靶血管的徒手吻合.其中4例患者旁路移植后接受了杂交技术于回旋支或右冠状动脉行支架植入术.术中均以超声血流检测仪测量桥血管的波形及血流.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受上述手术,无手术死亡病例.术中平均IMA血管桥血流量为(21±13) ml/min.1例于术后第1天突发心跳骤停经抢救后痊愈,复查桥血管通畅.1例合并脑梗死患者术后肺部感染,痊愈后出院.其余患者无并发症发生.术中及术后出血少,术后恢复快.随访1～51个月,平均(30±12)个月.术后冠状动脉造影或64排CT复查未见桥血管狭窄或闭塞,心绞痛症状缓解.结论 机器人IMA游离、小切口非体外循环冠状动脉旁路移植术创伤小、疗效确切、安全性好,是微创冠状动脉再血管化的重要方向之一.     

Treatment of double vessel coronary artery disease by totally endoscopic bypass surgery and drug-eluting stent placement in one simultaneous hybrid session

Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheter-based coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure.     

Robotic totally endoscopic coronary artery bypass and catheter based coronary intervention in one operative session

A 56-year-old male patient underwent robotically assisted totally endoscopic left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting. After protamine administration complete heart block developed in the patient. On intraoperative angiography the LIMA to LAD graft was perfectly patent but an acute occlusion of the right coronary artery (RCA) was noted. We performed an immediate on table percutaneous coronary angioplasty and stent placement to the RCA. The heart regained sinus rhythm and the wall motion abnormalities on the back wall of the heart resolved. No clinical symptoms indicating ongoing myocardial ischemia were noted postoperatively. This case demonstrates that a hybrid procedure of robotic totally endoscopic coronary artery bypass grafting and catheter based coronary intervention is feasible in one simultaneous session.     

Robotically enhanced coronary artery bypass surgery

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28–76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min⁻¹. Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.     

Coronary Surgery: off-pump and port access

Attempts to minimize the invasiveness of cardiac surgery have focused on decreasing access trauma and eliminating cardiopulmonary bypass. The initial procedures, minimally invasive direct coronary artery bypass (MIDCAB, limited access beating heart) and port access (limited access arrested heart), have become niche procedures. Off-pump coronary artery bypass (OPCAB, median sternotomy beating heart) presently accounts for approximately 15% of all coronary bypass operations performed in the United States. Morbidity and cost appear to be decreased with these procedures. Feasibility trials of endoscopic coronary bypass surgery using robotic devices are underway in many centers. It is anticipated that over the next 5 years the alternative approaches to conventional coronary artery bypass surgery will continue to grow as methods of coronary revascularization.     

Experience of coronary artery bypass grafting on the beating heart with right heart bypass; 3 cases of octogenarian

Right heart bypass (RHB) yields more stable hemodynamics by increasing left ventricular preload and collapse right ventricular chamber during the displacement of the heart on beating heart coronary artery bypass grafting (CABG). Recently beating heart CABG gaining popularity, and the indications for CABG have increasingly expanded to elderly person. Using RHB while exposing posterior branches by displacing the beating heart, we have attempted to make total revascularization in beating heart CABG. We performed beating heart CABG with RHB in 3 cases of octogenarian. All patients had left main trunk lesion and needed revascularization of posterior vessels. Introduction of RHB enabled us to approach to posterior target vessels in better exposure and under greater hemodynamic stability. All three patients had no complications postoperatively. Strictly speaking CABG with RHB is not off-pump CABG, but RHB system does not include either artificial lung or manipulation of the aorta. Therefore we think it is very effective support system which enables multiple coronary revascularization for elderly person.     

Off-pump bypass grafting is safe in patients with left main coronary disease

BACKGROUND: Because of a concern about the ability to tolerate beating heart grafting, patients with left main coronary artery stenosis have been excluded from off-pump bypass. We reviewed our experience with off-pump coronary artery bypass grafting for patients with left main coronary artery disease. METHODS: Eight hundred twenty-three patients underwent bypass grafting for left main coronary artery disease from January 1998 to October 1999. One hundred patients were revascularized without the use of cardiopulmonary bypass and compared with a contemporaneous cohort of 723 patients who underwent grafting with the aid of cardiopulmonary bypass. All patients had multivessel grafting performed through a sternotomy. RESULTS: There was one death (1%) in the group undergoing off-pump grafting as compared with a 30-day mortality of 4.7% (p = 0.059) in the on-pump group. Univariate analysis established that patients revascularized without cardiopulmonary bypass were significantly less likely to require postoperative inotropic support (23% versus 62%, p < 0.001) and transfusion (35% versus 67%, p < 0.001). Logistic regression analysis revealed that cardiopulmonary bypass was an independent risk factor for mortality (odds ratio, 7.3; 95% confidence interval, 1.34 to 138.4). CONCLUSIONS: Coronary artery bypass grafting using off-pump techniques are safe and effective in left main coronary artery disease.